Adhesive capsulitis(frozen shoulder): is a progressive shoulder pain &stiffness resolving spontaneously after 18 months. Cause: is unknown.
Pathology: the anterior shoulder capsule shows active fibroblastic proliferation.
Risk factors: diabetes, hyperthyroidism, cardiac disease,
Dupuytren s disease, hemiplegia &after neurosurgery.
CF: usual age is 40-60 yrs, there may be a history of mild trauma followed by arm &shoulder pain which ? gradually & prevents sleeping on the affected side. After several weeks, the pain begins to subside while stiffness increases &continue for 6-12 months before movement regained to normal.
O/E: slight wasting &some tenderness, but the cardinal feature is lack of active &passive movement in all directions. X-ray: is normal.
Differential diagnosis:
1-infection;
2-post-traumatic stiffness;
3-disuse stiffness;
4-reflex sympathetic dystrophy.
?? early(painful phase): reassurance that recovery is certain, NSAID, pendulum exercise & steroid injection.
Late: to improve range of movement? manipulation UGA or injecting 50-200ml of NS to rupture the joint capsule followed by steroid injection then exercise.
Prognosis: most get painless &satisfactory function, though some restriction of movement in 50% of cases.
Instability of the shoulder
The shoulder has a wide range of movement at the cost of stability, the humeral head is held in a shallow glenoid by glenoid labrum, glenohumeral &coracohumeral lig., CA arch &the surrounding muscles. Failure of these mechanisms may cause chronic instability: either recurrent ? or subluxation: anterior in 95% &posterior or multidirectional in 5%.
Anterior instability: recurrent ? usually follows acute injury that causes detachment of labrum & capsule from anterior glenoid rim(Bankart lesion) plus indentation of posterolateral humeral head(Hill-Sachs lesion) by anterior rim during each ?.
CF: often the patient is under 30 (recurrent ? develops in 1/3 of those <30 &in 20% of older) with history of first ? followed by similar episodes.
O/E between episodes: the shoulder looks normal with full movements, the clinical diagnosis depends on the
apprehension test? elevate the arm into abduction, external rotation &some extension, the patient feels as if the humeral head about to slip causing apprehension.
Drawer test? in severe cases the humeral head can be moved forward &backward.
X-ray: shows Hill-Sachs lesion on Ap view with internal rotation. Labral tear is seen on CT or arthroscopy.
?? if the patient can tolerate his condition by avoiding vulnerable positions of the shoulder &the episodes of ? are infrequent, then surgery is not necessary.
Surgery is indicated for frequent dislocation especially if painful &interfering with normal daily activities.
Bankart operation: repair the detached glenoid labrum &capsule.
Putti-Platt operation: shortening of anterior capsule &subscapularis by overlapping repair.
Bristow operation: transpose coracoid process with its attached muscles to the front of scapular neck.
Some of these procedures now can be done arthroscopically.
Posterior instability: is very rare & usually takes the form of recurrent post. subluxation. ?? muscle strengthening exercise.
Multidirectional instability: usually associated with lig. laxity, both anterior &posterior drawer tests are + ve. ?? muscle strengthening exercise.
Atraumatic dislocation or subluxation: due to lig. laxity, may occur spontaneously or voluntarily the patient dislocates &reduces his shoulder. ?? is supportive.
Tuberculosis of the shoulder: is uncommon, often starts in the bone(osteitis) then spreads to the joint (arthritis) with abscess &sinus formation.
CF: usually an adult with long history of pain &stiffness for
months or years. O/E: severe wasting especially deltoid. Sinus
may be seen over the shoulder or in the axilla. The shoulder is
warm & tender. All movements are painful &limited.
X-ray: generalized osteoporosis with erosion of joint surface, sometime, there is abscess cavity with no periosteal reaction.
?: early(before joint destruction): systemic anti-TB, joint rest until acute symptoms have settled, then encourage movement.
Late: arthrodesis if the joint is destructed.
Prognosis: is good if treated early.
Rheumatoid arthritis of the shoulder:
The patient is known to have generalized RA.
CF: painful, swollen, tender shoulder with limited movements. AC joint is often involved &may become unstable. Subacromial bursa &synovial sheath of long head of biceps also become inflamed &may rupture.
X-ray: is that of an erosive arthritis.
?? rest, NSAID, steroid injection &exercise.
If synovitis persists? synovectomy.
For AC J ? excision of lateral end of clavicle.
In advanced cases? joint replacement or arthrodesis.
Osteoarthritis of the shoulder: is usually secondary to # ,subluxation or long standing rotator cuff lesion.
CF: old patient with restriction of all joint movements.
X-ray: narrow joint space, sclerosis &osteophytes. OA of AC joint is more common.
?? rest, NSAID &exercise.
In advanced cases: arthroplasty or arthrodesis.
For ACJ OA: excision of lateral end of clavicle.
Congenital elevation of the scapula
The scapulae normally complete their descent from the neck by the 3rd month of fetal life. Incomplete descent results in abnormally high scapula (Sprengel s deformity) often associated with other anomalies like congenital cervical spine fusion (Klippel-Feil syndrome).
Sprengel s deformity:
CF: the shoulder is elevated, scapula is small &high, abduction
of the arm is limited, short neck. X-ray shows cervical spine
abnormality & sometimes an omovertebral bar which is a bridge
(bony, cartilage or fibrous) between scapula &cervical spine.
?? mild cases need no treatment.
Severe cases need surgery before age of 6 yr: repositioning of
the scapula lower down with excision of the supraspinous part.
Klippel- Feil syndrome: congenital fusion of any 2 or more of the 7 cervical spines often associated with other anomaly like cervical scoliosis &spina bifida. CF: very short neck with grossly limited movement.
Arthroplasty of the shoulder: either partial or complete
partial? replace the humeral head(Neer type).
complete? both humeral head &glenoid are replaced.
Indications:
1-chronic arthritis,
2-multiple # of proximal humerus.
3-destructive lesion of proximal humerus.
Arthroplasty require intact rotator cuff.
Arthrodesis of the shoulder:
Indications:
1- infection including TB.
2- paralysis of scapulohumeral muscles.
3- advanced erosive arthritis with massive cuff disruption.
Arthrodesis require intact scapulothoracic movement.
Operation:
excise the articular cartilage, add bone graft, fix
the joint by internal fixation like screws in the position
of function: 30° abduction, 30° flexion & internal rotation
so the hand can reach the mouth.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .