ShoulderPathology學(xué)習(xí)課程

1、Shoulder Pathology Background 6 million people a year see a doctor for a shoulder problem Shoulder injuries Overhead activities Most Common Acute injuries - traumatic Chronic injuries - develop slowly over a long period of time How do shoulder injuries occur? Athletics - Swimming, tennis, pitching,

2、weightlifting Highly susceptible to shoulder problems Can develop slowly through repetitive, intensive training routines Work - Manual labor or lifting Everyday Activities - washing wall, hanging curtains, gardening Congenital - hooked Acromion第1頁/共46頁第一頁，編輯于星期六：二十點 二十四分。 What are the signs of a sho

3、ulder injury? Stiff shoulder - decreased range of motion Loose shoulder (unstable) - dislocate or sublux A weak shoulder Click - due to a thickening of the inflamed bursa Difficulty sleeping Common Shoulder Problems Shoulder Instability Labral Tears Impingement/Bursitis Rotator Cuff TearsShoulder Pa

4、thology第2頁/共46頁第二頁，編輯于星期六：二十點 二十四分。Impingement/BursitisSupraspinatusInfraspinatusTeres MinorBursaAcromionAcromioclavicular AC Joint & Ligament第3頁/共46頁第三頁，編輯于星期六：二十點 二十四分。 Causes Decreased space between Humeral Head and Acromion Excessive rubbing (extension and abduction) Inflamation of Bursa and

5、 Rotator Cuff Tendons Hooked Acromion (thickening/curvature) rubs against bursa and tendonsImpingement/Bursitis第4頁/共46頁第四頁，編輯于星期六：二十點 二十四分。Causes Cont.Impingement can involve the Acromioclavicular (AC) JointBone Spurs - Bone growth around the joint decreasing space in the shoulderThe AC Joint sits a

6、bove the Bursa & Rotator Cuff and can make impingement worseImpingement/Bursitis第5頁/共46頁第五頁，編輯于星期六：二十點 二十四分。Impingement/Bursitis第6頁/共46頁第六頁，編輯于星期六：二十點 二十四分。 Symptoms Generalized aching Pain Abduction or Extension Sharp pain when trying to reach into you back pocket Catching sensation W Weakness

7、and inability to raise the arm Inability to sleep Diagnosis Physical Examination X-Ray, MRI Scan, ArthrogramImpingement/Bursitis第7頁/共46頁第七頁，編輯于星期六：二十點 二十四分。 PathologyImpingement/Bursitis第8頁/共46頁第八頁，編輯于星期六：二十點 二十四分。 Treatment Rest, Ice, Anti-Inflammatory Medications Physical Therapy Surgery Arthrosco

8、pic or Open Sub-Acromial Decompression Remove bone spurs and flatten Acromion (Shaver and Burr) Bursectomy - Removal of the Bursa (VAPR and shaver) Repair Rotator Cuff RC TearFlattenedAcromionAC JoinResectionImpingement/Bursitis第9頁/共46頁第九頁，編輯于星期六：二十點 二十四分。 Treatment Cont. Arthroscopic portal placeme

9、nt Sub-Acromial DecompressionImpingement/Bursitis第10頁/共46頁第十頁，編輯于星期六：二十點 二十四分。Rotator Cuff第11頁/共46頁第十一頁，編輯于星期六：二十點 二十四分。SupraspinatusInfraspinatusTeres MinorSubscapularisRotator Cuff第12頁/共46頁第十二頁，編輯于星期六：二十點 二十四分。 Background Responsible for overhead motion Causes Degeneration as a result of overhead

10、activities and the natural aging process Impingement Excessive forceRotator Cuff第13頁/共46頁第十三頁，編輯于星期六：二十點 二十四分。 Symptoms Pain and Weakness Inability to abduct the arm Catching sensation Diagnosis Physical Examination MRI scan, & Arthrogram Types Partial thickness tear Tear less than 50% Tear Grea

11、ter than 50% Full thickness (complete) tearRotator Cuff第14頁/共46頁第十四頁，編輯于星期六：二十點 二十四分。HorizontalVerticalHorizontalRetractedVertical &HorizontalInnerSubstanceTypes of Rotator Cuff TearsRotator Cuff第15頁/共46頁第十五頁，編輯于星期六：二十點 二十四分。HorizontalVerticalHorizontalRetractedVertical &HorizontalInnerSubst

12、anceAnchor RepairAnchor Repair &Suture RepairSuture RepairAnchor Repair &Suture RepairSuture RepairRotator CuffRepair Indications第16頁/共46頁第十六頁，編輯于星期六：二十點 二十四分。 Treatment Rest and Anti-Inflammatory Medication Surgery - within 3 months of injury for better outcomes Open 4-5 inch incision on th

13、e side of the shoulder Remove unhealthy Rotator Cuff tissue Humerus is prepared at the Tuberosities for reattachment of tendons Holes are drilled in the Humerus Mitek Soft tissue anchors are implanted into the Humerous and the Rotator Cuff is reattached with suture Rotator Cuff heals to bone over ti

14、me Arthroscopic Technically difficult repair that is performed through a scope, eliminating the need for the 4-5 inch incision Mitek Implants Super & RC Quick, Fastin RC, ROC, Panalok 3.5, Panalok RC, Bioknotless RC, SpiralokRotator Cuff第17頁/共46頁第十七頁，編輯于星期六：二十點 二十四分。nSTEP 1n5cm Longitudinal inci

15、sion from the tip of the acromion down the lateral aspect of the armn3 inch incision one centimeter lateral to the acromion. Rotator Cuff TechniqueSTEP 2Split the deltoid muscle in line with its fibers and insert stay suture at the inferior apex of split, this protects the axillary nerve. 第18頁/共46頁第

16、十八頁，編輯于星期六：二十點 二十四分。STEP 3Incise the Bursa to reveal the insertion of the Supraspinatus Tendon into the Greater Tuberosity and osteotomize the Acromion.STEP 4Some decortication is made in the indentation between the Humeral Head and the Greater Tuberosity.Rotator Cuff Technique第19頁/共46頁第十九頁，編輯于星期六：二

17、十點 二十四分。nSTEP 5nAn anchor is used by tapping or pushing into the bone. STEP 6Both ends of suture are placed through the tissue for a mattress stitch.Rotator Cuff Technique第20頁/共46頁第二十頁，編輯于星期六：二十點 二十四分。STEP 8Sutures are tied together creating a mattress stitch.Fastin RC Rotator Cuff TechniqueRotator

18、Cuff Technique第21頁/共46頁第二十一頁，編輯于星期六：二十點 二十四分。Bone Tunneling TechniqueCUFF LINKPrevent Suture Migration Through Soft Bone & Soft TissueCuff Link made from polyethylene polymerDrill Holes through Greater TuberosityThread Suture through drill holes and tie down Supraspinatus第22頁/共46頁第二十二頁，編輯于星期六：二十

19、點 二十四分。Belt and Suspenders TechniqueSTEP 1 - Drill anchor holes medial to the Greater TuberositySTEP 2 - Drill bone tunnel holes through Greater TuberositySTEP 3 - Insert Anchor and tie down Rotator CuffSTEP 4 - Thread Suture through drill holes and tie down Rotator CuffEXTENDS THE “FOOTPRINT” OF TH

20、E ROTATOR CUFF第23頁/共46頁第二十三頁，編輯于星期六：二十點 二十四分。Shoulder Instability第24頁/共46頁第二十四頁，編輯于星期六：二十點 二十四分。Articular CapsuleHumerusCoracoidAcromionSuperior Glenohumeral LigamentMiddle Glenohumeral LigamentInferior Glenohumeral LigamentPosterior Glenohumeral LigamentBiceps TendonGlenoid FossaGlenoid LabrumShoul

21、der Instability第25頁/共46頁第二十五頁，編輯于星期六：二十點 二十四分。 Causes Dislocation - Humeral Head is completely displaced Shoulder becomes unstable Stretching and/or tearing of the Glenohumeral Ligaments Subluxation - when the joint partially dislocates. The Humeral Head slides partly out of the socket but does not

22、dislocate completely.Shoulder Instability第26頁/共46頁第二十六頁，編輯于星期六：二十點 二十四分。 Types of instability - Loose shoulder Anterior (out the front) - Most Common Multidirectional (more than one direction) Anterior and inferior instability - Typical Posterior instability - Rare The ligaments of the joint capsule

23、 have a considerable amount of slack, or looseness, so that the shoulder is unrestricted as it moves through its rather large range of motion. If the shoulder moves too far the ligaments become tight and stop any further motion (like a dog coming to the end of its leash). Instability occurs when the

24、 shoulder moves beyond the leashShoulder Instability第27頁/共46頁第二十七頁，編輯于星期六：二十點 二十四分。 Treatment Physical Therapy strengthen the muscles substitute for the weakening of the Joint Capsule Ligaments Surgery stabilize by tightening the ligaments Capsuloraphy - Tightening of the Glenohumeral ligaments util

25、izing suture or Radio Frequency Technology. VAPR - Temperature Control (TC) Electrodes. Instability often is associated with a labral tear.Shoulder Instability第28頁/共46頁第二十八頁，編輯于星期六：二十點 二十四分。Capsular ShiftShoulder Instability第29頁/共46頁第二十九頁，編輯于星期六：二十點 二十四分。Labral Tear第30頁/共46頁第三十頁，編輯于星期六：二十點 二十四分。Labr

26、al Tear第31頁/共46頁第三十一頁，編輯于星期六：二十點 二十四分。 Causes Acute injuries - falling on an outstretched hand Chronic tears - commonly seen in unstable shoulders repeated subluxation or dislocation Types Bankart - Tears from 2:00 - 5:00 SLAP - Tears from 10:00 - 2:00SLAPBankartLabral Tear第32頁/共46頁第三十二頁，編輯于星期六：二十點

27、二十四分。Bankart & Slap LesionsSLAPBankart9:003:0010:007:0010:002:00Biceps Tendon always faces anterior12:00Left Shoulder第33頁/共46頁第三十三頁，編輯于星期六：二十點 二十四分。Posterior Labral Tear第34頁/共46頁第三十四頁，編輯于星期六：二十點 二十四分。Labral Tear Symptoms Sharp catching sensation Followed by aching pain May occur only with certai

28、n movements Diagnosis Physical Examination X-ray, MRI scan, Arthrogram Arthroscopy Small camera is inserted into the joint to view anatomy Most shoulder repairs can be done arthroscopically 第35頁/共46頁第三十五頁，編輯于星期六：二十點 二十四分。Arthroscopic Cannula PlacementSuperiorInferiorAnteriorPosterior第36頁/共46頁第三十六頁，編

29、輯于星期六：二十點 二十四分。Arthroscopic ShoulderBicepsTendonGlenoidLabrumMiddle GlenohumeralLigamentHumerusSubscapularusAnteriorCannulaPlacement2:005:00AnteriorPosteriorInferiorSuperior第37頁/共46頁第三十七頁，編輯于星期六：二十點 二十四分。Labral Tear Treatment Surgery Open Arthroscopic Bankart Repair - Reattachment of the Labrum Sutu

30、re Anchors GII, Fastin 3.0mm & 4.0mm, Panalok 3.5mm, ROC, Contack, Knotless, and Bio-Knotless Open Repair Arthroscopic Repair.第38頁/共46頁第三十八頁，編輯于星期六：二十點 二十四分。Bankart TechniqueSTEP 1 OSTEOTOMIZE CORACOID PROCESS WITH CONJOINED TENDONSTEP 2EXPOSE SUBSCAPULARISSTEP 4INCISE SUBSCAPULARISSTEP 5INCISE CAPSULESTEP 6EXPOSURE TOLABRUM AND CAPSULESTEP 7BANKART LESIONSTEP 8MITEKANCHOR REPAIRSTEP 3 INCISE SUBSCAPULARIS第39頁/共46頁第三十九頁，編輯于星期六：二十點 二十四分。STEP 9CLOSE SUBSCAPULARISSTEP 10REATTACH CORICOIDPROCESSSTEP 11COMPLETE REPAIRBankart