Flashcards in Instabilidade do Ombro Deck (76):
Quais lesões aumentam a chance de luxação recorrente do ombro?
Burkhart and DeBeer noted an increased recurrence rate (from 6.5% to 89%) in contact athletes when a 25% glenoid defect or an engaging Hill-Sachs lesion alone or in combination was present.
Qual o ponto de corte escore do índice de severidade da instabilidade do ombro?
Ponto de corte = 7
>7 fazer cirurgia com contensor osseo
A lesão de Bankart ósseo geralmente ocorre em qual posição no colo da glenóide?A lesão de Bankart ósseo geralmente ocorre em qual posição no colo da glenóide?
Saito et al. used three-dimensional CT evaluation of glenoid rim defects in recurrent dislocations. In 123 shoulders, the orientation of the glenoid defect was pointing at the 3-o’clock position. This information was helpful in locating and revising the bony Bankart defect arthroscopically.
Quais são as indicações para procedimentos de estabilização do ombro?
Indications for shoulder stabilization procedures include primary dislocation in high-risk patients involved in contact or collision sports near the season’s end or dislocation of the dominant shoulder in an athlete who uses an overhead motion. Recurrence of instability despite conservative treatment also is an indication for shoulder stabilization.
Quais são as contra-indicações dos procedimentos estabilizadores do ombro?
Contraindications include an uncooperative or medically unstable patient. Relative contraindications include a 25% (approximately 6 mm) glenoid bone loss and an engaging Hills-Sachs lesion involving 30% (approximately 6 mm indention) of the humerus and a HAGL lesion.
Qual a porcentagem de pacientes com instabilidade do ombro apresentam lesão por avulsão umeral do ligamento glenoumeral (HAGL)?
Wolf described the HAGL lesion in 9.3% of patients with shoulder instability.
Em qual porção o complexo ligamentar capsular deve ser liberado para permitir o avanço superior da capsula?
Release of the capsular ligamentous complex around to approximately the 6-o’clock position so that the underlying subscapularis muscle can be clearly seen to allow appropriate superior advancement of the capsule
Qual porção do ligamento glenoumeral inferior geralmente está rompida na instabilidade do ombro?
An injury to the posterior inferior glenohumeral ligament is often present, and plication of the posterior inferior capsule generally is indicated in recurrent instability in collision athletes.
Quais são os procedimentos indicados para estabilização do ombro?
■ Bone loss > 25% - Glenoid Latarjet procedure
■ Humeral head > 6 mm deep—Consider remplissage for collision athletes
■ Soft tissue multidirectional instability—Arthroscope capsular shift
■ Anterior labroligamentous periosteal sleeve avulsion— Restore anatomy anteriorly; consider plication
■ Anterior humeral avulsion of inferior glenohumeral ligament—Mini open or arthroscopic repair
■ Posterior humeral avulsion of inferior glenohumeral ligament—Arthroscopic repair
■ SLAP lesion—Concomitant repair
■ Cuff lesion—Concomitant repair
Quais são as contra-indicações relativas para os procedimentos de estabilização posterior do ombro?
Excessive bone loss of more than 25% of the glenoid, a large anterior Hill-Sachs lesion, excessive glenoid retroversion of more than 15%, or pathological collagen deficiency syndrome will result in inferior results and are relative contraindications to arthroscopic soft tissue techniques.
Quais tratamentos devem ser realizados para instabilidade multidirecional do ombro?
When anteroinferior instability with a 2 to 3+ suture sign is present, a rotator interval closure is performed, and the capsule is shifted along the entire inferior glenohumeral ligament from 3 o’clock to 9 o’clock.
No que consiste a tecnica de remplissage?
The Hill-Sachs remplissage technique is similar to an arthroscopic repair of a partial-thickness, articular-surface rotator cuff tear. It consists of fixation of the infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion.
Quais são os fatores que influenciam na probabilidade de luxações recorrentes do ombro?
Factors that influence the probability of recurrent dislocations are age, return to contact or collision sports, hyperlaxity, and the presence of a significant bony defect in the glenoid or humeral head.
Qual a incidência de luxação do ombro na população geral? Qual a porcentagem de luxação glenoumeral dentre todas as luxações?
Nearly 50% of all dislocations, with a 2% incidence in the general population.
Qual a taxa de recorrência de luxação glenoumeral de acordo com a idade?
Recurrence developed in 90% of the patients younger than 20 years old, in 60% of patients 20 to 40 years old, and in only 10% of patients older than 40 years old.
Por quanto tempo o ombro deve ficar imobilizado após um episódio de luxação?
The duration of immobilization also does not seem to afect stability; a recent meta-analysis determined that there is no benefit for conventional sling immobilization longer than 1 week for primary anterior dislocation.
A partir de qual porcentagem a perda óssea da glenóide afeta a estabilidade da articulação glenoumeral?
Glenoid bone loss of more than 20% results in bony instability and increased recurrence rates. This is because the “safe arc” that the glenoid provides for humeral rotation is diminished, resulting in instability when the deficient edge is loaded at extremes of motion.
Qual a porcentagem da cabeça do umero se articula com a glenóide?
Only one fourth (25%) of the large humeral head articulates with the glenoid at any given time.
Além de aumentar o contato da cabeça umeral com a glenóide, qual outra função do labrum?
Matsen et al. suggested that the labrum may serve as a “chock block” to prevent excessive humeral head rollback.
Qual o local de inserção do ligamento glenoumeral superior na glenóide e no umero?
The superior glenohumeral ligament attaches to the glenoid rim near the apex of the labrum conjoined with the long head of the biceps. On the humerus, it is attached to the anterior aspect of the anatomical neck of the humerus.
A diminuição do intervalo rotador reduz quais movimentos?
Tightening of the rotator interval (which includes the superior glenohumeral ligament) decreases posterior and inferior translation; external rotation also may be decreased.
Quais fatores aumentam a chance de instabilidade recorrente do ombro?
Voos et al. had an overall 18% recurrence rate, which increased to 37.5% in patients younger than 20 years, hyperlaxity, and a Hill-Sachs lesion larger than 25 mm3.
Onde ocorre a inserção do ligamento glenoumeral médio no umero e na glenóide?
The middle glenohumeral ligament has a wide attachment extending from the superior glenohumeral ligament along the anterior margin of the glenoid down as far as the junction of the middle and inferior thirds of the glenoid rim. On the humerus, it also is attached to the anterior aspect of the anatomical neck.
Qual a função do ligamento glenoumeral médio?
The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction.
Onde se insere o ligamento glenoumeral inferior no umero e na glenoide?
The inferior glenohumeral ligament attaches to the glenoid margin from the 2- to 3-o’clock positions anteriorly to the 8- to 9-o’clock positions posteriorly. The humeral attachment is below the level of the horizontally oriented physis into the inferior aspect of the anatomical and surgical neck of the humerus. The anterosuperior edge of this ligament usually is quite thickened. There is a less distinct posterior thickening, a hammock-type model consisting of thickened anterior and posterior bands and a thinner axillary pouch.
Como funciona o ligamento glenoumeral inferior?
With external rotation, the hammock slides anteriorly and superiorly. The anterior band tightens, and the posterior band fans out. With internal rotation, the opposite occurs. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more. The ligament provides a restraint at the extremes of motion and assists in the rollback of the humeral head in the glenoid.
Qual é o principal músculo extrínseco do ombro? Qual a direção da força que ele aplica a cabeça do umero?
The action of the deltoid (the principal extrinsic muscle) produces primarily vertical shear forces, tending to displace the humeral head superiorly. The intrinsic muscle forces from the rotator cuff provide compressive or stabilizing forces.
Lesão do labrum diminui em que porcentagem a estabilidade glenoumeral?
Loss of the labrum can reduce this stabilizing effect by 20%.
Que grupos musculares devem ser reforçados em atletas que realizam atividades esportivas com demanda do membro superior para melhorar a performance?
With normal synchronous function of the scapular stabilizers, the scapula and the glenoid articular structures are maintained in the most stable functional position. Strengthening rehabilitation of the scapular stabilizers (serratus anterior, trapezius, latissimus dorsi, rhomboids, and levator scapulae) is especially important in patients who participate in upper extremity-dominant sports.
Qual habilidade da glenóide diminui o impacto sobre o ombro quando uma força inesperada é aplicada sobre essa articulação?
The glenoid also has the ability to “recoil” when a sudden force is applied to the shoulder joint, such as in a fall on the outstretched hand. This ability to “recoil” lessens the impact on the shoulder as the scapula slides along the chest wall.
O que é a síndrome da SICK escapula?
A particular overuse muscle fatigue syndrome has been designated the SICK scapula: Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dyskinesis of scapular movement.
O que é a discinesia escapular?
Scapular dyskinesis is an alteration of the normal position or motion of the scapula during coupled scapulohumeral movements and can occur after overuse of and repeated injuries to the shoulder joint.
Quais outros aspectos apresentam uma menor importancia na estabilidade da articulação glenoumeral?
Another force that has a lesser effect on glenohumeral stability is glenoid version. Glenoid version probably is not a significant contributor to instability except in a severely deformed shoulder. Cohesion produced by joint fluid and the vacuum effect produced by negative intraarticular pressure in normal shoulders play lesser roles in joint stability.
Qual é a lesão essencial descrita por Perthes?
Perthes considered detachment of the labrum from the anterior rim of the glenoid cavity to be the “essential” lesion in recurrent dislocations and described an operation to correct it.
Como são os dois tipos de lesão descritos por Bankart?
In 1938, Bankart published his classic paper in which he recognized two types of acute dislocations. In the first type, the humeral head is forced through the capsule where it is the weakest, generally anteriorly and inferiorly in the interval between the lower border of the subscapularis and the long head of the triceps muscle. In the second type, the humeral head is forced anteriorly out of the glenoid cavity and tears not only the fibrocartilaginous labrum from almost the entire anterior half of the rim of the glenoid cavity but also the capsule and periosteum from the anterior surface of the neck of the scapula. This traumatic detachment of the glenoid labrum has been called the Bankart lesion.
Qual a lesão mais comum nos casos de luxação recorrente do ombro?
Most authors agree that the Bankart lesion is the most commonly observed pathological lesion in recurrent subluxation or dislocation of the shoulder, but it is not the “essential” lesion.
Nos casos de luxação de ombro, onde ocorre a desinserção capsular?
An arthroscopic study of anterior shoulder dislocations found that 38% of the acute injuries were intra-substance ligamentous failures, and 62% were disruptions of the capsuloligamentous insertion into the glenoid neck.
O que é o "circle concept" nas luxações do ombro?
The “circle concept” of structural damage to the capsular structures was suggested by cadaver studies that showed that humeral dislocation does not occur unless the posterior capsular structures are disrupted in addition to the anterior capsular structures. Posterior capsulolabral changes associated with recurrent anterior instability often are identified by arthroscopy.
A lesão de Hill-Sachs ocorre em qual porção da cabeça umeral?
This Hill-Sachs lesion is a defect in the posterolateral aspect of the humeral head.
Nas lesões de Hill-Sachs e defeitos da glenóide, a partir de quais porcentagens a estabilidade glenoumeral está comprometida?
Instability results when the defect engages the glenoid rim in the functional arc of motion at 90 degrees abduction and external rotation. In a cadaver model, humeral head defects of 35% to 40% were shown to decrease stability, whereas glenoid defects of as little as 25% were found to decrease stability.
Luxações recorrentes do ombro podem levar a quais desfechos?
Erosion of the anterior glenoid rim, stretching of the anterior capsule and subscapularis tendon, and fraying and degeneration of the glenoid labrum all can occur with repeated dislocation.
Como podem ser classificadas as luxações quanto a direção?
The direction of instability should be categorized as unidirectional, bidirectional, or multidirectional. Anterior dislocations account for about 95% of recurrent dislocations, and posterior dislocations account for approximately 5%. Inferior and superior dislocations are rare. Superior instability generally arises secondary to severe rotator cuff insuficiency.
Luxação crônica é considerada a partir de quanto tempo?
The dislocation is classified as chronic if the humeral head has remained dislocated longer than 6 weeks.
Qual a taxa de recorrência de luxação em pacientes jovens e adultos?
Age also is important in predicting pathological lesions and outcomes, with recurrence rates of more than 90% reported in patients younger than 20 years old compared with a recurrence rate of about 10% in patients older than 40 years old.
Como a instabilidade pode ser categorizada?
Instability should be categorized as macrotraumatic, in which a single traumatic event results in dislocation, or microtraumatic (acquired), in which repetitive trauma at the extremes of motion results in plastic deformation of the capsulolabral complex. Secondary trauma to the rotator cuff and biceps tendon may cause asynchronous rotator cuff function. The flexibility that allows an athlete to compete at a high level may be attributed to a generalized ligamentous laxity, which also predisposes the athlete to injury.
Quais pacientes devem ser tratados conservadoramente primariamente para instabilidade glenoumeral?
- In patients with primary neuromuscular disorders or syndromes and recurrent dislocation, conservative, nonoperative treatment should be the initial approach.
- Patients with primary collagen disorders, Ehlers-Danlos syndrome, or Marfan syndrome should be treated with extensive supervised conservative treatment;
Como é a classificação de Matsen's para instabilidade glenoumeral?
Matsen’s simplified classification system is useful for categorizing instability patterns: TUBS (Traumatic, Unidirectional, Bankart, Surgery) and AMBRII (Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior capsular shift, and Internal closure).
A queixa de "dead arm" refere ao alongamento de quais estruturas anatomicas?
The patient may complain of having a “dead arm” as a result of stretching of the axillary nerve or of secondary rotator cuff symptoms. It is important to diferentiate primary from secondary rotator cuff impingement.
Em qual ocasião ocorre o impacto interno do manguito na borda posterior da glenoide?
Internal impingement of the undersurface of the posterior rotator cuff against the posterior glenoid and labrum is caused by anterior humeral subluxation with the shoulder externally rotated. This secondary impingement is more common than primary impingement in patients younger than 35 years old who are involved in upper extremity-dominant sports.
Quais manobras são realizadas para se verificar fraqueza escapular? Qual o sinal presente nessas manobras?
Winging may indicate scapular weakness and can be evaluated by having the patient do a press-up from the examination table or an incline type of push-up of the wall.
Como é realizado o "shift and load" test?
Stability is evaluated with the patient upright. A “shift and load” test is done by placing one hand along the edge of the scapula to stabilize it and grasping the humeral head with the other hand and applying a slight compressive force. The amount of anterior and posterior translation of the humeral head in the glenoid is observed with the arm abducted 0 degrees. Easy subluxation of the shoulder indicates loss of the glenoid concavity, which must be surgically treated.
O teste do sulco é realizado em quais posições?
The sulcus test is done with the arm in 0 degrees and 45 degrees of abduction. This test is done by pulling distally on the extremity and observing for a sulcus or dimple between the humeral head and the acromion that does not reduce with 45 degrees of external rotation. The distance between the humeral head and acromion should be graded from 0 to 3 with the arm in 0 degrees and 45 degrees of abduction, with 1+ indicating subluxation, less than 1 cm, 2+ indicating 1 to 2 cm of subluxation, and 3+ indicating more than 2 cm of inferior subluxation, which does not reduce with external rotation.
Subluxação a 0 e a 45o de abdução indica frouxidão de quais estruturas, respectivamente?
Subluxation at 0 degrees of abduction is more indicative of laxity at the rotator interval, and subluxation at 45 degrees indicates laxity of the inferior glenohumeral ligament complex.
Quando o exame físico indica instabilidade por defeito ósseo? E por hiperfrouxidão?
Bony deformity of the glenoid or humerus is indicated by apprehension or instability at low ranges of motion (
Como é realizado o teste de hiperabdução de Gagey?
The hyperabduction test is done by stabilizing the scapula with one hand placed superiorly while passively abducting the shoulder with the other hand. A side-to-side diference of more than 20 degrees is suggestive of inferior capsular laxity. External rotation of more than 85 degrees at 0 degrees of abduction is indicative of hyperlaxity, which may need to be corrected with rotator interval closure.
Como é o escore de hiperfrouxidão de Beighton?
- Passive dorsilexion of the little inger beyond 90 degrees (1 ponto para cada mão);
- Passive apposition of the thumb to the ipsilateral forearm (1 ponto para cada mão);
- Active hyperextension of the elbow beyond 10 degrees (1 ponto para cada cotovelo);
- Acute hyperextension of the knee beyond 10 degrees (1 ponto para cada joelho);
- Forward flexion of the trunk with the knees fully extended so that the palms of the hands rest lat on the floor (1 ponto)
Pontuação maior ou igual a 4 = hiperfrouxidão
Quais são as radiografias iniciais para avaliação da instabilidade do ombro?
The initial radiographic examination should include anteroposterior and axillary lateral views of the shoulder.
Qual tipo de lesão pode ser vista em um rx com rotação interna do braço?
An anteroposterior radiograph of the shoulder in internal rotation often shows a Hill-Sachs lesion that may not be apparent on routine views.
Quais são as incidencias especiais mais utilizadas para se avaliar a instabilidade do ombro?
The most common special views that can be obtained in the office are the anteroposterior view of the shoulder in internal rotation, the West Point or Rokous view, and the Stryker notch view.
Como é realizado e para que serve a incidencia de West Point?
The West Point view is used to show calcification or small fractures at the anteroinferior glenoid rim. This is a modified, prone, axillary lateral view of the shoulder obtained with the shoulder abducted 90 degrees and the elbow bent with the arm hanging over the side of the table. The x-ray beam is directed 25 degrees medially and 25 degrees cephalad with the cassette placed above the shoulder perpendicular to the table.
Como é realizado a incidência de Stryker? Qual sua utilidade?
The Stryker notch view is obtained with the patient supine and the elbow elevated over the head. The x-ray beam is directed 10 degrees cephalad. Serve para avaliar a lesão de Hill-Sachs.
Como é realizado a incidência de Garth? Qual é sua utilidade?
Garth et al. also described an apical oblique radiograph that frequently shows posterior humeral head defects that might not be seen on routine films. With patient seated and injured shoulder adjacent to vertical cassette, chest is rotated to 45-degree oblique position. Beam is directed 45 degrees caudally, passing longitudinally through scapula, which rests at 45-degree angle on thorax while extremity is adducted. Origin of coracoid, midway between anterior and posterior margins of glenoid, aids in orientation on radiograph.
Qual é o exame mais sensível para detectar a falha óssea e mensurá-la?
CT, particularly three-dimensional CT, is the most sensitive test for detecting and measuring bone deficiency or retroversion of the glenoid or humerus. CT is indicated when there is blunting of the glenoid cortical outline or an obvious bone defect on plain radiographs. CT also is indicated for evaluating recurrences that occur with trivial trauma, low-angle instability, and failed surgical procedures.
Com quantos graus de rotação externa os achados de instabilidade são mais significantes?
The most significant findings of instability are demonstrable at 40 degrees and 80 degrees of external rotation.
Até qual porcentagem do diâmetro da glenóide o ombro permite de deslocamento posterior sem instabilidade patológica?
For posterior instability, the arm is pushed posteriorly. Normal shoulders may permit posterior displacement of 50% of the diameter of the glenoid without pathological instability.
Qual a indicação para a cirurgia de Bankart?
The Bankart operation is indicated when the labrum and the capsule are separated from the glenoid rim or if the capsule is thin. The advantage of this procedure is that it corrects the labral defect and imbricates the capsule without requiring any metallic internal fixation devices. The main disadvantage of the original procedure is its technical dificulty.
Quais são as chaves para se ter uma cirurgia de Bankart com sucesso?
Keys to success of this procedure are (1) maximizing the healing potential by abrading the scapular neck, (2) restoring glenoid concavity, (3) securing anatomical capsular fixation at the edge of the glenoid articular surface, (4) re-creating physiological capsular tension by superior and inferior capsular advancement and imbrication, and (5) performing supervised goal-oriented rehabilitation.
Qual a angulação das ancoras na glenóide para reparo da lesão de Bankart?
Suture anchors should be at edge of glenoid articular surface and aimed medially 20 degrees.
Qual a indicação da cirurgia de Eden-Hybbinette?
The Eden-Hybbinette procedure was originally described using an iliac crest autograft to reconstruct the anterior glenoid. Glenoid bone loss approaching 40% of the anterior glenoid or posterior bone loss of 25% with recurrent posterior dislocation should be reconstructed with an autogenous iliac crest bone graft, or, occasionally for posterior lesions, the medial aspect of the acromion can be used as a graft. More recently, Provencher et al. described using allograft from the lateral aspect of a distal tibia for reconstruction.
Quando está indicado o tratamento cirurgico para instabilidade multidirecional?
Surgery in these patients is not indicated unless disability is frequent and significant, an adequate trial of conservative treatment emphasizing muscular and rotator cuf rehabilitative exercises has failed, and the patient is not a voluntary dislocator.
Qual é o tratamento cirurgico para a instabilidade multidirecional?
The principle of the procedure is to detach the capsule from the neck of the humerus and shift it to the opposite side of the calcar (inferior portion of the neck of the humerus), not only to obliterate the inferior pouch and capsular redundancy on the side of the surgical approach but also to reduce laxity on the opposite side. To reduce inferior laxity with the arm in 0 degrees of abduction, closure of the rotator interval is indicated. Internal closure also has been shown to decrease posterior translation.
Quais eventos estão relacionados à luxação posterior?
Traumatic events that result in posterior dislocation often are associated with altered consciousness, such as occurs with seizures, electrical shock, and intoxication. Posterior dislocation also can be caused by a direct blow to the anterior shoulder or by a fall on a forward-flexed extremity.
A instabilidade posterior é mais frequente em qual situação?
Recurrent posterior subluxation, atraumatic or acquired as a result of repetitive microtrauma, is much more common than recurrence after a traumatic posterior dislocation.
Qual é o tratamento inicial para pacientes com luxação posterior recorrente?
The initial treatment of posterior shoulder instability should be nonoperative. The regimen includes having the patient avoid provocative activities and educating the patient to avoid specific voluntary maneuvers that would cause the posterior subluxation. A strengthening exercise program aimed at the external rotators and posterior deltoid is carried out. Normal motion also should be obtained. Most patients with posterior instability respond to an aggressive exercise program, especially patients with generalized ligamentous laxity and instability occurring as a result of repetitive microtrauma. If at least 4 to 6 months of an appropriate rehabilitation program has failed, if habitual dislocation has been ruled out, and if the patient is emotionally stable, surgery may be indicated if the pain and instability preclude adequate function of the involved shoulder.
Qual o tratamento cirurgico para instabilidade posterior?
Treatment of posterior instability is approached the same as anterior instability by restoring the anatomy and tensioning the capsule appropriately. If surgery is required for a disabling posterior subluxation or if posterior is the most significant plane in a multidirectional instability syndrome, the procedure that we have found most successful is the inferior capsular shift procedure through a posterior approach.