Introduction to Surgery of the Shoulder

Question 1

Why is Shoulder Pain Important?

• … most common MSK consultation in GP practice
• …% adults each year visit GP with shoulder pain
• …% of adults self reported prevalence of shoulder pain

Answer 1

• 3rd most common MSK consultation in GP practice
• 1% adults each year visit GP with shoulder pain
• 25% of adults self reported prevalence of shoulder pain

Question 2

Shoulder pain is the … most common MSK consultation in GP practice

Answer 2

Shoulder pain is the 3rd most common MSK consultation in GP practice

Question 3

What % of adults each year visit GP with shoulder pain?

Answer 3

1% adults each year visit GP with shoulder pain

Question 4

What % of adults self reported prevalence of shoulder pain?

Answer 4

25% of adults self reported prevalence of shoulder pain

Question 5

Common Shoulder Symptoms

Answer 5

• Pain
• Stiffness
• Weakness
• Instability

Question 6

The shoulder is an Inherently … Joint

Answer 6

The shoulder is an Inherently unstable Joint

Question 7

Glenohumeral Joint Stability

• Static stabilisers - C… and L
• Dynamic stabilisers - … … Muscles

Answer 7

• Static stabilisers - Capsule and Labrum
• Dynamic stabilisers - Rotator Cuff Muscles

Question 8

What are these muscles called?

Answer 8

Rotator cuff muscles (named based on position on scapula)

Question 9

Anterior shoulder - … (rotator cuff muscle) - internal rotation

Answer 9

Anterior shoulder - subscapularis (rotator cuff muscle) - internal rotation

Question 10

Posterior shoulder - …, …, … (rotator cuff muscles) - external rotation

Answer 10

Posterior shoulder - Supraspinatus, Infraspinatus, Teres minor (rotator cuff muscles) - external rotation

Question 11

Rotator cuff muscles - Tendon - attachment to bones

Answer 11

Question 12

Rotator Cuff Biomechanics

• Rotator cuff - work in … couples
• Not working - one of their roles keeps head … against glenoid, deltoid and pec cause instability type force on humeral head

Answer 12

• Rotator cuff - work in force couples
• A force couple is a system that exerts a resultant movement, but no resultant force. Two equal and opposite forces exert a purely rotation force. In the shoulder the body is the humeral head and the equal but opposite forces are the rotator cuff muscles.
• Not working - one of their roles keeps head pressed against glenoid, deltoid and pec cause instability type force on humeral head

Question 13

Rotator Cuff Role

• Stabilise the … Joint
• Provide a … for power muscles to move arm

Answer 13

• Stabilise the Glenohumeral Joint
• Provide a FULCRUM for power muscles to move arm

Question 14

Superficial ‘Power’ Muscles include

Answer 14

• Deltoid
• Pec major

Question 15

Risk Factors for Shoulder Pain

• … related injuries
• … injuries
• … conditions
• … related conditions

Answer 15

• Sports related injuries
• Traumatic injuries
• Degenerative conditions
• Work related conditions

Question 16

Causes of Shoulder Pain

• … space
  
  • Can get … arthritis, Rotator cuff …, calcific …

Answer 16

• Subacromial space - region underneath the acromion and humeral head - rotator cuff tendon reside
  
  • Can get ACJ arthritis, Rotator cuff tears, calcific tendonitis

Question 17

Subacromial region

Answer 17

can cause shoulder pain

Question 18

Subacromial Impingement

• Is it Common?
• Pain on … & … of arm
• Felt over …
• Cause:
  
  • Extrinsic
    
    • … spurs
  • Intrinsic:
    
    • …/… weakness

Answer 18

• Common
• Pain on abduction & rotation of arm
• Felt over deltoid
• Cause:
  
  • Extrinsic
    
    • Bony spurs
  • Intrinsic:
    
    • Tendinopathy/cuff weakness

Question 19

Treatment for Subacromial Impingement

• Non surgical
  
  • … modification
  • …therapy
• Surgical
  
  • Subacromial …
    
    • … of bony and soft tissue impinging areas

Answer 19

• Non surgical
  
  • Activity modification
  • Physiotherapy
• Surgical
  
  • Subacromial decompression
    
    • Debridement of bony and soft tissue impinging areas

Question 20

Subacromial decompression is an operation on your shoulder which treats a condition called shoulder …

Answer 20

Subacromial decompression is an operation on your shoulder which treats a condition called shoulder impingement

Question 21

An … is a type of keyhole surgery used to diagnose and treat problems with joints.

Answer 21

An arthroscopy is a type of keyhole surgery used to diagnose and treat problems with joints.

Question 22

Rotator Cuff Tears

• Most common - …/…
• Weakness & Pain
• Tendon … is normal
• …% in 60’s have a full thickness tear
• Repair if …

Answer 22

• Most common - supraspinatus/infraspinatus
• Weakness & Pain
• Tendon degeneration is normal
• 15% in 60’s have a full thickness tear
• Repair if symptomatic

Question 23

Most common Rotator cuff tears in which muscles?

Answer 23

supraspinatus/infraspinatus

Question 24

Rotator cuff tears present with … and …

Answer 24

weakness and pain

Question 25

Rotator cuff tears - ...% in 60’s have a full thickness tear

Answer 25

**15**% in 60’s have a full thickness tear

Question 26

_Glenohumeral Joint Problems_ * O.. * I... * ... shoulder

Answer 26

* **Osteoarthritis** * **Instability** * **Frozen shoulder**

Question 27

_Glenohumeral Arthritis_ * O.. * R.. Arthritis * Post ... arthritis

Answer 27

* **Osteoarthritis** * **Rheumatoid** Arthritis * Post **traumatic** arthritis

Question 28

_Symptoms of Arthritis - Shoulder_ * S... * C.. & g... * Pain at ... and at ... * Pain with ...

Answer 28

* **Stiffness** * **Crepitus & grinding** * **Pain at rest and at night** * Pain with **activity**

Question 29

Rotator cuff arthritis

Answer 29

Rotator cuff tear arthropathy is a type of shoulder arthritis that can develop after a massive and prolonged rotator cuff tear.

Question 30

_Rotator Cuff Tear Arthritis - 68yo retired nurse_

Answer 30

Question 31

Shoulder arthritis treatment is a shoulder ...

Answer 31

Shoulder arthritis treatment is a shoulder **replacement**

Question 32

_Shoulder replacement_ * Anatomic * Fulcrum for power muscles provided by ... ... * Reversed * Creates a ... fulcrum for power muscles

Answer 32

* Anatomic * Fulcrum for power muscles provided by **rotator cuff** * Reversed * Creates a **mechanical** fulcrum for power muscles

Question 33

_Frozen Shoulder - Adhesive Capsulitis_ * Pathology = ... thickened ... * Presents with ... and Pain, Loss of ... motion (EXTERNAL ROTATION) * X ray ... * Most common in ...-... years old * More common in ... * Especially common in D...

Answer 33

* Pathology = **Inflamed** thickened **capsule** * Presents with **Stiffness** and Pain, Loss of **PASSIVE** motion (EXTERNAL ROTATION) * X ray **normal** * **40-60** years old * More common in **Females** * Especially common in **Diabetics**

Question 34

_Frozen Shoulder Treatment_ * Non-... * Natural history is to resolve over ... years * Injections * Hydro... * If fails - Surgical * ... release and manipulation

Answer 34

* Non **surgical** * Natural history is to resolve over **2** years * Injections * **Hydrodilatation** * If fails - Surgical * **Capsular** release and manipulation

Question 35

Arthroscopic capsular release is a surgical procedure to improve movement in the shoulder. A stiff shoulder may sometimes be called a '... shoulder';

Answer 35

Arthroscopic capsular release is a surgical procedure to improve movement in the shoulder. A stiff shoulder may sometimes be called a '**frozen** shoulder';

Question 36

_Shoulder Instability_ * ...% anterior dislocations * ... age = higher chance of recurrence * Anterior labral tear (bankart lesion) * Risk factors * ... sports * Hyper...

Answer 36

* **95**% anterior dislocations * **Younger** age = higher chance of recurrence * Anterior labral tear (bankart lesion) * Risk factors * **Collision** sports * **Hyperlaxity**

Question 37

95% of shoulder dislocations are ... dislocations

Answer 37

95% of shoulder dislocations are **anterior** dislocations

Question 38

... age = higher chance of recurrence of shoulder dislocation

Answer 38

**Younger** age = higher chance of recurrence of shoulder dislocation

Question 39

_Surgical Treatment for Shoulder Dislocation_ * ... stabilisation - labral repair * Open stabilisation - ... tightening * Bony procedures - augmenting ...

Answer 39

* **Arthroscopic** stabilisation - labral repair * Open stabilisation - **capsule** tightening * Bony procedures - augmenting **glenoid**

Question 40

_Arthroscopic stabilisation (key hole)_

Answer 40

Question 41

_Traumatic Conditions - Shoulder_ * Bony Trauma * F... * D... * Soft Tissue Trauma * ... Problems * Pec ... Rupture

Answer 41

* Bony Trauma * **Fractures** * **Dislocations** * Soft Tissue Trauma * **Biceps** Problems * Pec **Major** Rupture

Question 42

_Shoulder Trauma_

Answer 42

* Fractures * Dislocations * Soft tissue injuries

Question 43

_Proximal Humeral Fractures_

Answer 43

* Common * Nails for treatment, or plates, or non operative

Question 44

_Acromioclavicular Joint Dislocations_

Answer 44

* An AC joint separation, often called a shoulder separation, is a dislocation of the clavicle from the acromion. * Issues with Shoulder blade movement

Question 45

Anatomically, why is impingement of the supraspinatus tendon a common sports injury?

Answer 45

Shoulder impingement syndrome is the result of a vicious cycle of rubbing of the rotator cuff between your humerus and top outer edge of your shoulder. Supraspinatus tendinopathy is a common source of shoulder pain in athletes that participate in overhead sports