Anatomy, diagnosis and classification of sports injuries in the

shoulderMr. Nnamdi Obi

Specialist registrar

United Kingdom

Objectives

• Review anatomy of the shoulder

• Review history and examination

• Acute traumatic shoulder instability

Introduction

• Instability– Glenohumeral dislocation

• SLAP tears

– ACJ dislocation

30 YO male,Professional Rugby payer, first episode

Anatomy• Synovial ball and socket

joint

• Articular surface covered with hyaline cartilage

• Glenoid cavity deepened by labrum

• Articulations

Rotator cuff

• Supraspinatus

• Infraspinatus

• Teres Minor

• Subscapularis

Ligaments• Glenohumeral

– Superior Glenohumeral ligament– Middle Glenohumeral Ligament– Inferior Glenohumeral Ligament

• Shoulder girdle– Coraco clavicular– ACJ proper– Acromioclavicular

Biomechanics

Static restraints

•Glenoid labrum

•Articular version + conformity

•Glenohumeral ligaments

•Negative intra-articular pressure

Dynamic restraints

• Rotator cuff muscles

• Biceps tendon

• Scapular stabilizers

• Neuromuscular factors

History(Acute traumatic instability)

• Age• Mechanism

• Traumatic• Atraumatic

• Chronicity– Ease of dislocation

• Expectations• Return to play

Examination

• Acutely– Pain limits most– Pre and post axillary nerve function

• Sensory• Motor

• Delayed• Hyperlaxity – predisposing• Provocative tests• Labral pathology (SLAP tear)

Sulcus sign

Apprehension

Relocation test

• O’Brien’s

Labrum (SLAP)

• Load & Shift

Labrum

Special investigations

• Bones– Glenoid– Head humerus

• Soft tissues– Rotator cuff– Labrum

X Ray CT scan

Ultrasound – no labrumMRI

MRI arthrogram

CT arthrogram

Lateral radiographs• Posterior oblique scapular projection (“Neer lateral”, Neer 1970)

– Produces considerable image overlap• Transthoracic (Vastamaki and Solonen 1980)

– Image overlap• Axial (Warrick 1965)

– Requires shoulder abduction• Modified axial (Rockwood 1984)

– Some shoulder abduction• Velpeau lateral (Wallace and Hellier 1983)

– Patient needs to sit up• Apical oblique (Garth, Slappey and Ochs 1984)

J Bone Joint Surg [Br] l988;70-B:457-60.

This is posterior dislocationBut outlines glenoid and humeral head

Almost normal AP

Axial viewSmall Hills sachsAnterior glenoid Fine

Same patient Apical obliqueLarge Hills sachsBlunting anterior glenoid

- Plain x-ray

- CT

- CT recon

Bone loss

30 YO male, football, first episode

How long ?

Treatment

• MRI study– IR Labrum off glenoid– ER tension rests on glenoid

• Randomized 40 pts– Sling IR Vs ER– Recurrence

• IR 6/20, 30%• ER 0/20

J Shoulder Elbow Surg 2003;12: 413-15

JBJS – B VOL. 91-B, No. 7, JULY 2009

• Premise– Younger = recurrent instability = immobilize longer– Older = stiffness = mobilize sooner

• No benefit to immobilization in internal rotation > 1 week in pts under 30 yrs of age

• Age of less than thirty years at time of injury predicts increased recurrence.

• Best available evidence does show a clinical benefit to treatment in external rotation over conventional sling immobilization, but this advantage did not reach significance

• BUT most ITOI

J Bone Joint Surg Am. 2010;92:2924-33

Take Home

• Reduce• Sling comfort

• Discard in 1 week• Physiotherapy, strengthen dynamic stabilizers

• Under 30 years, continue contact sport• Counsel recurrence rate• Consider surgery following first dislocation

SLAP Lesions• May be associated with

dislocation but commonly due to pull on the arm, weightlifting, throwing, tackling

• Symptoms – clicking, pain with overhead activities

• Clinically – pain with eccentric biceps loading (e.g. going down on bench press)

SLAP lesion classification

Acromioclavicular joint (ACJ) injuries

• Usually injured by a direct fall onto the point of the shoulder

• Scapular forced downwards

• Clinically, lateral end of clavicle prominent

30 YO rugby player again

Classification of ACJ Injuries (Rockwood)

Treatment

• Non Operative– Grade 1-3

• Operative– Grade 4-6

Conclusions

• Acute instability common in athletes– Glenohumeral– ACJ

• High level of function

• Early return to play

• Axillary or modified axillary view– Apical oblique

References

• Websites:– https://www.shoulderdoc.co.uk– https://www.orthobullets.com

The End

Email: njco@hotmail.com