Shulder And Elbow

Front 1

Crank test

Back 1

Front 2

Relocation test

Back 2

Front 3

Inferior apprehension test

Back 3

This test was initially described by Feagin, and further refined by Itoi et al,16 who suggested the name ABIS (abduction inferior stability). For this test, the upper limb is held in abduction, with the patient's forearm resting on the examiner's shoulder. The examiner exerts downward pressure over the neck of the humerus. If the shoulder is unstable, the head will be pushed down, and a groove will appear; also, the patient may show apprehension (Fig. 7).

Front 4

SMC Knot

Back 4

FARE!!!!

Front 5

Sulcus test

Back 5

Front 6

Drawer tests

Back 6

Front 7

GAGEY test

Back 7

Front 8

PRESENT-DAY CLASSIFICATION OF ANTERIOR SHOULDER INSTABILITY

Back 8

Front 9

T.U.B.S.

Back 9

Traumatic Undirectional Bankart Surgery

Front 10

A.M.B.R.I.

Back 10

Atraumatic Multidirectional Bilateral Rehabilitation
Inferior Capsular shift

Front 11

A.I.O.S.

Back 11

Acquired Instability of Overstressed Shoulder

Front 12

“Distal mobility with proximal stability”

Back 12

F.W.Jobe1990
…..la mobilit‚à dell’omero si basa paradossalmente sulla stabilit‚ della
scapola……

Front 13

Stabilizzatori della spalla

Back 13

Stabilizzatori dinamici
Muscoli rotatori

Stabilizzatori statici
• Versione glenoidea
• Versione omerale
• Congruenza articolare
• Cercine
• Strutture capsulo-legamentose
• Pressione intra-articolare negativa

Front 14

Pressione intra-articolare negativa

Back 14

 Il peso del braccio ,che tende a sublussare inferiormente la testa omerale rispetto alla glenoide, € contrastato dalla pressione
negativa intracapsulare o effetto vuoto creato da uno spazio articolare sigillato.
 In una spalla con una capsula lassa o di volume articolare troppo grande (in basso a sinistra), la testa omerale pu traslare
inferiormente fino a quando la pressione negativa € sufficiente a contrastare l'ulteriore traslazione.
 In una spalla con lesione capsulare o difetto capsulare nell'intervallo dei rotatori, il volume del compartimento articolare trova uno
sbocco ed viene perso l'effetto vuoto. La testa omerale pu ora migrare inferiormente fino a che la tensione capsulare superiore
si oppone alla traslazione inferiore.

Front 15

TRATTAMENTO CONSERVATIVO DELL'INSTABILITA DI SPALLA

Back 15

E' bene che la seduta inizi (e finisca) con una massoterapia palpatoria atta a mettere in evidenza lo stato nel quale si
trovano le strutture teno-muscolari
 La rieducazione prosegue con la mobilizzazione passiva atta a ricentrare la testa omerale nella glena
 Seguir‚ la fase di rinforzo muscolare dapprima con contrazioni isometriche, in seguito se non c'€ dolore con contrazioni
concentriche/eccentriche. Durante il rinforzo va posta l'attenzione onde evitare lo stiramento eccessivo della parete
capsulare anteriore.
 Seguendo lo schema delle 3 PS, il recupero della forza parte dai ProtectorS e dai PivotorS per terminare in una fase
avanzata con il potenziamento dei PositionerS.

Successivamente si possono proporre esercizi propriocettivi come quelli di stabilizzazione ritmica (facendo chiudere gli occhi
al paziente).
 Quando il paziente avr€ "coscientizzato" la propria spalla e il suo corpo rispetto ad essa, potr€ seguire gli esercizi di
rinforzo, autogestirsi con elastici e/o pesi, sempre sotto la supervisione del terapista.
 Dopo il raggiungimento di una buona forza si pu‚ introdurre l'allenamento isocinetico per i rotatori di spalla con una
posizione del braccio prima a 30ƒ sul piano scapolare per poi progredire sul piano coronale fino a 45ƒ. Si utilizzano velocit€
angolari medie.
 Il paziente deve sapere quali sono i movimenti da non fare (lavori over head, sollevamenti di pesi elevati), le posture da
evitare e gli esercizi da fare di fronte ad episodi di insorgenza del dolore (ad esempio l'esercizio di Codman per detendere
muscoli periarticolari contratti e dolenti).

Front 16

I tre "PS" della spalla (instabilità) e i "power drivers"

(Disorders of the shoulder: diagnosis & management, Volume 1 Di Joseph P. Iannotti,Gerald R. Williams)

Back 16

GLENOHUMERAL PROTECTORS
I muscoli della cuffia dei rotatori.
vanno rinforzati dapprima in contrazione isometrica,
successivamente se non dolenti in contrazione isotonica ed isocinetica.
SCAPULOTHORACIC PIVOTORS
Muscoli rotatori della scapola. Il rinforzo di questi muscoli va iniziato da subito; gli esercizi sono rivolti al potenziamento di diversi
gruppi muscolari
HUMERAL POSITIONERS
Il rinforzo dei muscoli deltoide (tre capi, gran pettorale va introdotto nel programma dopo che le altre due PS sono state
adeguatamente potenziate

POWER DRIVERS
Gran pettorale e gran dorsale

Front 17

Innervazione Spalla

Back 17

"SCALDA"

Front 18

Paralysis of this NERVE will result in a marked drooping and down turning of the affected shoulder at rest because of the loss of the ability to elevate and upwardly rotate the scapula. The latter loss will also prevent the patient from abducting their arm above the horizontal (shoulder level).

Back 18

Accessory nerve - innervates the trapezius muscle.

Front 19

Any attempt to retract the scapula will be accompanied by a marked upward rotation of the shoulder because the rhomboideus can no oppose the upward rotation on the scapula exerted by the trapezius. The patient will have difficulty retracting the scapula against resistance on the affected side

Back 19

Dorsal Scapular nerve - innervates the rhomboideus muscles

Front 20

Active contraction of this muscle results in scapula protraction and upward rotation. When the scapula is passively protracted by action of the pectoralis major muscle on the humerus , the serratus anterior acts to stabilize the scapula and keep it applied to the thoracic wall. Such action occur when a boxer throws a jab or a cross. Paralysis of the serratus anterior prevents the scapula from moving smoothly across the thoracic wall resulting in a bowing out of the medial border of the scapula. This condition is called "winged" scapula. In addition, the ability to actively upwardly rotate the shoulder is diminished and the patient can not abduct the humerus above the horizontal.

Back 20

Long thoracic nerve - Innervates the serratus anterior muscle.

Front 21

Paralysis of this nerve will result is weakness of the rotator cuff muscles resulting in pain form impingement and an inability of the patient to begin shoulder abduction. Such patients tend to swing the affected limb away from their side in order to provide momentum to start abduction.

Back 21

Suprascapular nerve - innervates the supraspinatus and infraspinatus muscles.

Front 22

Since the deltoid plays a major role in movement of the glenohumeral joint, paralysis will cause a loss &/or weakness of most shoulder functions.

Back 22

Axillary nerve (ascellare) - innervates the deltoid and teres minor muscles

Front 23

Symptoms of deltoid paralysis

Back 23

A. loss or roundness to the shoulder and a very visible acromion process
B. inability to abduct the glenohumeral joint more than a few degrees away from the side.
C. inability to laterally rotate the humerus
D. weakened movements of glenohumeral flexion and extension
E. loss of sensation just below the point of the shoulder

Hint 23

"RADAR"

Back 24

AXILLARY NERVE

Front 25

Back 25

atrophy of supraspinatus and infraspinatus muscles and rhomboid muscles (white arrow); on the right: scapular tilting and rotation caused by serratus anterior muscle weakness (white arrow with *)

Front 26

Back 26

severe scapular winging caused by serratus anterior paralysis (white arrow)

Front 27

Back 27

atrophy of supraspinatus and infraspinatus muscles (white arrow), and trapezius muscle (white arrow with *) showing underlying rhomboid muscles

Front 28

Back 28

Severe atrophy of the deltoid muscle (white arrow) and moderate atrophy of the biceps brachii muscle (white arrow with *)

Front 29

Ultrasound Effect on Healing

Back 29

Regarding tendon healing
Induce an increased rate of collagen synthesis and improve collagen alignment at the healing.
May enhance healing properties of rotator cuff repair
By accelerating bone remodeling at the attachment site
By improving collagen synthesis and alignment at the attachment site or a combination of both mechanisms.

Front 30

Literature on Cuff Healing

Back 30

Healed cuffs do better
Harryman (JBJS 1991)
82% “Re-tear” (Walton 2004)
Healed cuffs stronger (Boileau 2004)
Only 43% heal if greater age 65 (Boileau)
If just SS > 89% healed
If SS+IS > 50% healed

Front 31

Collagen is Different in the Healing Area

Back 31

Galatz … J Ortho Res 2006
More Type III Collagen
Growth Factors Influence Healing
TGF-B (Transforming Growth Factor Beta)
Associated with
… scar and adhesions
… cell migration and angiogenisis
FGF (Fibroblast Growth Factor)
Repair site unorganized histologically and biomechanical inferior.

Front 32

Cuff: Debridement of the Tendon Edge?

Back 32

Immunochemistry shows no difference in procollage production near or away from tendon edge.

Front 33

Cuff: Bone: Abrade or Repair Tendon to Cortical Surface

Back 33

“No significant benefit from the creation of a trough to expose the tendon to cancellous bone or just repair to cortical bone in goats.
At both six and twelve weeks, the tendon-to-bone healing process of the two groups appeared similar
The biomechanical properties were approximately equal.

St Pierre … JBJS 1995

Front 34

Cuff: Footprint: “Double Row” Repair

Back 34

Suture anchor covers 67% of the footprint

Front 35

Cuff: Where is the best place to put a suture anchor?

Back 35

Articular margin
Tension band
Double Row

Front 36

Cuff: What to do with the bursa?

Back 36

Blood supply to cuff
Provides cells and vessels for healing
No inflammation in the bursa
? Other opinion
Ulthoff says bursa is good

Consider Incorporating Bursa into Repair

Front 37

Cuff: Acromioplasty

Back 37

Probably not necessary
Does not prevent future tears.
Preserve the arch

Front 38

How Soon After a Cuff Tear Should You Do a Repair?

Back 38

Coleman … Warren JBJS 2004

Early surgery should prevent muscle fat accumulation
and Muscle Contraction

Front 39

Back 39

James C. Esch, M.D.
Tri-City Orthopaedics
Oceanside, CA

Front 40

Back 40

Dr. Louis U. Bigliani
Chief, The Shoulder Service
Chairman, Dept. of Orthopaedic Surgery
Columbia University
College of Physicians and Surgeons
New York, New York

Front 41

Rotator Cuff Repair History:
1st repair

Back 41

1909

Front 42

Rotator Cuff Repair History: Harrison McLaughlin

Back 42

Etiology
Pathophysiology
Surgical repair
Results of 100 cases
JBJS 1944

Successful Repair
Tension free
Continuity of cuff
Smooth acromion
JBJS 1951

Front 43

Cuff: Open Results

Back 43

Pre Post
FE > 90° 109 (59%) 169 (91%)
ER > 30° 123 (66%) 173 (93%)

85% Good to Excellent results
87% patient satisfaction
3.2% complication rate

Front 44

Cuff. Why Switch from Open Repair?

Back 44

Deltoid detachment/ scarring
Early post-operative pain
Post-op stiffness
Longer incision
Longer rehabilitation

"CD FREDDO"

Front 45

Arthroscopic RCR: Current Results:Arthroscopic Repair of Supraspinatus

Back 45

Boileau, JBJS, June 2005
65 Patients- Tension Band Technique
Follow up Arthro CT (51), MRI (15)
60/65 patients (92%) Good to Excellent results
Healed 46/65 (71%)
Partial 3/65 (4%)
Retear 16/65 (25%)
Age > 65 10/23 (43%) Healed

Bishop, Flatow, et al ASES Open 2004
Cuff integrity by MRI, min 1 yr F/U
In tears > 3 cm:
Open 62% intact
Arthroscopic 24% intact

Front 46

Cuff: Factors That Affect Cuff Fixation

Back 46

From Bardana et al 2003

Front 47

Back 47

Ken Yamaguchi, MD

Marilyn and Sam Fox Distinguished,
Professor of Orthopedic Surgery
Chief, Shoulder & Elbow Service
Dept. of Orthopaedic Surgery
Barnes-Jewish Hospital
Washington University School of Med
St. Louis, MO

Front 48

Cuff: How strong does it need to be?

Back 48

Maximal
contraction:
270 - 300 N

Muscle force: 200-300 N
Suture load: 35-60 N
Anchor load: 70-120 N

Burkhart et al., Arthroscopy 1993, 2000

Front 49

Clavicle Fractures
Generic

Back 49

Front 50

Clavicle Fractures
Treatment

Back 50

Front 51

SC Joint Dislocation

Back 51

Front 52

AC Joint Separation
General and clasification

Back 52

Front 53

AC Joint Separation
Treatment

Back 53

Front 54

AC Joint Separation
Operative Techniques

Back 54

Front 55

AC Arthritis
General

Back 55

Front 56

AC Arthritis
Treatment

Back 56

Front 57

Distal Clavicle Osteolysis

Back 57