Shoulder and Elbow

ORTHOPAEDIC SYPMPOSIUM APRIL 8, 2017

DANIEL DOTY MD Shoulder Articulations

— Glenohumeral Joint ¡ 2/3 total arc of motion ¡ Shallow Ball and Socket Joint ÷ Allows for excellent ROM ÷ Requires soft tissue to maintain reduction and function

— Scapulothoracic Articulation ¡ 1/3 total arc of motion ¡ No bony articulation ¡ Relies completely upon dynamic muscle function

— Acromioclavicular joint ¡ Links the upper limb to the axial skeleton ¡ Allows for some rotational motion of the clavicle during shoulder motion Glenohumeral Anatomy

— Scapula: 17 Muscle Attachments

¡ Body

¡ Acromion

¡ Glenoid Glenohumeral Anatomy

— Labrum: Circumferential cartilage ring ¡ Deepens socket by 50% ¡ Critical role in stability ¡ Tears can result in pain and/or instability Glenohumeral Anatomy

— Long Head of the Biceps Tendon ¡ Questionable role in glenohumeral stability ¡ Tendonitis/ tears can result in significant pain Glenohumeral Anatomy

— Glenohumeral Ligaments ¡ Static stabilizers ¡ Prevent instability at the extremes of motion ¡ Tears allow for instability ¡ Inflammation results in pain/stiffness Glenohumeral Anatomy

— Rotator Cuff ¡ 4 muscles: critical to active function and stability ¡ Dynamic stabilizers ¡ Center the humeral head in the glenoid throughout ROM ¡ Tears result in pain, weakness, varying degrees of dysfunction Shoulder

— Pathology typically affects multiple anatomic sites — A single problem can set off a chain reaction resulting in dysfunction throughout the shoulder girdle — Goals of treatment are to minimize pain while maintaining motion and function — Typically requires a concerted, multimodal effort by the physician, therapist, and patient to achieve a good result Glenohumeral Arthritis

— Destruction of Cartilage layer — Flattening of Humeral Head — Bone Spur/Osteophytes — Contracture of Anterior capsule — Loose Bodies — Rotator Cuff Intact Glenohumeral Arthritis

— Physical Exam Findings ¡ Painful ROM ¡ Limited PROM=AROM ¡ External Rotation Limited ¡ Crepitus ¡ Cuff testing typically 4/5 strength

Glenohumeral Osteoarthritis

— Nonoperative treatment ¡ Tylenol Arthritis ¡ NSAID’S ¡ Steroid Injections ¡ Activity Modification Glenohumeral Arthritis

— Surgical Treatment — Anatomic Total Shoulder Arthroplasty ¡ Typically utilized for arthropathy with rotator cuff intact Basics of Anatomic TSA

— Surgical approach ¡ Anteriorly between Deltoid and Pectoralis Major Muscles ¡ To Access the Shoulder Joint Subscapularis Must be Released Basics of Anatomic TSA

— Anterior Capsule is Released to allow for Ext Rot — Humeral Head and Glenoid are resurfaced — Long Head of Biceps Tendon tenodesed Basics of Anatomic TSA

— *Subscapularis is Repaired* Principles of Anatomic TSA Rehab

— Respect Subscapularis repair for 6 weeks ¡ Avoid aggressive External Rotation passive stretching ÷ Limit to ER may be set by the surgeon based on intraop findings ¡ Avoid resisted Internal Rotation

— Reinforce Patient Education and HEP

— Maintain Pain Control and Limit Inflammation Principles of Anatomic TSA Rehab

— Phase I: Immediate Postop – 2wk ¡ Sling at all times other than exercises ¡ Ice ¡ Exercises 3-6 times daily ÷ Straight arm hangs ÷ Pendulums ÷ Codmans ÷ NWB Elbow, Wrist, and Hand AROM as tolerated Principles of Anatomic TSA Rehab

— Phase II : 2-6 weeks postop ¡ Begin outpatient PT ¡ Goal to improve PROM ÷ Supine FE stretching ÷ IR ÷ Crossbody Adduction ÷ Extension ¡ Scapular Strengthening ÷ Shoulder Shrugs and Retraction ¡ Patient may use the arm for light ADL’s, bathing, eating, etc ¡ Sling while in public Principles of Anatomic TSA Rehab

— Phase III : 6weeks-3months ¡ Isometrics of RC transitioning into strengthening of ABD, FE, ER ¡ Increase resistance of shrugs, retraction, biceps and triceps ¡ Out of sling ¡ Encourage ADL’s ¡ Continue HEP Pitfalls Postop Anatomic TSA

— Subscapularis rupture ¡ Subscapularis is taken down and repaired in every case ÷ This is the limiting factor in post op rehab ¡ Poor tissue or repair can place at higher risk of rupture ¡ Passive external rotation places highest stress on the repair ÷ Gentle stretching in ER and nonresisted active internal rotation with limit set by surgeon is best method for the first 4-6 weeks until healing occurs Subscapularis Failure

¡ Signs of Subscapularis Failure ÷ Painful anterior shoulder “pop” ÷ Sudden increase in Passive External Rotation ÷ Decrease in Active Internal Rotation power

¡ Management ÷ Refer back to surgeon for evaluation as soon as possible ÷ Early ruptures may be repairable ÷ Chronic ruptures with poor function or instability can be treated with pectoralis transfer or reverse shoulder replacement Subscapularis Failure

— Typically results in poor outcome and may result in anterior instability and anterior superior escape Reverse Total Shoulder Arthroplasty

— FDA approved in US 2003 — Originally used for rotator cuff tear arthropathy — Indications have expanded rapidly and include cuff deficiency, proximal humerus fractures, revision with bone loss, chronic instability and some patterns of cuff intact arthritis

Reverse Total Shoulder Arthroplasty

— Creates a fixed fulcrum in the shoulder — Allows for a Constrained Joint: imparts stability despite lack of soft tissue restraints — Allows the Deltoid to power shoulder motion in the absence of a functional rotator cuff Rotator Cuff Deficient Shoulder

— Compression lost — Deltoid force results in sheer and superior translation Basics of Reverse Shoulder

— Typically performed through anterior approach — Often times done in the setting of a deficient subscapularis — Subscapularis repair/no repair has not been shown to impact the outcome — The operative arm will be lengthened after the procedure and the deltoid will be stretched Reverse Shoulder Rehab

— Rehabilitation is similar to that of anatomic TSA but typically at an accelerated pace because there is not a need to protect the subscapularis — Focus is to maintain Passive range of motion and strengthen the deltoid for forward flexion and abduction — Retraining to allow for ADL’s — Patients often have difficulty with active external rotation due to loss of posterior rotator cuff Pitfalls of Reverse Shoulder Arthroplasty

— Periprosthetic fractures ¡ Fall prevention ¡ If good bony fixation is achieved at surgery patients can use the implant with a walker — Dislocation ¡ Despite constraint, instability can be a problem for reverse ¡ Avoid extension, internal rotation, adduction and axial load ÷ Typical position is reaching behind to push up out of bed or a chair or unfastening a bra — Acromial Stress Fractures ¡ Increased stress on acromion due to deltoid tension ¡ Pt will have point tenderness to acromion ¡ Treatment is to hold therapy and rest in a sling Reverse for Revision, Fracture, Nonunion

— Rehab may be slower for these situations versus RCTA — Fractures: Goal is to limit stiffness while protecting repaired tuberosities ¡ 67 y M s/p bicycle crash with right proximal humerus fracture Reverse for Nonunion

• 67 yo F with a Nonoperatively treated proximal humerus fracture nonunion Elbow Basics

— General Elbow Principles ¡ Normal Arc of motion is 0-145 ¡ “Functional Arc of motion is 30-130, 45-45 pronation/ supination ¡ Post traumatic elbow tends to lose extension ¡ Position of stability is flexion and pronation Elbow Basics

— Active motion compresses the joint and typically improves stability — Passive motion can distract the joint — Supine active elbow flexion and extension is a good method to avoid distraction and work on motion — Work on Pronation and Supination with the elbow flexed to 90 degrees — Work on Flexion and Extension with the forearm in neutral or pronation — Avoid coupled extension and supination in the early recovery period Elbow Case

— 30 yo F falls from 3 feet landing on outstretched arm

Radial Head Shear fracture and coronoid tip fracture indicate a fracture dislocation Elbow Case

Intraop pivot shift test indicating rupture of the lateral ligaments resulting in posterolateral rotatory instability

— Repair Radial Head — Repair lateral ligament complex Postop Management

— Splint for 1 week — Ice, elevate, limit swelling — Begin ROM after 1 week ¡ Supine Active flexion and extension with forearm in neutral ¡ Pronation/Supination active and passive with elbow flexed to 90 degrees ¡ Avoid supination and full extension ¡ If needed limit extension to 30 degrees for first 3 weeks — Light ADL’s at 6-8 weeks postop — Activity as tolerated 3 months Thank You

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