Rudolf G. Hoellrich, MD 25th Annual Orthopedics & Sports Medicine Update December 2, 2017 Disclosure Information Presenter Rudolf G. Hoellrich, MD, has nothing to disclose Shoulder Instability: Case 1 HPI Physical Exam 16 year old male football Normal ROM player Normal strength Anterior dislocation Positive anterior shoulder during daily apprehension & doubles relocation test 2 subluxations since then Frequent “dead-arm” episodes Wants to play next year Imaging studies X-rays – instability series • AP • Axillary • Westpoint • Stryker notch MR arthrogram Preferred study for labral pathology Bankart lesion is found Treatment Options Nonsurgical • Physical therapy • Activity modification • Shoulder Harness • Injection? Surgical Arthroscopic Bankart repair Open Bankart repair Bankart Repair Shoulder Instability: Case 2 HPI Physical Exam 27 y/o male mill worker Reveals marked Traumatic dislocation apprehension and guarding Approximately 12 instability episodes Self-limited ROM since Normal strength and Reports hx of instability neuro exam in sleep and simple ADLs Failed PT Shoulder Instability: Case 2 Complex shoulder instability… CT scan with 3D reconstruction Glenoid and humeral bone loss Options? Shoulder Instability: Case 2 Surgery must address: Soft tissue injury Bone deficiency Surgical options: Coracoid transfer Iliac crest bone graft Osteochondral graft Case 3: Acute rotator cuff injury HPI Physical Exam 49 y/o right-hand Normal ROM dominant female + Impingement test Acute injury lifting Obvious weakness of compost 6 weeks ago rotator cuff on empty Pain at night can test Pain with reaching and repetitive ADLs Right arms feels “weak” Xrays Standard series: True AP Axillary SSOV MR Imaging Non-contrast MRI ordered Acute rotator cuff tear Recommended treatment: Rotator cuff repair Alternative options: NSAIDs Cortisone injection PT Case 4: Chronic cuff tear HPI Physical Exam 74 y/o male Popeye deformity Pain for 3 yrs Decreased AROM No specific injury Subacromial crepitus Global cuff weakness Imaging Xray shows superior migration of humeral head MRI shows massive cuff tear with atrophy Chronic cuff tear Non-repairable cuff tear Non-op treatment NSAIDs Cortisone injection PT Reverse TSA Case 5: low grade AC sprain HPI Physical Exam 19 y/o make Localized superior snowboarder shoulder pain and Fall onto shoulder swelling Normal strength and ROM Treatment Rest, ice, NSAIDS Sling for comfort Activity modification x 6 weeks PT program Injection? Case 6: High-Grade AC injury 47 year old female Prior grade 3 AC treated non-operatively Now has new fall injury Marked deformity, pain Grade 5 AC separation High grade AC injury Renders the shoulder complex unstable Pain Weakness Impingement Deformity AC Reconstruction Questions?.