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 Please call/text any questions about my patients .