Transcript Presentation1 2012 February Dr Mofokeng Res 1 Feb

Dr Khahliso Mofokeng
25 February 2012
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24 year old midfield soccer player.
C/O left shoulder pain of sudden onset.
Fell on his left shoulder following a tackle.
2nd episode according to him.
Similar incident a year ago.
Sent for an X-Ray and anterior shoulder
dislocation confirmed.
Without fracture.
Successful closed reduction was done.
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In a couple of weeks he resumed his play.
No other history of note.
O/E
Healthy looking and in pain.
Tramadol 50mg po stat.
Reduced ROM left shoulder joint esp. internal rotation.
Neurovascular intact.
Prominent left acromion process.
Differential Diagnoses
Shoulder dislocation/subluxation/Humeral fracture.
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X-Ray
showed
anterior
left
shoulder
dislocation without any fracture.
Closed reduction done to alleviate pain.
Left arm supported in a sling.
Orthopaedic appointment arranged.
MRI confirmed Bankart lesion and no HillSachs lesion.
No sport activity until properly treated.
In 10 days open Bankart repair performed.
Return to play in 3 months following
rehabilitation.
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Biologically the player is bothered by this
recurrent shoulder dislocation with its pain.
Psychologically the player is worried that his
arm might be permanently disabled so
reducing his chances of playing sport.
Socially his main concern is loss of income as
a result of this injury since he is the sole
breadwinner at home.
Epidemiology
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Occurs frequently in athletes with peaks in
the 2nd & 6th decades.
98% of traumatic cases are anterior.
dislocations.
2% posterior.
Trauma contributes about 95% of primary
shoulder dislocations.
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5% atraumatic e.g. raising the arm or moving
during sleeping.
Primary dislocation complicates into recurrent
dislocation.
70% of those who have already dislocated are
likely to redislocate within two years.
Comparable incidence of primary shoulder
dislocation in young & old.
The incidence of recurrence is higher in younger
people.
Static shoulder restraints refer to the bony
ball and socket configuration of the shoulder
and the major soft tissues holding these
bones together.
 The soft tissues include the capsule, the
glenohumeral ligament and the glenoid
labrum.
 Dynamic shoulder restraints refer to the
neuromuscular system, plus proprioceptive
mechanisms & scapulohumeral muscles.
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Superior glenohumeral ligament (SGHL)
primarily
limits
anterior
and
inferior
translation of the adducted humerus.
 Middle
glenohumeral
ligament
(MGHL)
primarily limits anterior translation in the
lower and middle ranges of abduction.
 Inferior glenohumeral (IGHL) is the longest
and the strongest of the glenohumeral
ligaments.
 IGHL is the primary restraint against anterior,
posterior & inferior translations when the
humerus is abducted beyond 45 degrees.
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The labrum constitutes the fibrocartilagenous
rim of the glenoid.
 Inferiorly it is firmly attached to the glenoid,
although it may be loose and mobile
anterosuperiorly.
 The
labrum
increases
resistance
to
glenohumeral translation by up to 20%.
 The labrum provides attachment of the
glenohumeral ligaments anteriorly, and the
biceps tendon superiorly.
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Rotator cuff works in a combined synergistic
action to create a compressive force at the
glenohumeral
joint
during
shoulder
movement.
 The biceps assist the rotator cuff in creating
glenohumeral joint compression.
 Synchronous scapular rotation and humeral
elevation is prerequisite for obtaining optimal
alignment of the glenoid fossa and humeral
head.
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Scapulothoracic muscles serve to stabilize the
scapula to the thorax since there are no
scapulothoracic ligamentous restraints.
 Stability of the scapula in relation to the moving
upper extremity provides a secure platform for
the glenohumeral articulation and action of
attaching humeral muscles.
 Proprioceptive mechanisms involving reflective
muscular action may protect against excessive
translations and rotations of the glenohumeral
joint.
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Mechanoreceptors (ruffinian and pacinian corpuscles)
within capsuloligamentous restraints of the shoulder
joint.
These specialized nerve endings relay afferent
information relating to joint position and joint motion
awareness (proprioception) to the central nervous
system.
The perceived sensation of shoulder joint position and
movement is likely to play an important role in
coordinating muscular tone and control.
It has been suggested that joint instability secondary to
trauma may be associated with a decrease in
proprioceptive reflexes and thus a predisposition to
subsequent reinjury.
The most common mechanism of anterior
shoulder dislocation has been described as
forced external rotation and abduction of the
humerus e.g. basketball player.
 Others include a fall onto outstretched arm
and direct force application to the posterior
aspect of the humeral head.
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The most significant in terms of recurrent
instability are those associated with the
inferior glenohumeral ligament complex and
its attachment to the labrum and humerus.
 Bankart lesion (anterior labral detachment).
 Detachment of the anterior labrum and
plastic deformation of the capsule and
inferior glenohumeral ligament complex
contribute to increased anterior humeral
translation.
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The most common bony lesion associated
with traumatic glenohumeral instability is a
compression fracture at the posterolateral
margin of the humeral head.
 This occurs as the humeral head impacts into
the glenoid edge during dislocation .
 Hill Sach’s lesion contributes about 80% of
traumatic dislocations.
 Proprioceptive defects have been shown for
patients with traumatic anterior shoulder
dislocation.
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 The
high incidence of recurrent shoulder
dislocation in the adolescent population as
opposed to recurrence in those over 40 years of
age may be explained, in part, by the collagen
profile of the encapsulating shoulder tissues.
 Collagen is the major protein of ligaments and
tendons.
 Collagen type I versus III.
 Collagen III which is elastic is found in younger
individuals hence recurrent shoulder dislocation
in this age group.
 Collagen I which is non-elastic is found in those
over 40 years of age.
Minimal force required and is rare.
 Multidirectional and less associated with
Bankart lesion.
 Increase in humeral translation and decrease
in upward rotation of the glenoid fossa.
 Deficiency in the rotator cuff interval.
 Connective tissue abnormalities.
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 Chronic
stress associated with repetitive
overhead sports.
 Athletes doing throwing, volleyball and
tennis.
 Extreme external rotation with the humerus
abducted and extended in the horizontal
plane.
 Repetitive glenohumeral capsular overload
in this position of extreme range of motion
leads to gradual attenuation of the
anteroinferior static restraints, increased
glenohumeral translation and a continuum
of shoulder pathology.
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Primary Traumatic Ant Shoulder Dislocation
Shoulder immobilization 4 to 6 weeks.
High recurrence rate in younger athletes.
Lack of capsulolabral glenoid contact.
Activity restriction 6 to 8 weeks is associated
with better outcome.
Exercise rehabilitation program.
Strengthening of rotator cuff, deltoid &
scapular stabilizer muscles.
Shoulder strengthening & coordination
exercises.
 Rotator cuff and deltoid control glenohumeral
joint translation.
 Infraspinatus and teres minor strengthening
reduces anterior glenohumeral ligament
strain during throwing.
 Strengthening exercises for biceps brachii,
latissimus dorsi, pectoralis major and teres
major enhance stabilizing action of rotator
cuff muscles at the glenohumeral joint.
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1)Stabilizing scapulothoracic articulation:
 Isometric exercises and manual stabilization
techniques.
2)Restoring normal patterns of scapular muscle
activity:
 Upper extremity weight-bearing activities.
3)Maximizing scapulothoracic muscle strength
and endurance preparing for return to play.
 Resistance exercises, plyometric exercises
and sport-specific drills.
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Traumatic Unidirectional Instability
Reattach detached labrum and associated
glenohumeral ligaments with little disruption to
the length or attachment of other structures
around the shoulder (Bankart repair).
Open Bankart repair associated with a 12
degree loss of external rotation of the shoulder
secondary to shortening of the subscapularis
tendon during detachment-reattachment.
Redislocation rate 11%.
Reattach the labrum without an open incision
and without subscapularis detachment.
 Redislocation rate of 18%.
 Less loss in external rotation of the shoulder.
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Multidirectional Instability
Anterior capsular shift, an open procedure
involving overlaying and shortening of the
anterior and inferior capsule.
 Activity restriction and strict range of motion
control post-operatively.
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Similar principles as non-operative rehabilitation.
 Cryotherapy applied for 15 minutes every 1to 2
waking hours for the first 24 hours, and 4 to 6
times daily for 9 days reduces the frequency and
intensity of shoulder pain both at rest and during
rehabilitation.
 Activity restriction.
 Isometric, rotator cuff & humeral muscle strength
exercise.
 Scapulothoracic muscle retrainig.
 Proprioception (neuromuscular & cardiovascular)
for return to normal.
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Hayes K, Callanan M, Walton J, Paxinos A,
Murrell
GAC.
Shoulder
Instability:
Management and Rehabilitation. J of Orthop &
Sports Phys Ther. 2002;32(10):1-10.
Kogon PL. Hill-Sachs lesion – a complication
of glenohumeral joint dislocation. JCCA.
1988; 32 (2):89-90.
Shoulder dislocation if not treated properly at
the beginning can pose serious complications
leading to athlete frustration.
 Early referral can reduce shoulder dislocation
recurrence rate dramatically.
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I thank you all.
Dr Khahliso Mofokeng (082 455 3388)
e-mail: [email protected]