Transcript Shoulder Case Presentation: The Belly Flop Blues Ben Burkam, MD

Shoulder Case Presentation:
The Belly Flop Blues
Ben Burkam, MD
Summa Center for Sports Health
February 27, 2016
Questions
A volleyball player presents with right shoulder pain after
attempting to spike the ball in practice. The player is holding
her arm in slight abduction and external rotation. The humeral
head is palpated anteriorly. Before proceeding, it is important
to first evaluate which of the following?
A. Supraclavicular nerve by testing sensation over the clavical.
B. Axillary nerve by testing sensation over lateral aspect of the
shoulder.
C. Radial nerve by testing sensation over inferolateral arm.
D. Medial cutaneous nerve by testing sensation over medial aspect of
arm.
Questions
What is the estimated return to play timeline for a 1st time
anterior shoulder dislocation in a high school athlete?
4 weeks
12 weeks
16 weeks
24 weeks
Questions
What percent of 1st time anterior shoulder dislocations after
found to have a Bankart lesion on advanced imaging?
5%
50%
75%
90%
Case
28 yo female
L shoulder injury while jumping into the pool
Denies specific impact to wall or other person
Did have arms stretched out wide to do a “belly flop”
Immediate severe anterior shoulder pain
Denies previous shoulder injuries
No other pertinent PMHx
Possible injuries?
Rotator cuff strain
Anterior capsule sprain
Biceps tendon injury
Anterior glenohumeral dislocation
Anterior Dislocation
• First step in management?
– Reduction
• First step in management after reduction?
– Immobilization
• Duration of immobilization?
– Depends!
Learning Objectives
Reinforce basic shoulder anatomy and stabilizing structures of
the glenohumeral joint
Be familiar with the types of glenohumeral dislocations
Be able to manage or educate patients on most common
complications of dislocation
Be ready to discuss prognosis and return to play (RTP) after
shoulder injury
Basic anatomy
Shoulder Stabilizers
Muscular vs. Static
Types of dislocations
Anterior
Subcoracoid
• Accounts for 75%
Subglenoid
Subclavicular
Intrathoraic
Types of dislocations
Posterior
~2% of all dislocations
 Inferior (Luxatio erecta)
 Very rare
Complications of Anterior Dislocations
Bankart lesions – 90% of 1st time dislocations
Hill Sacs deformity – 66% of 1st time dislocations
Humeral fracture
SLAP lesion
Rotator cuff tear
Nerve injury
Vascular injury
Bankart lesion
Bony Bankart (~5%)
Soft tissue Bankart (up to 90%)
Hill-Sachs deformity
A humeral head compression fracture created by the glenoid
rim during dislocation
Humeral fracture
Most common fractures:
humeral head, neck, or greater tuberosity
May have less frequent recurrent instability than dislocations
that occur without fracture
SLAP lesion
SLAP is an acronym for “superior labral tear from anterior to
posterior”
Occurs in 5-7% of first time dislocations
Rotator Cuff Tear
Most commonly seen in patients >30 years of age at time of
injury
Nerve Injury
Axillary Nerve
Subscapular nerve
Radial
Musculocutaneous
Vascular injury
Axillary artery
Rare
More common with inferior dislocations
Reduction
Method for self reduction
Scapular rotation manuver
Check the Standard Operating
Procedure (SOP) with your
organization’s management / legal
representatives
Check with your licensing board
Outpatient Management
After reduction, follow up within 1 week with Sports
Medicine / Orthopedics
If no surgical indication:
Immobilization x 3 weeks for age <30
Immobilization x 1 week for age >30
Rehabilitation x 12 weeks
Full RTP estimated at ~16 weeks
Surgical Indications
Irreducible dislocation
Displaced greater tuberosity fractures
Bankart fractures that create glenohumeral instability
Fracture >20% of the inferior glenoid requires urgent orthopedic
referral
Prognosis
 Recurrent dislocation is primary concern for 1st time shoulder
dislocations
 Based on age of 1st dislocation event
 Open proximal humeral growth plate = ~99-100%
 Young adults (< age 30) = 55-90%
 Older adults (>age 30) = 5-10%
 Young adult option of arthroscopic intervention
 May reduce rate of subsequent dislocation for athletes in highly
demanding sports
Case Conclusion
Immobilization in sling and swathe x 3 weeks
Significant improvement in pain and ROM at 3 weeks
PT x 6 weeks
Follow up at 12 weeks with 90% improvement
Released to progressive return to full activity over 4 weeks
CAQ Test Question
A volleyball player presents with right shoulder pain after attempting
to spike the ball in practice. The player is holding her arm in slight
abduction and external rotation. The humeral head is palpated
anteriorly. Before proceeding, it is important to first evaluate which
of the following?
A. Supraclavicular nerve by testing sensation over the clavical.
B. Axillary nerve by testing sensation over lateral aspect of the
shoulder.
C. Radial nerve by testing sensation over inferolateral arm
D. Medial cutaneous nerve by testing sensation over medial aspect of
arm.
Questions?
Please write down any questions you may have, and save them
to be turned in for the panel discussion.
References
Arthroscopy. 1999 Jul-Aug;15(5):507-14. Prospective
randomized clinical trial comparing the effectiveness of
immediate arthroscopic stabilization versus immobilization and
rehabilitation in first traumatic anterior dislocations of the
shoulder.
Audience Response
Question 1
Question 2
Question 3