وخرد جان خداوند وخرد بنام جان خداوند بنام

• A hundred times every A hundred times every day ,I remained myself day ,I remained myself that my inner and that my inner and outer life are based on outer life are based on the labors of other the labors of other men living and men living and dead,and that I must dead,and that I must exert myself in order exert myself in order to give in the same to give in the same measure as I have measure as I have received.received.

ALBERT EINSTEIN ALBERT EINSTEIN

Painful shoulderPainful shoulder

Dr.H.SaremiDr.H.Saremi

Orthopaedic surgeon, Hand and Shoulder fellowshipOrthopaedic surgeon, Hand and Shoulder fellowship

Hamedan university of medical sciencesHamedan university of medical sciences

Besat HospitalBesat Hospital

ShoulderShoulder

• 4jonts4jonts• The least stable jointThe least stable joint

HistoryHistory

• AgeAge• SexSex

Pain(character,onset,location,aggravating Pain(character,onset,location,aggravating factors,factors,

Factors that alleviate pain)Factors that alleviate pain)

AGEAGE

• Instability more common in youthful yearsInstability more common in youthful years• Slap lesion,biceps tendinitis ----younger than Slap lesion,biceps tendinitis ----younger than

30y30y• Calcific tendinitis---------middle age of womenCalcific tendinitis---------middle age of women• Cuff tear arthropathy-----mid70sCuff tear arthropathy-----mid70s

SEXSEX

• 3 conditions have a significantly higher 3 conditions have a significantly higher prevalence in femaleprevalence in female

• 1.multy directional shoulder instability1.multy directional shoulder instability• 2.adhesive capsulitis2.adhesive capsulitis• 3.cuff arthropathy3.cuff arthropathy

• History(pain,restrictedROM,instabiliHistory(pain,restrictedROM,instability)ty)

• PH.EX(CD)PH.EX(CD)

Impingement syndromImpingement syndrom

Impingement syndromImpingement syndrom

• Painful arc signPainful arc sign• Positive howkin’s sign and jobe testPositive howkin’s sign and jobe test• Non operative treatment Non operative treatment • Operative treatment(arthroscopic)Operative treatment(arthroscopic)

Rotator cuff tearRotator cuff tear• Progressive pain and weaknessProgressive pain and weakness• Restriction of ROMRestriction of ROM• May be an aging process(30-50% cadavr)May be an aging process(30-50% cadavr)• Partial or fullthicknessPartial or fullthickness• Non operative treatment Non operative treatment • Poerative treatment(arthroscopic)Poerative treatment(arthroscopic)• Rotator cuff arthropathyRotator cuff arthropathy

Frozen Frozen shoulder(adhessive shoulder(adhessive

capsulitis)capsulitis)• Restricted active and passive motionRestricted active and passive motion• Idiopathic(DM,IHD,cervical Idiopathic(DM,IHD,cervical

discopathyimmmobilizationhyperthyroidism,discopathyimmmobilizationhyperthyroidism,stroke,Mistroke,Mi

• Secondary(trauma,shoulder surgery)Secondary(trauma,shoulder surgery)• Pain and restrictedROM(Int .R,Flex,ext.Rot)Pain and restrictedROM(Int .R,Flex,ext.Rot)• Pain,Stiffness,ThawingPain,Stiffness,Thawing• Non operative treatmentNon operative treatment• Operative treatment(arthroscopic release)Operative treatment(arthroscopic release)

Calcific tendinitisCalcific tendinitis

• Site of diminished blood suply(1.5-2 cm to Site of diminished blood suply(1.5-2 cm to insertion of supraspinatus)insertion of supraspinatus)

• >30y/o>30y/o• W>MW>M• Precalcification stagePrecalcification stage• Calcification stageCalcification stagePhase of formationPhase of formationResting phaseResting phaseResorptive phaseResorptive phase• Post calcification phasePost calcification phase

Calcific tendinitisCalcific tendinitis

• Non operative treatmentNon operative treatment• Operative treatment(arthroscopic)Operative treatment(arthroscopic)

Biceps tendinitisBiceps tendinitis

Biceps tendinitisBiceps tendinitis

• >30-40 years>30-40 years• Pain during flx and supination of Pain during flx and supination of

elbowelbow• Non operative treatmentNon operative treatment• Operative treatmentOperative treatment• RUPTURERUPTURE

Trauma to shoulderTrauma to shoulder

Fx of the clavicleFx of the clavicle

Most common fx in childrenMost common fx in children

mechanismmechanism

N.V damageN.V damage

OpenOpen

Skin irritationSkin irritation

1/3 distal1/3 distal

>2cm over riding>2cm over riding

Fliale shoulder Fliale shoulder

ComplicationsComplications

N.V damageN.V damage

Non unionNon union

malunionmalunion

AC dislocationAC dislocation

• MechanismMechanism• ClassificationClassification• treatmenttreatment

Ac dislocationAc dislocation

Sc dislocationSc dislocation

• AnteriorAnterior• posteriorposterior

Scapular fxScapular fx

• GlenoidGlenoid• BodyBody

Glenohumeral Glenohumeral dislocationdislocation

• More than 90% anteriorMore than 90% anterior• Abd,ext.RotAbd,ext.Rot• PH.exPH.ex• ComplicationComplication• TreatmentTreatment• Post oppPost opp

Posterior dislocationPosterior dislocation

• Not obvious in Ap viewNot obvious in Ap view• Abd,Int.rotAbd,Int.rot• Following seizure and Following seizure and

electroctutationelectroctutation

Posterior dislocationPosterior dislocation

Fx arround the shoulderFx arround the shoulder

• Greater and lesser tuberosityGreater and lesser tuberosity• Surgical and anatomical neckSurgical and anatomical neck• shaftshaft

AP-LAT scapular viewAP-LAT scapular view

Axillary viewAxillary view

Neer classificationNeer classification