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Download PTP 521 Musculoskeletal Diseases and Disorders Spring/Summer 2012 Musculoskeletal Diseases and Disorders: Shoulder Girdle Complex

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  • PTP 521 Musculoskeletal Diseases and Disorders Spring/Summer 2012 Musculoskeletal Diseases and Disorders: Shoulder Girdle Complex
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  • Objectives By the end of this presentation, students will be able to: Identify common bone presentation on radiographs Identify common positions for radiographic shoulder studies Differentiate between an MRI, CT, and US of the Shoulder Discuss common fractures of the clavicle, scapula, and humerus Discuss necessary information to obtain on a surgical history to assist in clinical decisions for patients with post operative shoulder conditions 2
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  • Epidemiological Data According to the Centers for Disease Control and Prevention: Nearly 1.5 million Americans went to ER for shoulder injury in 2006 3
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  • Anatomy Review Joints of the shoulder Girdle Acromioclavicular Sternoclavicular Scapulothoracic Glenohumeral 4
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  • AcromioClavicular Joint AP view Alignment: distal clavicle aligns with the acromian Joint should be less than 6 mm wide Bone density: check distal end for any fractures or osteophytes Cartilage and Soft Tissue: not evaluated with this view 5
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  • Radiographic Imaging: AP View Anteroposterior positioning View position of humerus in relation to the glenoid cavity Clavicle to the acromion 6
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  • Three views: Internal Rotation External Rotation Neutral What anatomy do you see on the internal differently from external and neutral? What parts of the scapula overlap the humeral head. It helps to know the position of the arm when you review shoulder radiographs. You really have to keep the shoulder Anatomy in mind. These are all normal (no pathology) views. 7
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  • Anterior Posterior View of GH joint Search Strategy A: alignment B: bone density C: cartilage space S: soft tissue 8
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  • Radiographs: Anterior Posterior External Rotation View Humerus is in external rotation View position of humerus in relation to the glenoid cavity Clavicle to the acromion Exposes the greater tuberosity more than the lesser tuberosity 9
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  • Alignment: Relationship of the humeral head to the glenoid Is there an overlap by more than 7-8 mm between the superior portion of the humeral head and the inferior surface of the acromian? Rotator cuff tear: < 7 mm may indicate a subluxation of the humeral head through rotator cuff muscles into the acromian 10
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  • Bone Density Look for consistent trabecular lines Consistent cancellous patterns in both the humeral head and the glenoid Are there areas of increased or decreased density? Snow cap indicating avascular necrosis 11
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  • Cartilage Normal cartilage: Soft Tissue: May want to assess lung as well as the soft tissue that might be seen around the glenoid and humeral head 12
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  • Scapular Y view Position of the humerus in relation to the glenoid, acromian and coracoid process True lateral view of the scapula http://www.e- lder_scapula_normal_lateral.jpg 13
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  • Lateral View or Transcapular View Alignment: position of the humeral head within the Y Humeral head should be within the notch 14
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  • ALSO Called: Anterior Oblique: Scapular Lateral (Y) view So, many names, same view This is important when determining shoulder dislocations. Look for the humeral head to be outside the notch, posterior to or anterior to the Y when the shoulder is dislocated 15
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  • eye sign The eye sign is just posterior to the glenoid. If this eye is not present, the anterior glenoid edge will be obliqued by the superior or inferior glenoid edge - which may mask severe defects that only a properly aligned axillary view will reveal. If the "eye" is not seen on the axillary view, this shot should be redone. This view may also show decreased joint space, fractures, osteophytes, dislocations, Hill Sachs and reverse Hill Sachs Lesions. 16
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  • Axial Shoulder Difficult view as it requires the patient to be in abduction. Patient sitting, arm in abduction, film cassette below joint. X-ray beam directed from superior to inferior at an angle of 5-10 dg toward the elbow. image.asp?Image=6102-001.jpg&Film=6102&Features=1 17
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  • Variations of the Axillary View: Lawrence View Arm abducted to 90 dg Patient supine Beam directed inferior to superior with angulation medial and superior through the axilla West Point View Arm abducted to 90 dg Patient prone Film against the superior aspect of the shoulder Beam directed inferior to superior angled toward the axilla ~ 25 dg in frontal plane and ~ 25 dg posterior to joint. 18
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  • West Point View Similar to an Axillary view, patient is prone instead of supine Determine glenoid fractures 19
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  • CT Scans MRI have virtually replaced them Will still see them taken to have a reformatted view of a shoulder fracture Also common to use CT scan to determine if a patient will have a total shoulder or Reverse total shoulder surgery 20
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  • CT Scan of the Shoulder CT scan of a normal shoulder. For surgeons to consider replacement surgery, the glenoid bone should be at least 2 cm in depth 21
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  • Dysplasia of the shoulder Posterior aspect of the glenoid did not develop well 22
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  • Bankart Lesion Lesions of the glenoid fossa Erosion of the glenoid 23
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  • Arthroscopic Positioning 24
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  • MRI of the Shoulder through the posterior portal 25
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  • MRI Images Coronal Oblique Infraspinatus muscle and tendon Supraspinatus muscle and tendon Acromioclavicular joint Acromion Glenohumeral joint Subacromial/subdeltoid bursa Labrum superior and inferior portions fat suppressed T2 wt images and proton density weighted images 26
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  • MRI Images soft tissue around the shoulder joint Deltoid Tendon 27
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  • Sagittal View T1-weighted view. 1. Coracobrachialis muscle 2. Subscapularis muscle and tendon. 3. Humeral head. 4. Coracoid process 5. Deltoid muscle (Anterior part). 6. Coracoacromial ligament. 7. Acromion. 8. Supraspinatus tendon. 9. Infraspinatus tendon. 10. Deltoid muscle (Posterior part). 28
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  • Rotator Interval Triangular space coracoid process coming between the subscapularis and supraspinatus muscles and tendons. Floor of the rotator cuff interval is the cartilage of the humeral head Roof of the rotator cuff interval is the rotator interval capsule, which links the subscapularis and supraspinatus tendons and is composed of two layers: the CHL on the bursal side and the fasciculus obliquus on the articular side. Fig. 1. Drawing, according to Gohlke et al. of rotator cuff interval in sagittal plane, with superior capsular complex (in green), bridging subscapularis tendon (SSC), superior glenohumeral ligament (SGHL), and long portion of biceps tendon (LPB) and passing beneath deep fibers of supraspinatus (SSP). (Courtesy of F. Gohlke, Wuerzburg, Germany) 29
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  • Axial View Axial T2-weighted FATSAT view. (mid shoulder) 1. Deltoid muscle (Anterior part). 2. Biceps tendon, long head. 3. Coracobrachialis muscle. 4. Subscapularis muscle and tendon. 5. Glenoid. 6. Humeral head. 7. Infraspinatus muscle. 8. Deltoid muscle. 30
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  • Ultrasound 31
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  • Shoulder Pain: 32
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  • Fractures of the shoulder girdle complex Clavicle: 75% occur in children under 13 Proximal fracture Rare, differentiate from epiphyseal injuries Middle Third fracture- Most common, 80% Usually displaced upward by pull of the sternocleidomastoid muscle Distal fracture Displaced downward by the weight of the arm. 33
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  • MOI: Fall on the lateral aspect of the shoulder Fall on outstretched arm (FOOSH) 34
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  • RX: Arm sling For the first 1-2 weeks To support the weight of the arm. Figure of eight Figure of eight bandage, intent is to reduce the motion at the fracture site. Worn for a period of at least 6 weeks (adults) or 4 weeks (child). Can use the arm as wanted & symptoms allow. 35
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  • Scapular Fractures 1% of all fractures High energy: fall or direct blow Associated Injuries Ipsilateral rib fractures Pulmonary trauma Clavicular fractures Brachial plexus injuries Subclavian artery injuries Classified according to location 36
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