Instability of glenohumeral joint

Learning Objectives What is?Who gets?What types?How does manifest ?How do we investigate ?How do we treat? Definition / Anatomy Incidence Acute / Chronic Hystory / Physical exam Investigation Treatment

What is ? Definition Part of the shoulder joint complex 1. Scapulo thoracic joint 2. Acromio-clavicular joint 3. Gleno humeral joint 4. sterno-clavicular joint

What is ? Anatomy Bony structuresAnterior view

What is ? Anatomy Glenoid labrum Lateral view of glenoid Torn Labrum Bankart lesion

What is ? Anatomy Capsule and glenohumeral ligaments CapsuleAnterior glenohumeral ligaments- superior- middle - inferior

What is? AnatomyMuscles Dynamic stabilisation factors

What is ? Anatomy Other important structures

What is? Pathological AnatomyBankart lesion Capsule damageHill-Sachs indentation fracture of the humeral head

Who gets it ? Incidence / Epidemiology

The most commonly dislocated joint

U.K. 12.3 per 100.000 people

Approximately 2% of people dislocate their shoulder at some time

98% are anterior and inferior

What types? Acute dislocations

History - mechanism of injury - degree of trauma- first-time or recurrent

Assessment - neurologic function - vascular insufficiency

What types? Acute dislocations Anterior inferior dislocation ( 98% ) Epaulette appearance as the humeral head displaces anteriorly and inferiorlyPatients arm :30 deg adduction Internal rotated

How do we investigate ? Investigation Radiography - in two planes ( pre / post reduction ) - to confirm dislocation / reduction - to exclude fracture humeral head

How do we reduce? Reduction Reduction - preferable in hospital - patients comfortable ( analgesia / sedation ) Hippocrates Kochers

What after? Post reduction treatment No consensus regarding post reduction treatment

Young patients early immobilisation ( 7-10 days ) active physiotherapy

Older age group no immoblisation active physiotherapy

What types? Recurrent dislocation Classification Degree - subluxation ( dead arm syndrome ) - dislocation 2. Direction - anterior ( vast majority ) - posterior - multidirectional ( inferior and ant/post ) 3.Underlying cause - traumatic - atraumatic

4. Volition - voluntary

What types? Recurrent dislocation TUBSAMBRI TraumaticUnidirectionalBankart lesion Surgery AtraumaticMultidirectionalRehabilitation Inferior capsule repair

What types? Recurrent dislocations Assessment History - more complex - start with first episode - keep in mind TUBS -v- AMBRI

Assessment - check general joint laxity- Apprehension test - Drawer test ( anterior / posterior ) - Sulcus sign ( Multidirectional instab. )

How do we treat? Treatment Non operative treatment Most small / medium sized chronic tears

Anti-inflamatory medication ( NSAIDs )

Strengthening exercises

Physiotherapy

How do we investigate ? Investigation Radiography - standard in two planes ( ? Hill-Sachs lesion)

CT / MRI studies - beneficial with Artrography

CT - Hill-Sachs lesions - Glenoid fractures

MRI - labral lesions ( Bankart )

Arthroscopy - many centres = Gold standard

How do we treat ? Treatment Non-operative management Directed to - atraumatic, - volunatry

Addressing the imbalance between internal / external rotation

Muscle strengthening - deltoid, rotator cuff

How do we treat ? Treatment Operative management Aim of surgery Return to pre-injury level of activity Indicated when Rehabilitation has failed

Surgery correct anatomic defects ( Bankart procedure ) realign muscle actions Arthroscopic / Open procedure

Bony architecture accounts for its tendency to dislocate It is a ball and socket articulation with glenoid covering 1/3 of the humeral articular surfaceThe capsule of glenohumeral joint is attached around the margin of th ehumeral head and glenoid articular surfacecs, except inferiorly where is attached between 1 and 2 cm below the articular margin. It is thickned anteriorly to form the superior, middle and inferior glenohumeral ligamnetThe contribution of girdle muscles to the joint stability is not clear. ( testing the joint under supra-scapular block paralising the supra spinatus and infraspinatus, with no differencem implying that muscles are not important in stability ) It has however been sugested that the biceps tendon is important ( cadaveric studies ) Fractures associated with the acute dislocation : Hill-Sachs lesion osteochondral fracture of the humeral head- fractures of the greater tuberosity - fractures of the glenoid rim could give permanent instability - fractures ofFailure to closed reduction more likely to occur in longstanding dislocation- may occur in fracture-dislocation , when the fragment / soft tissue interposition between the humeral head and the glenoid- in a Hill-Sachs lesion , the humeral head is impossible to disimpact from the glenoid rim as a closed procedure

Sometimes need for open reduction !!!AMBRI group might be more difficult to differentiate from the history Often people with atraumatic dislocation childhood , check behavioral problems party trick= Does not respond well to surgery Apprehension test - patient seated / supine - arm 90 deg ABDuction & External rotated- aware not to dislocate - tendency to dislocate patient becomes apprehensive ( discomfort )

Drawer test - usefull in patients with a negative apprehension test - supine / seated , shoulder 80-120 degrees abduction, slight forward flexion and external rot.- examiner stabilses the scapula with one hand and with the other lifts the humeral head forward

Sulcus sign test - described by Neer and Foster ( 1980 )- gentle downward traction on th eupper limb , which is relaxed at the side in neutral position - positive = visible sulcus between the acromion and the humeral head- indicates Multidirectional instability