Musculoskeletal Diseases and
Disorders: Shoulder Girdle Complex
PTP 521
Musculoskeletal Diseases and Disorders
Spring/Summer 2012
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
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
Anatomy Review
• Joints of the shoulder
Girdle
–
–
–
–
Acromioclavicular
Sternoclavicular
Scapulothoracic
Glenohumeral
4
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
Radiographic Imaging: AP View
• Anteroposterior
positioning
• View position of
humerus in relation to
the glenoid cavity
• Clavicle to the acromion
6
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
emedicine.medscape.com/article/328253-overview
Anterior Posterior View of GH joint
Search Strategy
A: alignment
B: bone density
C: cartilage space
S: soft tissue
8
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
home.comcast.net/~wnor/radiographsul.htm
9
• Alignment:
• Rotator cuff tear: < 7
– Relationship of the
mm may indicate a
humeral head to the
subluxation of the
glenoid
humeral head
– Is there an overlap by
more than 7-8 mm
through rotator cuff
between the superior
muscles
into
the
portion of the humeral
acromian
head and the inferior
surface of the
acromian?
emedicine.medscape.com/article/1261152-overview 10
Bone Density
• Look for consistent
• Are there areas of
trabecular lines
increased or
decreased density?
• Consistent
– Snow cap indicating
cancellous patterns
avascular necrosis
in both the humeral
head and the glenoid
11
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
Scapular Y view
• Position of the humerus
in relation to the
glenoid, acromian and
coracoid process
• True lateral view of the
scapula
http://www.eradiography.net/technique/shoulder/Shou
lder_scapula_normal_lateral.jpg
13
Lateral View or Transcapular View
• Alignment: position
of the humeral head
within the Y
• Humeral head
should be within the
notch
cme.medscape.com/viewarticle/416588_2
14
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
www.rcsed.ac.uk/.../shoulder/overview.htm
15
“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
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.
http://classes.kumc.edu/som/radanatomy/
image.asp?Image=6102-001.jpg&Film=6102&Features=1
17
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
West Point View
• Similar to an Axillary
view, patient is prone
instead of supine
• Determine glenoid
fractures
19
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
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
www.bosshin.com/owners_manual_instability/
21
• Dysplasia of the
shoulder
• Posterior aspect of
the glenoid did not
develop well
www.bosshin.com/owners_manual_instability/
22
Lesions of the glenoid fossa
Bankart Lesion
Erosion of the glenoid
www.bosshin.com/owners_manual_instability/
23
Arthroscopic Positioning
24
• MRI of the
Shoulder through
the posterior portal
25
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
wheelessonline.com
26
MRI
• Images soft tissue
around the shoulder
joint
• Deltoid Tendon
stemcelldoc.wordpress.com/.../
27
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
Rotator Interval
• Triangular space
http://www.ajronline.org/cgi/content/full/184/5/1490
– 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
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.
www.info-radiologie.ch/shoulder-mri.php
30
Ultrasound
http://www.biij.org/2006/4/e58/e58.pdf
http://www.med.umich.edu/rad/muscskel/mskus/index.html
31
Shoulder Pain:
32
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
• MOI:
– Fall on the lateral aspect
of the shoulder
– Fall on outstretched arm
(FOOSH)
34
•
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
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
Scapula:
•
•
•
•
Type I: fractures of
scapular body 2
Type II: fractures of
apophyseal regions
including acromion and
coracoid process 3,4
Type III: fracture of
superolateral angle
including glenoid neck and
fossa 1
RX: generally minimal
treatment. Surgery only in
most drastic, displaced
fractures.
Donatelli RA, 1987
37
Scapular Fractures requiring surgery
• Acromion or scapular spine fractures with a
doward tilting of the lateral fragment and
subacromial narrowing
• Coracoid fractures that extend into the
glenoid fossa
• Glenoid rim and intra-articular glenoid
fractures associated with glenohumeral
instability
38
Rx of Scapular Fractures
• Sling 7-10 days
• Progressive regimen of pendulum and gentle
ROM exercises
• Progressive AROM and strengthening
exercises
39
Humeral Head Fractures
Fracture Dislocations
40
Proximal:
A. Greater Tuberosity
More commonly seen in older
individuals.
B. Lesser Tuberosity
Rare, usually avulsion fractures
C. Neck of the Humerus
Common fractures, transverse,
comminuted, impacted
D. Shaft of the Humerus
•
MOI: significant force applied
directly or indirectly to shoulder
region
•
Rx: depends upon the type of
fracture, age of the patient
41
Fractures Associated with Shoulder
Dislocations
Hill-Sachs lesion:
– depression fracture of
the posterior/lateral
humeral head.
– Area of soft cancellous
bone which is
compressed against the
glenoid rim.
– Occurs in 77% of
traumatic anterior
dislocations
http://www.athleticadvisor.com/Injuries/UE/S
houlder/shoulder_dislocation.htm
42
Bankart Lesion
– Defined as a detachment
of the labrum from the
glenoid rim
– occur in 87% of the
traumatic dislocations
– the most common
reason for recurrent
instabilities
www.sportsortho.co.uk/article.asp?article=86
43
• Quality of the Tissue
– Good tissue quality: heal
faster, less functional
issues
– Poor tissue quality: will
the repair hold, takes
longer to heal, more
functional deficits after
surgery
• Specifics of the Case:
– Did it involve the Biceps
Tendon or not?
– Removal of any bone?
– Other?
44
Rotator Cuff Dysfunction Resulting in
Impingement
• Key pathophysiological
factors
– Primary or secondary
impingement
– Tensile overload
– Macrotraumatic tendon
failure
– Posterior or
undersurface
impingement
• Key Muscles and Force
Couples
– Deltoid Rotator cuff
force couple
• Deltoid force:
• Rotator Cuff force:
– Trapezius and Serratus
anterior
– Anterior posterior
rotator cuff force couple
• Concavity-compression
mechanism
45
Rotator Cuff Impingement
• Primary Compressive Disease: Primary
Impingement
– Compression of rotator cuff tendons between the
humeral head and the overlying anterior third of the
acromion, coracoacromial ligament, coracoid or AC
joint
– Subacromial space
• Normals:
6mm-14mm
• Patients with shoulder pain:
7mm-13mm
46
Neer Classification
Stage I: characterized by edema, inflammation,
hemorrhage in the subacromial space. Swelling
is responsible for the impingement
– Risk Factors: age 25 or less
– SX: dull ache in the shoulder after activity, pain may
interfere with ADL’s
47
Signs: painful arc in abduction - between 60 and 120 dg, pain
free
– PROM, resisted tests are strong but painful for abduction
– Palpation: tender over the greater tuberosity and the anterior edge of
the acromian
– Special tests: + Neer impingement test, + Kennedy and Hawkins test.
– This stage is easy to reverse if the person rests from
aggravating activities and changes some work or play
postures, strengthens weak muscles
48
Stage II:
Characterized by aggravation of the subacromial
contents creating a thickness in the bursae and
fibrosis of the tendons.
• Risk Factors: 25 to 40 years of age
• SX and Signs: similar but increased in intensity
from Stage I
• Impairments: more limitation in the PROM and
with Hawkins and Kennedy test there is a
catching sensation with the return from an
elevated position.
• More difficult to reverse than Stage I
49
Stage III:
More complicated:
– get a partial or full thickness tendon tear,
– changes in the bony configuration of the humeral head
and acromion,
– osteophytes
• Risk Factor: 40 years of age or greater
• SX: increase in intensity of symptoms, interferes
with daily activities
• Signs: AROM more limited than PROM, resisted tests
show weakness in abduction and external rotation
50
• X-Rays: cystic changes in the greater tuberosity,
underside of the acromian or at the AC joint
• RX: surgery if conservative treatment doesn’t work.
Repair of the torn muscles would occur with all of the
surgical options.
• Surgical Options:
1. coracoacromial ligament resection
2. anterior acromioplasty
3. distal clavicle resection (Mumford
procedure)
4. AC joint inferior osteophyte resection
51
Mechanical Impingement:
• Abnormal shape of the
acromion.
• 3 types of acromion,
flat, curved and hooked.
• There is a close
association with a
hooked acromion (70%)
with full thickness
rotator cuff tears; 80%
association with
impingement syndrome
52
Secondary Compressive Disease
• Due to underlying instability of the GH joint
– Anterior instability – overhead athletes, throwing
athletes
– Increase in anterior translation, biceps tendon and
rotator cuff become impinged
– Continual loss of GH stability
– Leads to rotator cuff tears
53
Tensile Overload
• Repetitive intrinsic
tension overload
– Occurs during
deceleration and follow
through
– High load placed on
posterior rotator cuff
muscles
– Pathological changes of
angiofibroblastic
hyperplasia – early
tendon stages,
progresses to tears
• Tendinosis injuries
– Degenerative process
54
Macro traumatic Tendon Failure
• Single traumatic event
or a previous
traumatic event
• Forces are greater
than the tendon can
handle
• Normal tendons don’t
tear
• 30% damaged to
produce a substantial
reduction in strength
• Full thickness tears
• Bony avulsions
• May have had
repeated
microtraumatic insults
and degeneration over
time
• Failure over one heavy
load
55
Posterior impingement
• Undersurface
– In 90 dg of abduction
and 90 dg of Ext
rotation
– Supraspinatus tendon
and infraspinatus
tendon rotate
posteriorly and get
pinched between the
humeral head and the
posterior-superior
glenoid rim
56
• Add anterior translation of the
humeral head causes
mechanical fraying on
undersurface of the rotator
cuff tendons
• Halbrecht et al studied
baseball pitchers with MRI of
shoulder
• Paley et al studied 41
professional throwing athletes
– all had this problem
57