14/04/2014
Overzicht
•
Hoe blijft dat balletje nu op die tee?
Functionele anatomie van het
glenohumerale gewricht
Prof Dr Nicole Pouliart, MD, PhD
Head of the Shoulder and elbow Unit
Professor of Anatomy
Een rondje anatomie
van
• Mediaal naar lateraal
• Superieur naar
inferieur
• Diep naar oppervlakkig
•
Spectrum van
pathologie
© Primal Interactive Shoulder, 2005
Glenoid bone loss

Burkhart & De Beer 2000, Piasecki 2009
Hill-Sachs

Burkhart & De Beer 2000
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Coracoacromial arch
Coracoacromial arch
Instability
group Impingement group Cuff tear group
Small & flat CAA
Small head
– Large & closed CAA
– Big head
– Intermediate CAA
– Intermediate head
Gagey, PC
Scapulothoracic dyskinesis
Capsuloligamentous structures
What we’ve been told
Folds
Arthroscopy

during arthoscopy folds in
anterior shoulder capsule
 indicate

middle (MGHL) and inferior
(IGHL) glenohumeral
ligament
 more prominent

in adduction (AD) and
internal rotation (IR)
 smoothed out

upon abduction (AB) and
external rotation (ER)
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Folds
Arthroscopy

Inferior glenohumeral ligament
complex
Arthroscopic bands
 correspond with histological reinforcements of capsule

= the ligaments after fine dissection?
 but are not ligaments themselves
Integration
Integration
IGHLC and MGHL
Anterior sling and ring
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Superior glenohumeral capsule :
Literature
Superior glenohumeral capsule
= Coracoglenohumeral ligament
SGHLC
SGHLC
4 main types


10% absent
PSGHL
27% very small
or absent gap
 > confluent
SGHLC
 34 – 46 mm

20% small gap

43% broad gap

Rarely absent or
very thin
anterior limb

Humeral insertion
 Thru lateral circular band
 on anterior
biceps gutter
(Anterior limb)
 on posterior part
of greater tubercle
(Posterior limb)
= Transverse band = Rotator cable



Delimits “rotator crescent”
Continues into fasciculus obliquus anteriorly
Folds SGHLC
Folds SGHLC
Arthroscopy
Dissection of AS markers
Folds in superior
aspect of joint
 Anterosuperior


Taut in adduction
and external rotation
Folded in internal
rotation
 Posterosuperior


Taut in adduction
and internal rotation
Folded in external
rotation
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Integration
Folds SGHLC
Superior ring and sling
Dissection
Superior capsuloligamento-tendinous unit
Rotator cuff - ultrastructure

Five layers
1.
2.
3.
4.
5.
Superficial fibres CHL
Parallel tendon fibres in large
bundles
Less uniformly organised smaller
fibre bundles
Perpendicular large collagen
fibres (rotator cable)
Capsular layer with randomly
organised fibres
Burkhart SS,
1992 & 1993
LHB from pulley to glenoid
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Labrum
•
Periarticular fiber system
Anchors capsuloligamentous complex
 Ring around glenoid anchoring CLC


•
Esp in inferior part
In ¼ capsule not on labrum
Concavity-compression
 Seal for vacuum effect (>negative IAP)
 Chock-block
•
Conforming glenoid and humeral spheres
Huber and Putz, A’scopy 1997
Di Giacomo and Pouliart, 2008
CLC: ultrastructure
Musculocapsuloligamentous complex
Integration
Chainmail of linked rings
Capsuloligamentous
complex
Chinese finger trap
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Anterior rotator cuff
Four quadrants
Anterosuperior
Posterosuperior
•
•
•
•
•
Supraspinatus and
Subscapularis
ADIR
Impingement
(Instability)
• ADER
• Impingement
• Instability
PSGHL
ISp
• SGHL-RCI-MGHL
• LHB – pulley – SSp
• (SSc)
Posteroinferior
• ABIR
• Instability
• (Impingement)
Anteroinferior
• ABER
• Instability
• (Impingement)
• PBIGHL
• Ter min
• MGHL–ABIGHL–FO
• SSc – Tric/LD
Anterosuperior
Anterosuperior - lateral
•
Anterosuperior - lateral
Anterosuperior - lateral
•
•
•
Subscapularis
HAGL
Partial thickness undersurface tear
supraspinatus
Biceps pulley lesions
 With/without partial subscapularis tear
• MGHL
• SGHL
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Rotator cuff interval
Anterosuperior - medial
•
Fraying anterosuperior
labrum
•
Lesion rotator cuff
interval
•
Often subtle instability
= too much anterosuperior
translation
RCI – MG + SG
SLAP II Subdivision
anterior (37%)
posterior (31%)
combined
anterior and posterior
(31%)
Morgan et al. 1998
Anterior - anteroinferior - medial
•
•
•
Recurrent dislocation
Subluxation
Minor instability
SLAP - Internal impingement
Peel-back mechanism
•
Posterior
extension of
SLAP Type II
lesion
•
Often
excessive
external
rotation in
abduction
 Dead arm syndrome
Burkhart website
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Posterior rotator cuff
Posterosuperior - medial
•
Fraying posterosuperior
labrum
•
Often posterior or
posteroinferior capsular
tightness
Infraspinatus and Teres minor
= too little anterosuperior
translation
+ forced posterosuperior
translation with ABER
•
w/wo PTS ISp
Posterosuperior - lateral
•
Posterosuperior - lateral
Partial
thickness
undersurface
tear
infraspinatus
•
PHAGL
•
Hill-Sachs
Posteroinferior -medial

Kim, Ascopy 2004
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