shoulder

Definition

Instability in at least 2 planes

- postero-inferior

- antero-inferior

- antero-postero-inferior

Epidemiology

Recognised as a common problem 

- often misdiagnosed

Most patients athletic

Definition

A GH dislocation which has been missed for a significant period of time

- time period is arbitary

- > 3-6 weeks

Pathology

Humerus soft and osteoporotic

Significant soft tissue contractures

1.  Anterior / subcoracoid dislocation

Beware

- scarring to NV structures

- RC tears including SSC, especially > 40

Epidemiology

Traumatic initial cause in 95%

M:F 2:1

Age of initial dislocation inversely related to recurrence rate

- patients younger than 20 have a redislocation rate of 90%

- between 20 - 40 years, redislocation rate of 60%

- patients > 40 years have a 10% rate of dislocation but a higher rate of cuff tears (up to 40% in patients > 60yrs)

Anatomy & Stability

1. Passive Stabilisers

Epidemiology

Most common form of shoulder instability

- young males 

- M:F = 2:1

Aetiology

Indirect ER and abduction moment on arm

- disruption of anterior stabilisers

History

Initial injury

- severe pain in shoulder

Definition 

Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 

Epidemiology

2% incidence

- 40 - 60 years

- Women 2:1

Sedentary workers

- Non-dominant limb

Bilateral in 10 - 40%

Aetiology

Epidemiology

Much less common than hip OA

- usually presents late

Aetiology

Similar causes as hip (AS IT GRIPS 3C)

Alcohol / Steroid / Trauma / Idiopathic

Gauchers

RA / RTx

Sickle Cell 

Position

1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape

Issues

Rotator cuff

- often deficient

Bone stock

- often deficient

Glenoid

- often posterior version 

Management

Options

1.  TSR

Indications

- cuff intact

Indications

Indications have narrowed

- due to success of shoulder arthroplasty

1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

General Principles

All possible length should be preserved consistent with clinical judgement

- function of amputated stumps decrease progressively with each higher level of amputation 

- prosthetic rejection by patient increases with the more proximal amputations

- most ADL'S can be performed adequately with one limb, so don't use prosthesis

- all nerves are drawn distally into wound & sectioned so they retract well proximally to bone level of amputation