advances in the surgical management of the shoulder

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“Diagnostic Ultrasound Imaging for Shoulder Problems”

Presented by: Lisa Hackett (Briggs) – Clinical Sonographer

Will commence LIVE from Sydney, Australia at 8pm AEST

Andrew Ellis BSc (Ex. Sci), M. Phty

World Health Webinars CEO

World Health Webinars Host

Physiotherapist Sydney CBD

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Lisa Hackett (Briggs)

• Experienced Musculoskeletal specialist in ultrasound imaging

• Works exclusively with Professor George Murrell an Orthopaedic Surgeon specialising in shoulders at Kogarah, Dr Jeni Saunders and Dr Justin Paoloni in Sports Medicine and Dr Irwin Lim in Rheumatology

• Presented at National and International levels

• Actively involved in the ASA and SIG as a committee member and encourages education in ultrasound imaging

• Actively involved in research and had co-authored numerous peer viewed papers published in the AAOS, BJSM and authored her published paper on Shoulder Imaging in 2011 in the Journal of Orthopaedic Surgery in Shoulder and Elbow Surgery

Clinical Sonographer

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Diagnostic Ultrasound Imaging

for shoulder problems

Introduction

Pathology, examination, important ultrasound findings and treatment of:

• Impingement

• Rotator cuff tears

• Frozen shoulder

• Calcific tendinitis

• AC joint pain

• Arthritis

Demographics

Impingement

Rotator cuff tear #1

Demographics

Instability

#2

Demographics

Frozen

shoulder #3

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Demographics

#4 A-C joint

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Demographics

Arthritis #5

Patient Age

Young patient • Instability, AC joint separation

Middle-aged patient • Impingement syndrome, rotator cuff tears,

adhesive capsulitis

Older patient • Rotator cuff tears, degenerative arthritis

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Impingement

Bursa and rotator cuff impinge between humeral head and acromion

Pain often radiates down arm to elbow

Impingement

Triggering impingement

Rotator cuff tendinopathy

Excessive overhead activities

Hooked anterior acromion

Overuse

+ impingement sign

Tendinopathy

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Function of the Rotator Cuff

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Malfunction of the Rotator Cuff

Pain

With overhead activities

Pain

At night

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Stress

Heat

Shock

Proteins

APOPTOSIS

Tendinopathy Tendon

Degeneration Tear

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Diagnosing rotator cuff tears

Loss in Power

External

Rotation


Loss in Power

Supraspinatus


Impingement

in ER


or in IR

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•All positive

98% Rotator Cuff Tear

Lancet, 2001

•2 positive

98% Rotator Cuff Tear

> 60 years

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•1 positive

Need further imaging

•0 positive

R/O rotator cuff tear

X Lancet, 2001

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Treatment - Impingement

Ultrasound guided injections

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Treatment - Impingement

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Acromioplasty Rotator cuff tears

Full thickness tears (FTT)

Partial thickness tears (PTT)

• Bursal surface

• Under surface (articular surface)

• Intrasubstance

Rotator cuff tears

Full-thickness tears • Do not heal

Information needed from ultrasound:

• Size: AP and ML

• Distance from biceps

• If massive: muscle atrophy?

Full thickness tear

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Full thickness tear Supraspinatus muscle belly

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Rotator cuff tears

Partial-thickness tears

Info needed from ultrasound:

• Bursal sided?

• Undersurface/Articular sided?

• Intersubstance?

• Percentage of tendon thickness?

• >50% need repair

• <50% conservative or acromioplasty

Rotator cuff tears

Partial thickness tear

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Rotator Cuff Tear

Open repair

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Arthroscopic Rotator Cuff Repair Arthroscopic Knotted

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Arthroscopic Knotless

0%

20%

40%

60%

80%

100%

120%

Open Knotted Knotless

Procedure

Perc

en

tag

eRe-tear

Intact

**

6 months

**

2 years

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Anchor/suture demonstration

Rotator cuff arthropathy

Develops slowly over time after massive cuff tear

Superior migration of humeral head

Rotator cuff arthropathy

Hemi-arthroplasty

Reversed shoulder prosthesis

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Calcific tendinitis

a condition that causes the formation of a small, usually about 1-2 centimeter size, calcium deposit within the tendons of the rotator cuff.

usually found in patients at least 30-40 years old

Cause?: degeneration and hypovascularity of the tendon play a role

calcium deposits are not always painful

they may resolve

Evolution of calcific tendinitis

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Calcific Tendinitis

Calcific Tendinitis Instability

Gleno-humeral Ligaments

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Gleno-humeral Ligaments

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Apprehension sign

Augmentation sign PREVIEW ONLY


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Relocation sign

Bankart

lesion

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Frozen shoulder

Adhesive capsulitis

Typically 40-65 yrs old

Female>male; left>right shoulder

Capsule becomes very thick and stiff

Frozen shoulder

Cause?

Idiopathic

More common in diabetes

More common following (minor) shoulder trauma/ immobilisation

Frozen shoulder

Self-limiting

Whole process takes 2-2.5 years

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Frozen shoulder

Manipulation Under Anaesthesia

Frozen shoulder

Capsular release

Frozen shoulder

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Day 1

AC joint

pain

R L

Paxinos Sign = AC joint

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AC Joint Pain

Blair et al, 1996

AC joint

Long head of biceps rupture Biceps Brachii Long Head

Tendon rupture at M/T Junction

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Summary

Rotator Cuff Tear

Summary U/S findings

Full or partial thickness?

• Percentage of tendon thickness

• Bursal/undersurface/intersubstance

Size

Distance from biceps

Muscle atrophy ? if big tear

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Summary

O’Brien’s

Sign

= SLAP

Summary

Apprehension sign

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Summary Acknowledgements

Prof GAC Murrell

St George Hospital/South East Health

National Day Surgery - Sydney

GE Healthcare

ArthroCare

www.ori.org.au

Live Q & A With Lisa Briggs

Facebook, Twitter, LinkedIn, Google +

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Coming up next week

Live Q & A

With Lisa Briggs

Thank you

From Lisa Briggs

&

World Health Webinars Australia / NZ

http://worldhealthwebinars.com.au

advances in the surgical management of the shoulder

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