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David Limb
Consultant Orthopaedic Surgeon
Leeds Teaching Hospitals
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• Anatomy
• Variations of normal
• What happens with age
• Common problems
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Arm is connected to body viathe shoulder blade and collarbone
Humerus then forms a joint with theshoulder blade
Shoulder movement involves • the joint between the collarbone and chest• the joint between collarbone and shoulder blade• the ‘joint’ between shoulder blade and chest• the joint between humerus and shoulder blade
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Shoulder blade is suspended by muscles
26 muscles cross the shoulder joint
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• ‘shoulder’ joint unusual – socket is mostly soft tissues• Trade off of stability to allow maximum mobility
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CuffDeltoid
Shoulder movement involves balanced couples
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Rotator cuff provides fulcrum in otherwise ‘unstable’ joint
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Infraspinatus
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Subscapularis
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Supraspinatus
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Clinical examination good enough to direct non-operative treatment
Often need imaging before surgical treatment
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Investigations
Ultrasound
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MRI Arthroscopy
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Problems - Impingement
• Arthroscopic subacromial decompression• 700% increase in UK over last 10 years• Paracetamol for the shoulder headache
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Rotator cuff ‘tears’
Prevalence • about 50% in their 50’s have partial tears• about 1 in 3 in 70’s have full thickness tears• about 50% in 80’s have complete tears
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Rotator cuff repair with tissue anchors
• can be carried out arthroscopic or open
• anchors can be metallic or absorbable plastics
• 80% success rate in terms of pain relief and restoration of function• Rehabilitation to heavy use is 6 months• Up to 50% ‘fail’ within the first six months
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Dislocations
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Anterior dislocation
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Posterior dislocation
‘commonly’ missed
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Arthroscopic stabilisation
• employs suture anchors• metallic or absorbable• success rates catching up with open surgery
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Not dislocated!
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Ruptured long head of biceps tendon
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Shoulder injections
Steroid can cause painful reaction for several days Infection can first manifest as pain Fortunately infection extremely rare Adjunct to nonoperative treatment May inhibit healing of surgically repaired cuff tears
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Shoulder prostheses
Now well established in the treatment of shoulder arthritis and fractures
Survivorship comparable to hip and knee replacement
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Shoulder prostheses
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Shoulder prostheses
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Do we have the evidence?
In 2010 2 of largest grants ever were awarded in orthopaedics
Health technology assessment grants – Dept of Health
£2m – What is the place of surgery in rotator cuff disease£1m – What is the place of surgery in managing shoulder fractures
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Summary
In the normal shoulder there is a trade off of stability for mobility
There is a wide range of ‘normal’, even the anatomy
Very significant degenerative lesions occur with age
There is a very wide spectrum of outcome after treatment
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