orthopedics 5th year, 2nd lecture (dr. ariwan)

Shoulder Shoulder instabilityinstability Shoulder stability depends on Shoulder stability depends on

((muscular, ligamentous, bonymuscular, ligamentous, bony) factors.) factors.

Chronic instability may cause recurrent Chronic instability may cause recurrent dislocationdislocation or or subluxationsubluxation..

95% are anterior; others are posterior or 95% are anterior; others are posterior or multidirectional.multidirectional.

Recurrent Anterior Recurrent Anterior Shoulder DislocationShoulder Dislocation

Recurrent anterior dislocation Recurrent anterior dislocation caused by minimal daily activities caused by minimal daily activities (abduction, external rotation).(abduction, external rotation).

PathologyPathology Usually follow traumatic anterior Usually follow traumatic anterior

dislocation.dislocation. Glenoid labrum and capsule are Glenoid labrum and capsule are

avulsed anteriorely (avulsed anteriorely (BANKART BANKART LESIONLESION).).

Stretched capsule anteriorely.Stretched capsule anteriorely. Indentation on the posterolateral Indentation on the posterolateral

surface of the femoral head (surface of the femoral head (HILL-HILL-SACHS LESIONSACHS LESION).).

Clinical featuresClinical features Usually the patient is a young man.Usually the patient is a young man.

Previous history of acute dislocation Previous history of acute dislocation that’s reduced and immobilized for a that’s reduced and immobilized for a period; others have no traumatic period; others have no traumatic dislocation.dislocation.

Minimal daily activities which put the Minimal daily activities which put the arm in abduction, extension, external arm in abduction, extension, external rotation easily dislocate the joint rotation easily dislocate the joint (Throwing a ball, Serving at tennis, (Throwing a ball, Serving at tennis, Swimming).Swimming).

ExaminationExamination

At dislocationAt dislocation {Arm held by the other {Arm held by the other hand, flattened lateral shoulder, and hand, flattened lateral shoulder, and bulging of humeral head anteriorely}.bulging of humeral head anteriorely}.

Between attacksBetween attacks { {Apprehension Apprehension test,test, Drawer testDrawer test, , Test for ligament Test for ligament laxitylaxity}.}.

InvestigationsInvestigations Clinical DiagnosesClinical Diagnoses

Plain X-rayPlain X-ray: : AP- in internal AP- in internal rotation rotation Hill-Sachs lesion. Hill-Sachs lesion.

CT- scanCT- scan shows bony defect or shows bony defect or laberal avulsion.laberal avulsion.

ArthroscopyArthroscopy: show laberal tear & : show laberal tear & for treatment.for treatment.

TreatmentTreatment ConservativeConservative:: If infrequent, If infrequent,

modification of activities.modification of activities. Operative:Operative: Frequent painful Frequent painful

dislocation or subluxation:dislocation or subluxation:

1.1. BANKART OPERATION:BANKART OPERATION: reattachment of avulsed labrum and reattachment of avulsed labrum and capsule anteriorely (open or capsule anteriorely (open or arthroscopic).arthroscopic).

1.1. PUTTI- PLATT OPERATION:PUTTI- PLATT OPERATION: shortening the capsule and shortening the capsule and subscapulares by an overlapping subscapulares by an overlapping repair (double breast).repair (double breast).

2.2. BRISTOW OPERATION:BRISTOW OPERATION: Re- Re- attaches the tip of coracoid process attaches the tip of coracoid process and attached muscles to glenoid and attached muscles to glenoid anteriorely.anteriorely.

Orthopedic Problems of The Orthopedic Problems of The ElbowElbow

Congenital radial head Congenital radial head dislocationdislocation

1.1. Usually Usually bilateral,bilateral, part of other part of other

congenital anomalies.congenital anomalies.2.2. Lump Lump present in front of the joint, present in front of the joint,

limit elbow flexion.limit elbow flexion.3.3. Commonly Commonly function function is not severely is not severely

affected.affected.

X-rayX-ray shoes dome shaped radial shoes dome shaped radial head.head.

If sever limitation of elbow flexion If sever limitation of elbow flexion excise radial head after skeletal excise radial head after skeletal maturity.maturity.

Cubitus Varus ( Gun- Stock Cubitus Varus ( Gun- Stock Deformity)Deformity)

The forearm deviated medially over The forearm deviated medially over the arm.the arm.

Deformity most obvious when the Deformity most obvious when the elbow extended and the am elbow extended and the am abducted by the sideabducted by the side..

Most common cause is Most common cause is malunited malunited supracondylar facturesupracondylar facture in in childhood.childhood.

Most of the time function is not Most of the time function is not affected.affected.

If severe correct it by If severe correct it by supracondylar valgus Osteotomysupracondylar valgus Osteotomy (lateral closing wedge).(lateral closing wedge).