David Limb

Consultant Orthopaedic Surgeon

Leeds Teaching Hospitals

• Anatomy

• Variations of normal

• What happens with age

• Common problems

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

Shoulder blade is suspended by muscles

26 muscles cross the shoulder joint

• ‘shoulder’ joint unusual – socket is mostly soft tissues• Trade off of stability to allow maximum mobility

CuffDeltoid

Shoulder movement involves balanced couples

Rotator cuff provides fulcrum in otherwise ‘unstable’ joint

Infraspinatus

Subscapularis

Supraspinatus

Clinical examination good enough to direct non-operative treatment

Often need imaging before surgical treatment

Investigations

Ultrasound

MRI Arthroscopy

Problems - Impingement

• Arthroscopic subacromial decompression• 700% increase in UK over last 10 years• Paracetamol for the shoulder headache

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

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

Dislocations

Anterior dislocation

Posterior dislocation

‘commonly’ missed

Arthroscopic stabilisation

• employs suture anchors• metallic or absorbable• success rates catching up with open surgery

Not dislocated!

Ruptured long head of biceps tendon

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

Shoulder prostheses

Now well established in the treatment of shoulder arthritis and fractures

Survivorship comparable to hip and knee replacement

Shoulder prostheses

Shoulder prostheses

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

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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