Conditions of the Shoulder Joint Flashcards
common conditions affecting the shoulder
- Osteochondritis dissecans (OCD)
- Luxation
> Congenital
> Traumatic - Medial instability
- Bicipital tenosynovitis
- Supraspinatus tendinopathy
- Contracture of the infraspinatus
*…
Osteochondritis dessicans
- what is this?
- pathogenesis
- Failure of endochondral ossification resulting in focal thickening and eventual failure of the articular cartilage
- excess pressure on articular surface > fibrous tissue formation
> release of necrotic tissue and inflammatory mediators
> formation of cartilage flap
> synovitis
Osteochondritis Dissecans - what joints is it found in and how commonly?
- which locations in the joints?
- Shoulder (frequent)
- Elbow (frequent)
- Hock (infrequent)
- Stifle (rare)
- Sacrum (rare)
<><><> - Specific locations in each joint: generally weight
bearing area - No other locations in dogs!
osteochondritis dessicans Pathophysiology in dogs
- where it hurts?
- signalment / age?
- bi vs unilateral?
- etiology?
- Insidious or acute lameness localized to the shoulder
- Large to giant dog breeds
- Young and rapidly growing
> 4-7 months (<1year) - Male-to-female ratio ~ 2:1
- Often Bilateral (uni/bilateral lameness)
<><><><>
Polyfactorial - Hereditary > Polygenic
- Dietary factors > Excessive energy, Excessive calcium
at what anatomic location do we see OCD in dogs?
Always caudal aspect of humeral head
osteochondrosis dessicans - Principles of Surgical Treatment - what do we do?
- Remove the cartilage flap(s)
- Freshen cartilage edges perpendicular to defect
- Stimulate fibrocartilage formation
> Curettage until bleeding
> Drilling (i.e., forage) - Remove joint mice
<><><><> - Hereditary: recommend spay
or neuter - Asymptomatic?
osteochondrosis dessicans surgery
- Postoperative Management
- Exercise restriction for 1-2 month
> Allows healing of the defect with
fibrocartilage
<><><><> - ± NSAIDs
- ± Disease modifying agents
OCD Postoperative Management prognosis
Prognosis: Good to excellent in 97% (shoulder)
* 75% not lame
* 22.5% minimal lameness
* 2.5% lame
<><><><>
* (Prognosis guarded for other locations)
Shoulder Luxation
- two ways it can arise, and what is more common?
- who is at risk?
- etiology?
- character of each?
Congenital (Most Frequent)
* Generally small breeds
* Multiple bone/soft tissue deformities
* Minor to No trauma
<><><><>
Traumatic (Rare)
* Often associated with violent chest trauma
* Significant pain and swelling
<><><><>
80% of all luxations are medial (18% are lateral)
is shoulder luxation generally medial or lateral
80% of all luxations are medial (18% are lateral)
Congenital shoulder Luxation
- is this a common type of luxation?
- how / why does it occur?
- when may it be diagnosed?
- MOST FREQUENT
- Laxity and stretching of joint capsule
- Sometimes bone malformation
- May be diagnosed late in life!
Congenital shoulder Luxation
- signs / symptoms
- reducible?
- Acute / Chronic lameness
- Shoulder muscles atrophy
- Minimal-Moderate pain
- Crepitation
- Abnormal landmarks
> Acromion and greater tubercle - May or may not be reducible
Traumatic shoulder Luxation
- signs, history
- reducible?
Acute non-weight bearing
* History of violent trauma
<><><><>
* SEVERE Pain and crepitation
* Abnormal landmarks
* Significant swelling
* Bruising/edema
* Never reducible without anesthesia
Shoulder Luxation Treatments
- which is appropriate for congenital vs traumatic?
- conservative (medical)
- Closed reduction/immobilization
- Open reduction/Stabilization
- Glenoid excision (Salvage)
- Arthrodesis (Salvage)
- Amputation (Salvage)
conservative (medical)
> congential: YES
> traumatic: NO
<><><><>
Closed reduction/immobilization
> congenital: NO
> traumatic: YES (Stable)
<><><><>
Open reduction/Stabilization
> congenital: NO
> traumatic: YES (unstable)
<><><><>
Glenoid excision (Salvage)
> congenital: YES
> traumatic: If FAILED
<><><><>
Arthrodesis (Salvage)
> congenital: Possible
> traumatic: Possible
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Amputation (Salvage)
> congenital: Possible
> traumatic: Possible
can we attempt closed reduction in congenital luxations?
Do not attempt closed reduction in congenital luxations!
Closed Reduction / Immobilization for luxation
- when can we use it?
- what do we do? aftercare?
- contraindications?
- ONLY FOR TRAUMATIC LUXATION
- Closed reduction under general anesthesia
- Immobilization for 2 weeks
> Velpeau sling (MEDIAL)
> Spica splint (LATERAL) - Exercise restriction for 2-3 months
<><><>
Contraindications: - Acute luxation associated with fracture
- Unstable luxations
- Chronic traumatic or congenital shoulder luxations
Open Reduction / Stabilization for shoulder luxation
- what is this? what do we do?
- when is it used?
- what is our surgical approach?
- aftercare?
- Re-enforcement of gleno-humeral ligaments with screws and heavy non-resorbable sutures
- Mostly for TRAUMATIC LUXATION that failed closed reduction
> Likely to fail for congenital
<><><><>
Open surgical approach - Medial shoulder for medial luxation
- Lateral shoulder for lateral luxation
- Prosthetic ligament reconstruction/ capsulorrhaphy
> Heavy nonabsorbable polyester suture
<><><><> - Immobilization: 2 weeks
- Restricted exercise: 2-3 months
Glenoid Excision Arthroplasty (Salvage)
- what is this procedure?
- indications?
- when do we use this?
- Removal of the scapular neck and glenoid cavity to minimize bone to bone contact and create a pseudoarthrosis
<><><><>
Indications - Treatment of choice for congenital luxations
- Chronic luxations
- Failed conservative or surgical management
congenital luxation prognosis for treatments:
- conservative:
- closed reduction:
- Open reduction and Capsulorrhaphy:
- Glenoid excision:
- conservative: Fair
- closed reduction: Poor (will re-luxate)
- Open reduction and Capsulorrhaphy: Poor (likely to re-luxate)
- Glenoid excision: Good (small)
traumatic luxation prognosis for treatments:
- conservative:
- closed reduction:
- Open reduction and Capsulorrhaphy:
- Glenoid excision:
- conservative: Poor
- closed reduction: Good (60 to 80% good function)
- Open reduction and Capsulorrhaphy: Good (60 to 80% good function)
- Glenoid excision: Fair (large)
Shoulder Arthrodesis
- what is this?
- how do we do it? aftercare?
- prognosis?
Salvage for luxation
* Fusion of the shoulder joint
* Limb immobilized in spica splint until evidence of healing (6-12 weeks)
* Physiotherapy after an additional month
* Prognosis: reasonable, relatively pain free function (not normal)
Medial Shoulder Instability
- how common?
- what does it cause?
- how does it occur?
- who is at risk?
<><><>
- signs
- management
- Dx
Maybe one of the most common cause of shoulder lameness?
> Stretching/rupture of medial gleno- humeral ligaments
> Middle aged, Large breed
<><><><>
* Chronic, mild to severe lameness
* Minimally responsive to NSAIDs
* Muscle atrophy
* Pain on shoulder manipulation
* Abduction test:
> (Normal ≈30°- Abnormal ≈50°)
Medial Shoulder Instability Dx
- Rule out other causes…
- Palpation (Abduction test) (Reliability??)
> (Normal ≈30°- Abnormal ≈50°) - MRI / Arthroscopy
> Rupture of the medial gleno-humeral ligament
medial shoulder instability treatment
- should we treat?
- how? what are our options?
- prognosis?
- Controversial
<><>
Conservative (LONG! 7 m) - REST and rehabilitation
- Steroid injection or NSAIDS
- Elbow Hobbles (prevents abduction)
- Stem cell? PRP?
<><>
Surgical - Re-enforcement of medial gleno-humeral ligament
- Rest (3-4 months) +/- hobbles
<><>
Prognosis - Good to guarded?
Bicipital Tenosynovitis + Supraspinatus Tendinopathy
- who is at risk?
- prevalence?
- cause?
- Medium to Large breeds
- Middle-aged
- Relatively frequent ?
> Or is it shoulder instability ? - Trauma or overuse of the tendon(s)
Bicipital Tenosynovitis + Supraspinatus Tendinopathy
* Clinical Signs
* Diagnosis
Clinical Signs
* Similar to shoulder instability
* Chronic shoulder lameness
* Pain on shoulder test
* Muscle atrophy
<><><>
* Ultrasound
* Arthroscopy
* MRI
* Radiology (not specific)
> Osteoarthrosis
> Mineralization
* Bicipital Tendon Test?
Bicipital Tenosynovitis + Supraspinatus Tendinopathy
- treatment
Strict rest /Physiotherapy for 12 weeks
* (up to 7 months!)
<><><><>
Anti-inflammatory drugs
* Oral NSAIDS
* OR Depo-medrol IntraArticular (20-40 mg) ONCE
* OR Triamcinolone 5mg IA (repeated at 4 weeks)
<><><><>
* Shock wave therapy/Therapeutic ultrasound?
<><><><>
* Resection of the tendon if severe or failed medical (tenotomy/Tenorrhaphy) or tenodesis (attach to humerus)
<><><><>
* Prognosis favourable but frustrating
Supraspinatus tendinopathy
- how does this occur?
- is it bad?
- how can we visualize?
- treatment?
- prognosis?
- Mineralization of the supraspinatus tendon
- May be incidental finding
- Skyline radiograph – differentiate supraspinatus vs biceps
- Treatment similar to biceps
> (physio/rest, anti-inflammatory or tendon resection) - Prognosis favourable but frustrating
Infraspinatus contracture
- how common?
- signs? symptoms?
- radiographs?
- treatment
- Uncommon
- No pain on manipulation but not able to internally rotate shoulder
- Atrophy of infraspinatus muscle
- Radiographs = normal
<><><><> - Treatment – excise tendon attachment off humerus
- Moderate exercise for 14 days, slow return to normal
<><><><> - Px: Good with surgery
Osteochondritis dissecans summary - affects who, prognosis
- Large, young growing dogs
- Frequent, good prognosis if treated early
shoulder luxation
- tratments for congenital vs traumatic
- Congenital: Medical or salvage
- Traumatic: Reduction (open / close) or salvage
shoulder conditions of young dogs
- OCD
- Congenital Lux
- Traumatic Lux
shoulder conditions of adult dogs
- (Congenital Lux)
- Traumatic Lux
- medial instability
- Bicipital tenosynovitis
- Supraspinatus tendinopathy
shoulder conditions of small breed dogs
- Congenital Lux
- (Traumatic Lux)
shoulder conditions of large breed dogs
- OCD
- (Congenital Lux)
- Traumatic Lux
- medial instability
- Bicipital tenosynovitis
- Supraspinatus tendinopathy
