Degenerative shoulder conditions Flashcards
GH arthritis Adhesive capsulitis - frozen shoulder AVN of shoulder sacpulothoracic crepitus
1
Q
What are the causes of glenohumeral degenerative joint disease?
A
- OA
-
RA
- most prevalent form if inflammatory process affecting the shoulder with >90% developing shoulder symptoms
- commonly assoc with RC tears, 25-50% full thickness tears
- Connective tissue diseases
- Spondyloarthropathies
2
Q
What is the epidemiology of GlenoHumeral arthritis?
A
- More common elderly
- may assoc throwing athlete
- pathology
-
primary OA
- no cause known
- RX tears 5-10%
-
Secondary OA
- trauma
- prev surgery- over tightened ant capsule
- hardwear in and around shoulder
- instability= RC disease
-
primary OA
3
Q
What are the assoc conditions of GlenoHumeral arthritis?
A
-
Chondrolysis
- which has been associated with the use of intra-articular local anaesthetic infusion pumps after surgery
4
Q
Can you decribe any GlenoHumeral arthritis classification systems?
A
- Walch classification of glenoid wear
- type A
- concentric wear, no subluxation, well centralised
- A1= minor errosion
- A2= deeper central erosion
- Type B
- Biconcave glenoid, asymmetric glenoid wear & head subluxed posteriorly
- B1 - narrowing of post joint space, sunchondral scleorsis, osteophytes
- B2= post wear , biconcave glenoid
- Type C
- Glenoid retroversion >25o and post subluxation of humerus
5
Q
What is the presentation of GlenoHumeral arthritis?
A
- Pain at night
- Pain w activities involving the shoulder
O/E
- Tenderness at GH joint
- flattening of anterior shoulder contour
- due to post subluxation of humeral head
- Functional limitations of GH joint
- decreased rom
- limited external rotation
- painful shoulder rom
6
Q
What is seen on imaging in GlenoHumeral arthritis?
A
- Xrays
- ap , axillary, maybe see…
- subchondral sclerosis
- osteophyte at inferior aspect of humeral head ( goat’s beard)
- look for superior migration of head to indicate RC deficiency
- loss for prev surgery
- look for medialisation- in RA ( may preclude glenoid resurfacing if severe)
- posterior glenoid wear
- post humeral head subluxation
- CT
- In RA of large bony defect of glenoid
- MRI
- to identify any RC tears
7
Q
Describe the tx for GlenoHumeral arthritis?
A
Non operative
- Nsaids, dmards for RA, physio, corticosteriods injections
- first line of tx
Operative
-
Total shoulder arthroplasty
- unresponsive to non op tx
- progressive pain
- decreased rom, inability to do ADLs
- CI
- deltoid dysfunction
- insuff glenoid stock
- RC arthropathy
- Outcome lower rate of revision surgery cf hemi
-
Hemiarthroplasty
- OA
-
RA
- when large/ irrepairable RC tear
- inadequate bone stock to support glenoid prothesis
- Post traumatic arthritis
-
Reverse ball prothesis
- CI- deltoid deficiency
-
Fusion
- RC deficiency
- deltoid deficiency
- rare in OA
- position = 30/30/30 flexion/IR/Abduction
-
Arthroscopic debridement
- Temporising measure
8
Q
What is adhesive capsulitis ( frozen shoulder)?
A
- Defined as pain and loss of motion of the shouder with no other cause
- Pathanatomy
- soft tissue scarring and contracture of ossoeus change
- essential lesion involves the coracohumeral ligament and rotator interval
- fibroblastic proliferation is seen on biopsy
9
Q
Name the associated conditions of adhesive capsulitis?
A
- Diabetes
- thyroid disorders ( autoimmune disorder)
- Previous surgery ( lung/breast)
- prolonged immobilisation
- extended hospitalisation
10
Q
What is the rotator interval?
A
- A triangular region between the anterior border of supraspinatus and superior border of subscapularis
- contains the SGHL and coracohumeral ligament
11
Q
Describe the clinical stages of adhesive capsulitis?
A
-
Painful
- gradual onset of diffuse pain: 6wks-9mo
-
Stiff
- decreased ROM affecting ADLs: 4-9 mo
-
Thawing
- Gradual return of motion: 5-26months
12
Q
What is the presentation of a pt with adhesive capsulitis?
A
- Pain and stiffness
O/E
- Painful arc of motion
- decreased rom - esp EXTERNAL ROTATION
13
Q
What is seen on imaging of adhesive capsulitis?
A
- Xray
- disuse osteopenia
- concomitant oseoarthritis , calcific tendonitis, hardwear indicating prior surgery
- MR arthrogram
- loss of axillary recess = contracture of joint capsule
14
Q
What is the tx of adhesive capsulitis?
A
Non operative
-
NSAIDS, physio, intra-articulatr steriod injections
- program of gentle, painfree stretching and moist heat
- most successful
Operative
-
MUA
- failed consx tx
-
Arthroscopic surgical release
- only after extensive physio 3-6 months
- arthroscopic release of adhesions
- arthroscopic rotator interval release = increase ER
- arthroscopic posterior capsular release= increase IR
15
Q
What are the complications of adhesive capsulitis?
A
- Axillary nerve injury
- rotator cuff tendon disruption
- Iatrogenic chondral injury
- Fx or dislocation
- Recurrent stiffness
16
Q
What is AVN of the shoulder?
A
- A condition caused by the interruption of blood supply to humeral head
17
Q
What is the aetiology of AVN of shoulder?
A
Atraumatic = ASEPTIC
- Alcohol, Aids
- Steriods ( most common) , Sickle cell, SLE
- Erlenmeyer flask ( gaucher’s)
- Pancreatitis
- Infection/ Idiopathic
- Casson’s disease ( bends)
Posttraumatic
- 4 part fx dislocation= approach 100% avn
- displaced 4 part fx= 45% AVN
- valgus impacted 4 part= 11%AVN
- 3 part =14% AVN
18
Q
Describe the blood supply to humeral head?
A
-
Ascending branch of anterior humeral circumflex and arcuate artery
- provides blood supply ro head
- vessel runs parallel to lateral aspect of tendon of the long head of biceps in bicipital groove
- arcuate artery is the interosseous continuation of the ascending branch of anterior humeral circumflex artery and pentrates bone of the humeral head
-
Posterior humeral circumflex artery
- this is the main blood supply to H Head
19
Q
What is the classification of AVN of shoulder?
A
- Cruess classification
- stage 1= normal xray,, changes on mri
- stage 2= sclerosis, osteopenia
- stage 3= crescent sign= subchondral fx
- stage 4= flattening and collapse
- stage 5= degeneration extends to glenoid
20
Q
What is the presentation of AVN of shoulder?
A
- Insidous onset of pain, loss of motion , crepitus and weakness
- often without clear inciting event
O/E
- Limited rom
- crepitus
- weakness RC and deltoid muscles
21
Q
What is seen on imaging inAVN of shoulder?
A
- Xrays
- osteolytic lesion develops on radiographs demonstrating reabsorption of subchondral bone
- most inital site is= superior middle portion of humeral head
- crescent sign= subchndral collapse
- -> depression articular surface-> arthritic changes
- osteolytic lesion develops on radiographs demonstrating reabsorption of subchondral bone
- MRI
- 100% sensitivity in detection
- will demonstrate oedema of subchondral sclerosis
22
Q
What is the tx of AVN of shoulder?
A
Non operative
- Analgesic, activity modification, physio
- 1st line tx
- restrict overhead activities/manual labour
Operative
-
Core decompression
- early Cruess 1/2
-
Head head resurfacing
- stage 3- with focal chondral defects and sufficient remaining epiphyseal bone stock for fixation
-
Hemiarthroplasty
- moderate disease cruess stage 3/4
-
Total shoulder replacement
- advanced stage Creuss V
23
Q
What is scapulothoracic crepitus?
A
- Manifests as pain at the scapulothoracic junction with overhead acitivity
- pathophysiology: causes include
- Osteochondroma
-
Elastofibroma dorsi
- benign soft tissue tumour
- scapulothoracic dyskinesis
- Bursitits
24
Q
What is the presentation of scapulothoracic crepitus?
A
- complains of popping scapula
- painful crepitus with elevation of arm
- pan relieved with stabilisation of scapula
O/E
- Scapulothoracic dyskinesis may be present
25
Q
What is seen on imaging of scapulothoracic crepitus?
A
- Xray
- osseous abnormalities
26
Q
What is the tx of scapulothoracic crepitus?
A
Non operative
-
Nsaids, scapular strengthening exercises , local corticosteriord injections
- first line
operative
- Bursectomy ( open or arthroscopic) resection of osseous lesion, resection of scapular border
