Shoulder

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Shoulder Joint Prof. Saeed Shafi

Case of the Week : 

Case of the Week Yahya Sherazi, 25-year aged University student presented in emergency with history of fall from motorbike and complaint of pain and inability to abduct the right arm against resistance. He has a family H/O ischemic heart disease. Resident in ER observed loss of normal rounded contour of his right shoulder and absence of general sensations on it. However, Doctor was unable to perform motor examination of Right shoulder due to severe tenderness. Radiological examination revealed fracture of surgical neck of humerus. What kind of basic science knowledge is required to interpret the Anatomical basis of this problem?

Objectivs? : 

Objectivs?

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Bones of the Shoulder Girdle Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 5.20a, b

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Bones of the Upper Limb Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 5.21a, b

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The Synovial Joint Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 5.28

Parts of Synovial Joint : 

Parts of Synovial Joint Type of Joint? (Ball & Socket; multiaxial) Articular surfaces shape? Synovial membrane Fibrous capsule Accessory ligaments Muscles Intra-articular structures Bursae

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Gaps: Anteriorly: allows communication between synovial membrane and subscapularis bursa. Posteriorly: allows communication with infraspinatus bursa. Fibrous Capsule

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Attached around the glenoid labrum. Lines the capsule. Attached to articular margins of head of humerus. Covers intracapsular area of surgical neck. Communicates with 2 bursae through gaps in capsule. Invests long head of biceps in a tubular sleeve. Glides to and fro during adduction and abduction. Synovial Membrane

STABILITY : 

STABILITY Instability Larger humeral head compared to glenoid cavity. Lax joint capsule. Stability Glenoid labrum Bicep & tricep tendons Glenohumeral & coracohumeral ligaments. Rotator cuff

Accessory Ligaments : 

Accessory Ligaments TRANSVERSE HUMERAL LIGAMENT: GLENOHUMERAL LIGAMENTS: 3 thickened bands Coracohumeral ligament Coracoacromial ligament Coracoacromial Arch Rotator Cuff

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ANTERIORLY: Pectoralis major, Brachial plexus, Subscapularis POSTERIORLY: Infraspinatus muscle. Teres minor muscle. SUPERIORLY: Supraspinatus muscle. Subacromial bursa. Coracoacromial ligament. Deltoid muscle. INFERIORLY-- Long head of triceps muscle. Axillary nerve. Post. circumflex humeral BV. Long head of biceps is intracapsular. Relations of Shoulder Joint

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Netter’s Atlas 2nd ed

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Netter’s Atlas of Human Anatomy 2nd ed

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rotator cuff musculature Netter’s Atlas 2nd ed

MOVEMENTS OF SHOULDER JOINT : 

MOVEMENTS OF SHOULDER JOINT FLEXION: Normally upto 90 degrees. Clavicular head of pectoralis major. Anterior fibers of deltoid. Coracobrachialis. Short head of biceps. EXTENSION: Normally upto 45 degrees Latissimus dorsi. Teres major. Posterior fibers of deltoid. Sternocostal part of pectoralis major. ABDUCTION: 1200 Supraspinatus Deltoid Scapular rotation by Trapezius & Serratus anterior ADDUCTION: Normally upto 45 degrees. Pectoralis major. Latissimus dorsi. Teres major.

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Medial Rotation up to 55 degree Subscapularis. Teres major. Latissimus dorsi. Anterior fibers of deltoid. Lateral Rotation—normally 40-45 degrees. Infraspinatus Teres minor Posterior fibers of deltoid Circumduction: Rhythmical combination in sequence of flexion , abduction, extension and adduction.

NERVE SUPPLY : 

NERVE SUPPLY Hilton’s law of innervation of joints?

SHOULDER JOINT DISLOCATION : 

SHOULDER JOINT DISLOCATION INFERIOR DISLOCATION: Sudden violence applied to humerus with joint fully abducted tilts the humeral head downward into inferior weak part of capsule. The capsule tears and humeral head comes to lie inferior to the glenoid fossa. Strong flexors and adductors pull the humeral head into a subcoracoid position.

Shoulder Sublaxation : 

Shoulder Sublaxation

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POSTERIOR DISLOCATION: Due to direct violence to front of the joint. The rounded appearance of the shoulder is lost. Subglenoid displacement of the humeral head into quadrilateral space can damage the axillary nerve. Downward displacement of the humerus may also stretch and damage the radial nerve.

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Degenerative changes in subacromial bursa are followed by degenerative changes in the underlying supraspinatus tendon and then in the other tendons of rotator cuff. Tenderness over greater tuberosity of humerus. ROTATOR CUFF TEAR: Usually involves rupture of supraspinatus tendon. Patient is unable to initiate abduction. Subacromial Bursitis, Supraspinatus Tendinitis / Pericapsulitis

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Attached above to coracoacromial ligament and below to tendon of supraspinatus. Extends beyond lateral acromial border with arm at the side but rolls inwards under it when arm is abducted. SUBACROMIAL BURSA

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Rotator Cuff Tear

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While pain in shoulder joint may be produced by the aforementioned conditions, it can also be caused by disease elsewhere when the joint may be normal. These conditions include: Gall bladder disease. Gastric ulcer disease. Liver abcess. Subphrenic abcess. Referred Pain

Investigating Shoulder : 

Investigating Shoulder History/ Medical interviewing Clinical Examination Inspection Palpation Percussion Auscultation Imaging (X-ray, U/S, MRI, CT) Arthroscopy

Examination of Shoulder : 

Examination of Shoulder

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SUMMARY