Slide 1: 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? Slide 4: Bones of the Shoulder Girdle Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 5.20a, b Slide 5: Bones of the Upper Limb Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 5.21a, b Slide 7: 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?
Bursae Slide 9: Gaps:
Anteriorly: allows communication between synovial membrane and subscapularis bursa.
Posteriorly: allows communication with infraspinatus bursa. Fibrous Capsule Slide 10: 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.
Bicep & tricep tendons
Glenohumeral & coracohumeral ligaments.
Rotator cuff Accessory Ligaments : Accessory Ligaments TRANSVERSE HUMERAL LIGAMENT:
GLENOHUMERAL LIGAMENTS: 3 thickened bands
Rotator Cuff Slide 17: ANTERIORLY: Pectoralis major, Brachial plexus, Subscapularis
POSTERIORLY: Infraspinatus muscle.
Teres minor muscle.
SUPERIORLY: Supraspinatus muscle.
INFERIORLY-- Long head of triceps muscle.
Post. circumflex humeral BV.
Long head of biceps is intracapsular. Relations of Shoulder Joint Slide 18: Netter’s Atlas 2nd ed Slide 19: Netter’s Atlas of Human Anatomy 2nd ed Slide 20: 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.
Short head of biceps.
EXTENSION: Normally upto 45 degrees
Posterior fibers of deltoid.
Sternocostal part of pectoralis major.
Scapular rotation by Trapezius & Serratus anterior
ADDUCTION: Normally upto 45 degrees.
Teres major. Slide 23: Medial Rotation up to 55 degree
Anterior fibers of deltoid.
Lateral Rotation—normally 40-45 degrees.
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 Slide 29: 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. Slide 30: 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 Slide 31: 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 Slide 35: Rotator Cuff Tear Slide 36: 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.
Subphrenic abcess. Referred Pain Investigating Shoulder : Investigating Shoulder History/ Medical interviewing
Imaging (X-ray, U/S, MRI, CT)
Arthroscopy Examination of Shoulder : Examination of Shoulder Slide 40: SUMMARY