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Shoulder Instability Pt 3 - Coggle Diagram
Shoulder Instability Pt 3
what non-op management is appropriate after ant shoulder dislocation?
-ROM initially to prevent stiffness
-positions of ER and abduction avoided to prevent excessive stress on anterior structures
-strengthening of shoulder to improve dynamic stability: early focus on scapular stabilizers, then RC muscles
-should be performed in position of scaption for max congruency and decreased stress on anterior structures
activation of IS/TMi draws HH posteriorly unloading ant structures
core scapular exercises are scaption, protraction, retraction, and seated press-up
non-op management for post dislocations?
reduction achieved by longitudinal forward traction on arm with elbow bent with anterior pressure on HH
-arm then brought into adducted, ER, and IR to reduce HH
principles of non op treatment: pain management, activity modification, and shoulder strengthening of scapular and RC mm (ER and post deltoid emphasized)
non-op treatment produces superior results compared to ant instability
immobilized in handshake cast 2-3 weeks
bench press and push-ups should be avoided
avoid activities that put shoulder at limits of flexion, IR, or horizontal adduction
Non-op management for multidirectional instability
-overall, pts respond well to rehab
-strengthening of scap stabilizers, RC mm provides sufficient dynamic stability
-if failed conservative management, then inferior capsular shift shoulder be included as part of surgical intervention
modern surgical management of patients for whom it is advisable
-currently, gold standard is some sort of capsulorrhaphy
bankart repair: suturing anterior labrum/capsule to ant glenoid rim
capsular shift: tightening of joint capsule depending on precise amount and location of laxity
staple capsulorrhapy: securing the detached anterior capsule and labrum on the glenoid
thermal capsulorrhaphy: thermal shrinkage of collagen tissue to restore normal stability
putti-platt: subscap and capsular shortening
outcome of immediate surgical stabilization compared to non-op management in young, healthy adult
-first time traumatic ant dislocation with immobilization and rehab
-avg 32 months follow-up sig reduction in re-dislocation and improvement in disease specific QoL afforded to early arthroscopic stabilization in those > 30 y.o.
bankart lesion present in very high percentage
standard of care in OH athlete is early repair of capsular structures
-if labrum and/or capsule dont heal in anatomic positions depth of concavity is lost contributing to high recurrence rate, especially in abd/ER position.
-early stabilization in athletic high risk patients should diminish progressive soft tissue and bony damage
surgical repair and its affect on proprioceptive ability
at 5 years post-op joint position sense improved significantly to level of normal, healthy shoulders
SLAP lesions: most often result from sudden downward force on supinated outstretched UE of from fall on lateral shoulder
-pts often complain of popping and sliding of the shoulder, especially with OH activities
-avg time to diagnosis from onset of symptoms is 2.5 years
Types
Type 1: degenerative fraying off labrum
Type 2: avulsion of superior labrum and biceps tendon
Type 3: bucket handle tear of superior labrum
Type 4: same as grade 2/3 with extension into biceps tendon
Type 5: bankart lesion that propagates to biceps tendon
Type 6: unstable flap tear of labrum with seperation of biceps anchor
Grade 7: a superior biceps-labral detachment that extends anteriorly beneath the MGHL
Special tests:
-O'Briens
-SLAP test-
-Load-shift test
-Kibler test
Pg 348
active compression test: Sn 54-100%, SP 11-98.5%
anterior slide: SN 8-78%, SP 84-91%
Crank test: SN 35-91, SP 56-93%
Clunk test: SN/SP not reported
MRI SN 42-89%, SP 88-92%
treatment
-most respond well to NSAIDs, corticosteroid injection, or rehab of RC /scap stabilizers limiting strengthening to <90 deg
-those who fail conservative eligible for debridement (types 1/3) or repair (2/4) using anchors, tacks or transglenoid fixation (caspari technique)