Shoulder

Shoulder Treatment

Rotator Cuff Injury

The rotator cuff is formed by four muscles and tendons surrounding the shoulder joint giving it dynamic stability. There are many degrees of injury from mild tendon involvement, to partial or complete rupture, arthropathy, and massive rotator cuff rupture. Muscle atrophy and weakness can also be seen and tears may be accompanied by biceps tendon rupture or shoulder instability.

It is a common injury in the general population but especially with people or athletes who perform repeated overhead motions. There is also an increased risk with age.

Treatment

  • Conservative - consisting of physiotherapy, cryotherapy, anti-inflammatories and rehabilitation especially in the acutely painful stage.
  • Corticosteroid infiltrations in the subacromial area, Platelet-Rich Plasma PRP and Mesenchymal stem cells.
  • Surgery - considered if after one year of conservative treatment there is no improvement and even if there is no tear, or if there is a partial or complete tear. Surgery consists of Anterior Acromioplasty of Neer to increase the space under the acromion, removing the bursa, arthroscopic debridement to relieve the impingement, tighten the joint capsule or repairing the tear.

Anterior and Posterior Instability

The glenohumeral joint is one of the most mobile and complex joints in the body, with the greatest range of motion and the one that most frequently dislocates. Dislocation can be either acute or from recurrent instability and the most frequent complication of dislocation is its recurrence. There are different classifications to assess instability, depending on grade, chronology, trauma and direction of the dislocation.

Anterior dislocation is usually produced by abduction, extension and external rotation. In athletes it is due to repetitive overhead motions common for tennis players and swimmers.

Posterior dislocation usually occurs due to axial overload in adduction and internal rotation and is less common than anterior shoulder instability.

Treatment

  • Acute dislocation - requires reduction as soon as possible and immobilization, (not absolute immobilization), for two to five weeks depending on the patient's age.

    Recurrent anterior instability - treated with rehabilitation. If that fails and dislocation persists, then arthroscopic or open surgery will be needed to repair the injury and static and dynamic stabilizers. The success of arthroscopic surgery in glenohumeral instability lies in the ability to diagnose and treat all existing injuries.

  • Conservative treatment - consists of enhancing the external stabilizers of the shoulder and correcting the scapulothoracic alteration.

    Recurrent posterior dislocations - when conservative treatment does not succeed and having ruled out multidirectional instability, arthroscopy has the best result in treating all instabilities.

SLAP Superior Labrum Anterior & Posterior Injuries

This is an injury to the upper labrum. The labrum is a fibrocartilaginous ring that surrounds and adheres to the glenoid giving stability to the joint. The biceps tendon also attaches to the labrum.

Injuries can be in the front or in the back of the labrum and may involve the biceps tendon. It is common in athletes as an overload trauma or repetitive shoulder motion. Many however are the result of a slow wearing down of the labrum over time and an aging process.

Treatment

  • Conservative - treatment is initially conservative with physiotherapy and strengthening of the dynamic stabilizers.
  • Surgery - treatment depends on the type of lesion, age and associated injury of the biceps tendon. It will be done with arthroscopy potentially consisting of debridement, suture anchors or a biceps tenodesis.

Subacromial Syndrome

Hip replacement surgery is recommended when all other treatment options have failed to relieve pain. The hip joint is fully or partially replaced with an implant made of metal, ceramic, and plastic components.

Treatment

Treatment is similar to that of rotator cuff injuries. 

  • Conservative - consisting of cryotherapy, anti-inflammatories, physiotherapy, rehabilitation and subacromial corticosteroid injections.
  • Surgery - consisting of arthroscopic debridement and possible repair if there is an injury.

Suprascapular Nerve Neuropraxia

This is a compression of the peripheral nerve from the C5-C6 brachial plexus branch. It is a motor nerve which innervates the supra and infraspinatus muscles, causing interruption of the nerve impulse. It is rare and difficult to treat, producing a diffuse deep pain in the shoulder radiating to the neck and arm, with atrophy of the muscles that it innervates. It may occur in association with paralabral cysts and rotator cuff tears.

Treatment

  • Conservative - usually consisting of rest and physiotherapy and can be resolved in six to twelve months.
  • Surgery - If the compression is chronic with muscular atrophy or a massive nerve compression, then arthroscopic or open surgical decompression will be used.

Proximal Humeral Extremity Fractures

These fractures are caused by indirect trauma and occasionally by direct seizures or electric shock. They are very frequent and account for 4-6% of all fractures. There may also be associated lesions of the axillary nerve. They are classified depending on location of the fracture and number of segments.

Treatment

  • Conservative - possible for 80% of cases, with immobilization in a sling for three weeks and early mobilization after seven to ten days.
  • Surgery - consisting of anatomic reduction and early rehabilitation. It may also require a prosthesis.

Diaphyseal Fracture of the Humerus in Adults

Most of these fractures are caused by direct high energy trauma or by low energy trauma in elderly women. It can be classified according to skin integrity, fracture line, whether it is complete, if there is associated neurovascular injury and if it is due to a concomitant disease.

Treatment

  • Conservative - possible in most cases, with two weeks of immobilization with a U-splint or Cadwell pendant plaster and subsequently a functional brace for six to ten weeks.
  • Surgery - depends on the type of fracture, associated injuries and characteristics of the patient.

Distal Humerus Fractures

These fractures affect the distal part of the humerus and are classified as Extra-articular fractures, (supracondylar and transcondylar), Condylar fractures and Supra Intercondylar (intra-articular).

Treatment

  • Surgery - required in the majority of cases to reconstruct the articular surface, stably fix the fragments and restore the global geometry of the distal humerus.
  • Elbow arthroplasty.
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