‫פציעות ספורט בכתף‬

‫ערן ממן‬
‫מ"מ מנהל יחידת כתף‬
‫החטיבה האורטופדית‬
‫בי"ח איכילוב‬
 Anatomy
The shoulder joint :

- the body's most versatile joint

- composed of 4 joints:
• SternoClavicular (SCJ)
• AcromioClavicular (ACJ)
• GlenoHumeral (GHJ)
• ScapuloThoracic
 Shoulder injuries

Acute (fall):
• Fractures: clavicle, humerus, scapula
• Dislocations: GHJ, ACJ, SCJ
• Soft tissue:
-Tears:Rotator cuff / LH Biceps / SLAP /
Pectoralis major
- lacerations
- abrasions
- contusions

overuse:
 Pathomechanics
• FOSH (Fall Out Stretched Hand)
• Direct blow
• Traction
• Impaction
 Shoulder injuries

Acute (fall):
• Fractures: humerus, clavicle, scapula
Proximal Humerus. Fx.:
Neer’s
 Proximal Humerus. Fx.:
Treatment:
Non Surgical- minimally displaced (1cm/45º)
Surgical-
- Closed Reduction External Fixation
- Closed Reduction Internal Fixation
- Open Reduction Internal Fixation
 Proximal Humerus. Fx.:

.
Proximal Humerus. Fx.:
Proximal Humerus. Fx.:
 Greater T. Fx.:
Treatment:
Non Surgical- minimally displaced (0.5
cm/45º)
Surgical-
- Open/Mini Open Reduction Internal
Fixation
- Closed Reduction Internal Fixation
- Arthroscopic Reduction & Fixation
Greater T. Fx.:
Greater T. Fx.:
Clavicles Fx.:
Clavicles Fx.:
Clavicles Fx.:
Clavicles Fx.:
Clavicles Fx.:
 Clavicles Fx.:
Treatment:
Non Surgical- most fractures
 Clavicles Fx.:
Treatment:

Surgical-
- some of lateral end
- mid third: active/young/completely
displaced/shortening
(Altamimi SA, McKee MD; Canadian Orthopaedic Trauma SocietyNonoperative treatment
compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique. J
Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:1-8)
Clavicles Fx.:
clavicle . Fx.:
Clavicles Fx.:
Scapular Fx.:
 Shoulder injuries

Acute (fall):
• Fractures: clavicle, humerus, scapula
• Dislocations: GHJ, ACJ, SCJ
• Soft tissue:
-Tears:Rotator cuff / LH Biceps / SLAP /
Pectoralis major
- lacerations
- abrasions
- contusions

overuse:
‫אי יציבות ‪GHJ‬‬
 Instability
Assessment
Hyperlaxity Instability
Hyper laxity
Shoulder Laxity
asymptomatic passive translation of the
humeral head relative to the glenoid

Shoulder Instability
symptomatic translation of the humeral
head relative to the glenoid articular
surface during active motion
Matsen 1992
TUBS AMBRI
TUBS – Traumatic
Unidirectional Bankart
Surgery

AMBRII - Atraumatic
Multidirectional
Bilateral Rehabilitation Inferior
Interval
Mechanisims of injury

Indirect force

Direct trauma
 Recurrent Instability
Classification
Force
Degree of Stability
Traumatic
Dislocation
Atraumatic
Subluxation
Patient Contribution
Chronology
Voluntary
Congenital
Involuntary
Acute
Direction
Chronic
Subcoracoid
Locked
Subglenoid
Recurrent
Intrathoracic
posterior
 Habitual, Voluntary,
Obsessive

Multichanel surface EMG evaluation

treatment with Bio-Feed-Back
 Habitual, Positional
Posterior
 Traumatic
Types of anterior dislocation:

Subcoracoid most common

Subglenoid

Subclavicular

Intra thoracic-

Inferior (luxatio erecta)

Posterior dislocation:

Uncommon (5% of shoulder dislocations)-

Usually missed-

Superior dislocation:
Rare
consequences of anterior instability:

Bankart lesion-

Hill Sachs lesion-

posterolateral humeral head indentation fracture

erosion of the anterior glenoid, loose body formation, -

stretching of the joint capsule, rotator cuff tear,
neurovascular injuries, fractures
The Hill-Sachs Lesion
patho-mechanism
 Bankart Lesion
• Soft Bankart lesion
• Bony Bankart lesion
• Anterior Deficient Glenoid - “Inverted pear”
Bankart Lesion
Bankart Lesion
 Examination

• Neurologic
• ROM
• Strength
• AD/PD/Sulcus (laxity)
• Instability
• Hyperlaxity tests
– Sulcus
– Load and shift (anterior &
posterior drawer)
– Gagey test
• Instability tests
– Apprehension, Augmentation,
Fulcrum
– Relocation
– Posterior Jerk
 How to immobilize?
• Itoi et al JBJS am 2001 – 19 shoulders, 6 acute, 13
recurrent. MRI IR 29 deg, ER 35 deg ER better
approximates the bankart lesion
 Arthroscopy :
• A Comparison of the Spectrum of
Intra-articular Lesions in Acute and
Chronic Anterior Shoulder Instability
(Christos K. Yiannakopoulos, Elias Mataragas, Emmanuel Antonogiannakis)

acute chronic P

Bankart 78.2% 97.11% .002

HSL 65.21% 93.26%) .001

SLAP 16.34% 13.04%, .903

PTT 11.53% 8.69% .694

inverted pear 15.38% 0 .044

configuration
 complications
Acute anterior Dislocation

Injury at the Time of Dislocation

Injury at the Time of Reduction

 complications
Acute anterior Dislocation

• Shoulder instability
– Most common complication
– The majority of recurrences occur within
2 years of the first traumatic dislocation
– Young patients - 85% to 90%
– After the age of 40 - 10% to 15%
 complications
 Vascular Injuries

 Neural Injuries

Overall incidence is in the range of 30%.

The axillary nerve is the most commonly involved
 complications

 Rotator Cuff Injuries

 In patients older than 40 years > 30%
 After age of 60 > 80%
Rehab.
never trust a woman.mpe
 Treatment
Conservative:

Rowe – JBJS, 1957

324 young patient with ant. dislocations
• 94% had recurrence if < 20 years old
• 62% had recurrence if < 30 years old
• 14% had recurrence if > 40 years old
 Non operative treatment of shoulder
dislocation
in young athletes
1. Arciera – J Arthroscopy, 1995
2. De Beardino – J South Orthopaedic Ass, 1996
3. Haelen – J Arch Orthopaedic Trauma Surgery,
1990
4. Hovelius – J Orthopaedic Science, 1999
5. Wheeler – J Arthroscopy, 1998
6. Kirkby – J Arthroscopy, 1999
all over 80% recurrence rate
 –Arthroscopic stabilization of
acute 1st anterior shoulder
dislocation: the West Point
experience.
– 1986 - 1995, 127 acute initial shoulder
dislocator
– 55 - nonoperatively, 47 (85%) have had
recurrence of instability.

– The average age was 19.5 years (17 - 23

years). F/U 22 months.

DeBerardino TM, Arciero RA, Taylor DC J South Orthop Assoc. 1996 Winter;5(4):263
Operative:

1. Open Bankart +/- C. Shift

2. ABR +/- C. Shift
3. ABR +/- Remplissage
4. Coracoid Transfer-Latarjet
5. Subscapularis Muscle Procedures (Putti-Platt
Procedure)
6. Rotational Osteotomy
 Operative treatment for
Recurrent Anterior Shoulder Instability

Capsular Repairs
 Bankart Procedure - Repair of the capsule to the
bone of the anterior glenoid through the use of drill holes
and suture.
 Bankart/Capsular Reconstruction
Operative treatment for Recurrent
Anterior Shoulder Instability
Open capsular shift
Arthroscopic Bankart Repair-ABR
throscopic Bankart Repair-ABR
Preparation of the anterior
glenoid wall
Drilling
Anchor
• Hill Sachs Remplissage
Coracoid Transfer

Bristow-Helfet Procedure
Latarjet Procedure

Transfer of a larger portion of the coracoid process than is
used with the Bristow procedure, along with the biceps and
coracobrachialis tendons, to the anteroinferior aspect of the
neck of the scapula
Rehabilitation
Boszotta & Helperstorfer – Arthroscopy, July
2000
Transglenoid suture repair for initial Ant.
dislocation

72 patients (1988
(1988--95)
95)

Results
7% = Redislocation all due to trauma (severe in
2 out of 5)
85
85%% = Returned to unrestricted pre injury
sporting activities
Cases:

1. 20 Y.O. , special forces, 1st dislocation

2. 30 Y.O. sedentary job 1st dislocation
3. 25 Y.O. Multiple dislocations
4. 65 Y.O. 1st dislocation
5. 18 Y.O. voluntary dislocations
Acromio Clavicular Joint
(ACJ) Dislocations
ACJ Dislocations:
ACJ Dislocations:
 Clinical Anatomy
Hyaline cartilage  Fibrocartilage
- Capsule
- Synovial Membrane
- Intra articular Discs
ACJ Dislocations:
 Clinical Anatomy
Stability-
 LIGAMENTS:

- Acromioclavicular:
Horizontal

- Coracoclavicular: Vertical
 ACJ Dislocation
• 6 types:
-Severity
-Ligaments torn

-Clavicle position
 Classification –Rockwood

• Type I: sprain of joint with out a complete tear

of either ligament
 Classification –Rockwood
• Type II: tear of AC ligaments.

Coracoclavicular
ligaments intact/strain
 Classification –Rockwood
• Type III:

both AC & CC ligaments are torn;

- > 5 mm elevation of AC joint
 Classification –Rockwood
Type IV:
- distal clavicle impaled posteriorly into
trapezial fascia
 Classification –Rockwood
Type V:
- ACJ dislocation with extreme superior
elevation of clavicle (100 to 300% normal).
Complete detachment of deltoid and
trapezius from distal clavicle.
 Classification –Rockwood
Type VI -

Clavicle displaced subcoracoid

 MANAGEMENT
ACUTE

Type I & II (60%) -- Conservative

Type III (40%) -- Cons. Vs Surgical

Type IV,V ,VI (<1%) – Surgical (usually)

 MANAGEMENT
Surgical Options
- CC lig. Reconstruction (acute and chronic)
ACJ Dislocations:
SCJ Dislocations:
SCJ Dislocations:

‫מצב מסכן חיים‬

 Shoulder injuries

Acute:
• Soft tissue: LH Biceps & SLAP / Rotator cuff /
Pectoralis major tears, lacerations, abrasions &
contusions
SLAP=Superior Labrum Anterior
Posterior

A detachment lesion of the superior

aspect of glenoid labrum, which
serves as the insertion of long head
of biceps
CLASSIFICATION (Snyder 1990)
 DIAGNOSIS
History
– vague shoulder pain
– exacerbated by overhead activity
– popping
– Locking
– snapping (unstable fragment)
– Instability symptoms
– night pain & weakness (rotator cuff
tear)
– Weakness (ganglion cyst)
 DIAGNOSIS
Mechanisms of Injury:

– Traction:
overhead sports Motion or throwing,
attempting to break a fall from a height, sudden
pull
 DIAGNOSIS
Compression:

fall on outstretched hand in forward

flexion and abduction , direct blow
SURGICAL MANAGEMENT
SURGICAL MANAGEMENT
90% return to same level of
activity

only 75% among athletes

Rotator cuff tear
 Pectoralis major tear

(sternocostal head)
Long Head of Biceps Tear
THANK YOU!