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Tuesday 12 June 2018



Image result for saha shoulder muscles

Functions of Rotator cuff
  • depression of humeral head into glenoid fossa – as deltoid force humeral head superiorly in abduction
  • supraspinatus – abduction
  • subscapularis – internal rotation
  • infraspinatus and teres minor – external rotation
  • circumferential reinforcement of glenohumeral joint and joint compression ( static stabilization)
Saha's concept
  • prime movers – deltoid and pect. Major
  • prime steerers – rotator cuff muscles
  • Extrinsic factors
    1. Primary ( impingement syndrome)
      • acromion shape ( Bigilani and Morrison classification)
      • os acromiale
      • a/c joint pathology
      • bursitis
      • coracoacromial ligament hypertrophy
      • exostosis of greater tuberosity
    2. Secondary
      • instability
      • post capsule tightness
      • abnormal muscular or neurological control of cuff
  • Intrinsic factors
    1. over use
    2. insufficient blood supply
      • critical zone – 1cm proximal to rotator cuff insertion – water shed area between osseous and tendinous vessel supply

Neer Classification of Rotator cuff tendinopathy ( impingement syndrome)
Clinical course
Edema and hemorrhage – microscopic tear
25 - 40
Fibrosis and tendinitis – microscopic to partial
Recurrent pain with activity
Complete tear – small, medium, large, massive
Progressive disability

Classifications of Rotator cuff tears
  • a/c – after trauma : c/c – after 3 months
  • complete – communicates with bursa and joints
    • 4types – largest diameter based – can be retracted or non retracted
      • small <1cm
      • medium 1-3 cm
      • large 3-5 cm
      • massive 5cm
  • incomplete – tears with no communication
    • bursal tears
    • intratendinous tears
    • joint side tears
  • traumatic and degenerative
  • tendinitis
    • primary
      • intrinsic tendon degeneration
    • secondary
      • structural – acromial spur, os acromiale
      • dynamic – glenohumeral instability, capsular contracture, muscle imbalance, over use
  • calcific tendinitis
    • acute
    • chronic
Clinical evaluation
  • pain – anterior superior aspect of shoulder - overhead activities – painful arc 60 – 120o – progressive – h/o specific injury
  • crepitus – sub acromial
  • weakness – abduction, rotation ( IR>ER)
  • decrease in activities
  • muscle atrophy – reduced ROM
  • inability to initiate or maintain the abduction – large tear of cuff
  • Neer impingement sign – stabilize scapula – forced elevation of humerus – greater tuberosity impinges against acromion
  • Neer impingement test – 10ml lignocaine into subacromial bursa – repeat the sign
  • Jove supraspinatus test (empty can position) – 90o abduction – 30ohorizontal flexion – full IR
  • Hawkins Kennedy test – 900 forward flexion – forcible IR
  • rule out DJD with radicular symptoms in old people

  • X ray
    • AP view
      • subchondral cysts – sclerosis of greater tuberosity and edge of acromion
      • OA of AC jt., glenohumeral jt.
      • Calcific tendinitis
      • decreased interval between humeral head and acromion – full thickness tear
    • Axillary lateral view
      • to diagnose os acromiale
      • 3 centers of ossification – pre , meso, meta
      • bony Bankart's lesion
    • Supraspinatus outlet view
      • lateral view - in plane of scapula – beam directed 5-10o caudal
      • for sub acromial space
      • acromial variants and abnormalities
      • coracoacromial ligament calcification
    • Caudal tilt view
      • AP – beam tilted 300 caudal
      • better for viewing antero inferior projection of acromion
  • USG
    • moderate to large complete tears – not small or partial tears
  • MRI
    • gold standard – sub acromial fluid, osteophytes, a/c joint arthropathy, signal changes in cuff
Differential Diagnosis
  • glenohumeal instability
  • Scapulothoracic dysfunction
  • Glenohumeral degenerative jt. Disease (DJD), labral tears, loose bodies
  • Brachial neuritis
  • AC joint DJD
  • Cervical DJD
  • Adhesive capsulitis
  • Cervical neuritis
  • Suprascapular nerve entrapment
  • Apical lung tumors

  • Non surgical
    • initial care of tendinitis
    • NSAIDS
    • alleviating the pain by ice, heat, ultrasound, electrical stimulation, TENS
    • Physiotherapy exercises
      • increase depresser effect of rotator cuff or humeral head – isometric and isotonic exercises
      • stretching and ROM exercises
    • avoid overhead activities – rest
    • local subacromial steroid injection - <2 injections – 40ml methyl prednisolone – not in full thickness tear
  • natural h/o – do not heal with physiotherapy – remain symptomatic with use – enlarge with time leading to cuff tear arthropathy
  • Surgical
    • Decompression (Acromioplasty)
      • open
      • arthroscopic
    • Rotator cuff repair
      • open repair
      • mini open repair
      • arthroscopic cuff repair
Acromioplasty (Neer's principle)
  • coraco acromial ligament release not resection
  • removal of acromion anterior to the anterior border of clavicle
  • removal of distal 1-1.5cm of clavicle – if significant OA found
  • gold standard, established results
  • deltoid detachment, longer rehabilitation, weakness esp. deltoid – cons
Arthroscopic decompression
  • avoids deltoid detachment
  • glenohumeral pathology can be evaluated
  • cosmetic
  • earlier restoration of movements
  • technically demanding, inadequate resection – cons
Cuff repair
  • open repair – done by detaching deltoid insertion
  • mini open – arthroscopic subacromial decompression – repair of cuff through deltoid splitting approach
  • arthroscopic – exclusively arthroscopic
Treatment algorithm
Sub acromial bursitis
Arthroscopic bursectomy
Worn coracoacromial ligament
Arthroscopic bursectomy - ligament excision
Partial cuff tear
Arthroscopic bursectomy - ligament excision - acromioplasty - cuff debridement
Small/ medium full thickness tear
Mini open cuff repair
Large cuff tear
Open acromioplasty – cuff repair – coracoacromial ligament preservation

After treatment
  • repair – shoulder immobilization / abduction restriction – 6 wks
  • removed for assisted exercises in flexion and ER – to avoid adhesion, disuse therapy, disruption of the repair
  • repair weakest at 3wks
  • isometric exercises of ER – 6wks
  • active motion - 12 wks
Rotator cuff tear arthropathy
  • end stage rotator cuff disease
  • normal humeral head depression in supraspinatus in lost
  • unopposed pull leads to shearing forces across glenoid
  • articular cartilage can not resist the shearing force – degenerative changes follows
  • cartilage and bone atrophy – due to loss of fluid pressure – also due to loss of quality of chemical content of synovial fluid
X ray
  • Sourcil sign – erosion of inferior surface of acromion – due to humeral head articulation with it
  • inferior humeral osteophytes
  • loss of glenohumeral joint space
  • humeral head replacement + coracoacromial arch maintenance – hemiarthroplasty is preferred to total – shear forces lead to glenoid wear
  • reverse total shoulder arthroplasty – glenoid resurfaced with a ball – humeral head replaced with articular socket – requires a functioning deltoid
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