Intraarticular
Extraarticular
Asperity of articulating surfaces (humeral head/glenoid)
Adhesions in subacromial space
Rigid capsule
Adhesions in subcoracoidal space
Tight coracohumeral ligament
Non-anatomic healing of fragments
Atrophy, fatty degeneration, and rigidity of rotator cuff muscles
Intraarticular reasons for stiffness are first of all asperity of the articulating surfaces such as regional flat areas of the humeral head following posttraumatic necrosis or bony defects of the glenoid due to screw cut-out of locking plates, etc. However, stiffness of the shoulder joint is significantly more caused by surrounding soft tissue problems especially regarding the capsule. The capsule might show inflammatory changes, might be thickened, scarred, and rigid preventing movements in the corresponding direction. Especially the inferior portion of the capsule connecting the inferior glenoid and the inferior anatomical humeral neck may present a diameter of 1 cm or even more resulting in very effectively blocked elevation and rotation.
There are numerous extraarticular reasons for stiffness of the shoulder joint, such as scars and adhesions within the subacromial and subdeltoid space. For fractures involving the minor tuberosity scar formation and adhesions between the posterior portion of the short flexor muscles originating from the tip of the coracoid and the anterior surface of the subscapularis muscle are quite typical. In addition, the superior surface of the coracoid is covered by the coracohumeral ligament spreading out into the rotator cuff interval. In this context Mengiardi et al. [9] reported on a 59 % sensitivity and a 95 % specificity in patients suffering from a frozen shoulder syndrome in case the coracohumeral ligament reached a diameter greater than 4 mm, nicely demonstrated on sagittal MR images. In conclusion the described high specificity of a thickened coracohumeral ligament might presumably be true also for cases of posttraumatic shoulder joint stiffness.
In case a more or less dislocated fracture of the greater or minor tuberosity occurs this fracture might not necessarily heal physiologically in its original anatomical position.
As long as the dislocated fragments are within the course of the force vector of the respective tuberosity, only active motion exerted by that tuberosity is limited, but does not influence the passive range of motion. A typical example is the case of a formally dislocated fracture of the greater tuberosity being healed but not in its correct or adequate anatomical position but distinctly medially dislocated in refer to its original anatomy however still connected to the humeral head.
The scenario changes quite dramatically if the fragment is displaced in an inferior direction meaning that the major or minor tuberosity is healed in a non-anatomical position inferior to the surgical neck of the proximal humerus. Any other but anatomic positioning of the tuberosities is disadvantageous since the malpositioning does not only limit rotation but especially elevation due to the passive adductive force deriving from the tuberosity displaced in this way.
The intra- as well as extraarticular reasons for posttraumatic stiffness discussed so far have the distinct advantage of being treatable in one way or the other. However, there exists another extraarticular reason for stiffness of great importance, but very difficult to treat regarding changes of the rotator cuff muscles and also the deltoid muscle in terms of atrophy, fatty degeneration, and rigidity. Up to date it is still not quite understood, why this type of stiffness occurs very often in case of humeral head fractures. The definitely necessary immobilisation of the shoulder in the course of fracture treatment certainly favours atrophy and/ or inactivity of these muscles although this explanation presents only a part of the truth, however. From several studies [2] in the literature it is known that up to 30 % of all cases with humeral head fractures cause dysfunction of the axillary nerve as well as of the plexus, which may be another explanation for the disorders of the muscles involved, and it may also explain why treatment takes longer than in simple proximal humeral fractures.
Clinical Findings
In order to assess patients suffering from posttraumatic stiffness, fracture anamnesis and the treatment performed have to be evaluated. For the further clinical evaluation active and passive range of motion in external and internal rotation, abduction and flexion need to be assessed. In addition, active and passive external and internal rotation in 90° abduction of both shoulders should be tested for comparison reasons.
However, it is not only important to be able to define the extent of limited motion, but also important to get an idea whether these limits are reached abruptly with hard impact or gradually with a smooth end-point. The latter mentioned type is better tolerated by the patients, possibly resulting from scars, which can resolve in the course of time and appropriate conservative treatment. Another point of utmost importance is the fact that stiffness mostly does not only stand for restricted passive range of motion, but also for a painful restriction of motion. In this context it should be mentioned that many patients tolerate a global restriction of their shoulder motion quite well as long as it is painless, but even moderate stiffness is not well tolerated, if associated with pain.
The shape of the humeral head as well as of the glenoid is easily evaluated on radiographs possibly performed in three directions in terms of true a.p., transscapular, and axial. If 90° abduction can not be performed by the patient due to pain, adequate axial radiographs can not be assessed so that the so-called Velpeau view presents an option. If these x-rays are not conclusive or if there are decisions to take regarding therapy, a ct scan is mandatory including 3D-reconstructions. If the bony anatomy turns out to be normal using these imaging techniques, a MR exam may be useful in order to assess the rotator cuff including the condition of the respective muscles. In addition, thickened parts of the capsule and ligaments may be identified especially if contrast agent is administered either in terms of intravenously or intraarticularly [9].
Treatment
The very best treatment of shoulder joint stiffness following humeral head fractures is to avoid it from the very beginning. However, this presents a challenge, since not all factors contributing to stiffness are known [14], and factors like the severity of the initial injury cannot be controlled. Another factor at least difficult to influence is the compliance of the patient regarding rehabilitation, physiotherapy and self-mobilisation. One very important factor and probably the only one easily managed by the treating surgeon, however, is the duration of immobilisation, also presenting the principal consideration provided by the AO (Arbeitsgemeinschaft Osteosynthesis) in their recommendations to reduce risk of stiffness [6]:
immobilisation should be discarded as soon as possible in a progressive way beginning with eliminating the swath (circumferential bandage) during day time and encouraging pendulum exercises.
sling-usage on a part-time basis as soon as appropriate.
physical therapy should be considered for any patient with non-improving range of motion as expected.
However, a shortening of the duration of immobilisation always threatens the stability of the fracture. If the immobilisation phase is chosen too short, the risk of secondary fracture displacement increases, as well as the risk for pseudoarthrosis development. Therefore the treating surgeon has to create individual treating concepts with a distinct description of which movements in which direction are allowed at what time point always taking fracture stability in account. The individual treatment plan is the basis on which the physiotherapist as well as the patient himself has to rely on. The stability of the fracture needs to be re-evaluated every week, and treatment may accordingly be modified or even changed from conservative to operative treatment depending on the progress of fracture healing.
In case the prophylactic measures were not effective and the shoulder became stiff despite, the treatment to be performed depends on the underlying pathology described previously (see Table 24.1). However, even considerable amount of stiffness does not necessarily enforce surgery, as long as the patient still achieves improvement in motion. In this context the problem of differentiating stiffness due to underlying pathology from stiffness with chances of dissolving with time and patience needs to be mentioned. Nevertheless, there are also patients with failed conservative treatment, long-term residual pain and limited range of motion [1]. These individuals may benefit from operative intervention. There are no generally accepted rules on how to manage operative intervention of shoulder stiffness so that the author’s preferred decision making in shoulder stiffness treatment is described:
patients with proximal humeral fractures treated conservatively or surgically with intact articular surfaces and non-displaced fragments should undergo a minimum of 6 months of rehabilitation. In this context it should be mentioned that it is better evaluated if fragments are displaced in the area of the surgical neck of the proximal humerus compared to both tuberosities. Especially the major tuberosity is crucial, where displacement of more than 3 mm may be too much to be compensated for.Related posts:
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