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Shoulder and humerus

Jennifer A. Hart

Anatomy of joint

Bones: Figures 2-1 through 2-3

Figure 2-1. The scapula. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 8.)

Figure 2-2. The clavicle. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 9.)

Figure 2-3. The humerus. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 11.)

Ligaments: Figures 2-4 and 2-5

Figure 2-4. The glenohumeral joint. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 13.)

Figure 2-5. The acromioclavicular (AC) joint. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 13.)

Muscles and tendons: Figure 2-6

Figure 2-6. A to D, The muscles of the shoulder and upper arm. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 15.)

Nerves and arteries: Figures 2-7 through 2-9

Figure 2-7. The brachial plexus. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 16.)

Figure 2-8. Major branches of the brachial plexus in the upper arm. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 17.)

Figure 2-9. Arteries of the shoulder and upper arm. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 18.)

Surface anatomy: Figure 2-10

Figure 2-10. A to C, Surface landmarks and underlying anatomy of the shoulder. (From Miller MD, Chhabra AB, Hurwitz SR, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 20.)

Normal radiographic appearance: Figure 2-11 A-C

Figure 2-11. Normal shoulder radiographs. A, Anteroposterior view. B, Outlet view. C, Axillary view.

Physical examination

Inspect for deformity or muscle atrophy.

Palpate the specific structures to evaluate for deformity or tenderness:

• Acromioclavicular (AC) joint

• Glenohumeral joint

• Scapula body

• Coracoid process

• Biceps tendon/bicipital groove

Normal range of motion (ROM): Table 2-1

Table 2-1.

Normal Shoulder Range of Motion

Forward Flexion	180 degrees
Abduction	180 degrees
External Rotation	90 degrees
Internal Rotation	90 degrees

Special tests

Neer impingement sign

 Tests for shoulder impingement

 Performed by fully passively forward flexing the shoulder

 Positive test indicated by pain in this position

Hawkins impingement sign

 Tests for shoulder impingement

 Performed by passively forward flexing the shoulder to 90 degrees and internally rotating with the elbow flexed.

 Positive test indicated by pain in this position

Cross-body adduction test

 Tests for AC joint dysfunction (e.g., osteolysis, shoulder separation, arthritis)

 Performed by passively moving the arm into maximum adduction across the body

 Positive test indicated by pain over the AC joint in this position

Supraspinatus stress test

 Tests for rotator cuff abnormality (e.g., impingement or tear)

 Performed by having the patient hold the arm in 90 degrees of abduction and the thumb pointed down to the floor while holding against downward resistance by the examiner

 Positive test indicated by weakness and/or pain

Drop arm sign

 Tests for rotator cuff tear, usually massive

 Performed by having the patient hold the arms with the shoulder abducted to 90 degrees with the thumbs down

 Positive test indicated by an inability to hold the arm in this position

External rotation strength

 Tests for rotator cuff tear (infraspinatus)

 Performed by asking the patient to hold the arm against the side with the elbow in 90 degrees of flexion and externally rotating against resistance from the examiner

 Positive test indicated by weakness

Lift-off test

 Tests for rotator cuff tear (subscapularis)

 Performed by asking the patient to internally rotate the arm to allow the dorsum of the hand to rest just off the back and then to hold that position against resistance by the examiner

 Positive test indicated by weakness

Belly press test

 Tests for rotator cuff tear (subscapularis); alternative to lift-off test for patients unable to position their arm behind their back

 Performed by asking the patient to use the heel of the hand and press it into his or her abdomen while holding the elbow forward

 Positive test indicated by an inability to hold the elbow forward, thus allowing it to drift back to the side

Sulcus sign

 Tests for general shoulder laxity

 Performed by applying downward force on the humerus

 Positive test indicated by the appearance of a “gap” between the humeral head and the acromion

Apprehension test

 Tests for shoulder instability (anterior)

 Performed by asking the patient to lie supine while the examiner passively moves the shoulder into an abducted and externally rotated position

 Positive test indicated by “apprehension” on the part of the patient as he or she feels the shoulder slide anteriorly

Relocation test

 Tests for shoulder instability

 Performed by first doing an apprehension test and, after obtaining a positive response, applying a posterior force to the humeral head with the examiner’s other hand

 Positive test indicated by relief of the “apprehension”

Jerk test

 Tests for posterior shoulder instability

 Performed by abducting the arm to 90 degrees, internally rotating it, and applying an axial load to the shoulder while adducting the arm

 Positive test indicated by a sudden jerk as the humeral head slides over the edge of the glenoid

O’brien test

 Tests for superior labrum anterior to posterior (SLAP) tear

 Performed by having the patient hold the arm in 90 degrees of forward flexion and 10 to 20 degrees of adduction with the thumb down then resisting a downward force to the arm applied by the examiner; test repeated with the thumb up

 Positive test indicated by pain, which should be worse with the “thumb down” position; if pain present also in the “thumb up” position, may indicate an AC joint problem

Differential diagnosis: Table 2-2

Table 2-2.

Differential Diagnosis

Anterior shoulder pain	Shoulder impingement Biceps tendinitis Arthritis Rotator cuff tear Instability Labral tear
Posterior shoulder pain	Periscapular muscle pain Posterior instability Cervical radiculopathy Posterior labral tear Subscapular bursitis Scapula fracture
Superior shoulder pain	Acromioclavicular joint osteolysis Acromioclavicular joint arthritis Clavicle fracture Shoulder (AC) separation Superior labral tear
Arm pain	Humerus fracture Rotator cuff tear Shoulder impingement Cervical radiculopathy

Shoulder impingement

History

 Overuse, repetitive activity

 Shoulder pain, worse with overhead lifting or reaching, can radiate to lateral upper arm (deltoid area)

Physical examination

 May be tender anteriorly

 ROM typically normal (if not, suspect adhesive capsulitis)

 Positive Hawkins and/or Neer impingement signs

 May have weakness secondary to pain with abduction or supraspinatus strength testing

Imaging

 Anteroposterior (AP), axillary, outlet commonly used “standard” radiographic views

Radiographic image: Figure 2-12A and B

Figure 2-12. Subacromial spur of the shoulder. A, Anteroposterior view. B, Outlet view.

Initial treatment

Patient education

 Shoulder impingement is part of the spectrum of rotator cuff injury. Generally, in the early stages this involves inflammation (bursitis and rotator cuff tendinitis) without actual tearing of the tendon. Partial tears can develop over time and can progress to a full-thickness tear. If symptoms do not improve with early treatment, call the office because a magnetic resonance imaging (MRI) scan may be necessary to evaluate for a rotator cuff tear.

First treatment steps

 Begin general antiinflammatory measures including nonsteroidal antiinflammatory drugs (NSAIDs), ice, and activity modification.

 Perform subacromial steroid injection.

 Begin physical therapy that emphasizes rotator cuff strengthening exercises.

 If symptoms persist despite injection and physical therapy, consider ordering an MRI scan with an arthrogram of the shoulder to evaluate the integrity of the rotator cuff.

 Use of a sling is generally discouraged because this can lead to shoulder stiffness and adhesive capsulitis.

Treatment options

Nonoperative management

 Nonoperative management is indicated if the patient has pain without evidence of a full-thickness rotator cuff tear (night pain, weakness on examination, history of recent shoulder dislocation in patient over the age of 40 years).

 Treatment generally begins with the addition of NSAIDs and/or subacromial steroid injection.

 Physical therapy and/or a home program with Thera-Bands should be started to focus on rotator cuff strengthening.

 Work restrictions may be necessary if the patient has a job that involves repetitive activity or overhead reaching with the affected arm, to prevent repeat aggravation of the inflammation.

 Prognosis for shoulder impingement is good with these nonsurgical treatment options.

 Generally the patient should be reevaluated in 6 weeks to check ROM and strength.

 Failure to improve at that point may warrant further evaluation of rotator cuff integrity with an MRI arthrogram.

 Generally, failure to improve with one to two subacromial injections and a minimum of 6 weeks of physical therapy should prompt referral to a surgeon to consider surgical options for shoulder impingement.

Operative management: Subacromial decompression

Codes

ICD-9 code: 726.10 Shoulder impingement, disorders of the bursae and tendons in the shoulder region, unspecified

CPT codes: 29826 Arthroscopic acromioplasty (Shoulder arthroscopic decompression of the subacromial space with partial acromioplasty, with or without coracoacromial release)

23130 Open acromioplasty (acromioplasty or acromionectomy, partial with or without coracoacromial ligament release)

Operative indications

 Shoulder pain that has failed to improve with nonoperative treatment including subacromial injection and physical therapy

 Absence of other potential causes of shoulder pain such as cervical radiculopathy

Informed consent and counseling

 Routine surgical risks should be discussed with the patient (infection, bleeding, bruising, surgical pain, continued symptoms, and anesthesia complications).

 If your institution routinely uses nerve blocks as part of postoperative pain management, the expected duration of action of these blocks should be discussed.

 Generally, the patient is expected to be in a sling for up to 2 weeks, and use of the sling is discontinued based on patient comfort.

 Physical therapy is generally expected after surgery for approximately 6 weeks.

 Informed consent should include the possibility of rotator cuff repair if an unexpected tear is discovered at the time of surgery because this could lead to a longer recovery time (6 weeks in a sling and an average of 12 weeks of physical therapy).

Anesthesia

 General anesthesia with or without nerve block

Patient positioning

 Beach chair or lateral decubitus (surgeon preference)

Surgical procedures

 Arthroscopic acromioplasty

 Open acromioplasty

Arthroscopic acromioplasty:

 The posterior portal is first created as the primary viewing portal for the arthroscope, followed by the anterior portal (working portal) for instruments.

 Diagnostic arthroscopy should be performed before the initiation of any procedure, with careful evaluation of the glenohumeral joint, labrum, biceps tendon, rotator cuff, and joint capsule.

 Placing the camera in the posterior portal and directing it superiorly allows visualization of the subacromial space.

 A lateral portal can be made to pass instruments for the acromioplasty.

 Electrocautery or radiofrequency devices may be superior to routine arthroscopic shavers because they help to control bleeding as the highly vascular bursa is débrided.

 After the bursa is adequately débrided, the coracoacromial ligament is cut, and an arthroscopic bur is used to remove impinging bone from the inferior surface of the acromion.

 Adequate bony resection should be confirmed before removing the arthroscope and closing the portals.

Estimated postoperative course

 Initial postoperative visit (7 to 14 days)

• Suture removal

• Physical therapy orders

• Pain medication refill, if necessary

• Discontinuation of sling as tolerated

• Review of work status, light duty desk work generally for 6 weeks

 6-week postoperative visit

• Evaluate wound healing, ROM, and strength.

• Determine the need for additional physical therapy.

• Review the return to work plan.

 12-week postoperative visit (optional)

• Generally only if pain is persistent, motion is limited, or reevaluation of work status is needed

Suggested readings

Mazzocca AD, Alberta FG, Cole BJ, et al: Shoulder: patient positioning, portal placement, and normal arthroscopic anatomy. In Miller MD, Cole BJ, editors: Textbook of arthroscopy, Philadelphia, 2004, Saunders.

Miller MD, Hart JA, MacKnight JM, editors: Essential orthopaedics, Philadelphia, 2010, Saunders.

Willenborg MD, Miller MD, Safran MR: Shoulder arthroscopy. In Miller MD, Chhabra AB, Safran MR, editors: Primer of arthroscopy, Philadelphia, 2010, Saunders.

Rotator cuff tears

History

 Pain is located in the anterior and lateral shoulder.

 Pain frequently radiates to the deltoid area, but not usually below elbow.

 Tears are generally atraumatic, with progression of pain and weakness over time.

 They may be related to an acute trauma (e.g., fall on the outstretched hand).

 Waking at night is one of the frequently described symptoms.

 The patient may or may not complain of weakness in that arm.

Physical examination

 Active ROM may be limited, but passive ROM is generally full.

 Hawkins and Neer impingement signs may or may not be present.

 The drop arm sign (inability to hold the arm in an abducted position against gravity) indicates a likely massive rotator cuff tear.

 The supraspinatus stress test (weak with resisted abduction) is positive.

 Weakness with resisted external rotation indicates involvement of the infraspinatus.

 A positive lift-off or belly press sign indicates involvement of the subscapularis.

 A positive O’Brien sign indicates involvement of the biceps tendon.

Imaging

 Plain radiography should include AP, axillary, and outlet views.

 An MRI scan with arthrogram is the “gold standard” for diagnosing and evaluating the extent of rotator cuff disease (Fig. 2-13).

Figure 2-13. Complete tear of the supraspinatus tendon (arrow). (From Miller MD, Sanders TG, editors: Presentation, imaging, and treatment of common musculoskeletal conditions: MRI-arthroscopy correlation, Philadelphia, 2012, Saunders, p 41.)

 A computed tomography (CT) arthrogram may be necessary for patients who are unable to undergo MRI (e.g., patients with a pacemaker).

Classification system

 Rotator cuff tears are typically described by the number of tendons involved, the size of the tear, the amount of tendon retraction, and the degree of fatty atrophy of the rotator cuff muscles.

 Partial tears are commonly seen in patients who are more than 40 years old and may or may not be symptomatic. It is helpful to determine the percentage of involved tendon with MRI to determine treatment.

 Complete rotator cuff tears should be described by the number of involved tendons and the amount of retraction.

 Massive tears are generally defined as those involving two or more tendons and retracted more than 5 cm.

 Rotator cuff arthropathy denotes massive, retracted, chronic rotator cuff tears that are generally considered irreparable.

• These patients are significantly weak on examination and may demonstrate a drop arm sign.

• Diagnosis can be made by plain radiographs when proximal migration of the humeral head relative to the glenoid is seen (Fig. 2-14).

Figure 2-14. Radiologic appearance of rotator cuff arthropathy. Note superior migration of the humeral head.

 At the time of arthroscopy, rotator cuff tears can further be described by the shape of the tear (e.g., U-shaped tear).

Initial treatment

 Initial treatment is determined by the size of the rotator cuff tear.

 Partial rotator cuff tears involving less than 50% of the total tendon area may respond well to conservative treatment including NSAIDs, subacromial steroid injections, and physical therapy.

 High-grade partial rotator cuff tears (involving >50% of the total tendon area) may be treated conservatively but may require surgical repair. This decision is determined by the degree of the patient’s pain and dysfunction and the severity of the tear (for a 60% tear, an attempt at conservative treatment is more likely, whereas a 90% tear may suggest the need for earlier operative intervention).

 Complete rotator cuff repairs should be treated with surgery in most cases.

Patient education

 Rotator cuff tears occur as a spectrum of injury ranging from tendinitis to partial tearing to complete tear to irreparable tear.

 Complete tears of the rotator cuff require surgery to repair the tendon.

 Patients should use the shoulder normally to maintain ROM but avoid repetitive overhead activities and heavy lifting.

First treatment steps

 Complete rotator cuff tears should be referred to a shoulder surgeon.

 Although surgical treatment is not urgent, ideally surgery occurs in the first 1 to 3 months of diagnosis because of the risk of tendon retraction with longer delays.

 The use of a sling should be avoided because this can lead to the development of adhesive capsulitis.

Treatment options

Nonoperative management

 Nonoperative management typically is reserved for partial, low-grade rotator cuff tears.

 NSAIDs, subacromial steroid injections, and physical therapy effective in managing pain and improving function.

 Patients should be instructed to follow up for a new evaluation if conservative treatment does not improve symptoms in 6 to 8 weeks.

 MRI arthrogram, if not already performed, may be necessary at that point to evaluate for a full-thickness rotator cuff tear.

Operative management: Rotator cuff repair

Codes

ICD-9 code: 727.61 Complete rupture of the rotator cuff

CPT code: 29827 Arthroscopy, shoulder, with rotator cuff repair

Operative indications

 Complete tear of the rotator cuff

 High-grade partial tear of the rotator cuff

 Partial rotator cuff tear that has failed to improve with conservative treatment

Informed consent and counseling

 Routine surgical risks should be discussed with the patient (infection, bleeding, bruising, surgical pain, continued symptoms, and anesthesia complications).

 If your institution routinely uses nerve blocks as part of the postoperative pain management, the expected duration of action of these blocks should be discussed.

 Generally, the patient is expected to be in a sling for approximately 6 weeks postoperatively.

 Physical therapy is generally started after the first postoperative appointment and continued for 12 weeks.

 Return to full function can take 6 to 12 months.

Anesthesia

 General, often with accompanying nerve block

Patient positioning

 Beach chair or lateral decubitus (surgeon’s preference)

Surgical procedures

 Arthroscopic rotator cuff repair

 Open rotator cuff repair (may be used based on the surgeon’s experience or because of massive tears in which adequate repair cannot be obtained arthroscopically)

Rotator cuff repair:

 For arthroscopic repair, the posterior portal is first created as the primary viewing portal for the arthroscope, followed by the anterior portal (working portal) for instruments.

 Diagnostic arthroscopy should be performed before the initiation of any procedure, with careful evaluation of the glenohumeral joint, labrum, biceps tendon, rotator cuff, and joint capsule.

 For open repair, an incision is made in the anterior aspect of the shoulder lateral to the acromion along the Langer lines; access to the joint capsule is gained through the deltoid either by splitting the fibers (traditional open approach) or detaching it from the acromion (mini-open approach).

 Acromioplasty is typically performed as described earlier.

 The rotator cuff is evaluated to determine the degree of tear, the shape of the tear, and retraction.

 Partial-thickness tears of less than 50% can be débrided with the shaver rather than repaired.

 Full-thickness tears and high-grade partial tears must be mobilized and repaired.

 Arthroscopic repair is performed by passing sutures through the cuff tissue and directly repairing it to the bone by suture anchors.

 Margin convergence may be necessary before direct repair of tendon back to bone in the case of L-shaped or U-shaped tears (Fig. 2-15).

Figure 2-15. A to C, Margin convergence technique. IS, infraspinatus; SS, supraspinatus. (From Miller MD, Cole BJ: Textbook of arthroscopy, Philadelphia, 2004, Saunders.)

 Sutures are then passed either in antegrade or retrograde fashion and are secured to suture anchors placed in the footprint (single row, double row, suture bridge technique, as preferred by the surgeon).

 In open repair, direct suture repair to bone is performed by passing sutures through bone tunnels and then tying knots.

 Sutures are tensioned, and the repair is examined before irrigation and closure of the portals and/or incision.

Estimated postoperative course

 Initial postoperative visit (7 to 14 days)

• Suture removal

• Physical therapy orders given to focus on passive ROM of the shoulder only

• Pain medication refill, if necessary

• Continued use of sling removing only for pendulum exercises and elbow motion

• Review of work status; light duty desk work begun as tolerated by patient, with no use of surgical arm

 6-week postoperative visit

• Evaluation of wound healing, ROM, and strength

• New physical therapy orders to begin active-assisted ROM, active motion, and gentle early rotator cuff strengthening exercises

• Removal of sling

• Light duty work continued for a minimum of 6 additional weeks

 12-week postoperative visit

• Evaluate the progression of ROM and strength.

• Determine the need for additional physical therapy.

• Discuss the return to work plan.

Suggested readings

Miller MD, Hart JA, MacKnight JM, editors: Essential orthopaedics, Philadelphia, 2010, Saunders.

Morse K, Davis AD, Afra R, et al: Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis, Am J Sports Med 36:1824–1828, 2008.

Willenborg MD, Miller MD, Safran MR: Shoulder arthroscopy. In Miller MD, Chhabra AB, Safran MR, editors: Primer of arthroscopy, Philadelphia, 2010, Saunders.

Wolf BR, Dunn WR, Wright RW: Clinical sports medicine update: indications for repair of full-thickness rotator cuff tears, Am J Sports Med 35:1007–1016, 2007.

Shoulder instability

History

 Shoulder instability may be traumatic or atraumatic.

 Traumatic shoulder dislocations most commonly occur with the shoulder in an abducted and externally rotated position causing immediate pain, shoulder deformity, and loss of motion.

 Patients may report a “dead” arm syndrome resulting from transient traction on the brachial plexus or the axillary nerve.

 Atraumatic shoulder instability may be more vague, with pain or subluxation events during activity such as overhead throwing or swimming.

 It is important to differentiate dislocation from subluxation during the history, as well as the number of episodes (acute, recurrent).

 Other causes of shoulder dislocation include seizure disorders and electric shock (posterior dislocation).

 Hyperligamentous laxity can predispose to instability, as can a history of such conditions as Ehlers-Danlos syndrome or Marfan syndrome.

Physical examination

 Acute dislocations produce deformity and loss of motion.

 Decreased sensation occurs over the “deltoid patch” initially and resolves with time.

 Apprehension and relocation tests are positive.

 A positive sulcus sign with inferior instability, often bilateral, indicates multidirectional instability.

 A positive supraspinatus stress test may indicate an associated rotator cuff tear in patients who are more than 40 years old.

Imaging: Figures 2-16 and 2-17

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