Many Directions. Overview of the shoulder instabilities and of their patho anatomy. Four «basic contributors» And two joints
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1 Overview of the shoulder instabilities and of their patho anatomy. Olivier GAGEY, MD, PhD Paris- South University Many Directions Antero inferior Posterior Antero superior Superior Multidirectional Voluntary the most frequent much less frequent the most unknown and rare it is a cuff problem only! motor control trouble, the less surgery, the best never propose surgery! Four «basic contributors» Bones Ligaments * Muscles Motor control system (including scapula) And two joints Scapulohumeral joint And Scapulothoracic joint * * Involved through motor control system troubles. Never forget it! 1
2 Regarding the ligaments Never forget that the ligaments play a double function : 1) primary passive stabilization AND 2) recruitment of muscles through the motor control system = a ligament doesn t work alone Bone only Glenoïd : At least 16 % of the surface of the glenoïd (E. Itoi). Notch of the head : Obvious in posterior instability. Much less clear in antero inferior. Large cuff tears create basically a superior instability! Muscle only Deltoïd palsy may lead to inferior instability Muscle only 2
3 Ligament only Traumatic antero inferior instability, without substantial bony lesion, may be explained by pure ligament lesion (post traumatic laxity). Motor Control only Motor control trouble is the base of MDI, of atraumatic dislocation and of voluntary dislocation. Single causes Motor Control Bone Muscle Ligament system A traumatic MDI Cuff tear Glenoid loss > 16% Anterior Head notch Deltoïd palsy Post traumatic laxity Or voluntary D (2 tendons) Anteroinferior Anteroinferior Posterior instability Any direction! Superior instability Inferior instability instability instability Single causes but not necessarily simple problems! But! Even in traumatic antero inferior instability, we all know patients with bilateral problems, and families with trend toward shoulder instability. We do consider (and fear) a multi factorial origin even in absence of evidence! 3
4 A constant factor R- 45 test The Inferior glenohumeral ligament laxity is constant in Antero Inferior instability! Study both MGHL and upper subscapularis A positive Hyperabduction test (> 90 ) is always present in anteroinferior instability Posterior capsule can t be tested alone! Posterior test This test involves posterior capsule AND external rotator muscles FuncZon of the ligaments of SHJ anatomical evidences Movement Lateral rotation R0 Passive abduction R 45 Retropulsion Restricted by Coracohumeral ligament alone Inferior glenohumeral ligament alone Both MGHL and Upper subscapularis Both posterior capsule and external rotators Ms. 4
5 What does sulcus sign mean? In cadaver the humeral head stays in its normal posizon. A_er opening the capsule the humeral head migrates inferiorly unzl 3 cm No ligaments are tensed in the reszng posizon What does sulcus sign mean? Sulcus doesn t demonstrate any ligaments laxity at all! Sulcus sign belongs to muscle paberning! Anteroinferior Instability Anterosuperior instability The importance of the Bankart lesion is highly variable. Experimental Bankart lesion doesn't provide any instability! This means that laity is the constant factor in anteroinferior instability. Rare and difficult to treat. Utility of the R 45 test that is always positive (> 15 ) 5
6 Antero superior instability The R 45 test asses both MGHL and upper part of the subscapularis Instead of a triangle (Stanmore).. (non structural) The arm is hold at 45 elevation in the scapular plane, then gently provide passive external rotation and then measure. I would propose a pyramid! (structural) The more the laxity the less the trauma! Antero inferior instability Antero inferior instability Antero inferior instability is the sum of post traumatic ligament laxity and of constitutional hyperlaxity and of other factor like trouble of motor control system. We still don t know where is the amount of associated hyperlaxity that leads to increased rate of failure after surgery. The more the constitutional hyperlaxity, the less the traumatism!? 6
7 Conclusion We have the logical and useful tools to asses both anteroinferior and anterosuperior instabilities. For other cases we lack of evidences for the clinical diagnosis. Take Home! Hyperabduction test normal : can t be an anteroinferior instability! R-45 test positive : look at the anterosuperior instability! Presence of constitutionnal hyperlaxity look at the scapula dysfunction! Thank You! London Interna+onal Shoulder Symposium 18 October 2014 Just look at the left arm position! 7
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