1. Mr. T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital Redhill

2.  Anatomy  Diagnostic clues  Examination  Investigations (X-ray indications)  Injection- indications & techniques  Referral to Orthopaedic Specialist  Red flag signs  Surgical procedures performed

16.  AGE  10-35 yrsInstability  30-50 yrsAC joint disease  40-60 yrsFrozen Shoulder  >60 yrsGH arthritiis  35-75 yrsRotator cuff disease

17.  HISTORY  Pain on overhead activitiesImpingement  Night PainRotator cuff disease, GH arthritis, Frozen shoulder  Dead armInstabiltiy  TraumaRotator cuff tear, Fracture Diagnostic Clues

18. LOCATION OF PAIN Rotator cuff disease 1. Under deltoid 2. Side of arm 3. Front of arm

19. Pain in the shoulder blade area (location 4) is usually muscular or nerve related

20. Obvious deformities AC joint subluxation Scapula winging

21. Wasting of supraspinous and infraspinous fossae Long head of biceps rupture Obvious deformities

22.  SUPRACLAVICULAR FOSSA  NEUROLOGICAL EXAMINATION  VASCULAR EXAMINATION

23. CERVICAL SPONDYLOSIS

24. CERVICAL SPINE FRACTURE AND TUMOUR

25. ACTIVE/PASSIVE

26.  DELTOID FUNCTION  SUPRASPINATUS FUNCTION  TERES MINOR/INFRASPINATUS FUNCTION  DROP SIGN  SUBSCAPULARIS FUNCTION 1. GERBER’S LIFT OFF TEST 2. NAPOLEON’S BELLY PRESS TEST  BICEPS TENDON 1. YERGASSON’S TEST 2. SPEED’S TEST

27. Abduction in scapular plane

28. ELBOW AT 90 DEGREES Ext. Rotation against resistance

30. GERBER’S LIFT OFF TEST BELLY PRESS (NAPOLEON’S) TEST

31. SPEED’S TEST

32. NEER’S IMPINGEMENT TEST GREAT CAUTION! IN YOUNG PATIENTS CLOSELY EVALUATE FOR SIGNS OF INSTABILITY, THE MOST LIKELY CAUSE OF IMPINGEMENT

33. Why do we need X-rays?  Frozen Shoulderto exclude other pathology  Rotator cuff disease ◦ ImpingementSclerosis GT and Acromion ◦ Cuff tearSuperior migration of humerus(+/-) ◦ Cuff arthropathyHumero-acromial articulation  InstabilityHill Sachs lesion  Glenohumeral OA  AC joint dislocation / OA

34.  ACJ arthritis  Acromial spur

35. OSTEO ARTHRITIS ROTATOR CUFF ARTHROPATHY

36. PATHOLOGICAL FRACTURE CALCIFICATION

37.  Ultrasound (one stop clinic)  MRI  Arthrogram  CT Scan  EMG  Bone Scan  ARTHROSCOPY

38.  Rest  NSAIDs / Analgesia  Physiotherapy  Steroid Injection Frozen shoulder Calcific tendinitis Impingement syndrome AC joint disease Glenohumeral arthritis Treatment at Primary Care

39.  Diagnostic  Subacromial impingement  Acromioclavicular joint pain  Aspiration  Therapeutic  Subacromial impingement  Rotator cuff tendinitis / Bursitis  Calcific tendinitis  Glenohumeral OA  Long head of biceps tendinitis  Frozen Shoulder  AC joint arthritis

40. a) Subacromial space b) Glenohumeral joint

41. Injection techniques Subacromial space  Palpate the posterolateral corner of acromion  1-2 cm below and medial to point  Needle directed towards the coracoid process

42. Glenohumeral joint  Palpate the coracoid process  1-2 cm below and lateral to point  Needle directed towards the joint

43.  Failure of conservative treatment for 6 months  Signs & Symptoms of INSTABILITY  Suspected ACUTE ROTATOR CUFF TEAR  Uncertain diagnosis  Red flags

44.  Infection: red hot skin, pyrexial, systemically unwell  Unreduced dislocation: h/o trauma/fit/electric shock, abnormal contour, loss of movements  Acute rotator cuff tear: acute onset pain and weakness, recent trauma, drop arm sign  Tumour: S/S of cancer, h/o cancer, abnormal mass, swelling or deformity  Neurological: severe sensori-motor deficit, unexplained muscle wasting.

45. Subacromial Impingement Subacromial decompression

46.  RECONSTRUCTIVE ANTERIOR STABILISATION

47. Surface replacement Total shoulder replacement

48. Reverse Delta Shoulder replacement