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Acute Shoulder Trauma: Snap, Crack and Pop - Nicholas Colyvas, MD
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Acute Shoulder Trauma: Snap, Crack and Pop - Nicholas Colyvas, MD
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Language: EN.
Segment:0 .
NICHOLAS COLYVAS: Thank you, everyone for being here.
NICHOLAS COLYVAS: Hopefully you've had some coffee and are going to be able to stay awake for the next 25 minutes or so. I'm going to be talking about acute shoulder trauma. A snap, crackle and pop. As a little bit of a sort of contrast to what we have a lot is chronic shoulder pain. We're going to talk a little bit more about acute shoulder pain and I don't have any disclosures for this talk. But, you know, what I want to say is that pretty much everyone in this room, whoever you are and whatever you do for a living, is going to end up seeing somebody for a shoulder problem
NICHOLAS COLYVAS: so I'm sure shoulders and knees are going to be a big part of your practice. And we're surgeons and and you know sort of my group here and some of the people talking to you today are surgeons and we love to do surgery and surgery is sort of what we train for and what we live for and what we enjoy. But a big part of surgery is knowing when to not do surgery, because surgery doesn't always go well.
NICHOLAS COLYVAS: So I want to talk about that to some degree. You know, what, what is, what is surgical and what is not surgical. So I think like many of the talks, we're going to go over a basic outline of of the subject, the most common trauma, excuse me, acute trauma for the shoulder, discuss the nature of the injuries and sort of the physical, the pertinent history, physical exam and imaging and go through some of the treatment options.
NICHOLAS COLYVAS: But what this is not going to be is a super comprehensive, all inclusive talk about each of these. What I want to do is focus on the pathology and some of the rationale for why we treat these the way we do, why they're surgical or not surgical, and sort of highlight what you should be looking for in the sort of primary care sports medicine world and when maybe to refer those patients to ortho. So here are our top five; rotator cuff of course, biceps, tendon ruptures pretty common, ac joints
NICHOLAS COLYVAS: we see those all the time, shoulder dislocations, most common joint to dislocate and then, of course, fractures. So we'll go through each one of these and have a, have a discussion. So let's go through rotator cuff tears first. So shoulder has a complex anatomy. It's a very versatile joint, goes in every direction. It has force and power and fine tuning in every direction and in order to do that, it's a, it's a complex ballet of dynamic forces with all these muscles.
NICHOLAS COLYVAS: And an important component of this is, of course, the rotator cuff. Four muscles, three major ones that sort of surround the shoulder, and the rotator cuff is not the power generator in the shoulder. It really is the positioning group of muscles that puts the shoulder in the best place for leverage and efficiency for your big muscles, your deltoids and your pecs and your lats to really provide the power in the shoulder. And
NICHOLAS COLYVAS: when you look at rotator cuff, of course, there's the the obvious discussion about the more chronic injuries, we're going to focus more on the acute injuries and those are generally sort of traumatic and that's a fall or a sports injury or a work injury or even an intense sort of repetitive, repetitive activity will give you an acute rotator cuff tear.
NICHOLAS COLYVAS: The presentation is generally the male older group, older age group and importantly, I think what we see commonly is this acute on chronic phenomenon. You know, many of these acute patients that we see will have had shoulder problems in the past, will have maybe had even physical therapy or cortisone injections, but have been doing reasonably well and then have a sudden acute event and oftentimes associated with a hey doc, you know, there was a tearing sensation.
NICHOLAS COLYVAS: I couldn't move my arm after that. I'd been having problems, but now it's definitely worse. And and you know, this is a subgroup we're interested in because they tend to do better if they have surgery acutely. Now many rotator cuff tears we can treat non surgically, but this acute group we would want to see earlier and potentially want to do surgery earlier. So when you see these patients and they get worked up and they have their MRIs, what you're going to see is essentially a partial tear or a full thickness tear
NICHOLAS COLYVAS: and many of the partial tears, we can treat that conservatively. The full thickness tears are the ones where you see the the clinical signs of weakness and and loss of range of motion and generally it's the supraspinatus that's the one that's the tendon that has had usually some kind of degeneration over time. That tears,
NICHOLAS COLYVAS: but the bigger tears that will zipper out into the infraspinatus, the biceps tendon can dislocate out of the groove. The subscapular can tear, you can get tear of all of these things and obviously the bigger the tear, the worse the prognosis. And these acute tears we really feel should should be seen early and get surgery early. So the chronic tears again, there's this sort of generally well recognized, try conservative treatment first and get to the point where either they get better or ultimately six months or a year, they end up getting surgery.
NICHOLAS COLYVAS: But the acute tears, I think you need to have a sort of a high level of suspicion for them and that's based mostly on the history and the physical exam. If you've got a patient who was doing well or had some mild shoulder pain and has suddenly had a change, that's a patient where you want to get that MRI earlier and we're always discussing the indications for MRI and saying, well, you know, oftentimes if you're not going to act on it, why are you getting the MRI?
NICHOLAS COLYVAS: But this is a case where MRIs are helpful and you want to certainly consider getting an MRI early to look at exactly what's going on. Also, if you don't do injections in your practice, think about actually starting to do these because they're very, very helpful in the shoulder. If you have a patient that comes in acutely, has a lot of pain in their shoulder, won't move it, you're not sure if their rotator cuffs involved.
NICHOLAS COLYVAS: You give them a subacromial injection of marcaine or lidocaine. You tell them to sit and wait. You go see another patient. You come back in the room and suddenly they say, well, I don't have any pain anymore and guess what? I can actually move my arm, it doesn't hurt.
NICHOLAS COLYVAS: And the pain is what's stopping them, not actual rotator cuff tear. So all of this improves your diagnostic accuracy. How do these tears do when we, when we do the surgery on them? Well, the acute tears definitely do better. Smaller tears definitely do better. Bigger tears particularly have a risk of retearing but interestingly, with rotator cuff tears, not all of those will end up having to have another surgery and I think that you just have to manage some expectations that oftentimes, particularly with the massive tears, it's going to be difficult to get that patient back to square one, back to their original baseline.
NICHOLAS COLYVAS: And surgery is probably the best choice for that if you're looking at an acute rotator cuff tear. Let's move on to a somewhat maybe easier topic, which is biceps tendon, OK? Biceps tendon. We're looking at the rupture of the long head. I don't think I've ever seen a short head rupture.
NICHOLAS COLYVAS: But just to remind everyone, the biceps and this is an important discussion to have with your patients too has two attachments proximally. One is the short head that goes to the coracoid and the other is the long head that runs up in the groove, comes into the shoulder joint and attaches to the labrum. And the classic story, I was doing something, I was pulling something, I was
NICHOLAS COLYVAS: trying to lift a heavy weight or something, felt a ripping sensation in my arm and then you get the classic popeye deformity is, I think, pretty common in most people have probably seen this at least more than once. And this is a clinically clinical diagnosis really. Excuse me. It's, it's not often sometimes in a big shoulder, a big arm,
NICHOLAS COLYVAS: you might not see the popeye deformity. It might not be quite as obvious. Some patients, you can see it from the minute they walk in their room. And it's generally a clinical diagnosis and it's not one that typically needs a lot of imaging studies but I think you have to be a little bit careful because the biceps tendon again, the older patient that may have had shoulder problems can be degenerative at the same time as the rotator cuff.
NICHOLAS COLYVAS: And if they have a biceps tendon rupture, there is a reasonable chance they'll have a rotator cuff tear as well. So if the patient's just saying, I have pain over here in the biceps, but actually my shoulder function is pretty good, I don't have too much pain, you probably don't need to do anything. But if you've got a patient who says, I felt that ripping sensation, my biceps is sitting down in my, by my elbow and now I can't really move my shoulder
NICHOLAS COLYVAS: and their exam is is significant for weakness. Injection or MRI is probably not a bad idea because again, that could be a rotator cuff tear hiding out there in that biceps tendon rupture. We do surgery for that for biceps tendon tears, isolated biceps tendon tears but it's not common because most of our patients, we tell them about the two attachments that they won't lose much strength.
NICHOLAS COLYVAS: There are some studies out there. They have variable amounts, but I often quote 15% loss of supination. Remember, the biceps is a, is a, is a powerful supinator not as much as a flexor of the elbow. So I often tell them you can expect maybe 10 or 15% loss in your strength. If it's a non-dominant arm, most times most patients actually this is a non surgical treatment, but certain patients we do end up doing surgery for.
NICHOLAS COLYVAS: This is just one of the studies showing loss of strength. So let's move on to the AC joint, OK. Again, a common injury by half of my rugby players have AC joint injuries often seen and AC joint injuries, it's a predominantly male, mostly trauma contact sports. I think it's a, it's a common, there are common entities but there are different types and we love to torture our residents with classifications of everything.
NICHOLAS COLYVAS: Every, every injury or joint gets some kind of a classification and we usually try and have them tell us who made the classifications but basically for the AC joint, I like using the classification system because it helps sort of give you a good idea of what the pathology is and and which ones really are sort of more concerning than others. So if you look at the the AC joint, this is the joint we're talking about here.
NICHOLAS COLYVAS: Here's your clavicle. It's really held down by two main structures. First are the AC ligaments here that hold the joint across there. And this is your conoid and trapezoid CC ligaments between the clavicle and the coronoid here. And these are the stabilizers of the AC joint. So in a type one injury, all these injuries really are a blow to the shoulder like this, where the acromion gets pushed down and the the clavicle goes up.
NICHOLAS COLYVAS: Type one, we're just looking at a little sprain of these AC ligaments. Now in a type two, more force sprain or a stretching of the CC ligaments, but the AC ligaments tear. Again, these are, it's still a stable structure so if we go back sorry, you know, no surgery for these these are these are all conservatively treated even at type two, that same thing, you might have a little elevation of the clavicle, but for the most part, it's still a stable injury that doesn't need surgery.
NICHOLAS COLYVAS: Type three, a little bit more controversial. You've now torn the AC ligaments and the CC ligaments. This one is the one where the orthopaedic conferences, there's a lot of back and forth about do we do surgery? Do we don't, do we not do surgery? Personally, the vast majority of these I do not do surgery for because you have a late surgery that you can do if it causes a problem and most of them will just have a period of time where it hurts and then it gets better.
NICHOLAS COLYVAS: And what they're left with is a fully functional shoulder with a deformity, with a bump, and I often just use the comment, do you want a bump or do you want a scar because we can do the surgery and give you a scar with no bump or you can have the bump, but the outcome is going to probably be about the same. So for me, this is a non surgical one.
NICHOLAS COLYVAS: And then we go to a type V where this thing is floating up in the breeze. It's trying to come out through the skin. That's a more obviously a surgical treatment. And if you look at the categories, of course, I've skipped type IV because this particular classification system looks at these very rare entities where the the clavicle goes into the trapezius, it gets pushed posteriorly or it gets pushed inferiorly.
NICHOLAS COLYVAS: Those are very rare. They're surgical, but it's very, very unlikely you'll see these. So for the most part, AC joints are treated conservatively. Highly active sports players in their dominant arm. You might be more aggressive or laborers to get them back earlier, perhaps, but you have to talk about the cosmetic deformity and sometimes it can be quite impressive. You can see this big bump and patient's like, well, what's going on there?
NICHOLAS COLYVAS: And you can say, well, if we're going to do surgery, it's going to be for the cosmesis and not necessarily for function. And I oftentimes will just let them wait it out a little bit and see how they do. And surgery is not without its problems. This is also one of those cases where you can have some significant complications. All right.
NICHOLAS COLYVAS: So let's move on to shoulder dislocations. Again, I think something that we we commonly see and even acutely see on the sports field when we're, when we're out there I've had a few, I've had a few of these myself. And certainly the most common joint that's injured. You have subluxations and dislocations and I think we'll talk more about dislocations. And if you're a betting person, really, you're going to bet that it's an anterior dislocation.
NICHOLAS COLYVAS: 95% of these go anteriorly but you can't count on that because certainly you've got to take a history and physical exam and try and determine what sort of direction the arm was in when it had the injury. And if you look at these, it's a it's a it's a young male disease to some degree, and then there's a sort of a another peak in the in the bimodal distribution for the, for the older patients. And the anterior ones, the most common ones are usually an external rotation force that pushes the, the humeral head out from the from the joint, rupturing the anterior labrum and the capsular structures there.
NICHOLAS COLYVAS: That's a classic Bankart lesion we talk about. And then when it comes out, it gets impacted on the rim of the glenoid and that causes the Hill-Sachs lesion you hear about, which can just be a small dent, or sometimes it looks like a shark bite out of the out of the back of the shoulder. And these are important injuries to think about some associated problems.
NICHOLAS COLYVAS: OK? So when we look at the bone injuries that come with these, some of them fracture at the same time that they dislocate, and you also have to figure out where the dislocation is. So in an ideal setting, you would have an X-ray. Now, I know practically we'll oftentimes reduce these acutely, but in an ideal setting, you need to get an axillary view on your x-rays to see where the, where the thing is dislocated and it actually post-op to make sure that it is actually in place.
NICHOLAS COLYVAS: You can be fooled by just an AP and a lateral. It doesn't necessarily show you exactly where the the humeral head is so always, always try and obtain an axillary view. In older patients with maybe a bit of sclerosis in their vessels, you've got to watch for vascular problems so always check your neurovascular status. Same thing with nerve injuries.
NICHOLAS COLYVAS: They're actually quite common. Axillary nerve patients will have some numbness over the side and so always check your neurovascular status before and after. And I think maybe one of the take homes for today is, in that older age group always be highly suspicious of a potential rotator cuff tear because there is actually a much higher association with the older patients. Younger patients,
NICHOLAS COLYVAS: it's a higher trauma force and it seems to be all imparted onto those anterior structures, the labrum and the capsule. And that seems to take most of the force. The rotator cuff is stronger in younger patients. It doesn't seem to tear. Older patients have weaker rotator cuffs and they tend to tear their rotator cuffs much more often and so you always have to have a pretty high degree of suspicion.
NICHOLAS COLYVAS: So if you have a patient who has a dislocation and is not responding well to physical therapy after they've been relocated, be aware that they may have a cuff tear and definitely order an MRI if you have any concerns. As far as the reduction techniques, I think the bottom line is there's no consensus. Have a technique that you're comfortable with if this is something you're going to do and if you're particularly if you're doing it acutely, relaxation, to me, relaxation is the whole key to the entire relocation episode.
NICHOLAS COLYVAS: So however you do that, whether it's talking sweetly to the patient or giving them drugs, if you can relax them, you can generally get it back in. And after you treat them, you know, there's various different suggestions. My protocol is usually about two weeks in a sling and then physical therapy. Again, this is particularly for the older patient who you don't want to lose their range of motion, but you have to really, really worry about the older patients and the rotator cuff tear. And younger patients,
NICHOLAS COLYVAS: what you worry about is re dislocation. And I think for some surgeons, an acute traumatic dislocation in a young patient is a surgical event even at the first time now. We tend to say, let's give it a try with physical therapy and see how they do and if they re-dislocated, OK, they've bought themselves a surgery. But it's, it's it's a high level up to 95% that will re-dislocate if they continue to be active.
NICHOLAS COLYVAS: So just something to be aware of and probably to tell the patients. I just went over that. And then the surgery is really basically repairing those anterior structures. Fractures. Common, particularly the clavicle and we've gone through a bit of a circle with how we treat clavicle fractures. When I was a resident called down to the ER, if I saw this comminuted fracture over here with butterfly pieces, here's a piece sticking down. 20 years ago now or about that,
NICHOLAS COLYVAS: I would be telling the patient, this is something you don't need surgery for and you'll probably do well and some of them end up needing surgery ultimately but I think we went through sort of a revolution with some studies showing that these patients didn't actually do that well and so then lots of clavicle fractures got surgery. Maybe most of them ended up getting surgery.
NICHOLAS COLYVAS: This one didn't get surgery and it went on to heal so they can heal without surgery. But I think our our basic basic algorithm now, we've sort of swung back a little bit in doing a little less surgery on clavicle fractures. Is that the non displaced one really do not need any surgery and that if they are displaced, if they meet certain criteria such as bayonetting of the pieces or shortening, you can sometimes see the patient has a rolled over arm.
NICHOLAS COLYVAS: If you're tenting the skin, of course that's going to need surgery and if there's significant comminution, those are probably the ones that need surgery. And always we have to be very worried about the surgery because this is what we call tiger country right under the clavicle, big veins, big nerves, big blood vessels. So surgery is, again, not without its problems and I think it's, it's always good for us to be a little bit concerned when we have the the clavicle fractures as to which ones we're going to operate on. A sort of, that sort of covers mostly the mid-shaft fractures, but a sort of more distinct entity is the, the distal clavicle fractures
NICHOLAS COLYVAS: and these are a little bit complex to consider. They also have stability issues or stability concerns there where we probably are more likely to operate on on the type two B's. And there is some sort of different types of techniques because they are unstable tears, and I think for that particular entity, if it's not a non-displaced, if it's a non-displaced with no significant comminution, probably you could just consider treating it conservatively.
NICHOLAS COLYVAS: But maybe those ones are the ones you, you want to have an opinion, an orthopedic opinion about a little bit earlier. And then the other fractures we see, of course, the the classic older female osteoporotic bone takes a fall at home and has proximal humerus fracture. These come in all types and it's, they can be quite problematic even, you know, even as surgeons, we don't look at these cases as easy cases.
NICHOLAS COLYVAS: When you have to do the open reductions and internal fixations on these patients, they're difficult.
NICHOLAS COLYVAS: And I think the the the criteria for doing surgery is generally displacement and this is some of the some of the sort of more specific criteria. But I think you can sort of look at these fractures as non displaced ones typically don't need surgery and if you have displacement then you have to think about putting a plate and screw on, or we have these intramedullary devices and the really bad ones that actually we can't repair and we can't put humpty dumpty back together again and we just take it all out and we put a shoulder replacement in. [AUDIO DISTORTS]
NICHOLAS COLYVAS: This is, these are these are difficult and and can be quite challenging to treat from our point of view. So in summary, I think this obviously we've covered the top five. There are others, but I think those are the main ones and many of them can be treated non-surgically. But I hope I've sort of given you a little bit of an idea of which ones to have some more concern about and which ones to refer to us a little bit earlier.
NICHOLAS COLYVAS: Thank you very much. [APPLAUSE]
Segment:0 .
NICHOLAS COLYVAS: Thank you, everyone for being here.
NICHOLAS COLYVAS: Hopefully you've had some coffee and are going to be able to stay awake for the next 25 minutes or so. I'm going to be talking about acute shoulder trauma. A snap, crackle and pop. As a little bit of a sort of contrast to what we have a lot is chronic shoulder pain. We're going to talk a little bit more about acute shoulder pain and I don't have any disclosures for this talk. But, you know, what I want to say is that pretty much everyone in this room, whoever you are and whatever you do for a living, is going to end up seeing somebody for a shoulder problem
NICHOLAS COLYVAS: so I'm sure shoulders and knees are going to be a big part of your practice. And we're surgeons and and you know sort of my group here and some of the people talking to you today are surgeons and we love to do surgery and surgery is sort of what we train for and what we live for and what we enjoy. But a big part of surgery is knowing when to not do surgery, because surgery doesn't always go well.
NICHOLAS COLYVAS: So I want to talk about that to some degree. You know, what, what is, what is surgical and what is not surgical. So I think like many of the talks, we're going to go over a basic outline of of the subject, the most common trauma, excuse me, acute trauma for the shoulder, discuss the nature of the injuries and sort of the physical, the pertinent history, physical exam and imaging and go through some of the treatment options.
NICHOLAS COLYVAS: But what this is not going to be is a super comprehensive, all inclusive talk about each of these. What I want to do is focus on the pathology and some of the rationale for why we treat these the way we do, why they're surgical or not surgical, and sort of highlight what you should be looking for in the sort of primary care sports medicine world and when maybe to refer those patients to ortho. So here are our top five; rotator cuff of course, biceps, tendon ruptures pretty common, ac joints
NICHOLAS COLYVAS: we see those all the time, shoulder dislocations, most common joint to dislocate and then, of course, fractures. So we'll go through each one of these and have a, have a discussion. So let's go through rotator cuff tears first. So shoulder has a complex anatomy. It's a very versatile joint, goes in every direction. It has force and power and fine tuning in every direction and in order to do that, it's a, it's a complex ballet of dynamic forces with all these muscles.
NICHOLAS COLYVAS: And an important component of this is, of course, the rotator cuff. Four muscles, three major ones that sort of surround the shoulder, and the rotator cuff is not the power generator in the shoulder. It really is the positioning group of muscles that puts the shoulder in the best place for leverage and efficiency for your big muscles, your deltoids and your pecs and your lats to really provide the power in the shoulder. And
NICHOLAS COLYVAS: when you look at rotator cuff, of course, there's the the obvious discussion about the more chronic injuries, we're going to focus more on the acute injuries and those are generally sort of traumatic and that's a fall or a sports injury or a work injury or even an intense sort of repetitive, repetitive activity will give you an acute rotator cuff tear.
NICHOLAS COLYVAS: The presentation is generally the male older group, older age group and importantly, I think what we see commonly is this acute on chronic phenomenon. You know, many of these acute patients that we see will have had shoulder problems in the past, will have maybe had even physical therapy or cortisone injections, but have been doing reasonably well and then have a sudden acute event and oftentimes associated with a hey doc, you know, there was a tearing sensation.
NICHOLAS COLYVAS: I couldn't move my arm after that. I'd been having problems, but now it's definitely worse. And and you know, this is a subgroup we're interested in because they tend to do better if they have surgery acutely. Now many rotator cuff tears we can treat non surgically, but this acute group we would want to see earlier and potentially want to do surgery earlier. So when you see these patients and they get worked up and they have their MRIs, what you're going to see is essentially a partial tear or a full thickness tear
NICHOLAS COLYVAS: and many of the partial tears, we can treat that conservatively. The full thickness tears are the ones where you see the the clinical signs of weakness and and loss of range of motion and generally it's the supraspinatus that's the one that's the tendon that has had usually some kind of degeneration over time. That tears,
NICHOLAS COLYVAS: but the bigger tears that will zipper out into the infraspinatus, the biceps tendon can dislocate out of the groove. The subscapular can tear, you can get tear of all of these things and obviously the bigger the tear, the worse the prognosis. And these acute tears we really feel should should be seen early and get surgery early. So the chronic tears again, there's this sort of generally well recognized, try conservative treatment first and get to the point where either they get better or ultimately six months or a year, they end up getting surgery.
NICHOLAS COLYVAS: But the acute tears, I think you need to have a sort of a high level of suspicion for them and that's based mostly on the history and the physical exam. If you've got a patient who was doing well or had some mild shoulder pain and has suddenly had a change, that's a patient where you want to get that MRI earlier and we're always discussing the indications for MRI and saying, well, you know, oftentimes if you're not going to act on it, why are you getting the MRI?
NICHOLAS COLYVAS: But this is a case where MRIs are helpful and you want to certainly consider getting an MRI early to look at exactly what's going on. Also, if you don't do injections in your practice, think about actually starting to do these because they're very, very helpful in the shoulder. If you have a patient that comes in acutely, has a lot of pain in their shoulder, won't move it, you're not sure if their rotator cuffs involved.
NICHOLAS COLYVAS: You give them a subacromial injection of marcaine or lidocaine. You tell them to sit and wait. You go see another patient. You come back in the room and suddenly they say, well, I don't have any pain anymore and guess what? I can actually move my arm, it doesn't hurt.
NICHOLAS COLYVAS: And the pain is what's stopping them, not actual rotator cuff tear. So all of this improves your diagnostic accuracy. How do these tears do when we, when we do the surgery on them? Well, the acute tears definitely do better. Smaller tears definitely do better. Bigger tears particularly have a risk of retearing but interestingly, with rotator cuff tears, not all of those will end up having to have another surgery and I think that you just have to manage some expectations that oftentimes, particularly with the massive tears, it's going to be difficult to get that patient back to square one, back to their original baseline.
NICHOLAS COLYVAS: And surgery is probably the best choice for that if you're looking at an acute rotator cuff tear. Let's move on to a somewhat maybe easier topic, which is biceps tendon, OK? Biceps tendon. We're looking at the rupture of the long head. I don't think I've ever seen a short head rupture.
NICHOLAS COLYVAS: But just to remind everyone, the biceps and this is an important discussion to have with your patients too has two attachments proximally. One is the short head that goes to the coracoid and the other is the long head that runs up in the groove, comes into the shoulder joint and attaches to the labrum. And the classic story, I was doing something, I was pulling something, I was
NICHOLAS COLYVAS: trying to lift a heavy weight or something, felt a ripping sensation in my arm and then you get the classic popeye deformity is, I think, pretty common in most people have probably seen this at least more than once. And this is a clinically clinical diagnosis really. Excuse me. It's, it's not often sometimes in a big shoulder, a big arm,
NICHOLAS COLYVAS: you might not see the popeye deformity. It might not be quite as obvious. Some patients, you can see it from the minute they walk in their room. And it's generally a clinical diagnosis and it's not one that typically needs a lot of imaging studies but I think you have to be a little bit careful because the biceps tendon again, the older patient that may have had shoulder problems can be degenerative at the same time as the rotator cuff.
NICHOLAS COLYVAS: And if they have a biceps tendon rupture, there is a reasonable chance they'll have a rotator cuff tear as well. So if the patient's just saying, I have pain over here in the biceps, but actually my shoulder function is pretty good, I don't have too much pain, you probably don't need to do anything. But if you've got a patient who says, I felt that ripping sensation, my biceps is sitting down in my, by my elbow and now I can't really move my shoulder
NICHOLAS COLYVAS: and their exam is is significant for weakness. Injection or MRI is probably not a bad idea because again, that could be a rotator cuff tear hiding out there in that biceps tendon rupture. We do surgery for that for biceps tendon tears, isolated biceps tendon tears but it's not common because most of our patients, we tell them about the two attachments that they won't lose much strength.
NICHOLAS COLYVAS: There are some studies out there. They have variable amounts, but I often quote 15% loss of supination. Remember, the biceps is a, is a, is a powerful supinator not as much as a flexor of the elbow. So I often tell them you can expect maybe 10 or 15% loss in your strength. If it's a non-dominant arm, most times most patients actually this is a non surgical treatment, but certain patients we do end up doing surgery for.
NICHOLAS COLYVAS: This is just one of the studies showing loss of strength. So let's move on to the AC joint, OK. Again, a common injury by half of my rugby players have AC joint injuries often seen and AC joint injuries, it's a predominantly male, mostly trauma contact sports. I think it's a, it's a common, there are common entities but there are different types and we love to torture our residents with classifications of everything.
NICHOLAS COLYVAS: Every, every injury or joint gets some kind of a classification and we usually try and have them tell us who made the classifications but basically for the AC joint, I like using the classification system because it helps sort of give you a good idea of what the pathology is and and which ones really are sort of more concerning than others. So if you look at the the AC joint, this is the joint we're talking about here.
NICHOLAS COLYVAS: Here's your clavicle. It's really held down by two main structures. First are the AC ligaments here that hold the joint across there. And this is your conoid and trapezoid CC ligaments between the clavicle and the coronoid here. And these are the stabilizers of the AC joint. So in a type one injury, all these injuries really are a blow to the shoulder like this, where the acromion gets pushed down and the the clavicle goes up.
NICHOLAS COLYVAS: Type one, we're just looking at a little sprain of these AC ligaments. Now in a type two, more force sprain or a stretching of the CC ligaments, but the AC ligaments tear. Again, these are, it's still a stable structure so if we go back sorry, you know, no surgery for these these are these are all conservatively treated even at type two, that same thing, you might have a little elevation of the clavicle, but for the most part, it's still a stable injury that doesn't need surgery.
NICHOLAS COLYVAS: Type three, a little bit more controversial. You've now torn the AC ligaments and the CC ligaments. This one is the one where the orthopaedic conferences, there's a lot of back and forth about do we do surgery? Do we don't, do we not do surgery? Personally, the vast majority of these I do not do surgery for because you have a late surgery that you can do if it causes a problem and most of them will just have a period of time where it hurts and then it gets better.
NICHOLAS COLYVAS: And what they're left with is a fully functional shoulder with a deformity, with a bump, and I often just use the comment, do you want a bump or do you want a scar because we can do the surgery and give you a scar with no bump or you can have the bump, but the outcome is going to probably be about the same. So for me, this is a non surgical one.
NICHOLAS COLYVAS: And then we go to a type V where this thing is floating up in the breeze. It's trying to come out through the skin. That's a more obviously a surgical treatment. And if you look at the categories, of course, I've skipped type IV because this particular classification system looks at these very rare entities where the the clavicle goes into the trapezius, it gets pushed posteriorly or it gets pushed inferiorly.
NICHOLAS COLYVAS: Those are very rare. They're surgical, but it's very, very unlikely you'll see these. So for the most part, AC joints are treated conservatively. Highly active sports players in their dominant arm. You might be more aggressive or laborers to get them back earlier, perhaps, but you have to talk about the cosmetic deformity and sometimes it can be quite impressive. You can see this big bump and patient's like, well, what's going on there?
NICHOLAS COLYVAS: And you can say, well, if we're going to do surgery, it's going to be for the cosmesis and not necessarily for function. And I oftentimes will just let them wait it out a little bit and see how they do. And surgery is not without its problems. This is also one of those cases where you can have some significant complications. All right.
NICHOLAS COLYVAS: So let's move on to shoulder dislocations. Again, I think something that we we commonly see and even acutely see on the sports field when we're, when we're out there I've had a few, I've had a few of these myself. And certainly the most common joint that's injured. You have subluxations and dislocations and I think we'll talk more about dislocations. And if you're a betting person, really, you're going to bet that it's an anterior dislocation.
NICHOLAS COLYVAS: 95% of these go anteriorly but you can't count on that because certainly you've got to take a history and physical exam and try and determine what sort of direction the arm was in when it had the injury. And if you look at these, it's a it's a it's a young male disease to some degree, and then there's a sort of a another peak in the in the bimodal distribution for the, for the older patients. And the anterior ones, the most common ones are usually an external rotation force that pushes the, the humeral head out from the from the joint, rupturing the anterior labrum and the capsular structures there.
NICHOLAS COLYVAS: That's a classic Bankart lesion we talk about. And then when it comes out, it gets impacted on the rim of the glenoid and that causes the Hill-Sachs lesion you hear about, which can just be a small dent, or sometimes it looks like a shark bite out of the out of the back of the shoulder. And these are important injuries to think about some associated problems.
NICHOLAS COLYVAS: OK? So when we look at the bone injuries that come with these, some of them fracture at the same time that they dislocate, and you also have to figure out where the dislocation is. So in an ideal setting, you would have an X-ray. Now, I know practically we'll oftentimes reduce these acutely, but in an ideal setting, you need to get an axillary view on your x-rays to see where the, where the thing is dislocated and it actually post-op to make sure that it is actually in place.
NICHOLAS COLYVAS: You can be fooled by just an AP and a lateral. It doesn't necessarily show you exactly where the the humeral head is so always, always try and obtain an axillary view. In older patients with maybe a bit of sclerosis in their vessels, you've got to watch for vascular problems so always check your neurovascular status. Same thing with nerve injuries.
NICHOLAS COLYVAS: They're actually quite common. Axillary nerve patients will have some numbness over the side and so always check your neurovascular status before and after. And I think maybe one of the take homes for today is, in that older age group always be highly suspicious of a potential rotator cuff tear because there is actually a much higher association with the older patients. Younger patients,
NICHOLAS COLYVAS: it's a higher trauma force and it seems to be all imparted onto those anterior structures, the labrum and the capsule. And that seems to take most of the force. The rotator cuff is stronger in younger patients. It doesn't seem to tear. Older patients have weaker rotator cuffs and they tend to tear their rotator cuffs much more often and so you always have to have a pretty high degree of suspicion.
NICHOLAS COLYVAS: So if you have a patient who has a dislocation and is not responding well to physical therapy after they've been relocated, be aware that they may have a cuff tear and definitely order an MRI if you have any concerns. As far as the reduction techniques, I think the bottom line is there's no consensus. Have a technique that you're comfortable with if this is something you're going to do and if you're particularly if you're doing it acutely, relaxation, to me, relaxation is the whole key to the entire relocation episode.
NICHOLAS COLYVAS: So however you do that, whether it's talking sweetly to the patient or giving them drugs, if you can relax them, you can generally get it back in. And after you treat them, you know, there's various different suggestions. My protocol is usually about two weeks in a sling and then physical therapy. Again, this is particularly for the older patient who you don't want to lose their range of motion, but you have to really, really worry about the older patients and the rotator cuff tear. And younger patients,
NICHOLAS COLYVAS: what you worry about is re dislocation. And I think for some surgeons, an acute traumatic dislocation in a young patient is a surgical event even at the first time now. We tend to say, let's give it a try with physical therapy and see how they do and if they re-dislocated, OK, they've bought themselves a surgery. But it's, it's it's a high level up to 95% that will re-dislocate if they continue to be active.
NICHOLAS COLYVAS: So just something to be aware of and probably to tell the patients. I just went over that. And then the surgery is really basically repairing those anterior structures. Fractures. Common, particularly the clavicle and we've gone through a bit of a circle with how we treat clavicle fractures. When I was a resident called down to the ER, if I saw this comminuted fracture over here with butterfly pieces, here's a piece sticking down. 20 years ago now or about that,
NICHOLAS COLYVAS: I would be telling the patient, this is something you don't need surgery for and you'll probably do well and some of them end up needing surgery ultimately but I think we went through sort of a revolution with some studies showing that these patients didn't actually do that well and so then lots of clavicle fractures got surgery. Maybe most of them ended up getting surgery.
NICHOLAS COLYVAS: This one didn't get surgery and it went on to heal so they can heal without surgery. But I think our our basic basic algorithm now, we've sort of swung back a little bit in doing a little less surgery on clavicle fractures. Is that the non displaced one really do not need any surgery and that if they are displaced, if they meet certain criteria such as bayonetting of the pieces or shortening, you can sometimes see the patient has a rolled over arm.
NICHOLAS COLYVAS: If you're tenting the skin, of course that's going to need surgery and if there's significant comminution, those are probably the ones that need surgery. And always we have to be very worried about the surgery because this is what we call tiger country right under the clavicle, big veins, big nerves, big blood vessels. So surgery is, again, not without its problems and I think it's, it's always good for us to be a little bit concerned when we have the the clavicle fractures as to which ones we're going to operate on. A sort of, that sort of covers mostly the mid-shaft fractures, but a sort of more distinct entity is the, the distal clavicle fractures
NICHOLAS COLYVAS: and these are a little bit complex to consider. They also have stability issues or stability concerns there where we probably are more likely to operate on on the type two B's. And there is some sort of different types of techniques because they are unstable tears, and I think for that particular entity, if it's not a non-displaced, if it's a non-displaced with no significant comminution, probably you could just consider treating it conservatively.
NICHOLAS COLYVAS: But maybe those ones are the ones you, you want to have an opinion, an orthopedic opinion about a little bit earlier. And then the other fractures we see, of course, the the classic older female osteoporotic bone takes a fall at home and has proximal humerus fracture. These come in all types and it's, they can be quite problematic even, you know, even as surgeons, we don't look at these cases as easy cases.
NICHOLAS COLYVAS: When you have to do the open reductions and internal fixations on these patients, they're difficult.
NICHOLAS COLYVAS: And I think the the the criteria for doing surgery is generally displacement and this is some of the some of the sort of more specific criteria. But I think you can sort of look at these fractures as non displaced ones typically don't need surgery and if you have displacement then you have to think about putting a plate and screw on, or we have these intramedullary devices and the really bad ones that actually we can't repair and we can't put humpty dumpty back together again and we just take it all out and we put a shoulder replacement in. [AUDIO DISTORTS]
NICHOLAS COLYVAS: This is, these are these are difficult and and can be quite challenging to treat from our point of view. So in summary, I think this obviously we've covered the top five. There are others, but I think those are the main ones and many of them can be treated non-surgically. But I hope I've sort of given you a little bit of an idea of which ones to have some more concern about and which ones to refer to us a little bit earlier.
NICHOLAS COLYVAS: Thank you very much. [APPLAUSE]
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