Acute Musculotendinous Injuries of the Shoulder

1. Acute Musculotendinous Injuries of the Shoulder April 7, 2008 Taylor Brown, M.D.

2. Basic Themes • Restore normal anatomy if the patient is an acceptable risk for surgery

3. Basic Themes • Repair is most easily completed within the first weeks after injury

4. Basic Themes • Injury occurs with sudden forceful overload of a maximally contracted muscle

5. Basic Themes • Associated with steroid use • Associated with weightlifters and bodybuilders • Associated with weightlifters and bodybuilders who use steroids

6. Common Injuries • Rotator Cuff • Biceps Brachii Long Head

7. Less Common Injuries • Pectoralis Major

8. Reportable Injuries • Deltoid • Latisimus Dorsi • Coracobrachialis • Biceps Brachii Short Head • Pectoralis minor

9. Acute Rotator Cuff Tears • Associated with a distinct trauma • Fall or Near Fall • Lifting or Catching a heavy or falling object • Subluxation or dislocation

10. Acute Rotator Cuff Tears • Suspect with any persistent loss of abduction or forward elevation 2 weeks after a seemingly benign trauma • Diagnose with early MRI

11. Acute Rotator Cuff Tears • Usually a large tear of supraspinatus and infraspinatus

12. Acute Rotator Cuff Tears • Carefully evaluate subscapularis with belly press or bear hug • lift off test usually impossible

13. Acute Rotator Cuff Tears • Repair acutely within first several months to obtain the best outcome • fatty degeneration • Tissue contracture

14. Acute Rotator Cuff Tears • Fatty degeneration present within first 4 months after an acute tear

15. Acute Rotator Cuff Tears • Fatty degeneration does not reverse, even with a successful repair • Fatty degeneration, however, does not preclude a successful outcome

16. Acute Rotator Cuff Tears • Tissue contracture, if present, requires specific soft tissue releases • Coracohumeral ligament • Capsule between cuff and glenoid neck • You can bill an appropriate code for soft tissue releases associated with large, retracted cuff tears • Lysis of adhesions 29825 Bert and Beach

17. Acute Rotator Cuff Tears • Carefuly evaluate tear pattern • “L” shaped tear crescent

18. Acute Rotator Cuff Tears • Go forward with your standard arthroscopic rotator cuff repair Single row Dual row Convergence

19. Acute Rotator Cuff Tears • Postoperative protocol • Use your usual protocol for a large tear • Pillow sling 6 to 8 weeks • Avoid strengthening for at least 3 months

20. Acute Rotator Cuff Tears • Nonoperative care of large tears • Counsel patient regarding expectations • Persistent loss of function • Possible pseudoparalytic shoulder • Possible rotator cuff arthropathy

21. Biceps Long Head Rupture • Popeye deformity • Bimodal distribution • 40 year old heavy laboring or active man • 70 year old former or persistent laboring man

22. Biceps Long Head Rupture • Diagnose with • History of painful pop • Deformity and ecchymosis on exam • MRI to confirm diagnosis and evaluate rotator cuff

23. Biceps Long Head Rupture • Nonoperative treatment • Persistent deformity • Persistent loss of supination strength (10-20%) • Most appropriate for older age group • Chronic spasm or ache (s. snyder)

24. Biceps Long Head Rupture • Subpectoral Tenodesis • Accurate restoration of length • Cosmetically appealing • Removes diseased portion of tendon • easy

25. Biceps Long Head Rupture • Subpectoral Tenodesis • Accurate restoration of length • Proximal musculotendinous junction placed at inferior border of pectoralis major tendon

26. Biceps Long Head Rupture • Subpectoral Tenodesis • Cosmetically appealing • Axillary fold incision and scar • Restoration of biceps contour

27. Biceps Long Head Rupture • Subpectoral Tenodesis • 3 cm axillary fold incision • Blunt dissection directly toward humerus • Palpate inferior border of pectoralis tendon • Blunt hohman retractor laterally elevates pectoralis tendon • Chandler medially to protect neurovascular structures

28. Biceps Long Head Rupture • Subpectoral Tenodesis • Withdraw biceps tendon from groove or anterior arm • Remove all of diseased tendon except 15mm just proximal to musculotendinous junction • Weave permanent stitch through tendon • ACL guidewire into groove 5mm above inferior border of pec tendon

29. Biceps Long Head Rupture • Subpectoral Tenodesis • Acorn reamer over guidewire through one cortex only • Usually 6.5mm wide socket • Seat tendon within socket and drive 6.25 x 15mm screw down over biotenodesis driver

30. Biceps Long Head Rupture • Subpectoral Tenodesis • Suture anchors have been used as well • Mitek G2 or G4

31. Biceps Long Head Rupture • Subpectoral Tenodesis • Keyhole technique

32. Biceps Long Head Rupture • Subpectoral Tenodesis • Complications • Loss of tendon fixation • Fracture at screw site • Persistent defect at PLLA screw site

33. Biceps Long Head Rupture • Humeral Head Fixation • Requires open approach to identify biceps tendon distally in arm • Suture passer is fed through bicipital groove to retrieve tendon • Fixed at humeral head with Biotenodesis screw or suture anchors

34. Biceps Long Head Rupture • Humeral Head Fixation • Hard to do • May end up maintaining diseased tendon

35. Biceps Long Head Rupture • associated partial or full thickness rotator cuff tears which may have caused prodromal symptoms • Fix it at the same setting

36. Biceps Long Head Rupture • Postoperative protocol • Sling for 2 to 4 weeks • Begin passive and active assist motion immediately • Avoid heavy lifting for 6 weeks • More commonly limited by associated rotator cuff repair

37. Pectoralis Major Tear • Cosmetic and Functional Deformity • Young to Middle age male weightlifters

38. Pectoralis Major Tear • Diagnose with • History of painful pop • Thin anterior axillary fold on exam • Visual deformity • MRI to confirm exact location of injury (tendon versus muscle belly)

39. Pectoralis Major Tear • Nonoperative care for • Partial tears • Muscle belly ruptures

40. Pectoralis Major Tear • Operative Repair • tendon avulsions from bone • most easily achieved in first weeks following injury • Open anterior axillary fold incision

41. Pectoralis Major Tear • Weave permanent stitches through tendon • Anchor to lateral ridge of bicipital groove with bone tunnels or suture anchors

42. Deltoid Rupture • Acute traumatic rupture • Reportable • No published treatment regimen

43. Deltoid Rupture • More commonly, a postoperative complication from open shoulder surgery • Reportedly very difficult to obtain a solid repair with permanent sutures woven through muscle and acromial bone tunnels • May benefit from patch augmentation

44. Latissimus Dorsi Tear • 4 tears reported in the literature • Combined anterior and posterior approaches • Repair with suture anchors to medial ridge of bicipital groove • Beware of axillary neurovascular bundle

45. Coracobrachialis Tear • Have not seen it • 2 cases reported

46. Pectoralis Minor Tear • Have not seen it • 1 case report

47. Questions? St. Luke’s Orthopedic Symposium “Sports Medicine and the Team Physician” The Houstonian April 11-12, 2008 www.sleh.com/orthosymposium