Shoulder anatomy

Shoulder Region

Lippincott Williams & Wilkins

http://lww.com

X-ray of Normal Right Shoulder

Shoulder Region

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Neck of Right Scapula

The Right Scapula (Lateral View)

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The Glenoid Cavity

Neck of Right Scapula

The Elbow Joint (X-ray)

Text written by Dr Fiona Cowieson
Copyright for this resource owned
by St George's University 2007 ©.

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The Elbow Joint

Shoulder Region (Anterior View)

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Shoulder Region (Posterior View)

Subscapularis Muscle

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The left subscapularis muscle viewed from the front.

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Shoulder Region (Posterior View)

Shoulder Region (Rotator Cuff)

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The Triceps Brachii Muscle

The Biceps Brachii Muscle

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The Brachialis & Coracobrachialis Muscles

Muscle Attachments

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Muscle Attachments

The anterior (A) and posterior (B) aspects of the lower end of the right humnerus and the upper
end of the radius and ulna showing muscular and ligamentous attachments.
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Upper Arm Muscles

Text reviewed by Dr N Lawes.

Copyright for this resource owned by St
George's University of London, 2007 ©

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Shoulder and upper arm nerve supply
Posterior Triangle of the Neck

Posterior Triangle of the Neck

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Brachial Plexus

Brachial Plexus Branches

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Brachial Plexus

Bracial Plexus (Posterior View)

Text reviewed by N Lawes

Copyright for this resource owned by St George's University 2007 ©

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Treatment of Shoulder Instability
Conservative:
The only non-surgical approach available is an intensive exercise regime which concentrates on
balancing muscle activity around the shoulder and improving proprioceptive feedback from the
joint capsule and surrounding ligaments so that movements likely to cause dislocation are
automatically checked. This approach is of limited success.

Surgical:
Over 100 operations have been described for stabilisation of the shoulder. Techniques span the
ages from Hippocrates who used a red hot poker to produce scarring of the capsule to the recent
development of arthroscopic repair procedures.

It is a surgical "truism" that "if there are more than three surgical techniques for a given condition
none of them are any good".

Published research on these procedures is mostly of very poor quality involving small numbers of
patients, inadequately controlled for risk factors, with limited periods of follow-up. Many papers are
just observational series, not controlled trials.

Procedures can be broadly divided into two groups - those that restrict joint movement and those
that increase the "buttressing" effect of the anterior glenoid rim.

The first group aim to prevent the patient moving far enough into lateral rotation for the joint to
dislocate. The anterior joint capsule is tightened by "reefing" and/or reinforced by moving muscles,
tendons or ligaments across it. The most commonly used procedure of this group is the "Putti-
Platt" operation. It is not however uniformly successful and the limited movement may seriously
inconvenience the patient. Surgical preference has gradually shifted to the second group.

These are based on a belief in the importance of the Bankart lesion and therefore include some
procedure to reattach the glenoid labrum to the rim of the glenoid as first described by Bankart
himself in 1938. It may be sewn or stapled into position and this may now be done
arthroscopically. Other procedures involve the transfer of a block of bone to the front of the
glenoid, eg transposing the tip of the coracoid and its attached muscles to this position.

How to tie a sling Reef knot

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What a sling should not
look like

A broad arm sling A collar and cuff sling A collar and cuff sling

Treatment of Dislocation
The first priority is pain relief. The dislocation should be reduced as soon as possible as this will
relieve pain and reduce the risk of complications. There is evidence that nerve injuries are more
common and take longer to recover if reduction is delayed.

Most dislocations can be reduced by closed manipulation though open surgery may be needed if
there are associated fractures, if diagnosis is delayed and the dislocation is "chronic", or if soft
tissue becomes trapped between the bearing surfaces. General anaesthetic will be needed for open
reduction but closed reduction can often be carried out just with pain relief and some sedation. The
mechanism of displacement should be considered and reversed and the process should not involve
a lot of force.

Reduction of a dislocated shoulder involves traction to relieve the muscle spasm, particularly in
subscapularis which draws the head of the humerus medially in front of the neck of the scapula.
Once stretched the muscles themselves will tend to pull the shoulder back into place. Some
techniques also involve levering the head of the humerus back over the glenoid rim but this must
be done with care to avoid further damage to peri-articular structures.

A range of techniques for reduction and pain relief are described by Gleeson in the attached paper
[Gleeson AP J A&E medicine Vol 15 1 pp7 - 12]. Very slow gentle lateral rotation with the elbow
kept adducted to the side can achieve reduction in about 50% of acute cases, generally with little
or no pain relief needed.

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