Glenoid Fracture = Adhesive Capsulitis?

[adamd9]

Hi Everyone,

I'm almost 14 months down the track from a pretty severe fall in which I sustained a number of injuries including a fractured glenoid (left shoulder), and while everything healed up fairly well, I still have extremely poor external rotation (0 - 5 deg active / 5 - 10 passive) and I feel like nothing I'm doing is making any real headway.

I'm hoping that I can tap into some of the knowledge and experience on this forum and get some opinion about whether I'm on the right path or whether I should be approaching this differently.

Original accident: Glenoid fracture, with open shoulder surgery performed at 4 weeks for glenoid repair & put 2 screws in).

I have had almost weekly physio since having the arm out of the sling (about 6 weeks after surgery) - mostly doing a lot of mobilisation and soft tissue work. I'm also doing a lot of rotator cuff strengthening exercises and theraband work. My internal rotation seemed to come good (but not perfect) fairly quickly; extension isn't great but it's definitely made significant gains; external rotation is extremely poor (0 - 5 deg) and hasn't really improved since the original surgery.

In addition to the physio, I have had three hydrodilations and two arthriscopes. My original surgeon performed the first scope, and removed one of the screws and did some capsular release. The second scope was done by a different surgeon, who did some more release and cleaned out the joint space significantly. The surgeon indicated that the joint surface looks relatively good. There is one screw still in place, which is protruding about 8mm from the bone but is clear of the glenoid cavity (I' told it's just on the outside edge of the glenoid labrum).

For all the surgery and hydros, I would have expected some gains in ER. But essentially the 0 - 5 deg I have now is the same 0 - 5 deg I had when I ditched the sling 12 months ago. I'm told it's adhesive capsulitis, but should't I expect to see some gains from the capsular releases at least, if not the constant physio and rehab?

Adam

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[physiobob]

Sound to me as though you have been trying a little to much to soon. Why are you so worried on getting more external rotation so soon? How is your flexion and abduction? Shoulder take a long...long... time to heal and restore function and in my opinion should not be pushed, especially following a fracture.

Do you have any active external rotation strength from full internal rotation back to neutral? i.e. are the external rotators intact. Is your neuro assessment normal? Lot's to ask really. Did the surgeon get more passive external rotation on the table etc.

Also how did you injure it? Any x-ray or MRI images you can post?

[adamd9]

Hi Physiobob,

Flexion is around 120 - 130 deg, abduction is around 100 - 110 deg. Active ER strength is good - close to normal from full IR but it drops off significantly as I approach the limits of my ER.

I guess the main thing that concerns me is that I've seen improvements in all other aspects, but almost none for ER.

I had an MRI and ultrasound done via my GP when I wasn't seeing a lot of progress after the scope (3D MRI attached). Muscle atrophy is minimal - none. Conclusions:
"Bone screw projecting 8mm anterior to the glenoid anterosuperiorly. Fracture of the glenoid is united. Limited external rotation on ultrasound. No discrete cuff tear identified. Small split tear long head of biceps tendon."

I fell approximately 2.5m through a ceiling cavity onto a carpeted concrete surface.
Report on the fracture: Cominuted scapular fracture, originating from superior aspect of the glenoid fosse, with moderate stepping and displacement at the articulation surface; extending through the supraspinatus compartment at two levels, traversing the suprascapular nucha; with significant dorsal displacement of the intervening bony plate - compatible with a type III glenoid intraarticular fracture.
Other injuries sustained:
-Left skull fracture, bleed on brain
-Left rib fractures: 1, 3-7
-Left lung puncture
-Left wrist hamate fracture
-Left transverse process fractures of T5 and T6

On the table (first scope) my surgeon said he achieved 70 deg but I doubted this. He took a photo during surgery which I have attached.

I've only included scans I think you'll find relevant, but I also spent some time this morning uploading all of the operative notes, reports, scans & other details I have, which might be useful.

Google docs link here: https://docs.google.com/leaf?id=0B6_...2NmUy&hl=en_US

[physiobob]

Hi again, Looking at your second image of the surgeon demonstrating external rotation it looks like there is only about 5% when you are under the general anaesthetic. A quick glance makes it look more but that is due to the lax pec and the retracted scapula position which is giving a false sense of external rotation.

When the humerus moves on the glenoid it required a rotation and a slide movement to keep it centered on the glenoid surface. This is usually controlled by the rotator cuff muscles which right now will need some balancing. It also requires a smooth articular surface. on both the humerus and the glenoid. I'd suspect that there is also a type of Hill–Sachs lesion that accompanied the fracture (i.e. a dent in the humeral head). This is also an articular surface deformation to consider when assessing the normal roll and slide movements.

Maybe you can ask you physio to provide some mobilization type assistance to the humeral head while you are working on your external rotation and also some depression when you are working on abduction (or better scaption) movements. Get them to look into what are know as NAGS, SNAGS and MWMs for the glenohumeral joint.

[adamd9]

Thanks Physiobob - I'll suggest this to my physio. I might even see if he knows about this forum - it seems like a good resource for physio's looking for a place to share & bounce off ideas.

You're right about the ER photo while I was under genreal anaesthetic - when he showed me this and said he achieved 70 deg I felt it was quite disingenuous, which is partly why changed surgeons soon after.

The only other thing I find odd about my situation is that the physio & surgeon both seem to expect me to feel a "tightness" at the front of the shoulder when at the end of my external rotation, but I feel almost nothing when mobilising except a pain down the front of my bicep (almost to my elbow). If I (or the physio) push it quite hard this pain becomes very sharp. The pain doesn't seem to remain afterwards. I'm told this is referred pain, but could it be something else?

[physiobob]

Best of luck. Let us know how you get on.

[MrPhysio+]

Hello Adam,
PhysioBob has given you some good answers. As you do not mention any problems with the other damaged areas, you obviously have a good healing capacity!
I am interested in the hydrodilatation history. I have been involved with hydrodilatations in Melbourne (or nearby) since 1991, shortly after the original technique was described in the American Journal of Orthopaedics. It is worth noting that the majority of these procedures are now undertaken by radiologists rather than Doctors or surgeons and that results vary widely. There is only one clinic in Melbourne that seems to have consistently good results via guided injection of the saline mix. The original technique, in my experience, works much better. In fact, one Doctor that I introduced the technique to has had Orthopaedic surgeons comment that the results were the best that they had seen (and this was related to some patients that had received multiple failed guided hydrodilatations).

Having commented upon the hydrodilatation process, it remains to be seen as to whether you actually have capsular adhesions and if you do whether other problems co-exist. PhysioBob is correct to comment that the rotator cuff musculature will require retraining to ensure the scapulat moves correctly upon the rib cage and the humeral head is correctly stabilised in the glenoid.

It sounds to me that you may also have some bicep tendon sheath adherence, possible sub deltoid bursal impingement and poor scapulo-humeral rhythm.
Thanks for providing all the information as it is helpful, but examination may provide even more relevant treatment direction.
Has anyone discussed glenoid labral tears with you?

I would try to strengthen the shoulder retractors and depressors, address the bicep long head tendon sheath, check the teres muscles and sub deltoid bursa and question the type of hydrodilatation technique. Given your history, a thorough check of your Cx to rule out some nerve root involvement or Cx facet joints (lower) contribution to the shoulder range of movement control would also be in order.

I have tried to cover the obvious areas - this is not to say that any of the above is occurring or that the list is fully comprehensive. Further assessment may bring forth more important findings. I hope the above helps to generate further comments that could be of assistance to you.

One more thing. The behaviour of your symptoms during daily activity and therapy sessions can often provide clues to the cause of your problem.

MrPhysio+

[theshoulderguy]

Hi Adam, mate you have been through a lot over the last 12+ months. I must say that your case is very interesting reading.

While my clinical physiotherapy practice is solely shoulders please understand that my expertise isn't surgical although I spend a lot of time working with them in the upper limb area.

There is some research on type III glenoid fracture fixation to suggest that you potentially should have more ER than you do although this study looks at patients 2 years down the track and surgery was arthroscopic.

Now I am not a shoulder surgeon but the things that jump out at me from looking at your docs folder is the surgery performed, the location of the screws, the anatomy within close proximity of the screws and the existing pathology present.

In particular the op notes and ultrasound and CT in June this year.

The majority of surgical work has been performed in the anterior superior aspect of your shoulder, potential involving areas such as subcoracoid/subscapularis, coracohumeral ligament, glenohumeral ligaments and capsule, coracoacromial ligament, rotator interval, long head of biceps attachment.



Significant post operative scarring anterosuperiorly, mechanical impingement of long head of biceps and capsulitis in these areas, could potentially explain your ER deficit??

Moreover, the location of the screw that remains and protrudes is placed at the superior aspect of the glenoid. The long head of biceps could be involved here??

Now where does the head of humerus go when cuff control is lacking and forces across the joint are not balanced?

You guessed it...ANTEROSUPERIORLY!

Could it be that a mechanical impingement of the head of humerus and/or long head of biceps is preventing the external rotation despite an anterior capsulotomy being performed??

I agree with the other contributor that the intraoperative ER photo is not a true reflection of your ER and it looks in reality to more restricted than depicted in the photo.


Something to think about and to ask your current surgeon or a new set of eyes.


Your physiotherapist could try a simple posterior head of humerus relocation test to see if your ER range can be improved manually.


If I can also suggest a look at general upper limb neural tension test to assess mechanosensitivity to ER/ABD due to proximity of the plexus to fractured ribs.

Food for Thought?

Good Luck!

Luke

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[adamd9]

Hi MrPhysio+,

Thanks for your insights. Yes considering that laundry list of breaks, I had essentially no complaints other than the shoulder after about 6 - 8 weeks.

The three hydrodilations I had were all very different experiences. The first I had at RMH and it was done with a local anaesthetic, then die, and then (saline?) fluid. The doctor/radiologist who applied it was relatively new to the technique, and missed the capsual a couple of times and so had to reposition, all in all taking about 40 minutes. They got about 35ml in total; the feeling of internal pressure was pretty intense and diminished over the next few hours. The second was at Melbourne Radiology Clinic and used essentially the same technique, but with a little less fuss and similar outcome. The third was done at Victoria House Medical Imaging; I believe the doctor that helped develop the technique in Victoria was the one who treated me (Frank?). This one was a little different - no anaesthetic, no die, and over in about 10 minutes!

In all cases they were able to get 30 - 35 ml in, in one of them I seem to remember a build-up of pressure and then a 'pop' sensation followed by the loss of that pressure. All three provided no gains in ER and minimal gains gains elsewhere.I think in my case they haven't been effective in the way the surgeon had hoped.

Nobody has mentioned labral tears to me, and I couldn't read the operative notes to see if this was part of the original accident (I really wish surgeons would type their notes!). Even if there is a labral tear, I doubt I've got to worry too much about stability the way this shoulder is going...It's interesting to note that the remaining screw is very close to the edge of the joint surface. When I asked my original surgeon about this, he told me it was embedded in the cartilage (so I guess the labrum?).

In terms of my symptoms during the session, there is definitely some protective reactions going on there - I have to make a point of relaxing and letting the physio take the arm through it's motion (pain tolerance is fairly good though). While it's painful during the session, the pain almost non-existant about 15 minutes after.

[adamd9]

Hi Luke,

Thanks for your reply. I suspect the nature of my original surgery (open) would have contributed to the current situation. I guess the problem with surgery is that every time they go in, they create more scar tissue and more chance for adhesions and other issues.

My new surgeon (who performed the last scope) suggested we try another 3 months of manual therapy before considering open surgery to:
-remove the remaining screw (this couldn't be removed arthriscopically)
-potentially fix a device to smooth over a divit/dent in the humeral head that might lead to arthritis later in life
-potentially look at splicing a tendon (can't remember which one) to allow more ER, but this obviously has more risk.

I'm interested in your comments around the placement of the screw and the movement of the humeral head. Are you saying that weak rotator cuff control could be causing the humeral head to sit forward (or not be pulled backwards in line with the joint surface when rotating), therefore potentially interfering with the screw? What about the original surgeon saying that the screw is buried in the cartilage? The new surgeon didn't want to rule out that the screw might be playing a part, but seemed pretty non-committal about it's role.

I'll get my physio to try as you suggest and relocate the posterior head of the humerus (which I assume means basically pushing it to the back of the joint surface and then trying to rotate).

Cheers,


Adam

[adamd9]

Hi All,

For those of you who followed this thread and suspected some sort of impingement due to the placement of the remaining screw (just outside the glenoid joint space), I found an interesting article that gives that theory a lot more merit. I was seaching for "glenoid fracture internal fixation mechanical impingement" and found a research article titled Arthroscopic screw fixation of large anterior glenoid fractures, which mentioned "In one case, removal of the screw was necessary due to mechanical impingement."

What was interesting was the CT image that indicated the position of the impinging screw:



The article talks about a lack of internal rotation due to the screw placement. The lack of ROM was resolved with the removal of the screw.

From the article: "In the first treated case of this series, damage to the cartilage was observed in the anterior region of the humeral head due to mechanical impingement with the screw head. Implant removal became unavoidable because of pain and restricted internal rotation and was carried out 54 months after arthroscopic screw fixation. Clinical suspicion, based on complaints and physical exam, was complemented by a CT-scan, which revealed moderate sticking out of the screw head (Fig. 7). Meticulous study of the postoperative radiographs led us to believe that the screw was initially placed too close to the cartilage. After this first case, no implant complication occurred any more"................................."The serious problem of screw impingement with intra-articular damage could not be ignored. The implant-related complication had occurred in the first case of this series and was related, retrospectively, to the technical fault of setting the screw too close to the glenoid cartilage."

...which makes my first surgeon's causal response to the CT a little more interesting: "The screw might be protruding 8mm, but it's buried in the cartilage, so it's ok".

Even though my problem is mostly external rotation, I'm now more confident that the screw is more likely to be a primary factor of my lack of external rotation, especially given the more agressive angle of my screw:



I'd be interested in your thoughts...

[adamd9]

Hi All,

Just thought I'd post here to round off this discussion with some good news. A few weeks back I arranged to have a CT scan done while in external rotation and I finally got my report back:

Clinical Notes: Limited external rotation. ? screw impingement from prior surgery.

Findings: The patient was scanned in external rotation. Comparison is made to the prior
study from June 23, 2011. In fact it does appear that the protruding screw limits the
degree of external rotation. The humeral head lies immediately adjacent to the screw.

Conclusion: External rotation does appear limited by the anteriorly positioned screw as the humeral
head abuts the screw when compared to the prior study which was performed in neutral
position.

So, I now have all the justification I need to ask my surgeon to take that screw out as soon as he thinks it's a good idea to go in (bearing in mind it will probably be an open surgery).

Thanks for all your contributions!

Adam

[MrPhysio+]

Good detective work, well done and thanks for letting us know the results. Good luck for your corrective surgery when it is undertaken.
Case discussions such as this are a good way to improve the knowledge of all participants - thanks again for sharing.
Cheers,
MrPhysio+

[theshoulderguy]

Great News Adam, I am glad my little CT tip worked out for you.

Interestingly enough I saw another young fellow this week that has had some issues with a poorly placed bone anchor
during a reconstruction and he too has had it removed with good pain relief although the humeral head is now somewhat eroded.

I am hoping that you can dodge a bullet with your shoulder.

Good Luck!

Luke

[physiobob]

Also a big thanks from me Adam for continuing to keep us informed of your progress. I'd like to thank all for their contributions and hopefully you can let us know the results once the screw is out. You can link to youtube videos in your posts so it would be great to see a range of motion video before and after the removal. Best of luck with a speedy progress.