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Avascular Necrosis of the Shoulder

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Topic updated on 12/07/14 10:47pm
Introduction
  • A condition caused by interruption of blood supply to humeral head
  • Pathophysiology
    • pathoanatomy 
      • decreased blood supply to humeral head leading to death of cells in bony matrix.
      • bone is resorbed and remodeled, causing subchondral bone collapse and may lead to joint incongruity and arthritic changes
    • etiology similar to hip
      • atraumatic (remember ASEPTIC mneumonic) 
        • Alcohol, AIDS
        • Steroids (most common), Sickle, SLE
        • Erlenmeyer flask (Gaucher’s)
        • Pancreatitis
        • Trauma
        • Idiopathic/ Infection
        • Caisson’s (the bends)
      • posttraumatic
        • four-part fracture-dislocations approach 100% AVN
        • displaced four-part fractures ~45% AVN
        • valgus impacted four-part ~11% AVN
        • three-part ~14% AVN
  • Prognosis
    • related to stage of disease
Anatomy
  • Blood supply
    • Humeral head
      • ascending branch of anterior humeral circumflex artery and arcuate artery
        • provides blood supply to humeral head
        • vessel runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove
          • beware not to injure when plating proximal humerus fractures
        • arcuate artery is the interosseous continuation of ascending branch of anterior humeral circumflex artery and penetrates the bone of the humeral head
      • posterior humeral circumflex artery
        • most current literature supports this as providing the main blood supply to humeral head  
Classification
 
Cruess Classification (stages)
Stage I Normal x-ray. Changes on MRI
Stage II Sclerosis (wedged, mottled), osteopenia
Stage III Crescent sign indicating a subchondral fracture
Stage IV Flattening and collapse
Stage V Degenerative changes extend to glenoid  
 
Presentation
  • Symptoms
    • insidious onset of shoulder pain
      • often without a clear inciting event
    • pain, loss of motion, crepitus, and weakness
  • Physical exam
    • limited range of motion
    • crepitus
    • weakness of the rotator cuff and deltoid muscles
Imaging
  • Radiographs
    • recommended views
      • five views of shoulder (shown best in neutral rotation AP)
    • findings
      • no findings on radiograph at onset of disease process
      • osteolytic lesion develops on radiograph demonstrating resorption of subchondral necrosis
        • most common initial site is superior middle portion of humeral head
      • crescent sign demonstrates subchondral collapse
      • may progress to depression of articular surface and consequent arthritic changes.
  • MRI
    • preferred imaging modality
      • ~100% sensitivity in detection
    • will demonstrate edema at the site of subchondral sclerosis 
Treatment
  • Nonoperative
    • pain medications, activity modification, physical therapy
      • indications
        • first line of treatment
      • technique
        • physical therapy
          • restrict overhead activity and manual labor
  • Operative
    • core decompression  
      • indications
        • early disease (Cruess Stage I and II)
    • humeral head resurfacing
      • indications
        • Stage III disease with focal chondral defects, and sufficient remaining epiphyseal bone stock for fixation.
    • hemiarthroplasty  
      • indications
        • moderate disease (Cruess Stage III and IV)
    • total shoulder arthroplasty 
      • indications
        • advance stage (Cruess V)

 

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Qbank (3 Questions)

TAG
(OBQ11.78) A 66-year-old male presents with a three-month history of increasing right shoulder pain. He denies any trauma or prior shoulder problems, and has good rotator cuff strength. His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. A current MRI image of his shoulder is shown in Figure A. What is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. Gaucher disease
2. Osteoarthritis
3. Chronic rotator cuff tendinopathy
4. Osteonecrosis
5. Calcific tendinitis

PREFERRED RESPONSE ▶
TAG
(OBQ10.10) A 37-year-old severe asthmatic has been taking daily corticosteroids for twenty years and now reports 4 months of worsening left shoulder pain. He is unable to complete a full day of work due to the pain. A radiograph is provided in Figure A. Which of the following describes the pathogenesis behind this disease process? Topic Review Topic
FIGURES: A          

1. Cell-mediated immune response inciting synovial hypertrophy and mononuclear destruction of cartilage
2. Humoral immune response following a systemic infection in an HLA-B27 positive individual
3. Hyperuricemia induced crystalline deposition within the synovial fluid
4. Cellular death of the subchondral bone following an interruption in the vascular supply
5. Bacterial seeding of the joint inducing polymorphonuclear cell destruction of the cartilage

PREFERRED RESPONSE ▶
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Smith RG, Sperling JW, Cofield RH, Hattrup SJ, Schleck CD
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