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 Remember ASEPTIC mneumonic Alcohol, AIDS Steroids (most common), Sickle, SLE Erlenmeyer flask (Gaucher’s) Pancreatitis Trauma Idiopathic/ Infection Caisson’s (the bends) may be atraumatic 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 provides 35% of blood supply to humeral head posterior humeral circumflex artery most current literature supports this as providing the main blood supply to humeral head provides 65% of blood supply Classification Cruess Classification (stages) Stage I Normal x-ray. Changes on MRI. Core decompression. Stage II Sclerosis (wedged, mottled), osteopenia. Core decompression. Stage III Crescent sign indicating a subchondral fracture. Resurfacing or hemiarthroplasty. Stage IV Flattening and collapse. Resurfacing or hemiarthroplasty. Stage V Degenerative changes extend to glenoid. TSA. 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 + arthroscopy (confirm integrity of cartilage) indications early disease (precollapse 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)
QUESTIONS 1 of 2 1 2 Previous Next PASS Peak is our new Personalized Adaptive Learning System. The beta version will be available to VC members free for a limited time. Click here for more information on PASS Peak. PASS Peak is our new Personalized Adaptive Learning System. The beta version will be available to VC members free for a limited time. Click here for more information on PASS Peak. (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? Review Topic QID:3501 FIGURES: A 1 Gaucher disease 0% (4/2147) 2 Osteoarthritis 0% (6/2147) 3 Chronic rotator cuff tendinopathy 2% (44/2147) 4 Osteonecrosis 96% (2061/2147) 5 Calcific tendinitis 1% (26/2147) Select Answer to see Preferred Response PREFERRED RESPONSE 4 The atraumatic lesion shown in Figure A is most consistent with osteonecrosis (also known as avascular necrosis, or AVN). Initial MRI findings of AVN include decreased signal intensity in the subchondral region on both T1- and T2-weighted images, suggesting edema in early disease. In the shoulder, this is most commonly associated with the chronic use of corticosteroids, such as prednisone. Sarris et al provide a review of osteonecrosis of the shoulder. They state that treatment is most effectively guided by staging of the disease, and that stage I and II disease can be treated conservatively. Surgical intervention is advocated when the patient is persistently symptomatic, and signs of articular collapse are evident. The surgical options include arthroscopic débridement, core decompression, vascularized bone grafting, and shoulder arthroplasty. Incorrect Answers: 1-Gaucher disease is usually associated with large boney infarcts on MRI and severe pain. It is also a less common cause of AVN than chronic corticosteroid use. 2-Osteoarthritis is not frequently associated with subchondral collapse and fragmentation, especially in the absence of prior symptoms. 3-Chronic rotator cuff tendinopathy does not typically present with the changes noted on the MRI in Figure A. 5-Calcific tendinitis usually presents with severe acute pain, and a hypointense area within the soft tissues around the shoulder representing the calcific deposit. An example of calcific tendinitis is shown in Illustration A. ILLUSTRATIONS: A References: Pathogenesis and treatment of osteonecrosis of the shoulder. Sarris I, Weiser R, Sotereanos DG Orthop. Clin. North Am.. 2004 Jul;35(3):397-404, xi. PMID: 15271548 (Link to Abstract) Sarris, CORR 2004 Vote for CME Authors: Joshua Blomberg MD, John Badylak MD, Patrick McCulloch MD, Jeremy Stern MD, Please rate question. Average 3.0 of 13 Ratings Question COMMENTS (2) Please login to add comment. PASS Peak is our new Personalized Adaptive Learning System. The beta version will be available to VC members free for a limited time. Click here for more information on PASS Peak. (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? Review Topic QID:3098 FIGURES: A 1 Cell-mediated immune response inciting synovial hypertrophy and mononuclear destruction of cartilage 2% (70/2874) 2 Humoral immune response following a systemic infection in an HLA-B27 positive individual 0% (13/2874) 3 Hyperuricemia induced crystalline deposition within the synovial fluid 0% (8/2874) 4 Cellular death of the subchondral bone following an interruption in the vascular supply 96% (2764/2874) 5 Bacterial seeding of the joint inducing polymorphonuclear cell destruction of the cartilage 0% (4/2874) Select Answer to see Preferred Response PREFERRED RESPONSE 4 The radiograph demonstrates AVN of the humeral head and early collapse of the articular surface. Patients with radiographic evidence of proximal humerus AVN should also have hip radiographs performed as part of their evaluation. Cruess reviews 95 patients with steroid-induced AVN of the humeral head reporting success with both conservative and arthroplasty treatment. L'insalata et al reviews 65 shoulders with AVN of the humeral head reporting mixed results with 35 shoulders requiring arthroplasty after failure of conservative therapies. Surgical drilling and decompression did not alter the progression of disease. Incorrect Answers: Answers 1, 2, 3, and 5 describe rheumatoid arthritis, Reiter's Syndrome, gout, and septic arthritis respectively. References: pdf Steroid-induced avascular necrosis of the head of the humerus. Natural history and management. Cruess RL. J Bone Joint Surg Br. 1976 Aug;58(3):313-7. PMID: 956247 (Link to Abstract) Cruess, BJJ 1976 Vote for CME Humeral head osteonecrosis: clinical course and radiographic predictors of outcome. L'Insalata JC, Pagnani MJ, Warren RF, Dines DM J Shoulder Elbow Surg. 1996 Sep-Oct;5(5):355-61. PMID: 8933457 (Link to Abstract) L'Insalata, JSES 1996 Vote for CME Authors: John Badylak MD, Patrick McCulloch MD, Michael Hughes MD, Please rate question. Average 4.0 of 19 Ratings Question COMMENTS (2) Please login to add comment. Sorry, this question is available to Virtual Curriculum members only. Click HERE to learn more and purchase the Virtual Curriculum today!