Updated: 6/5/2021

Avascular Necrosis of the Shoulder

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  • summary
    • Avascular necrosis of the shoulder is a condition characterized by interruption of blood supply to the humeral head which may lead to humeral head sclerosis and subchondral collapse. 
    • Diagnosis is made radiographically with orthogonal radiographs of the shoulder in moderate/late disease. MRI may be needed for detection of early or subclinical avascular necrosis.
    • Treatment may be observation for very early and minimally symptomatic disease. Surgical management is indicated for progressive symptoms in the setting of moderate to advanced disease.
  • Etiology
    • 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
  • 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)
      Radiographic findings
      Treatment
      StageI

      Normal x-ray, changes on MRI only
      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
      Total shoulder arthroplasty

  • 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)
  • Prognosis
    • Related to stage of disease

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Flashcards (1)
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Questions (5)

(OBQ13.174) A 45-year-old man complains of chronic right shoulder pain. He has a history of chronic steroid use because of asthma. He recently completed a course of physical therapy and has given up his job as a laborer in favor of a desk job. Examination reveals diminished shoulder abduction strength. A radiograph of his shoulder is shown in Figure A. Which of the following surgical treatment options (Figures B through F) is the most appropriate?

QID: 4809
FIGURES:
1

Figure B

66%

(3687/5591)

2

Figure C

15%

(846/5591)

3

Figure D

5%

(254/5591)

4

Figure E

10%

(536/5591)

5

Figure F

4%

(207/5591)

L 3 C

Select Answer to see Preferred Response

(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?

QID: 3501
FIGURES:
1

Gaucher disease

0%

(14/3961)

2

Osteoarthritis

0%

(18/3961)

3

Chronic rotator cuff tendinopathy

3%

(113/3961)

4

Osteonecrosis

94%

(3741/3961)

5

Calcific tendinitis

1%

(57/3961)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 3098
FIGURES:
1

Cell-mediated immune response inciting synovial hypertrophy and mononuclear destruction of cartilage

2%

(92/4398)

2

Humoral immune response following a systemic infection in an HLA-B27 positive individual

1%

(24/4398)

3

Hyperuricemia induced crystalline deposition within the synovial fluid

0%

(17/4398)

4

Cellular death of the subchondral bone following an interruption in the vascular supply

96%

(4228/4398)

5

Bacterial seeding of the joint inducing polymorphonuclear cell destruction of the cartilage

0%

(11/4398)

L 1 C

Select Answer to see Preferred Response

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Evidence (11)
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EXPERT COMMENTS (6)
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