Anatomy 結構
Shoulder is a joint made of 3 bones, Humerus (the arm bone), Scapula (the shoulder blade) and clavicle (the collar bone).
The scapula articulate with the ball head of humerus through a dish like structure called glenoid. In contrast to ball-and-socket joint like hip, it has much much bigger range of motion, but with a significant sacrifice of stability. A ring of firm fibrous tissue, called labrum, deepens the glenoid dish, increases the stability and prevents dislocation.
The shoulder allows a hemisphere of manipulation for the upper limb.
A group of muscles, called rotator cuff, sits on the shoulder blade and attach to the humerus. When it pulls, it will rise the arm to overhead. The tendon of the rotator cuff pass underneath a bony roof, formed by the scapula and clavicle. This space, called sub-acromial space, might have the tendon impinged and attrited. The result is pain on rising the arm, reaching the back. And in late stage, can cause rupture of the rotator cuff tendon and hence weakness or even inability to move the shoulder.
肩膀是由1塊及2根骨頭組成的關節。肱骨（上臂骨），肩胛骨（雞翼骨）和鎖骨組成。
肩胛骨通過一個稱為關節盂的碟狀結構與肱骨的球形頭連接。與髖關節的的球窩關節相比，它的運動範圍大得多，但犧牲了穩定性。為了保持部份的穩定性，一塊水泡狀的堅韌組織，叫肩關節盂唇（裙邊），增加了關節盂的深度，避免關節脱位。
因這特別結構，肩膀允許上肢可以有超過半球體的立體活動操控空間。
一組稱為肩袖的肌肉銜接在肩胛骨上，並伸展到肱骨上端。當它發力收縮時，便能將手臂伸到頭頂。肩袖的肌腱穿過由肩胛骨和鎖骨形成的骨隧道。這個空間被稱為肩峰頂下空間。如有骨刺或增生，可能會使肌腱受到磨損。結果是當手臂抬起時，或旋到後背時，會感到疼痛及僵硬。並且在後期，可能會導致肩袖肌腱撕裂，而導致抬起時乏力甚至無法移動肩膀。
Pathology 毛病
Disease 病變
The followings are common pathologies in shoulder
以下是常見肩膀病變
- Rotator cuff tear
- Adhesive capsulitis
- Massive cuff tear
- Labrum tear
- Dislocation with Hill-Sachs lesion
- Proximal humeral fracture
- Clavicle fracture
- 旋轉肌腱撕裂
- 冷凍肩（五十肩）
- 大範圍旋轉肌腱撕裂
- 肩盂唇撕裂
- 肩關節前脫位伴隨的肱骨頭後外側凹陷性骨折
- 肱骨近端骨折
- 鎖骨骨折
Investigation 評估
MRI is required to review soft tissue status. X-ray would be needed for bony pathology. Nerve conduction study might be indicated for possible nerve palsy.
磁力共震片能夠提供軟組織情況。骨頭問題，例如骨折，就會需要照X光。神經線問題可以電神經測試得知情況。
Management 治療
Conservative treatments are indicated for majority of cases. They included,
- Physiotherapy
- Chiropractor
- TCM practitioner
- Prescribed Exercise
- Medication
For cases failed conservative treatments, or when the injury is unstable, then surgical intervention would be indicated.
For patients with witnessed deterioration, surgical intervention might be advocated.
絕大多數病人只需採取保守治療。他們包括
- 物理治療
- 脊醫
- 中醫
- 處方運動
- 藥物（口服及外敷）
對於保守治療無效的病例，或受傷位置不穩定，醫生會改為介入治療，例如打針甚至手術。
對於持續惡化的患者，醫生往往會建議手術，以保肢體功能。
Common Interventions include
- Injection of steroid
- Injection of PRP
- Injection of hyaluronic acid
- casting
- Arthroscopic capsular release
- Arthroscopic acromioplasty
- Arthroscopic rotator cuff repair
- Arthroscopic labrum repair
- Remplissage procedure
- CoracoClavicular Ligament reconstruction
- Surgical reduction and plating
- Reverse shoulder replacement
Reference
- Mathias Wellmann, Thore Zantop,Wolf Petersen. Minimally Invasive Coracoclavicular Ligament Augmentation With a Flip Button/Polydioxanone Repair for Treatment of Total Acromioclavicular Joint Dislocation. Arthroscopy 2007;23:1132.e1-1132.e5 https://www.sciencedirect.com/science/article/abs/pii/S0749806306015088