Blanco Moreno Atlas of Arthroscopic Anatomy of the Major Joints

1. Auflage 2016
ISBN: 978-3-13-258140-1
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 204 Seiten, ePub

-- European Journal of Orthopaedic Surgery & Traumatology

An accurate knowledge of anatomy is essential for the safe and effective performance of arthroscopic procedures on joints. With more than 450 high-quality arthroscopic images and photographs showing dissections, this atlas is an important orientation tool that makes the complex anatomy of joint structures accessible. The text covers all the major joints and includes concise explanations of diagnostic and therapeutic indications, patient positioning, external landmarks, arthroscopic portals and related anatomy, and the structures at risk for damage. This practical book also offers technical tips and valuable suggestions for avoiding injury to neurovascular structures.

Key Features:

• More than 450 stunning, full-color photographs clearly depict the anatomical relationship between the different arthroscopic portals and joint structures
• Chapters devoted to all major joints in the body: shoulder, elbow, wrist, hip, knee, and ankle
• Vital information on how to avoid potential complications caused by the arthroscopic instrumentation during portal installation
• Hints and advice for implementing best practices in arthroscopic procedures
• Leading specialists in the field of arthroscopic surgery contribute their insights and expertise

is an indispensable guide for orthopedic surgeons and hand or foot surgeons approaching arthroscopic techniques for the first time or who perform them infrequently. Residents and fellows will find outstanding illustrations and pertinent details for understanding joint structures and treating a variety of pathologies with arthroscopy. This volume can also serve as a useful teaching resource for instructors in orthopedic surger

Zielgruppe

Ärzte

Autoren/Hrsg.

Blanco Moreno, Cristian

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Orthopädie- und Unfallchirurgie

Inhaltsverzeichnis

1 Shoulder
2 Elbow
3 Wrist
4 Hip
5 Knee
6 Ankle

Leseproben

1    Shoulder

1.1 Introduction

Shoulder arthroscopy has developed greatly over the last two decades. This technique allows a complete evaluation of the shoulder and the treatment of a variety of pathologies with minimal tissue distortion. The shoulder anatomy is complex and located near important neurovascular structures; therefore, detailed knowledge of this anatomy allows for an efficient and safe arthroscopic procedure.

The shoulder is one anatomical and biomechanical entity; however, from an arthroscopic point of view, it is easier to analyze its components separately—the glenohumeral joint, the subacromial space, and the acromioclavicular joint. This chapter presents patient positioning, external anatomical landmarks, arthroscopic portals, and the related anatomy for each of these shoulder components.

1.2 Pathologies Treated by Shoulder Arthroscopy

The therapeutic indications for a shoulder arthroscopy include:

• Rotator cuff lesions

• Labral lesions

• Glenohumeral instability

• Removal of loose bodies

• Synovium and bursa pathologies

• Septic arthritis

• Arthroscopic assistance in fracture treatment

• Acromioclavicular degenerative disease

• Acromioclavicular instability

• Subacromial pathology

1.3 External Anatomical Landmarks and Portals

To establish the shoulder portals, it is necessary to identify and mark the osseous landmarks: the acromion in its posterolateral border, the anterodistal clavicle, the acromioclavicular joint, the coracoid process, and the supraclavicular fossa (Figs. 1.1 and 1.2).

1.4 Patient Positioning

Shoulder arthroscopy can be performed with the patient in two basic positions: the beach chair and the lateral decubitus. In the beach chair position, the arm is located in 20 degrees of anterior flexion with the help of an assistant or an arm holder. In the lateral decubitus position, the upper limb is put in traction in 70 degrees of abduction and an anterior flexion of 20 degrees (Fig. 1.3). The authors of this chapter prefer the lateral decubitus position; therefore, all of the arthroscopic images included here were taken with the patient in this position. Before any arthroscopic procedure, physical examination should assess range of motion, joint stability, and laxity.

Fig. 1.1 (a, b) Anterior and posterior views of the external landmarks for a right shoulder arthroscopy.

1 Clavicle
2 Acromion
3 Coracoid process
4 Deltoid muscle
5 Deltopectoral sulcus
6 Infraspinatus muscle
7 Teres minor muscle
8 Teres major muscle
9 Triceps brachii muscle

Fig. 1.2 Proximal view of a right shoulder in the lateral decubitus position showing the osseous landmarks and most frequently used portals.

1 Lateral portal
2 Acromion
3 Anterior portal
4 Acromioclavicular joint
5 Acromioclavicular portal
6 Posterior portal
7 Superior portal

Fig. 1.3 (a, b) Patient in the lateral decubitus position for a right shoulder arthroscopy.

1.5 Suggested Arthroscopic Sequence

1.5.1 Glenohumeral Joint

Once the patient is in position, evaluate shoulder stability and range of motion. The arthroscopic evaluation of the glenohumeral joint starts from the posterior portal. The tendon of the long head of the biceps brachii muscle is the first articular structure to find and provides adequate orientation within the joint. Next, evaluate the rotator interval, the subscapularis muscle tendon, the glenoid cavity, the labrum, and the ligaments, followed by the humeral head and supraspinatus muscle tendon. Then, the arthroscope is moved posteroinferiorly to visualize the infraspinatus muscle and teres minor muscle tendons, which end at the axillary recess. Finally, the arthroscope is moved to the anterior and anterolateral portal of the glenohumeral joint as needed.

1.5.2 Subacromial Space

The subacromial evaluation should begin at the posterior portal to check the subacromial space and its bursa. Changing the orientation of the lens allows the evaluation of the rotator cuff, the acromial morphology, the coracoacromial ligament, and the inferior part of the acromioclavicular joint. The rotator cuffcan be evaluated from the lateral portal of the subacromial space to better define a tear before the repair, if necessary. The anterior portal and the accessory portals (the direct acromioclavicular and superior portals) are used as needed.

1.6 Glenohumeral Joint

1.6.1 Posterior Portal

The posterior portal for the glenohumeral joint is the main portal for shoulder arthroscopy and is the first portal to be established; it is 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion (Fig. 1.4). It allows for an initial arthroscopic evaluation and is the starting point of any procedure in the glenohumeral joint.

Anatomy and Structures at Risk

The posterior portal—when in the correct location—passes between the infraspinatus and teres minor muscles. If the posterior portal is located medially from the correct location, the circumflex scapular artery is at risk. If the posterior portal is located medially and superiorly from the correct location, the suprascapular artery is at risk. The axillary nerve and posterior circumflex humeral artery are at risk if the posterior portal is located lateral and inferior to the correct location. The anatomy of the posterior shoulder is shown in Figs. 1.5–1.8.

Intra-articular and Arthroscopic Anatomy

An adequate knowledge of the articular anatomy of the glenohumeral joint is key for a good arthroscopic orientation from the posterior portal and necessary to perform a safe surgical procedure. For additional safety the anterior portal is located under direct arthroscopic control from the same posterior portal (Figs. 1.9–1.15).

Fig. 1.4 Right shoulder in the lateral decubitus position showing the external landmarks with the arthroscope in the posterior portal.

Fig. 1.5 Posterior view of a right (cadaveric) shoulder with the muscular layer partially exposed.

1 Deltoid muscle
2 Infraspinatus muscle
3 Triceps brachii muscle

Fig. 1.6 (a, b) Posterior views of a right (cadaveric) shoulder showing the posterior muscles as well as the location of the posterior portal.

1 Deltoid muscle
2 Posterior portal
3 Infraspinatus muscle
4 Teres minor muscle
5 Teres major muscle
6 Triceps brachii muscle (long head)
7 Axillary nerve and posterior circumflex humeral artery
8 Scapula
9 Infraspinatus muscle tendon
10 Suprascapular artery
11 Posterior joint capsule
12 Circumflex scapular artery

Fig. 1.7 (a, b) Posterior views of a right (cadaveric) shoulder after cutting and elevating the deltoid muscle to expose the posterior part of the rotator cuff.

1 Deltoid muscle, 2 Infraspinatus muscle, 3 Teres minor muscle, 4 Triceps brachii muscle (long head), 5 Teres major muscle, 6 Acromion, 7 Supraspinatus muscle tendon, 8 Humeral head, 9 Infraspinatus/teres minor muscle tendons, 10 Axillary nerve and posterior humeral circumflex artery, 11 Deltoid muscle cut and mobilized distally, Posterior portal

Fig. 1.8 Posterior view of a right (cadaveric) shoulder after cutting and moving the posterior muscles to expose the posterior capsule of the glenohumeral joint.

1 Deltoid muscle, 2 Infraspinatus muscle, 3 Teres minor muscle cut, 4 Teres major muscle, 5 Triceps brachii muscle (long head), 6 Axillary nerve and posterior humeral circumflex artery, 7 Acromion, 8 Infraspinatus muscle tendon cut, 9 Humeral head, 10 Shoulder joint capsule, 11 Teres minor muscle tendon cut, 12 Deltoid muscle cut and distally mobilized

Fig. 1.9 (a, b) A right (cadaveric) shoulder that shows the lateral view of the glenoid process and the superior view of the proximal humerus.

1 Deltoid muscle
2 Supraspinatus muscle/tendon
3 Infraspinatus muscle/tendon
4 Teres minor muscle/tendon
5 Joint capsule
6 Glenoid labrum
7 Acromion
8 Clavicle
9 Coracoacromial ligament
10 Coracoid process
11 Tendon of the long head of the biceps brachii muscle
12 Glenoid cavity
13 Subscapularis muscle tendon
14 Middle glenohumeral ligament
15 Inferior synovial recess
16 Humeral head

Fig. 1.10 (a) Right shoulder with the arthroscope in the posterior portal. (b) Arthroscopic view of the tendon of the long head of the biceps brachii muscle. (c) Arthroscopic view of the rotator interval. (d) Arthroscopic view of the humeral head and posterior labrum margin. (e) Arthroscopic view of the rotator cuff.

1 Humeral head, 2 Tendon of the long...