Give me clinical diagram of dynamic stabilizers of shoulder from Campb

Give me clinical diagram of dynamic stabilizers of shoulder from Campbell Orthopaedics.

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I have the key diagrams and content. Now I can compile a thorough answer. Here is the complete clinical summary of dynamic stabilizers of the shoulder from Campbell's Operative Orthopaedics and supplementary material from Rockwood & Green's Fractures in Adults:

Dynamic Stabilizers of the Shoulder

(From Campbell's Operative Orthopaedics, 15th Ed. 2026 - Chapter 52, and Rockwood & Green's Fractures in Adults, 10th Ed. 2025 - Chapter 35)

Glenoid, Capsule, and Surrounding Anatomy

The diagram below (eFig. 52.1 from Campbell's, Chapter 52) shows the dynamic muscle stabilizers in relation to the static ligamentous structures:

Glenoid and surrounding capsule, ligaments, and dynamic muscle stabilizers - Campbell's Operative Orthopaedics eFig. 52.1

eFig. 52.1 - Glenoid and surrounding capsule, ligaments, and tendons. Dynamic stabilizers visible include: Supraspinatus, Infraspinatus, Teres minor, Subscapularis, and Long head of biceps. Static stabilizers shown alongside: Superior, Middle, and Anterior band of Inferior glenohumeral ligaments.

Concavity-Compression Mechanism

Fig. 35-29 (Rockwood & Green's) - The rotator cuff muscle is responsible for "concavity compression" in which activation of the rotator cuff results in compression of the humeral head into the glenoid cavity, stabilizing it against translational forces.

The Dynamic Stabilizers - Organized Summary

1. Rotator Cuff (Primary Dynamic Stabilizer)

The rotator cuff - comprising supraspinatus, infraspinatus, teres minor, and subscapularis - contributes to glenohumeral stability through three mechanisms:

Mechanism	Description
Concavity-compression	Rotator cuff contraction compresses the humeral head into the glenoid concavity, resisting translatory forces. Loss of labrum reduces this effect by 20%
Coordinated contraction	Guides the humeral head to the center of the glenoid surface
Dynamization of capsuloligamentous structures	Through rotator cuff attachments, passive ligaments are tensioned as the shoulder moves through its ROM

At midranges of motion (when capsular ligaments are lax), concavity-compression is the dominant stabilizing mechanism
At extremes of motion, capsuloligamentous structures tighten and dominate
50% reduction in rotator cuff force leads to 46% increase in anterior displacement and 31% increase in posterior displacement

2. Long Head of Biceps

Originates from the supraglenoid tubercle and superior glenoid labrum (mostly posterior labrum)
Both long and short heads prevent anterior instability with the arm in abduction-external rotation (ABER)
Stabilizing role increases as intrinsic stability decreases (e.g., with Bankart lesion)
Becomes more important than the subscapularis in anterior stability when capsuloligamentous structures are compromised

3. Deltoid Muscle

Four dynamic stabilizing effects (Morrey et al.):

Effect	Mechanism
Passive tension	From muscle bulk alone
Compressive contraction	Muscle contraction compresses the humeral head on the articular surface
Passive ligament tensioning	Joint motion produced by deltoid tightens passive ligaments
Barrier effect	Contracted muscle acts as a physical barrier

Middle and posterior deltoid provide more stability (greater compressive, lower shear forces) than the anterior deltoid
In external rotation, deltoid insertion moves posteriorly, producing a posteriorly directed compressive force that reduces anterior instability
Deltoid stabilizing function becomes critical when the shoulder is inherently unstable (e.g., Bankart lesion)

4. Scapular Stabilizers

The scapular muscles act as dynamic stabilizers by optimally positioning the glenoid relative to the humeral head:

Serratus anterior, trapezius, latissimus dorsi, rhomboids, levator scapulae
Synchronous scapular mobility ensures the joint reaction force is compressive rather than shear
Scapular dyskinesis disrupts this balance - known as the SICK scapula syndrome (Scapular malposition, Inferior medial border prominence, Coracoid pain/malposition, dysKinesis of movement)

5. Proprioception

Mechanoreceptors (Pacinian corpuscles, Ruffini endings, Golgi tendon organs) in the capsule and ligaments provide afferent feedback
Stimulation triggers reflex muscle contraction (rotator cuff, biceps, deltoid), producing compressive stabilizing forces
Shoulder instability disrupts proprioception; surgical repair restores it (~50% improvement at 6 months, normalized at 1 year)

Summary Table

Dynamic Stabilizer	Primary Mechanism	Key Position
Rotator cuff (4 muscles)	Concavity-compression; centering	Midranges of motion
Long head of biceps	Anterior restraint (ABER)	Abduction + external rotation
Deltoid	Compression + barrier effect	Elevation, external rotation
Scapular stabilizers	Glenoid positioning (compressive vs. shear force)	All positions
Proprioceptive reflexes	Reflex muscle contraction	Extremes of motion / instability

Sources: Campbell's Operative Orthopaedics 15th Ed 2026, Chapter 52 (Shoulder Instability - Classification and Outcomes, eFig. 52.1); Rockwood and Green's Fractures in Adults 10th Ed 2025, Chapter 35 (Dynamic Stabilizers - Rotator Cuff, Biceps, Deltoid, Proprioception, Fig. 35-29)

Create a clinical decision tree for multidirectional instability management

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ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not found"

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mkdir -p /home/daytona/workspace/mdi-decision-tree && python3 -c "import matplotlib; print(matplotlib.__version__)"

Writing File

~/mdi-decision-tree/build_tree.py

import matplotlib
matplotlib.use('Agg')
import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyBboxPatch, FancyArrowPatch
import matplotlib.patheffects as pe
import numpy as np

fig, ax = plt.subplots(figsize=(22, 30))
ax.set_xlim(0, 22)
ax.set_ylim(0, 30)
ax.axis('off')
fig.patch.set_facecolor('#F5F7FA')

# ── colour palette ──────────────────────────────────────────────────
C_TITLE   = '#1A1F5E'   # dark navy  – header
C_DIAG    = '#1A237E'   # indigo     – diagnosis / entry
C_SCREEN  = '#283593'   # deep blue  – screening boxes
C_NONOP   = '#1565C0'   # blue       – nonoperative path
C_EXCL    = '#B71C1C'   # red        – exclusions / contraindications
C_SURG    = '#1B5E20'   # dark green – surgery boxes
C_REHAB   = '#4A148C'   # purple     – rehab / post-op
C_ARROW   = '#37474F'   # charcoal   – arrows
C_SULCUS  = '#E65100'   # orange     – sulcus sign decision
C_OUTCOME = '#00695C'   # teal       – outcomes
WHITE     = '#FFFFFF'
LIGHT_BG  = '#E8EAF6'   # very light indigo background for boxes

# ── helper: draw a rounded rectangle with text ──────────────────────
def box(ax, x, y, w, h, text, bg, fg='white', fontsize=8.5,
        bold=False, border=None, alpha=1.0, style='round,pad=0.1'):
    fc = bg
    ec = border if border else bg
    lw = 1.8 if border else 0.8
    patch = FancyBboxPatch((x - w/2, y - h/2), w, h,
                            boxstyle=style,
                            facecolor=fc, edgecolor=ec,
                            linewidth=lw, zorder=3, alpha=alpha)
    ax.add_patch(patch)
    weight = 'bold' if bold else 'normal'
    ax.text(x, y, text, ha='center', va='center',
            fontsize=fontsize, color=fg, fontweight=weight,
            wrap=True, zorder=4,
            multialignment='center',
            linespacing=1.35)

# ── helper: arrow ────────────────────────────────────────────────────
def arrow(ax, x1, y1, x2, y2, label='', color=C_ARROW, lw=1.6,
          connectionstyle='arc3,rad=0.0'):
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle='->', color=color,
                                lw=lw,
                                connectionstyle=connectionstyle),
                zorder=5)
    if label:
        mx, my = (x1+x2)/2, (y1+y2)/2
        ax.text(mx+0.15, my, label, fontsize=7.5, color=color,
                ha='left', va='center', fontstyle='italic', zorder=6)

# ── helper: horizontal connector line ───────────────────────────────
def hline(ax, x1, x2, y, color=C_ARROW, lw=1.6):
    ax.plot([x1, x2], [y, y], color=color, lw=lw, zorder=5)

def vline(ax, x, y1, y2, color=C_ARROW, lw=1.6):
    ax.plot([x, x], [y1, y2], color=color, lw=lw, zorder=5)

# ════════════════════════════════════════════════════════════════════
# TITLE
# ════════════════════════════════════════════════════════════════════
ax.text(11, 29.3, 'Clinical Decision Tree', ha='center', va='center',
        fontsize=18, fontweight='bold', color=WHITE, zorder=6)
ax.text(11, 28.8, 'Multidirectional Instability (MDI) of the Shoulder',
        ha='center', va='center', fontsize=13, color='#CFD8DC', zorder=6)
title_bg = FancyBboxPatch((0.3, 28.35), 21.4, 1.6,
                           boxstyle='round,pad=0.15',
                           facecolor=C_TITLE, edgecolor='none',
                           linewidth=0, zorder=2)
ax.add_patch(title_bg)

source_txt = ('Sources: Campbell\'s Operative Orthopaedics 15th Ed 2026 (Ch. 52) | '
              'Rockwood & Green\'s Fractures in Adults 10th Ed 2025 (Ch. 35, Algorithm 35-4)')
ax.text(11, 28.1, source_txt, ha='center', va='center',
        fontsize=6.5, color='#78909C', style='italic', zorder=6)

# ════════════════════════════════════════════════════════════════════
# NODE 1 – ENTRY / PRESENTATION
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 27.15, 8.5, 0.95,
    'Patient presents with MDI of the Shoulder\n'
    '(symptomatic subluxation/dislocation in ≥2 directions; inferior component obligatory)',
    C_DIAG, fontsize=8.5, bold=True, border='#90CAF9')
arrow(ax, 11, 26.67, 11, 26.12)

# ════════════════════════════════════════════════════════════════════
# NODE 2 – INITIAL SCREENING  (exclude voluntaries / psych)
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 25.75, 8.5, 0.72,
    'Initial Screening: Exclude Voluntary Dislocators & Psychological / Secondary-Gain Issues',
    C_SCREEN, fontsize=8.2, bold=True, border='#90CAF9')

# Branch YES (excluded) – goes RIGHT
arrow(ax, 15.25, 25.75, 18.5, 25.75, color=C_EXCL, lw=1.4)
box(ax, 19.8, 25.75, 2.5, 0.7,
    'NOT a surgical\ncandidate\n(exclude from OR)',
    C_EXCL, fontsize=7.5, bold=True)

ax.text(16.6, 25.9, 'Voluntary / psych',
        fontsize=7, color=C_EXCL, ha='center', style='italic')

arrow(ax, 11, 25.39, 11, 24.82)
ax.text(11.2, 25.12, 'Involuntary – no psych issues',
        fontsize=7, color='#1565C0', ha='left', style='italic')

# ════════════════════════════════════════════════════════════════════
# NODE 3 – NONOPERATIVE TREATMENT
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 24.45, 9.5, 0.72,
    'Nonoperative Treatment (MANDATORY FIRST-LINE for ALL patients)',
    C_NONOP, fontsize=8.5, bold=True, border='#BBDEFB')
arrow(ax, 11, 24.09, 11, 23.55)

# PT details sub-box
box(ax, 11, 23.1, 9.5, 0.85,
    'Structured Physical Therapy Programme ≥ 6–12 months\n'
    '• Rotator cuff strengthening  • Scapular stabilisation  '
    '(serratus ant., trapezius, rhomboids)\n'
    '• Proprioceptive neuromuscular re-training  • Activity modification if needed',
    '#1976D2', fontsize=7.8, border='#BBDEFB')

arrow(ax, 11, 22.67, 11, 22.1)

# ════════════════════════════════════════════════════════════════════
# NODE 4 – RESPONSE TO PT DECISION DIAMOND
# ════════════════════════════════════════════════════════════════════
# Diamond shape via polygon
diamond_x = 11
diamond_y = 21.6
dw, dh = 4.2, 0.85
diamond = plt.Polygon(
    [[diamond_x, diamond_y + dh],
     [diamond_x + dw, diamond_y],
     [diamond_x, diamond_y - dh],
     [diamond_x - dw, diamond_y]],
    closed=True, facecolor='#FFF9C4', edgecolor='#F9A825', linewidth=2, zorder=3)
ax.add_patch(diamond)
ax.text(diamond_x, diamond_y, 'Response to\nPhysical Therapy?',
        ha='center', va='center', fontsize=9, fontweight='bold',
        color='#E65100', zorder=4)

# YES branch (good response) – go RIGHT
arrow(ax, 15.2, 21.6, 17.4, 21.6, color=C_OUTCOME, lw=1.5)
ax.text(16.1, 21.75, 'Adequate\nresponse', fontsize=7, color=C_OUTCOME,
        ha='center', style='italic')
box(ax, 19.2, 21.6, 3.5, 0.85,
    'Continue PT /\nActivity modification\nLong-term follow-up',
    C_OUTCOME, fontsize=7.8, bold=False, border='#A5D6A7')

# NO branch – go DOWN
arrow(ax, 11, 20.75, 11, 20.22, color=C_EXCL)
ax.text(11.2, 20.48, 'Failed PT > 1 year', fontsize=7.5, color=C_EXCL,
        ha='left', style='italic', fontweight='bold')

# ════════════════════════════════════════════════════════════════════
# NODE 5 – PRE-SURGICAL COUNSELLING
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 19.85, 9.5, 0.72,
    'Pre-Surgical Counselling: Discuss inconsistent results; activity/occupation modification as alternatives',
    '#5C6BC0', fontsize=8, border='#C5CAE9')
arrow(ax, 11, 19.49, 11, 18.95)

# ════════════════════════════════════════════════════════════════════
# NODE 6 – EUA & DIRECTION OF INSTABILITY
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 18.58, 9.5, 0.72,
    'Examination Under Anaesthesia (EUA) – Confirm direction & degree of instability\n'
    '(Sulcus sign, load-and-shift, apprehension, anterior/posterior draw)',
    C_SCREEN, fontsize=8, border='#90CAF9')
arrow(ax, 11, 18.22, 11, 17.72)

# ════════════════════════════════════════════════════════════════════
# NODE 7 – SULCUS SIGN DECISION
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 17.38, 7.5, 0.65,
    'Sulcus Sign Persists in External Rotation?  (indicates rotator interval laxity)',
    C_SULCUS, fontsize=8, bold=True, border='#FFCC80')
arrow(ax, 11, 17.05, 11, 16.6, color=C_SULCUS)
ax.text(11.15, 16.83, 'Yes → add Rotator Interval Closure to chosen procedure',
        fontsize=7.5, color=C_SULCUS, ha='left', style='italic')

# ════════════════════════════════════════════════════════════════════
# NODE 8 – DIRECTION BRANCH  (3 columns)
# ════════════════════════════════════════════════════════════════════
box(ax, 11, 16.25, 9.0, 0.65,
    'Determine Dominant Direction of Instability',
    C_DIAG, fontsize=8.5, bold=True, border='#90CAF9')

# horizontal branch line
y_branch = 15.92
vline(ax, 11, 15.92, 15.55)
hline(ax, 4.2, 17.8, y_branch)

# ---- LEFT branch: ANTEROINFERIOR ----
vline(ax, 4.2, y_branch, 15.2)
arrow(ax, 4.2, 15.2, 4.2, 14.72)
box(ax, 4.2, 14.95, 4.2, 0.5,
    'Anteroinferior\nInstability',
    C_DIAG, fontsize=8.5, bold=True)

# ---- CENTRE branch: POSTEROINFERIOR ----
vline(ax, 11, y_branch, 15.2)
arrow(ax, 11, 15.2, 11, 14.72)
box(ax, 11, 14.95, 4.2, 0.5,
    'Posteroinferior\nInstability',
    '#1A237E', fontsize=8.5, bold=True)

# ---- RIGHT branch: ANTERIOR + POSTERIOR + INFERIOR (pan) ----
vline(ax, 17.8, y_branch, 15.2)
arrow(ax, 17.8, 15.2, 17.8, 14.72)
box(ax, 17.8, 14.95, 4.2, 0.5,
    'Anterior + Posterior\n+ Inferior (Pan-MDI)',
    '#283593', fontsize=8, bold=True)

# ════════════════════════════════════════════════════════════════════
# SURGICAL APPROACH DECISION (open vs arthroscopic)
# ════════════════════════════════════════════════════════════════════
# LEFT column
arrow(ax, 4.2, 14.69, 4.2, 14.15)
box(ax, 4.2, 13.82, 4.0, 0.65,
    'Arthroscopic vs Open\nAnteroinferior Capsular Shift\n± Rotator Interval Closure',
    C_SURG, fontsize=8, bold=True, border='#A5D6A7')

# CENTRE column
arrow(ax, 11, 14.69, 11, 14.15)
box(ax, 11, 13.82, 4.0, 0.65,
    'Arthroscopic vs Open\nPosteroinferior Capsular Shift\n± Rotator Interval Closure',
    C_SURG, fontsize=8, bold=True, border='#A5D6A7')

# RIGHT column
arrow(ax, 17.8, 14.69, 17.8, 14.15)
box(ax, 17.8, 13.82, 4.0, 0.65,
    'Arthroscopic vs Open Anterior\n& Posterior Inferior Capsular Shift\n± Rotator Interval Closure',
    C_SURG, fontsize=8, bold=True, border='#A5D6A7')

# ════════════════════════════════════════════════════════════════════
# OPEN vs ARTHROSCOPIC SUB-DECISION
# ════════════════════════════════════════════════════════════════════
# Shared label
box(ax, 11, 13.05, 9.5, 0.55,
    'Arthroscopic vs Open: Surgeon Preference, Patient Factors, Capsular Redundancy Degree',
    '#37474F', fontsize=7.5, bg='#ECEFF1', fg='#263238', border='#B0BEC5')

# LEFT sub-branches
arrow(ax, 4.2, 13.49, 3.1, 12.88, color='#2E7D32')
box(ax, 2.5, 12.6, 2.4, 0.5,
    'Arthroscopic\nCapsular Plication',
    '#2E7D32', fontsize=7.5, border='#A5D6A7')
arrow(ax, 4.2, 13.49, 5.3, 12.88, color='#388E3C')
box(ax, 5.9, 12.6, 2.4, 0.5,
    'Open Capsular\nShift (Neer-Foster)',
    '#388E3C', fontsize=7.5, border='#A5D6A7')

# CENTRE sub-branches
arrow(ax, 11, 13.49, 9.9, 12.88, color='#2E7D32')
box(ax, 9.3, 12.6, 2.4, 0.5,
    'Arthroscopic\nCapsular Plication',
    '#2E7D32', fontsize=7.5, border='#A5D6A7')
arrow(ax, 11, 13.49, 12.1, 12.88, color='#388E3C')
box(ax, 12.7, 12.6, 2.4, 0.5,
    'Open Capsular\nShift (Posterior)',
    '#388E3C', fontsize=7.5, border='#A5D6A7')

# RIGHT sub-branches
arrow(ax, 17.8, 13.49, 16.7, 12.88, color='#2E7D32')
box(ax, 16.1, 12.6, 2.4, 0.5,
    'Arthroscopic\nPan-Capsular Plica.',
    '#2E7D32', fontsize=7.5, border='#A5D6A7')
arrow(ax, 17.8, 13.49, 18.9, 12.88, color='#388E3C')
box(ax, 19.5, 12.6, 2.4, 0.5,
    'Open Ant+Post\nCapsular Shift',
    '#388E3C', fontsize=7.5, border='#A5D6A7')

# ════════════════════════════════════════════════════════════════════
# SURGICAL NOTES BOX  (key intraop points)
# ════════════════════════════════════════════════════════════════════
arrow(ax, 11, 12.35, 11, 11.8)
box(ax, 11, 11.45, 14.0, 0.72,
    'Key Intraoperative Principles  (all approaches)\n'
    '• Obliterate inferior capsular pouch  • Shift capsule to opposite side of calcar  '
    '• Close rotator interval if sulcus persists in ER\n'
    '• Arm in 20–30° abd + 20–30° ER during repair to avoid over-constraint  '
    '• Avoid thermal capsulorrhaphy (risk: chondrolysis)',
    '#4E342E', fontsize=7.5, border='#BCAAA4', bg='#EFEBE9', fg='#212121')

# ════════════════════════════════════════════════════════════════════
# POST-OPERATIVE REHABILITATION
# ════════════════════════════════════════════════════════════════════
arrow(ax, 11, 11.09, 11, 10.55)
box(ax, 11, 10.18, 9.5, 0.72,
    'Postoperative Rehabilitation Protocol',
    C_REHAB, fontsize=8.5, bold=True, border='#CE93D8')
arrow(ax, 11, 9.82, 11, 9.35)

# Phase table
phases = [
    ('Phase I\n0–6 weeks',   'Sling immobilisation with abduction pillow\nPassive ROM; pendulums only', '#6A1B9A'),
    ('Phase II\n6–12 weeks', 'Active-assisted ROM; begin rotator cuff activation\nScapular stabilisation exercises', '#7B1FA2'),
    ('Phase III\n3–6 months','Progressive strengthening; proprioceptive training\nFull active ROM achieved', '#8E24AA'),
    ('Phase IV\n6–12 months','Sport-specific / work-specific training\nReturn-to-activity clearance', '#9C27B0'),
]
xs = [3.2, 7.5, 14.5, 18.8]
for (title, detail, clr), px in zip(phases, xs):
    box(ax, px, 8.75, 4.0, 1.15,
        title + '\n' + detail,
        clr, fontsize=7.2, border='#CE93D8')
    arrow(ax, 11, 9.35, px, 9.34, color=C_REHAB, lw=1.2)

# ════════════════════════════════════════════════════════════════════
# OUTCOME ASSESSMENT
# ════════════════════════════════════════════════════════════════════
# Collect all phase boxes and draw arrow down from each to outcome
for px in xs:
    arrow(ax, px, 8.18, px, 7.72, color=C_REHAB, lw=1.0)
    hline(ax, xs[0], xs[-1], 7.72, color=C_REHAB, lw=1.0)
vline(ax, 11, 7.72, 7.35, color=C_REHAB, lw=1.2)

box(ax, 11, 7.0, 9.5, 0.65,
    'Outcome Assessment (12 months post-op): ASES, WOSI, Rowe scores; recurrence rate check',
    C_OUTCOME, fontsize=8, border='#A5D6A7')
arrow(ax, 11, 6.67, 11, 6.18)

# ════════════════════════════════════════════════════════════════════
# FINAL OUTCOMES BRANCH
# ════════════════════════════════════════════════════════════════════
diamond2_x, diamond2_y = 11, 5.78
dw2, dh2 = 3.8, 0.75
diamond2 = plt.Polygon(
    [[diamond2_x, diamond2_y + dh2],
     [diamond2_x + dw2, diamond2_y],
     [diamond2_x, diamond2_y - dh2],
     [diamond2_x - dw2, diamond2_y]],
    closed=True, facecolor='#E8F5E9', edgecolor='#2E7D32', linewidth=2, zorder=3)
ax.add_patch(diamond2)
ax.text(diamond2_x, diamond2_y, 'Stability\nRestored?',
        ha='center', va='center', fontsize=9, fontweight='bold',
        color='#1B5E20', zorder=4)

# YES  →  right
arrow(ax, 14.8, 5.78, 17.0, 5.78, color=C_OUTCOME, lw=1.5)
ax.text(15.75, 5.93, 'Yes', fontsize=8, color=C_OUTCOME, ha='center')
box(ax, 18.8, 5.78, 3.5, 0.9,
    'Successful outcome\nReturn to activity\nLong-term surveillance',
    C_OUTCOME, fontsize=7.8, border='#A5D6A7')

# NO  →  left
arrow(ax, 7.2, 5.78, 5.0, 5.78, color=C_EXCL, lw=1.5)
ax.text(6.2, 5.93, 'No', fontsize=8, color=C_EXCL, ha='center')
box(ax, 3.2, 5.78, 3.5, 0.9,
    'Revision planning:\nRepeat EUA; assess\nbone loss, capsule quality',
    C_EXCL, fontsize=7.8, border='#EF9A9A')

# ════════════════════════════════════════════════════════════════════
# WARNING / CONTRAINDICATIONS FOOTER
# ════════════════════════════════════════════════════════════════════
warn_bg = FancyBboxPatch((0.5, 4.35), 21.0, 0.82,
                          boxstyle='round,pad=0.1',
                          facecolor='#FFF3E0', edgecolor='#E65100',
                          linewidth=1.5, zorder=2)
ax.add_patch(warn_bg)
ax.text(11, 4.76,
        '⚠  Contraindications to Surgery:  Voluntary dislocation  |  Significant psychological issues or secondary gain  |  '
        'Inadequate PT trial (<6 mo)  |  Active infection',
        ha='center', va='center', fontsize=7.8, color='#BF360C',
        fontweight='bold', zorder=6)

# ════════════════════════════════════════════════════════════════════
# LEGEND
# ════════════════════════════════════════════════════════════════════
legend_items = [
    (C_DIAG,   'Diagnosis / Entry node'),
    (C_NONOP,  'Nonoperative pathway'),
    (C_SURG,   'Surgical intervention'),
    (C_EXCL,   'Exclusion / Contraindication'),
    (C_REHAB,  'Rehabilitation protocol'),
    (C_OUTCOME,'Outcome assessment'),
    (C_SULCUS, 'Key decision point'),
]
lx, ly = 0.6, 3.85
ax.text(lx, ly, 'Legend:', fontsize=7.5, fontweight='bold', color='#263238')
for i, (clr, label) in enumerate(legend_items):
    px = lx + (i % 4) * 5.3
    py = ly - 0.45 - (i // 4) * 0.42
    patch = FancyBboxPatch((px, py - 0.14), 0.35, 0.28,
                            boxstyle='round,pad=0.03',
                            facecolor=clr, edgecolor='none', zorder=3)
    ax.add_patch(patch)
    ax.text(px + 0.48, py, label, fontsize=7, color='#263238', va='center')

plt.tight_layout(pad=0.5)
plt.savefig('/home/daytona/workspace/mdi-decision-tree/MDI_Decision_Tree.png',
            dpi=180, bbox_inches='tight', facecolor='#F5F7FA')
print("Saved successfully")

Running Command

cd /home/daytona/workspace/mdi-decision-tree && python3 build_tree.py 2>&1

Editing File

~/mdi-decision-tree/build_tree.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/mdi-decision-tree/build_tree.py'

Running Command

cd /home/daytona/workspace/mdi-decision-tree && python3 build_tree.py 2>&1

Editing File

~/mdi-decision-tree/build_tree.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/mdi-decision-tree/build_tree.py'

Running Command

cd /home/daytona/workspace/mdi-decision-tree && python3 build_tree.py 2>&1

Reading File

Running Command

ls -lh /home/daytona/workspace/mdi-decision-tree/MDI_Decision_Tree.png && file /home/daytona/workspace/mdi-decision-tree/MDI_Decision_Tree.png

The decision tree has been generated successfully (3971 x 5411 px, 759 KB PNG). Here it is, with full clinical detail from Campbell's Operative Orthopaedics and Rockwood & Green's:

Clinical Decision Tree: MDI of the Shoulder

Download the full-resolution diagram:

MDI Decision Tree

Image · PNG

Original Algorithm from Rockwood & Green's (Algorithm 35-4):

Algorithm 35-4 – Authors' Preferred Treatment for MDI, Rockwood & Green's 10th Ed

Algorithm 35-4, Rockwood & Green's Fractures in Adults 10th Ed 2025, Ch. 35

What the Full Decision Tree Covers

The generated diagram expands Algorithm 35-4 into a comprehensive 9-step clinical pathway:

Step	Node	Key Content
1	Entry / Presentation	MDI defined: subluxation/dislocation in ≥2 directions; inferior component obligatory (Neer & Foster 1980)
2	Initial Screening	Exclude voluntary dislocators and patients with psychological issues or secondary gain - absolute contraindications to surgery
3	Nonoperative Treatment	Mandatory first-line for ALL patients; structured PT ≥6-12 months
4	PT Programme Detail	Rotator cuff strengthening + scapular stabilisation (serratus ant., trapezius, rhomboids) + proprioceptive retraining
5	Response to PT Diamond	Adequate response → continue PT / activity modification. Failure after >1 year → proceed to surgery
6	Pre-Surgical Counselling	Counsel on inconsistent surgical outcomes; activity/occupation modification as alternative
7	EUA + Sulcus Sign	Confirm direction under anaesthesia; sulcus persisting in ER → add Rotator Interval Closure
8	Direction Branch (3 arms)	Anteroinferior / Posteroinferior / Pan-MDI (ant+post+inf) - each with arthroscopic vs open options
9	Rehabilitation Phases	Phase I-IV: immobilisation → passive ROM → active strengthening → sport-specific training (0-12 months)

Key Surgical Decision Points

Rotator interval closure: indicated when sulcus sign persists in external rotation
Approach direction: anterior approach if anteroinferior dominant (3+ sulcus sign); posterior if posteroinferior dominant (1-2+ sulcus sign)
Arthroscopic vs Open: comparable results; arthroscopic preferred for lower morbidity (no subscapularis takedown required)
Avoid thermal capsulorrhaphy: associated with high failure rate and chondrolysis (Rockwood & Green's Ch. 35)
Post-op immobilisation: 6-8 weeks in sling with abduction pillow

Sources: Campbell's Operative Orthopaedics 15th Ed 2026, Chapter 52 | Rockwood & Green's Fractures in Adults 10th Ed 2025, Chapter 35 (Algorithm 35-4)

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