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Injuries around the shoulder

This document discusses common shoulder and humerus injuries seen in the emergency department. It covers AC separation, clavicle fractures, scapula fractures, shoulder dislocations, and humeral fractures. For each injury, the mechanism of injury, physical exam findings, diagnostic imaging, classification, and management approach are described. Complications for certain injuries like shoulder dislocations are also outlined.

Health & Medicine◦
Injuries around the Shoulder Dr Siddhartha Sinha Dept Of Orthopaedics HAH Centenary Hospital & Medical College
Overview  Common shoulder and humerus injuries seen in the ED  For each injury  Mechanism  Physical exam  Diagnostic imaging  Classification  Management  Watch out!
Mechanism of Injury
Injuries to be Covered  AC separation  Clavicle fracture  Scapula fracture  Shoulder dislocation  Humeral Fractures  proximal  mid shaft
Shoulder Anatomy
AC Separation  Mechanism  Downward force on tip of shoulder  AC and Costoclavicular ligaments disrupted  Watch for associated # of clavicle, coracoid process
Normal AC joint
How bad is it doc??
AC classification – Clinically  Grade I  Mild tenderness over AC joint, mild swelling  Full ROM  Grade II  Mod/severe pain, clavicle slightly displaced up  Grade III  Arm kept in adduction, obvious deformity
AC Classification Grade I Mechanism Grade II Grade III
AC Imaging  AP shoulder (cephalic tilt)  Normal CC distance 1.1-1.3cm (injury if > 5mm on comparison)  Axillary lat view  ?Stress views - 10-15lbs tied to wrists  Watch for os acromiale  Secondary ossification centre on distal acromion
AC Separation
Management  I and II  Conservative (sling, ice, analgesia, physio)  6/52 before lifting  III  Conservative with late distal clavicle excision  Refer to Ortho <72h
Ouch!
Clavicle Fractures  Function  “strut”, only bony connection to axial skeleton  Mechanism  direct blow > FOOSH
Clavicle - Physical Exam  Gross deformity  Palpation  potential injury to medial cord (Ulnar N dysfunction)
Clavicle fracture
Clavicle Imaging  AP  30 degree cephalad view
Is it broken?
Classification  Proximal/middle/distal third
Clavicle # - Middle third  80% of fractures  medial portion - displaced up by sternocleidomastoid  lateral portion - displaced down by weight
Clavicle # - Middle third Management  Management  figure of eight vs sling (J Acta Ortho Scand 58 (1):71-4, 1987)  2-4 wks kids, 4-8 wks adults  Kids: possible greenstick – immobilize and recheck in 7-10d  Indication for OR (increases risk of non union) - cosmesis, tenting, open, vascular injury
Clavicle Fracture Sling and Swathe
Clavicle Fracture Velpeau
Clavicle # - Distal Third  10-15%  Classification  I: minimal displacement  II: torn CC ligament, prone to non-union  III: articular surface (may mistake for 1st AC)  Management  conservative (J. Acta. Ortho. Scand. 64 (1):87-91, 1993  ?OR for II (BJAS 23(1): 44-6, 1992.
Distal third #
Clavicle # - complications  Injury to brachial plexus, great vessels, lungs  watch out for floating shoulder  if associated with scapular surgical neck #
Scapular Fractures  Rare, high energy  Males ~30 y.o.  Associated with other injuries (lung, rib, clavicle)
Scapular #  If awake, arm adducted  Tender, crepitus, hematoma
Scapular # Classification  Type I  Body and spine  Type II  Acromion or coracoid process  Type III  Scapular neck or glenoid fossa Type I Type III Type II
Scapular Fracture
Scapular # - Management  Conservative  OR  Displaced acromial # impinging on joint  Associated coracoid # if CC ligament disrupted  Scapular neck/glenoid fossa #
Shoulder Dislocation  Men 20-30, women 60-80 yo  kids more prone to # through growth plate (joint capsule and ligaments 2-5x stronger than epiphyseal plate)
Shoulder Dislocation - Classification  Anterior (95-97%)  Subcoracoid (most common)  subglenoid (1/3 associated with # greater tuberosity, or # glenoid rim)  subclavicular  Posterior  Inferior and superior
Shoulder Dislocation Anterior dislocations  Traumatic/nontraumatic  Primary/recurrent
Shoulder Dislocation Anterior
Shoulder Dislocation Anterior  Clinically  Slight abduction, ext rotation  Squared off, loss of coracoid process  Mechanism  abduction+extension+posterior force  shoulder capsule torn
Shoulder Dislocation Anterior: Exam  Check brachial plexus, Axillary N
Shoulder Dislocation - Imaging  Do you want films?  Recurrent dislocation vs primary, ?nontraumatic  Avulsion # of greater tuberosity in 10-15%  True AP  Axillary view  trans-scapular view  Stryker Notch:  West point Axillary  Apical oblique view
Anterior dislocation
Shoulder dislocation - Management  Anesthesia - conscious sedation vs intra-articular lidocaine  Reduction (“know three methods well”)  External rotation  Scapular rotation  Stimson’s  Milch
Shoulder Dislocation Reductions
Shoulder Dislocation Reductions
Shoulder dislocation - Management  Check NV post reduction  ? Repeat films (advised by Rosen)  Sling and swathe, Velpeau  Uncomplicated: sling x 3-4/52 if < 20 y.o., 1-2/52 if > 40 y.o. (early mobilization!)  Complications: NV injury, rotator cuff tear, etc. f/u with ortho
Shoulder Dislocation - Complications  Bankart lesion  primary lesion in recurrent ant instability  Hill Sach lesion  35-40% of ant dislocations, predisposes to recurrent injury  recurrent dislocation  young adults redislocation in 55-95%  skeletally mature, < 30yo: ? Early arthroscopic reconstruction (Arthroscopy 15(5) 1999: 507-12)
Shoulder Dislocation Posterior  2-4% of shoulder dislocations  Secondary to seizure, direct blow to shoulder  Need to dx early to prevent long term complications
Shoulder Dislocation Posterior: clinical features  Arm held across chest  Adducted  Internally rotated  Flat and squared off
Shoulder Dislocation Posterior: Imaging  AP may appear normal!  Loss of half moon elliptical overlap of humeral head and glenoid fossa  “Rim sign” – increased distance between ant glenoid rim and articular surface of humeral head  “light bulb” – int rotation of humeral head  “trough sign” Reverse Hill Sachs (anteromedial impaction)
Shoulder Dislocation Posterior: Imaging
Shoulder Dislocation Posterior: Management  Conscious sedation and closed reduction  Axial traction, pressure on humeral head, external rotation  Complications:  Missed Dx: “locked” – ORIF  # glenoid rim, tuberosities, humeral head
Shoulder Dislocation Inferior (Luxatio Erecta)  Rare  Arm locked overhead 110-160 deg abduction, hand resting on head  AP radiograph: spine parallel to humerus  Reduce with traction
Shoulder Dislocation Inferior (Luxatio Erecta)
Rotator Cuff tears
Injuries around the shoulder