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SHOULDER
The shoulder joint is a unique and complex articulation unit.
It has the largest range of motion of any appendicular
joint in the body and can be moved through a space that
exceeds a hemisphere in extent.
Anatomy
The shoulder girdle connects the upper extremity to the
axial skeleton.
It consists of three bones and three joints:
 clavicle
 humerus
 scapula
 acromioclavicular
 glenohumeral
 sternoclavicular
CLINICAL FEATURES
Pain ,Stiffness, instability ,weakness
Physical exmamination:
Palpation beginning at the SCJ and moving laterally
along the clavicle to the ACJ. Next, the scapula,
glenohumeral joint, and humerus are palpated. Any point
tenderness, crepitus,swelling, or deformity should be
noted.
Note to:
deformity, ecchymosis, laceration, swelling, or
hematoma, the masses of the trapezius swelling, or
hematoma, deltoid, infraspinatus, and supraspinatus
muscles should be compared with the unaffected side
to detect any atrophy
Active and passive ranges of motion should be
tested:

Active range of motion is best determined with the patient
in the sitting position.

Passive range of motion is best evaluated with the patient
in the supine position.
Examination of the neurovascular function:
sensory and full motor examination:
The radial pulse should also be checked, although collateral
circulation may preserve this in the presence of a vascular
injury.
The presence of pallor, paresthesias, or an expanding
hematoma should raise suspicion for a vascular injury.
DIAGNOSTIC STRATEGIES
Radiology:

True anteroposterior (AP) (45 degree lateral)

Transscapular lateral (“Y” view)

axillary lateral view
Axillary view define :

relationship of the humeral head with the glenoid
fossa
 lesions of the coracoid process, humeral head, and
glenoid rim.
transscapular view define:
scapula is projected as a Y, with the body forming the lower
limb and thecoracoid and acromion processes forming
the upper limbs.
anterior and posterior glenohumeral dislocations.
The apical oblique view (obtained by having the patient
stand bending forward, and angling the central ray 45
degrees caudally) shows:

the glenohumeral joint in a unique coronal projection

Hill-Sachs lesions in shoulder dislocations

displacement and angulation of proximal humerus fractures
Clavicle fracture:
The clavicle accounts for 5% of all fractures and is the most commonly
fractured bone in children.
Clavicular fractures are classified anatomically and mechanistically
into three groups :

Medial third Fx(5%): mechanism of injury:
Direct blow to the anterior chest.
 Middle

third Fx (80%)
mechanism of injury involves a direct force applied
to the lateral aspect of the shoulder as a result of a
fall, sporting injury, or motor vehicle collision (MVC)

Lateral third Fx (15%):
Result from a direct blow to the top of the shoulder.
Types of this Fx:
I.
stable and minimally displaced because the coracoclavicular
ligament remains intact.
II.
associated with a torn coracoclavicular ligament and have a
tendency to displace because the proximal fragment lacks any
stabilizing forces.
III.
injuries involve the articular surface.
Clinical Features


Pain over the fracture site
Ecchymosis, crepitus palpable, visible deformity

Tenting of the skin

Neurovascular injury

Pneumothorax and pulmonary injuries are also rare
unless an open or medial third fracture is present.
Management

pain control, immobilization, and proper followup care.

Immobilization:
o
simple sling or sling and swathe
o
Figure-of-eight splint
o
Velpeau sling
Disposition
Immediate orthopedic consultation include:

Open fractures

Skin tenting

Fractures associated with neuro vascular injuries

Interposition of soft tissues
Urgent orthopedic consultation (before 72 hours) :

Type II lateral clavicle fractures

Severely comminuted or displaced fractures of the middle
third (defined as over 20 mm of initial shortening)
Early passive shoulder range of motion exercises are encouraged to
reduce the risk of adhesive capsulitis.
Younger children generally require shorter periods of immobilization (2 to
4 weeks) than adolescents and adults (4 to 8 weeks).
Greenstick fractures of the mid clavicle are common in children.Most of
these fractures are nondisplaced and heal uneventfully. Initial
radiographs may appear normal despite suggestive clinical findings. In
these instances, the arm should be immobilized in a simple sling
and the radiographic evaluation repeated in 7 to 10 days if pain
persists, to evaluate for early callus formation.
AARD
An uncommon but important association is that between
clavicle fractures and atlantoaxial rotatory displacement.
Most cases occur in girls younger than 10 years.
Early diagnosis is important because delayed diagnosis
can lead to a chronic deformity requiring surgical correction.
AARD should be suspected if the child has a
clavicle fracture and demonstrates a “cocked-robin”
position with the head bent toward the fractured side but
rotated in the opposite direction.
The injury is best demonstrated by CT scan and, if
recognized early, can be treated with a soft cervical collar or
halotraction.
Scapula


Fractures of the scapula are rare.
In general, considerable force and energy are
required to fracture the body & neck of the scapula.

Most fractures, including fractures with severe
comminution and displacement.The most important
aspect of scapula fractures is the high incidence of
associated injuries to the ipsilateral lung,chest wall,and
shoulder girdle complex.

Diagnosis of fractures scapula
:

True AP veiw:body of scapula.

Lateral trans scapular veiw:evaluation of displacement of
body of scapula and glenoid.

Lateral axillary veiw:fractures of acromion, coracoid
process.
:
Management

Analgesia

Immobilization: sling for 2 to 4 weeks

close radiographic follow up for assessment for delayed
displacement.

Displaced acromial fractures that impinge on the glenohumeral joint
require surgical management.

Fractures of the body and spine and nondisplaced fractures
require no further therapy.
Proximal Humerus
Neer’s classification system:
Major categories of humerual fracture

Minimal displacement

Two part displacement

Three part dis placement

Four part displacement
Management


Most nondisplaced fractures heal over 4 to 6 weeks.
In two part, three part, and four part displaced an
orthopedic surgeon should be consulted, because
many of these injuries require operative repair.
Fracture-dislocation injuries are best managed in consultation with an
orthopedic surgeon before attempts at reduction (except in cases of
neurovascular compromise or unavailability of an orthopedic
surgeon).
Proximal Humeral Epiphysis
The most common mechanism of injury involves a fall onto the
outstretched hand.
The fracture is most common in adolescent boys.
Management

Early orthopedic consultation should be obtained

Children younger than 6 years:
•
Salter I epiphyseal injuries
•
sling and swathe and analgesic agents
Children older than 6 years

Salter II epiphyseal injury

Salter II injuries with more than 20 degrees of angulation may
benefit from reduction.

After reduction, unstable injuries should be immobilized in a
shoulder spica cast, whereas stable lesions can be immobilized
with a sling and swathe.

Fractures of the proximal humeral epiphyses generally heal in 3 to 5
weeks.
Dislocations:
Sternoclavicular:
The most common mechanisms are MVCs and injuries sustained in
contact sports.
The SCJ can dislocate in an anterior or a posterior direction.
Types of SCJ dislocation:
I.
Mild sprain secondary to stretching of the sternoclavicular and
costoclavicular ligaments.
II.
subluxation of the joint (anterior or posterior) secondary to rupture
of the sternoclavicular ligament but the costoclavicular ligament
remains intact.
III.
Complete rupture of the sternoclavicular,costoclavicular ligaments.
Diagnostic Strategies

Standard AP, oblique, and specialized (40 degree cephalic tilt)
views


CT scan
Ultrasound imaging
Management

Grade I Immobilization (simple sling for1-2 weeks), analgesia

Grade II immobilized with a sling or soft clavicular (figur-of-eight)
splint(3-6weeks)

The patient referred for orthopedic followup care.

All grade III injuries should be managed by closed reduction.

Anterior dislocations may be reduced in the ED after orthopedic
consultation and intravenous analgesia.

Most reductions are unstable.

Because the deformity is primarily cosmetic and not functional, the
current treatment of choice for recurrent anterior dislocations is
benign neglect.

Posterior dislocations constitute true orthopedic emergencies and
should be reduced expeditiously.
Acromioclavicular Joint dislocation
The most common mechanism of injury involves a fall or direct
blow to the point of the shoulder with the arm adducted.
Classification is based on the degree of damage sustained by the
acromioclavicular and coracoclavicular ligaments.
Classification of ACJ Dislocation

Type I sprain of the acromioclavicular ligaments with no separation of
the acromion and clavicle.

TypeII: disruption of the acromioclavicular ligaments.
The joint space is widened, and the clavicle is displaced slightly upward.
There are minor tears in the attachments of the deltoid.
and trapezius muscles, but the coracoclavicular ligament remains intact

A type III: complete disruption of the AC ligaments,
coracoclavicular ligament,muscle attachments. The joint space is
widened, the coracoclavicular distance is increased by 25 to 100%.
Type IV and V injuries, the ligamentous and muscle disruptions are
similar to the disruptions encountered in type III injuries, but the clavicle
is displaced either posteriorly into the trapezius (type IV) or
superiorly in an exaggerated fashion (coracoclavicular distance
increased 100 to 300%; type V)
In the rare type VI injury, the clavicle is displaced inferiorly.
Clinical Features
Patients should be examined while they are in the sitting or standing
position because the supine position can mask ACJ instability.

Type I and type II: mild tenderness and swelling over the ACJ
margin, with minimal deformity. A full range of motion often
is possible, although painful.

Type III, IV, V, and VI: severe pain and adduction of arm.

Type IV injuries, the clavicle may be palpable posteriorly.
Diagnostic Strategies

AP view

Axillary lateral view: fractures and posterior dislocation of clavicle
15 degree cephalic tilt view.


The normal coracoclavicular distance:11 to 13 mm.
A difference of more than 5 mm between the injured and uninjured
sides is diagnostic of a complete coracoclavicular disruption.

Type I the radiographic appearance is essentially normal.
 Type II radiographic features:
1.
widening of the joint
2.
a slight upward or posterior displacement of the clavicle
3.
a normal coracoclavicular distance

a)
b)
c)
Type III, IV, and V radiographic features:
widened joint
an increased coracoclavicular distance
either superior or posterior displacement of the clavicle
Management

Type I and II: sling for comfort and to protect against further injury.

When pain has subsided (1 to 3 weeks), range-of-motion and
strengthening exercises can begin, return to sports when painfree
function has been achieved.


Type III: sling immobilization,early orthopedic referral(within 72 h)
Type IV, V, and VI: early surgical treatment.
Surgical indication


Young patient
severe displacement (more than 2 cm)
Glenohumeral Dislocations

The glenohumeral joint is the most commonly dislocated major joint in
the body.
Anterior Dislocations

The most common mechanism of injury consists of an indirect
force transferred to the anterior capsule from a combination of
abduction,extension, and external rotation.

characteristic pathologic:avulsion the anteroinferior glenohumeral
ligament with capsulolabral detachment (Bankart’s lesion).
Types of anterior dislocation
Clinical Features

severe pain

the dislocated arm held in slight abduction and external rotation by
the opposite extremity.

The lateral edge of the acromion process is prominent, and the
normally rounded shoulder assumes a“squared-off” appearance.

The coracoid process is indistinct, the anterior shoulder appears full.
Diagnostic Strategies:
Radiology:

Associated fractures may be present in 50% of cases.

The most common of these is a compression fracture of the
posterolateral aspect of the humeral head caused by forceful
impingement against the anterior rim of the glenoid fossa.


This defect in the humeral head, or Hill-Sachs deformity(11-50%)
The defect is best visualized on an internal rotation AP view of
the glenohumeral joint.
Management

Radiography: before reduction

Ideal method of reduction:simple, quick, and effective.

Analgesia and muscle relaxation with procedural sedation.

Local anesthetic agent intra articular with

injection(Lidocain,Bupivacaine).
This technique is especially useful when procedural sedation is
contraindicated.
Technique

Stimson or hanging weight technique

traction-counter-traction method

Snowbird technique

external rotation method of Leidel-meyer

Milch technique

Scapular manipulation
After reduction







o
o

Neurovascular Examination
Post reduction radiography
Immobilization:(sling & swathe velpeau bandage)
Duration of immobilization:
In younger patients:3-4 weeks
In older patients>40 years :1-2 weeks
Orthopedic follow-up care:
Primary disloctaion
Complicated cases
Patients discharged with analgesia
Anterior Subluxation
(Dead arm syndrome)

In young athletic adults

The patient reports sudden sharp shoulder pain and weakness that
occurred while performing an abduction and external rotation
maneuver. Radiography:Normal


confirm the diagnosis: apprehension sign
A lax or redundant anterior capsule is thought to be responsible for
this syndrome

Treatment: referred for orthopedic follow-up care(capsulorrhaphy)
Posterior Dislocation
rare(2 to 5% )
More than 50% are missed on initial evaluation, and many
remain unrecognized (“locked posterior dislocations”) for weeks
or months.
mechanisms of injury:
 Convulsive seizures (epileptic or after electrical
shock) have been associated with unilateral or bilateral posterior
dislocations.

fall onto the outstretched hand with the arm held in flexion,
adduction, and internal rotation

Types of posterior dislocation



subacromial (most common)
subglenoid
subspinous
Clinical Features




The patient hold the affected arm across the chest in
adduction and internal rotation.
Usually painful, but may be painless.
Abduction is severely limited.
External rotation is completely blocked.
Diagnostic Strategies

Radiography:

True or standard AP radiographs can appear deceptively normal with posterior
dislocations.



characteristic radiographic features in Standard AP films:
loss of the half moon elliptic overlap of the humeral head and glenoid fossa.
The distance between the anterior glenoid rim and the articular surface of the
humeral head is increased (Rim sign).

The humeral head is profiled in internal rotation and takes on a “lightbulb” or
“drumstick” appearance.

A true AP film shows abnormal overlap of the glenoid fossa with the humeral
head.

An impaction fracture of the anteromedial humeral head (reverse Hill-Sachs
deformity) is invariably present ( trough sign)
Figure 53-34. Anteroposterior (A) and transscapular (B) radiographic
views of a posterior glenohumeral dislocation. Note the “lightbulb”
or
“drumstick” appearance of the humeral head.
Management


In the ED Closed reduction with procedural sedation.
The technique of reduction:
o
Internal rotation and lateral traction to disimpact the humeral head from
the glenoid rim.
o
The humeral head can also be disimpacted with use of the “lever
principle”.

If this technique fails, reduction with the patient under general anesthesia is
indicated.

After reduction the shoulder should be immobilized in external rotation
with slight abduction.

Refer for orthopdist:
o
missed initially
o
chronic
o
“locked” posterior dislocations(open reduction and internal fixation or
arthroplasty).
Inferior Glenohumeral Dislocation (Luxatio
Erecta)



Rare(Less than 0.5%)
mechanism of injury: indirect or direct forces.
Most inferior dislocations result from indirect forces that
hyperabduct the affected extremity.
Clinical Features

The patient has the arm locked overhead in 110 to 160 degrees
of abduction.

The elbow usually is flexed, and the forearm typically rests on
top of the head.
Diagnostic Strategies


Radiology:
Many cases of luxatio erecta are mistakenly diagnosed and treated as
subglenoid anterior dislocations because the radiographic features of these two
clinical entities are remarkably similar.

1.
2.
Standard AP radiographs show:
the superior articular surface inferior to the glenoid fossa
the humeral shaft paralled to the spin of the scapula

In subglenoid anterior dislocation:
o
Latter the humeral shaft lies parallel to the chest wall.
Management

Reduction by traction-countert-raction maneuvers under procedural
sedation.

open reduction “buttonholing” of the capsule will prevent closed
reduction

Refer to orthopedic

An alternative approach is the two-step closed reduction maneuver:
o
single operator
o
fewer attempts
o
minimal force
o
local analgesia
o
minimal procedural sedation.