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October 2007
Shoulder Girdle Fractures
And Dislocations
Volume 9, Number 10
Authors
You are working in the ED during football season and receive a call from
the local university team physician who is sending you two patients with
shoulder-related complaints. One patient is the team’s quarterback who was
tackled to the ground and complains of pain over the lateral tip of his
shoulder. Your medical student, who is interested in orthopedics, asks if you
will request weighted views of the shoulder to evaluate the acromioclavicular joint in this patient.
The second patient is the team’s star wide receiver who complains of
difficulty breathing and pain over the inner part of the clavicle after taking a
direct helmet blow to the upper chest. The charge nurse wonders if this
patient should be moved into the trauma bay due to the mechanism of
injury and associated dyspnea.
T
he shoulder joint has the largest range of motion of any appendicular joint in the body. It allows the upper extremity to rotate
up to 180 degrees in three different planes, enabling the arm to
perform a versatile range of activities but also predisposing the joint
to instability and injury. The shoulder can be injured by trauma
(indirect or direct) or by overuse. Traumatic injuries are more common in sports such as swimming, tennis, volleyball, and baseball.1
Children are vulnerable to the same injuries as adults; however,
the presence of epiphyseal centers changes the pattern of injuries.2
An injury that produces a sprain or dislocation in an adult often
causes a fracture through the hypertrophic zone of the growth plate
in a child. The shoulder has epiphyseal plates at the acromion
process, proximal humeral head, coracoid process, glenoid cavity,
and medial end of the clavicle. Fortunately, most shoulder injuries
in the pediatric population do well and have a good prognosis for
full return of function.2
Editor-in-Chief
Andy Jagoda, MD, FACEP, Professor
and Vice-Chair of Academic Affairs,
Department of Emergency Medicine;
Mount Sinai School of Medicine;
Medical Director, Mount Sinai
Hospital, New York, NY.
Associate Editor
John M. Howell, MD, FACEP, Clinical
Professor of Emergency Medicine,
George Washington University,
Washington, DC; Director of
Academic Affairs, Best Practices,
Inc, Inova Fairfax Hospital, Falls
Church, VA.
Editorial Board
William J. Brady, MD, Associate
Professor and Vice Chair,
Department of Emergency Medicine,
University of Virginia, Charlottesville,
VA.
Peter DeBlieux, MD
Professor of Clinical Medicine, LSU
Health Science Center, New Orleans,
LA.
Wyatt W. Decker, MD, Chair and
Associate Professor of Emergency
Medicine, Mayo Clinic College of
Medicine, Rochester, MN.
Francis M. Fesmire, MD, FACEP,
Director, Heart-Stroke Center,
Erlanger Medical Center; Assistant
Professor, UT College of Medicine,
Chattanooga, TN.
Michael J. Gerardi, MD, FAAP,
FACEP, Director, Pediatric
Emergency Medicine, Children’s
Medical Center, Atlantic Health
System; Department of Emergency
Medicine, Morristown Memorial
Hospital, NJ.
Michael A. Gibbs, MD, FACEP, Chief,
Department of Emergency Medicine,
Maine Medical Center, Portland, ME.
Steven A. Godwin, MD, FACEP,
Associate Professor and Emergency
Medicine Residency Director,
University of Florida
HSC/Jacksonville, FL.
Gregory L. Henry, MD, FACEP, CEO,
Medical Practice Risk Assessment,
Inc; Clinical Professor of Emergency
Medicine, University of Michigan,
Ann Arbor.
Keith A. Marill, MD, Instructor,
Department of Emergency Medicine,
Massachusetts General Hospital,
Harvard Medical School, Boston,
MA.
Charles V. Pollack, Jr, MA, MD,
FACEP, Professor and Chair,
Department of Emergency Medicine,
Pennsylvania Hospital, University of
Pennsylvania Health System,
Philadelphia, PA.
Michael S. Radeos, MD, MPH,
Research Director, Department of
Emergency Medicine, New York
Hospital Queens, Flushing, NY;
Assistant Professor of Emergency
Medicine, Weill Medical college of
Cornell University, New York, NY.
Robert L. Rogers, MD, FAAEM,
Assistant Professor and Residency
Director, Combined EM/IM Program,
University of Maryland, Baltimore,
MD.
Mohamud Daya, MD, MS, FACEP
Associate Professor of Emergency Medicine, Oregon Health
& Science University, Portland, OR
Yoko Nakamura, MD
Clinical Assistant Professor of Emergency Medicine, Oregon
Health & Science University, Portland, OR
Peer Reviewers
Sheldon Jacobson, MD, FACEP, FACP
Chair, Department of Emergency Medicine, Mount Sinai
School of Medicine, New York, NY
John Munyak, MD
Sports Medicine Fellowship Program Director, North Shore
University Hospital, New York
Michael S. Radeos, MD, MPH
Research Director, Department of Emergency Medicine,
New York Hospital Queens, Flushing, NY; Assistant
Professor of Emergency Medicine, Weill Medical College of
Cornell University, New York, NY
CME Objectives
Upon completion of this article, you should be able to:
1. Describe the clinical presentations of shoulder girdle fractures and dislocations in the ED and how to assess for
any associated complications.
2. Understand which radiographic studies to order and the
principles for correct interpretations.
3. Discuss several different techniques for reduction of
glenohumeral dislocations.
4. List conditions or circumstances that require orthopedic
consultation or referral in patients with shoulder injuries.
5. Appreciate current concepts and controversies in the
management of these injuries.
Date of original release: October 1, 2007
Date of most recent review: August 23, 2007
Termination Date: October 1, 2010
Time to complete activity: 4 hours
Prior to reading this activity, see “Physician CME
Information” on back page.
Medium: Print & online
Method of participation: Print or online answer form
and evaluation
Alfred Sacchetti, MD, FACEP,
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA.
Corey M. Slovis, MD, FACP, FACEP,
Professor and Chair, Department of
Emergency Medicine, Vanderbilt
University Medical Center, Nashville,
TN.
Jenny Walker, MD, MPH, MSW,
Assistant Professor; Division Chief,
Family Medicine, Department of
Community and Preventive Medicine,
Mount Sinai Medical Center, New
York, NY.
Ron M. Walls, MD, Professor and
Chair, Department of Emergency
Medicine, Brigham & Women’s
Hospital, Boston, MA.
Research Editors
Nicholas Genes, MD, PhD, Mount
Sinai Emergency Medicine
Residency.
Beth Wicklund, MD, Regions Hospital
Emergency Medicine Residency,
EMRA Representative.
International Editors
Valerio Gai, MD, Senior Editor,
Professor and Chair, Dept of EM,
University of Turin, Italy.
Peter Cameron, MD, Chair,
Emergency Medicine, Monash
University; Alfred Hospital,
Melbourne, Australia.
Amin Antoine Kazzi, MD, FAAEM,
Associate Professor and Vice Chair,
Department of Emergency Medicine,
University of California, Irvine;
American University, Beirut,
Lebanon.
Hugo Peralta, MD, Chair of
Emergency Services, Hospital
Italiano, Buenos Aires, Argentina.
Maarten Simons, MD, PhD,
Emergency Medicine Residency
Director, OLVG Hospital, Amsterdam,
The Netherlands.
Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of Mount Sinai School of Medicine and Emergency Medicine Practice. The Mount Sinai School of Medicine is accredited by the ACCME to
provide continuing medical education for physicians.
Faculty Disclosure: Dr. Daya, Dr. Nakamura, Dr. Jacobson, Dr. Munyak and Dr. Radeos report no significant financial
interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation
Commercial Support: Emergency Medicine
Practice does not accept any commercial support.
ligament. The costoclavicular ligament opposes the
pull of the sternocleidomastoid thus resisting the
elevation of the clavicle. It is also the most important
stabilizing ligament of the sternoclavicular joint.4
Immediately posterior to the joint is the superior
mediastinum with its great vessels, trachea, lung
apices, esophagus, brachial plexus, and thoracic duct.
The diarthroidal acromioclavicular joint (Figure 2)
has little or no bony stability and is dependent on the
associated ligaments and muscles for support. The
weak acromioclavicular ligaments provide posterior
support while the clavicular and acromial attachments
of the deltoid and trapezius muscles provide static
and dynamic support for the superior aspect of the
joint. The most important stabilizers are the coracoclavicular ligaments (conoid and trapezoid) which
provide vertical and anterior support.
Critical Appraisal Of The Literature
The literature review was launched with an Ovid
MEDLINE® search for articles on shoulder injuries
published through February 2007. Keywords
included shoulder dislocation, clavicle fracture,
humerus fracture, scapula fracture, acromioclavicular
joint injury, sternoclavicular joint and dislocations,
and scapulothoracic dissociation. The search was
limited to humans and English language. This
produced 1789 articles, over 300 of which were
reviewed; 104 are referenced here. In addition to
those articles, several key textbooks were also
reviewed. It should be noted that the orthopedic and
sports medicine literature is largely based on observational studies supplemented by case reports and case
series. There are few randomized clinical trials.
Figure 2. Anatomy Of The Acromioclavicular Joint
Anatomy
The shoulder girdle connects the upper extremity to
the axial skeleton and is composed of three bones
(clavicle, humerus, and scapula), three joints (acromioclavicular, glenohumeral, and sternoclavicular), and
one articulation (scapulothoracic).
The clavicle is an S-shaped bone that acts as a
strut to support the upper extremity and keep it away
from the chest wall. It articulates medially with the
sternum and laterally with the acromion process. The
clavicle provides the neck with an acceptable cosmetic
appearance and protects the subclavian vessels and
brachial plexus. Its middle-third, which is thin and
untethered, is the most commonly fractured segment.
The sternoclavicular joint (Figure 1) is the only
true articulation between the upper extremity and the
axial skeleton. It is the most moved joint in the body.3
Stabilizers of this diarthroidal joint include the
anterior and posterior sternoclavicular ligaments, the
interclavicular ligament, and the costoclavicular
Reprinted from Primary Care: Clinics In Office Practice, Volume 31,
Phyllis Montellese and Timothy Dancy, “The acromioclavicular
joint,” Page 858, Copyright © 2004, with permission from Elsevier.
The scapula is a flat triangular bone that forms the
posterior aspect of the shoulder girdle. Its thickened
borders are the attachment sites for eighteen muscle
origins and insertions.5 It’s thick muscle coat and
ability to recoil along the chest wall protects the
scapula from both direct and indirect trauma.
The glenohumeral articulation is a ball-and-socket
type joint. The glenohumeral joint depends largely on
associated capsule, muscles, and ligaments for stability. A synovial membrane extends from the glenoid
fossa to the humeral head. The membrane is large
and redundant inferiorly to accommodate the extensive range of movement. Overlying the synovial
membrane is a loose and redundant fibrous capsule.
Anteriorly, the capsule is thickened to form the
superior, middle, and inferior glenohumeral ligaments. The anterior band of the inferior glenohumeral ligament is the most important restraint to
anterior glenohumeral dislocations.6
The proximal humerus articulates with the
glenoid fossa and provides for the attachment of a
number of important muscles. The supraspinatus,
infraspinatus, and teres minor insert onto facets of the
Figure 1. Anatomy Of The Sternoclavicular Joint
Reprinted from Clinics in Sports Medicine, Volume 22, Lauren A.
Ernberg, MD and Hollis G. Pooter, MD, “Radiographic evaluation of
the acromioclavicular and sternoclavicular joints,” Page 256,
Copyright © 2003, with permission from Elsevier.
Emergency Medicine Practice®
2
October 2007 • EBMedicine.net
greater tuberosity, whereas the subscapularis inserts
onto the lesser tuberosity. Together, this group of
muscles forms the rotator cuff which helps stabilize
the humeral head within the glenohumeral joint.
Long muscles that cross the articulation are primarily
involved in the movements around the glenohumeral
joint. Displacements encountered with fractures of
the humerus usually reflect the pull of these attached
muscle groups. The proximal humerus is primarily
composed of trabecular bone with a thin cortical shell.
Changes in bone density with age (osteoporosis)
greatly increase the risk of fractures in this area.7
The brachial plexus and subclavian vessels enter
the shoulder girdle complex superiorly between the
clavicle and the first rib, traverse under the coracoid
process, and exit anterior to the inferior aspect of the
glenohumeral joint as the median, ulnar and radial
nerves, and axillary vessels.
59% of cases and in only 47% of children younger
than four years of age.9 Furthermore, among patients
with documented moderate or severe pain, only 73%
were treated with an analgesic with 54% receiving an
opioid. Pediatric patients were least likely to receive
analgesics, especially an opioid.9
Prehospital Care
Physical Examination
History
The most important factors to determine in patients
with shoulder injuries are the time and mechanism of
injury along with the location and severity of the pain.
Timing is important since injuries (especially dislocations) that have been present for several hours or days
can be more challenging to diagnose and treat. It is
also important to determine a list of current medications, allergies, past medical history, and time of the
last meal in the event that procedural sedation or
emergency operative treatment is required.
In patients with multi-system trauma, examine the
shoulder as part of a complete secondary examination. Inspect the shoulder from all directions. Palpate
the shoulder systematically, beginning at the sternoclavicular joint and moving laterally along the
clavicle to the acromioclavicular joint. This is followed by palpation of the scapula, glenohumeral
joint, and proximal humerus. The exam is completed
by an assessment of the neurovascular function. A
complete sensory and full motor examination of the
brachial plexus must be performed. This is best
evaluated by assessing the myotomes and
dermatomes (Table 1) pertinent to each nerve root
within the brachial plexus. The classic presentation of
a brachial plexus injury – the “stinger” or “burner”
traction injury of the brachial plexus – is the mixed
neurological abnormalities one finds on physical
examination. The radial pulse should also be checked,
although it should be noted that collateral circulation
may preserve this in the presence of a vascular injury.
The presence of pallor, paresthesias, or an expanding
hematoma raises suspicion of a vascular injury. The
neurovascular exam must be repeated and findings
recorded following any manipulation in the ED.
The prehospital care of the patient with an injured
shoulder begins with an assessment and stabilization.
Once this has been accomplished, a history of the
events leading to the injury should be obtained from
the patient as well as witnesses. The patient should
be assessed for any associated injuries of the head,
neck, thorax, abdomen, spine, pelvis, and lower
extremities. Splint the injured shoulder in a position
of comfort; a sling is sufficient for most isolated
injuries. Perform a neurovascular examination of the
affected extremity before and after splinting as well as
following any major movement. In isolated injuries,
the use of analgesia as permitted by standing orders
or through online medical consultation may be
appropriate. Choices include morphine sulfate,
fentanyl citrate, and nitrous oxide. Benzodiazepines
are an excellent choice since they may help achieve or
maintain muscle relaxation. Kanowitz et al recently
reviewed over 2100 prehospital uses of fentanyl citrate
for analgesia and found it to be safe and very effective, with pain scores decreasing from 8.4 to 3.7.8 In
some selected circumstances (rural and wilderness
settings), it may be appropriate to proceed with
reduction procedures if personnel have received
appropriate training, although there is no published
data on the efficacy or safety of this approach.
General Radiographic Principles
The initial assessment of shoulder injuries should
ideally include a three-view trauma series of radiographs consisting of a true anteroposterior (45-
ED Evaluation
Initiate full immobilization if there is a concern for an
accompanying spinal injury, and activate the trauma
team if appropriate. Since pain is a common presenting complaint, the timely determination of severity
scores and administration of oral or parenteral analgesia is important during the clinical and radiographic
assessment process in the ED. In a recent retrospective review of 2828 patients with isolated closed
fractures of the extremities or clavicle, Brown et al
reported that pain severity scores were recorded for
EBMedicine.net • October 2007
Table 1: Sensory And Motor Examination Of The Brachial
Plexus
Level
Sensory Area
Motor Area
C5
C6
C7
C8
Lateral arm
Lateral forearm and tip of thumb
Tip of the long finger
Tip of the fifth finger and
medial forearm
Medial arm
Deltoid muscle
Biceps muscle
Thumb extensors
Finger flexors
T1
3
Hand interossei
Emergency Medicine Practice®
degree lateral), transscapular lateral, and axillary
lateral view.10 The true anteroposterior (AP) view
(Figure 3) is essential because it projects the glenohumeral joint en face without any bony overlap.
Orthogonal views include the axillary lateral,
transscapular (“Y”view), and apical oblique.11 The
preferred view is the axillary lateral which projects the
glenohumeral joint in a cephalocaudal plane (Figure
4A and 4B). This view is useful for defining the
relationship of the humeral head with the glenoid
fossa and identifying abnormalities of the coracoid
process, humeral head, and glenoid rim.12 This is
especially helpful in identifying either a posterior or a
questionable anterior glenohumeral dislocation.
Difficulty in obtaining the axillary view has led to the
popularity of the transscapular “Y” view. In this view,
the scapula is projected as a “Y,” with the body forming the lower limb and the coracoid and acromion
processes forming the upper limbs (Figure 5). The
humeral head is normally superimposed over the
glenoid, located at the junction of the three limbs.
One must be cautious when interpreting the “Y” view
as normal, for a posterior glenohumeral dislocation
may present with the humeral head actually situated
posterior to the “Y” but projecting as normal on the
“Y” view. Another view that can be obtained easily
and painlessly is the apical oblique (AO) view, which
is obtained by placing the injured shoulder in a 45Figure 4B. Diagram Highlighting The Pertinent
Anatomy
Figure 3. Normal True AP View Of The Shoulder
Reprinted with permission from Michael L. Richardson, MD, UW
Radiology. Available at http://www.rad.washington.edu/radanat/AxillaryLabelled.html. Copyright © 1997. All rights reserved.
Figure 5. Normal Transscapular Or “Y” View Of The
Shoulder
Courtesy of Dr. Daya.
Figure 4A. Lateral Axillary View Of The Shoulder
Reprinted from http://www.aafp.org/afp/20000601/3291.html, “The
Painful Shoulder: Part II. Acute and Chronic Disorders.” By Thomas
W. Woodward, MD and Thomas M. Best, MD, June 1, 2000.
Emergency Medicine Practice®
Courtesy of Dr. Daya.
4
October 2007 • EBMedicine.net
degree oblique position and angling the central ray 45
degrees caudally. This view (Figure 6) provides a
unique coronal view of the glenohumeral joint. In a
retrospective review of 511 patients, Kornguth et al
reported that the AO view detected 153 (81%) of 190
injuries compared to 168 (88%) for the true AP view.13
More importantly, 20 of the radiographic abnormalities were only seen with the AO view. Similar findings were also reported by Sloth et al, who recommended that the AO be used routinely in the
evaluation of acute shoulder trauma.14
In addition to the shoulder trauma radiographs,
additional bone and soft tissue details may be
obtained using computed tomography (CT) or magnetic resonance imaging (MRI) in selected cases.15
coracoclavicular ligaments and enter the
acromioclavicular joint.
Clinical
The affected extremity is held close to the body and
there is pain over the fracture site. With fractures of
the middle third, the shoulder is typically slumped
downward, forward, and inward. This is a result of
the effect of gravity (weight of the arm) and the pull
of the pectoralis major and latissimus dorsi on the
distal fragment. The proximal fragment is often
displaced upward by the action of the sternocleidomastoid. Associated neurovascular injury is rare.20
Associated pneumothorax and pulmonary injuries are
also rare unless an open fracture exists.21
Management and Disposition
Principles of initial management include pain control,
immobilization, and appropriate follow-up (Table 2).
Immobilize fractures of the clavicle with a supportive
device such as a sling. Treatment with a clavicular
(figure-of-eight) splint is still recommended in major
Figure 6. Normal Apical Oblique View
Figure 7. Mid-Clavicular Fracture
Reprinted with permission from Wheeless’ Textbook of
Orthopaedics. www.wheelessonline.com © 2007 Data Trace
Publishing Company. All rights reserved.
Fractures
Clavicle Fractures
Classification And Pathophysiology
The clavicle accounts for 5% of all fractures and is the
most commonly fractured bone in children.16,17
Clavicle fractures are classified anatomically and
mechanistically into three types. Fractures of the
medial third are uncommon (5%) and occur as a result
of a direct blow to the anterior chest. Fractures of the
middle third (Figure 7) account for 70-80% of all
injuries.18 The usual mechanism of injury involves a
direct force applied to the lateral aspect of the shoulder. Fractures of the lateral third (15%) result from a
direct blow to the top of the shoulder and can be
further classified into three main subtypes:19
• Type I fractures are minimally displaced since
the coracoclavicular ligament remains intact.
• Type II fractures (Figure 8) are associated with a
torn coracoclavicular ligament and have a
tendency to displace, since the medial fragment
lacks any stabilizing forces.
• Type III injuries occur distal to the
EBMedicine.net • October 2007
Courtesy of Dr. Daya.
Figure 8. Type II Lateral Clavicle Fracture: The
Coracoclavicular Ligaments Are Torn And The Medial
Fragment Is Displaced Superiorly
Courtesy of Dr. Daya.
5
Emergency Medicine Practice®
orthopedic textbooks, although its use is not evidencebased.3 In a randomized, controlled study of 79
patients comparing a clavicular splint to a sling, those
treated with a sling were more satisfied (93% vs. 74%,
P = 0.09) and had less local complications.22 These
results, while favoring the sling, were not statistically
significant. The functional and cosmetic results of the
two methods of treatment were identical and alignment of the healed fractures was unchanged from the
initial displacement. Stanley et al reported similar
findings in 140 patients.23 In summary, the evidence
suggests that treatment with a sling is a valid and
appropriate alternative to the clavicular splint.
Greenstick fractures of the mid-clavicle are
common in the pediatric population. Most of these
fractures are non-displaced and will 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
radiographs repeated in 7 to 10 days if symptoms
persist. The newborn clavicle fracture suffered during
childbirth classically presents as a concerned parent
bringing the child in for an uneventful “lump” that
represents the area of callus formation.
Immediate orthopedic consultation should be
sought for fractures that are open or fractures
associated with neurovascular injuries, skin tenting, or
interposition of soft tissues. More urgent orthopedic
consultation (within 72 hours) is recommended for
Type II lateral clavicle fractures, since these fractures
have a 30% incidence of nonunion and may benefit
from surgical repair.19,24 Severely comminuted or
displaced fractures (Figure 10A and 10B) of the middle third (defined as over 20 mm of initial shortening)
may also benefit from early orthopedic referral, since
these have been associated with a higher incidence of
nonunion and long-term functional deficits.18,25,26
Complications
Complications are unusual, the most common ones
being delayed union, malunion, or nonunion.16,17,19,25
A recent prospective study of 222 patients reported
that sequelae from clavicle fractures with nonoperative treatment may be higher than previously
reported.27,28 Non-union occurred in 15 patients (7%),
and 93 patients (42%) had persistent symptoms, such
as pain and shoulder weakness, at six months. Fracture displacement, degree of comminution, and older
age were associated with increased risk of persistent
symptoms at six months.28 Malunion as well as
Figure 10A. Significantly Displaced Mid-Clavicular
Fracture
Table 2: General Management Principles
• Apply ice intermittently
• Provide appropriate immobilization
• Provide adequate analgesia
• Use passive pendular shoulder exercises to minimize the
risk of adhesive capsulitis (Figure 9)
• Refer to orthopedics in selected circumstances
Courtesy of Dr. Daya.
Figure 9. Pendular Shoulder Exercises
Figure 10B. Same Patient After Open Reduction And
Internal Fixation
Reprinted from http://asanscience.re.kr/healthinfo/disease/attach/
img/924/20061123162538_3_924.jpg.
Courtesy of Dr. Daya.
Emergency Medicine Practice®
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October 2007 • EBMedicine.net
exuberant callus formation can also lead to symptoms
related to vascular and brachial plexus compression.25
Patients should be advised that articular surface
injuries (Type III lateral clavicle fractures) can lead to
subsequent osteoarthritis within the acromioclavicular
joint.
Since 1990, an uncommon but important association between clavicle fractures and atlantoaxial
rotatory displacement (AARD) in children has also
been reported in the literature. Recently, Bowen et al
reported two new cases and reviewed 11 previously
reported cases.29 Most cases occurred in females
younger than 10 years of age. The pathophysiology of
AARD is not well understood but it is suspected that
the clavicle fracture and AARD occur sequentially and
may be associated with a lax or disrupted alar ligament.29,30 Sternocleidomastoid muscle spasm may
also be a contributing factor.29 Early diagnosis is
important since delayed diagnosis can lead to a
chronic deformity. The diagnosis should be suspected
if the child has a clavicle fracture and holds the head
in the classic “cocked-robin” position. In this position,
the head is bent toward the fractured side but rotated
in the opposite direction. Plain cervical spine radiographs will detect approximately 93% of AARD,
although the injury is best demonstrated by dynamic
CT. Bowen et al reported that 7 of the 13 cases were
recognized within the first three weeks; in these cases,
the AARD was reduced with the use of a soft cervical
collar or halo traction.29 The remaining six cases were
recognized between six weeks and three years following the initial injury. All had developed a fixed
deformity requiring surgical correction.
• Type III injuries are intra-articular fractures of
the glenoid fossa.
• Type IV fractures involve the body of the
scapula (Figure 12A and 12B).
The most important clinical aspect of scapular
fractures is the high incidence of associated injuries to
the ipsilateral lung, chest wall, and shoulder girdle
complex.5,33,34 Brown et al reported associated injuries
in 99% of patients; of note, however, was that blunt
thoracic aortic injury was not more common in
patients with a fractured scapula.32
Clinical
In the conscious patient with a scapula injury, the
shoulder is adducted and the arm held close to the
body. Any attempts at movement result in significant
pain. There may be associated tenderness, crepitus, or
hematoma over the fracture site. Hemorrhage into the
rotator cuff associated with the scapula fracture can
result in spasm and a temporary reflex inhibition of
function.33 The presence of a scapula fracture requires
a careful search for associated injuries.
In many patients, fractures of the scapula are
initially overlooked because of the life-threatening
nature of associated injuries. In a retrospective
review of 100 patients with blunt chest trauma and
associated scapular fractures, Harris et al reported
that the scapular fracture was initially missed in 31
cases, despite being readily apparent on the initial
supine trauma chest radiograph.34 The trauma series
of shoulder radiographs will identify most fractures
and the axillary lateral view is especially useful in
evaluating fractures of the glenoid fossa and the
acromion or coracoid processes.5 The os acromiale
(unfused acromial process epiphysis) is present in 3%
of the population and should not be confused with a
fracture of the acromion.7 A comparison film is
useful since the abnormality is present bilaterally in
60% of cases.
Scapula Fractures
Classification And Pathophysiology
Fractures of the scapula are rare and account for 3-5%
of all fractures of the shoulder girdle.31 Considerable
force and energy are required to fracture the body and
neck of the scapula. Coracoid process fractures are
usually secondary to avulsion, and glenoid rim fractures are commonly associated with anterior glenohumeral dislocations. Acromial process fractures result
from direct blows applied to the top of the shoulder.
Brown et al retrospectively reviewed 386 patients
with 718 associated injuries admitted to two Level I
trauma centers. Most patients were male (80%), with
a mean age of 38. The mean Injury Severity Score
(ISS) was 15, with a mortality rate of 3%. Common
mechanisms of injury were motor vehicle accident
(42%), pedestrian struck by automobile (33%), fall
(11%), and motorcycle accident (10%).32
Fractures of the scapula may be classified according to their anatomic location:33
• Type I fractures involve the acromion process,
scapular spine, or coracoid process.
• Type II fractures involve the scapular neck
(Figure 11).
Figure 11. Type II Scapular Fracture Involving
The Neck
Courtesy of Dr. Daya.
EBMedicine.net • October 2007
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Emergency Medicine Practice®
acromion process also respond well to conservative
therapy. Displaced acromial fractures that impinge on
the glenohumeral joint require surgical management.
If the coracoclavicular ligaments remain intact,
fractures of the coracoid process respond well to
conservative therapy. Severely displaced coracoid
fractures with ruptured coracoclavicular ligaments
usually require open reduction and internal fixation.3
Scapular neck and glenoid fossa fractures present the
most difficult management issues. Although most of
these injuries may do well with conservative therapy,
open reduction and internal fixation is needed for
more than 2 mm of displacement of the glenoid and
is recommended for severely displaced or angulated
fractures of the scapular neck.33,35 In a recent evidence-based review of 520 scapula fractures from 22
case series, Zlowodzki et al reported that 80% of all
fractures with glenoid involvement were treated
operatively, while 83% of all neck injuries and 99% of
all isolated scapula body fractures were treated nonoperatively.31
Management And Disposition
Most fractures, including those with severe comminution and displacement, heal rapidly with conservative
therapy.5,33,35 Initial therapy consists of analgesia and
immobilization in a sling to support the ipsilateral
upper extremity. Initiate pendular shoulder exercises
(Figure 9) followed by active range of motion exercises as soon as discomfort subsides to reduce the risk
of adhesive capsulitis. In general, patients require a
sling for two to four weeks.35
Fractures of the body and spine usually require no
further therapy. Undisplaced fractures of the
Figure 12A And 12B. AP And CT Images Of A Type IV
Scapula Fracture Involving The Body
Complications
Associated injuries of the ipsilateral lung, chest wall,
and shoulder girdle account for most of the acute
complications after fractures of the scapula. Neurovascular (brachial plexus, axillary artery) injuries
have also been reported with fractures of the coracoid
process.3 Delayed complications include adhesive
capsulitis and rotator cuff dysfunction.35
Proximal Humerus Fractures
Classification And Pathophysiology
Fractures of the proximal humerus are common and
account for 4-5% of all fractures.36 They occur primarily in the elderly, in whom structural changes associated with aging (osteoporosis) weaken the proximal
humerus. Although most of these injuries are minimally displaced and do well with conservative
therapy, significantly displaced fractures may require
operative intervention.
The classic mechanism of injury involves a fall on
an outstretched abducted arm. This produces a
fracture or dislocation, depending on the tensile
strengths of the bone and surrounding ligaments.
Older patients are prone to fracture, whereas younger
individuals are apt to dislocate.
Fractures of the proximal humerus separate along
old epiphyseal lines, producing four distinct segments
consisting of the articular surface (anatomic neck),
greater tuberosity, lesser tuberosity, and proximal
humeral shaft (surgical neck). The Neer classification
(Figure 13) is based on the relationship of these
fracture fragments.37,38 In the Neer system, a segment
is considered displaced if it is angled more than 45
degrees or separated more than 1 cm from the
neighboring segment. The number of fracture lines is
considered irrelevant. This lends to four major
categories of fracture:
Courtesy of Dr. Daya.
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• Minimal displacement (Figure 14)
• Two-part displacement
• Three-part displacement (Figure 15A and 15B)
• Four-part displacement
When present, anterior and posterior dislocations
are included within the Neer classification system.
Impaction and head-splitting fractures are also
classified separately.
Figure 13. Neer’s Classification Of Proximal Humerus
Fractures
Clinical
The affected arm is held close to the body and movement is restricted by pain. Tenderness, hematoma,
ecchymoses, deformity, or crepitus may be present
over the fracture site. A thorough neurovascular
examination is essential to identify associated injuries
of the axillary nerve, brachial plexus, or axillary
artery. The three-view trauma series of shoulder
radiographs will allow for assessment of the number
Figure 15A And 15B. Three-Part Displaced Fracture
Of The Proximal Humerus That Required Open
Reduction And Internal Fixation
Reprinted with permission from Neer CS, Modified Neer Classification. J Bone Joint Surg. 1970;52:1077-1089. Copyright © 1970 The
Journal of Bone and Joint Surgery.
Figure 14. Minimally Displaced Three-Part Fracture
Of The Proximal Humerus Involving The Greater And
Lesser Tuberosities
Courtesy of Dr. Daya.
Courtesy of Dr. Daya.
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of fracture fragments and degree of displacement or
angulation.
encountered with displaced surgical neck fractures
and fracture-dislocations.
Management And Disposition
Minimally displaced fractures constitute up to 85% of
all cases. No displacement or angulation is present,
and the fracture segments are held together by the
capsule, periosteum, and surrounding muscles. Good
evidence for the management of these fractures is
limited. Initial treatment consists of analgesia and
immobilization with a sling or sling and swathe
device. A recent Cochrane review of 12 randomized
trials, eight of which evaluated conservative therapy,
concluded that there was very limited evidence that
the use of special bandage immobilization affected
time to fracture union or functional outcome.39
However, the evidence suggested that the arm sling
was more comfortable then a body bandage.39 Have
the patient slowly replace initial passive pendular
exercises (Figure 9) with more active and resistive
exercise. Traditionally, immobilization is recommended until clinical union is achieved (head and
shaft move together). The Cochrane review also
noted that immediate or earlier commencement of
physiotherapy (within one week) resulted in less pain
and faster recovery then prolonged immobilization
(three weeks), followed by rehabilitation in patients
with nondisplaced two-part fractures.39 Most nondisplaced fractures will heal over four to six weeks.
Operative management may be favored for
displaced two-, three-, and four-part fractures and
orthopedics should be consulted.38 Prospective and
retrospective observational studies have failed to
show a significant functional difference between
operative and non-operative treatment of displaced
two-part and three-part fractures in the elderly.
Current literature continues to support operative
treatment of four-part fractures in the elderly where
the procedure of choice is hemiarthroplasty.40
Fracture-dislocation injuries may deserve orthopedic consultation in the ED. Care must be used
because closed reductions of these injuries are often
unsuccessful and can cause separation of previously
undisplaced segments. Closed reduction under
fluoroscopy and general anesthesia may be
preferable.41
Proximal Humeral Epiphysis Injuries
Pathophysiology
Fractures of the proximal humeral epiphysis are
uncommon and account for 10% of all shoulder
fractures in children.42 The injury can occur at any
age while the epiphysis remains open but is most
common in young males aged 11 to 17 years.43 The
most common mechanism of injury involves a fall
onto the outstretched hand. Injuries can be classified
according to their Salter type (Figure 16), stability, and
degree of displacement.3,44 This injury should also be
suspected in young athletes and is commonly known
as little league shoulder.
Figure 16. Salter Classification System For
Epiphyseal Injuries
Young SJ et al. Fractures and minor head injuries: minor injuries in
children ll. MJA 2005;182:644-648. Copyright © 2005 The Medical
Journal of Australia. Reproduced with permission.
Clinical
The patient will have the injured arm held tightly
against the body by the opposite hand. The area over
the proximal humerus will be swollen and tender to
palpation. Radiographs obtained at 90 degrees to
each other will confirm the diagnosis. Comparison
views may be helpful with minimally displaced
fractures.43
Management
Fractures of the proximal humeral epiphysis should
not be taken lightly because the potential for growth
disturbance exists until fusion has taken place
between the ages of 20 and 22. The very active
healing process at the site of an epiphyseal injury
makes delayed reduction extremely difficult. Early
orthopedic consultation should be obtained for all
such injuries. Children less than six years of age
usually have Salter I epiphyseal injuries and can be
treated conservatively with sling and swathe immobilization and analgesia. Children older than six years
of age usually have a Salter II epiphyseal injury.
Salter II injuries with greater than 20 degrees of
angulation should be reduced.45 Closed reduction is
accomplished by reversing the mechanism of injury.
Imperfect reductions are often acceptable because
growth and remodeling correct the deformity with
time. After reduction, unstable injuries should be
immobilized in a shoulder spica cast whereas stable
Complications
The most common complication of proximal humeral
fractures is adhesive capsulitis (“frozen or stiff shoulder”). This can be prevented by the early initiation of
passive shoulder pendular exercises along with a
thorough rehabilitation program. One of the most
devastating complications is that of avascular necrosis
(AVN) of the humeral head. The highest rate of AVN
(up to 90%) occurs with four-part fractures.40 It
should be anticipated with anatomical neck fractures
as well. Neurovascular injuries (axillary nerve,
brachial plexus, and axillary artery) may be
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October 2007 • EBMedicine.net
lesions can be immobilized with a sling. Little league
shoulder is treated with a sling and activity modification dictated by symptomatology. Fractures of the
proximal humeral epiphyses will heal in three to five
weeks.45
often flexed toward the injured side.4,48 The clavicular
notch of the sternum may be more or less prominent,
and there may be complaints of hoarseness, dysphagia, and dyspnea as well as weakness or paresthesias
in the upper extremity. Although rare, airway complications secondary to tracheal injury have been
reported.49 The presence of cyanosis and venous
congestion of the neck and arm is typical of an
innominate vein injury.48
Although the diagnosis of sternoclavicular dislocations can be made clinically, it should be confirmed
through radiographic studies. Standard AP chest
radiographs as well as other recommended (40-degree
cephalic tilt) views are often difficult to interpret
because of overlapping rib, sternum, and vertebral
shadows. These dislocations and associated mediastinal injuries are best visualized by CT (Figure 17).15,48
Ultrasound (Figure 18) may also be a useful adjunct in
some circumstances.4,50
Complications
Complications include malunion, growth plate
disturbances, and injuries to the neurovascular
bundle.
Dislocations
Sternoclavicular Dislocations
Pathophysiology And Classification
Sternoclavicular joint (SCJ) dislocations are infrequent,
with the most common causes from motor vehicle
accidents and contact sports.46 Significant forces are
required to disrupt the strong ligamentous stabilizers
of this joint. The SCJ can dislocate in an anterior or
posterior direction. Anterior dislocations, which
result from indirect forces, are far more common (9:1
ratio).4 The usual mechanism of injury involves an
anterolateral force to the shoulder, followed by
backward rolling which levers the medial clavicle out
of its articulation. Posterior dislocations can result
from a direct blow to the medial clavicle (30%) or
from a posterolateral force to the shoulder, followed
by inward rolling (70%).3 Posterior dislocations can be
associated with life-threatening injuries within the
superior mediastinum. Injuries to the SCJ (Figure 1)
can be graded into three types: 4
• A Grade I injury is a mild sprain secondary to
stretching of the sternoclavicular and costoclavicular ligaments.
• A Grade II injury is associated with subluxation
of the joint (anterior or posterior) secondary to
rupture of the sternoclavicular ligament while
the costoclavicular ligament remains intact.
• A Grade III injury is complete rupture of the
sternoclavicular and costoclavicular ligaments
that results in dislocation.
Management and Disposition
Treatment of Grade I injuries includes immobilization
(simple sling), adequate analgesia, and primary care
follow-up. Immobilization is generally maintained
(one to two weeks) until full painless motion is
restored. Grade II injuries should be immobilized
with a sling and referred for orthopedic follow-up.
Grade III injuries require a longer course of immobilization (three to six weeks) and are more likely to be
associated with persistent pain.3,4
All Grade III injuries should be managed by
closed reduction. Anterior dislocations may be
reduced in the ED after orthopedic consultation and
intravenous analgesia. A rolled sheet is placed
posteriorly between the shoulder blades to elevate
both shoulders approximately 5 cm above the table.
Traction is applied to the arm in an extended (10- to
Figure 17. CT Image Demonstrating A Right Posterior
Sternoclavicular Dislocation
It is important to note that in patients under 25
years of age, these actually represent Salter I injuries,
since the medial epiphysis of the clavicle has not yet
fused.47
Clinical
Patients present with the injured extremity flexed at
the elbow and supported across the trunk by the
opposite arm.48 There is usually pain in the region of
the SCJ which increases with arm motion, although
atraumatic cases (attributable to ligamentous laxity in
teenagers) may have minimal symptoms.46 The SCJ
may be mildly swollen and tender to palpation. With
an anterior dislocation, the displaced medial end of
the clavicle may be palpable. Posterior dislocations
are associated with more severe pain, and the neck is
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Courtesy of Dr. Daya.
11
Emergency Medicine Practice®
15-degree) and abducted (90-degree) position. If
reduction does not occur, an assistant can add inward
pressure on the medial end of the clavicle. Stable
reductions should be maintained in a sling or clavicular splint and referred for orthopedic follow-up.
Although major orthopedic textbooks still recommend
immobilization with the clavicular splint in grade II
and III injuries, there is no published evidence to
support this.3 Many of these reductions remain
unstable, and since the deformity is primarily cosmetic and not functional, recurrent anterior dislocations are treated conservatively with benign neglect.
Posterior dislocations are true orthopedic emergencies and should be reduced expeditiously.4 Closed
reduction of retrosternal dislocations is considered the
treatment of choice, with open reduction and internal
fixation required only in cases where the clavicle
cannot be reduced or remains unstable after reduction.46 Reduction of posterior dislocations can be
attempted in the operating room under general
anesthesia or in the ED under procedural sedation. A
cardiothoracic surgeon should be consulted before
reduction of these injuries in the event that a vascular
injury requiring thoracotomy becomes apparent
during the procedure.46 The patient is positioned as
described previously, and traction is applied in an
extended and abducted position. If traction alone
does not reduce the dislocation, concurrent clavicular
manipulation may be helpful. With this technique,
the skin is sterilely prepped and the clavicle shaft is
grasped with a sterile towel clip and pulled out
anterolaterally. Once reduced, these injuries are
generally stable and can be immobilized with a
clavicular splint. Buckerfield and Castle have
described an alternate method of reduction for
posterior dislocations.51 In this technique, traction is
applied to the adducted arm while both shoulders are
simultaneously forced posteriorly using direct pressure. This levers the clavicle into place and requires
much less force than the traditional abductionextension method.
Complications
Significant complications are associated with retrosternal dislocations. Ono et al reviewed 102 cases
reported in the literature as of 1998 and documented
complications in 31 (30%) patients, with three
deaths.48 Complications include compression or
laceration of the great vessels, tracheoesophageal
fistula, tracheal compression, pneumothorax, thoracic
outlet syndrome, and brachial plexus injuries.46,48,52
Figure 18. (A) Ultrasound Scan Of The Sternoclavicular Joint Showing Posterior Dislocation; (B) Ultrasound Scan Of A Normal Sternoclavicular Joint; (C)
Diagram Of The Captured Anatomy; (D) Diagram Of
The Structures Seen
Acromioclavicular Joint
Pathophysiology And Classification
Injuries of the acromioclavicular joint (ACJ) occur
primarily in young men secondary to sporting or
motor vehicle accidents. They account for up to 25%
of all dislocations of the shoulder girdle.53,54 The most
common mechanism of injury involves a fall or direct
blow to the point of the shoulder with the arm
adducted. The resultant force drives the scapula
downward and medially away from the clavicle to
produce the injury. The weak acromioclavicular
ligaments rupture first. With increasing force, the
coracoclavicular ligaments rupture and the attachments of the deltoid and trapezius muscles are torn
from the distal clavicle. The ACJ can also be injured
after a fall onto the outstretched hand.55
Classification is based on the degree of damage
sustained by the different joint stabilizers.56 The most
commonly used system is that modified by Rockwood:47,57
• Type I: Sprains of the acromioclavicular (AC)
ligaments with no separation of the acromion
and clavicle.
• Type II: Disruption of the AC ligaments. The
joint space is widened and the clavicle displaces
slightly upward. There are minor tears in the
attachments of the deltoid and trapezius muscles, but the coracoclavicular (CC) ligaments
remain intact and the coracoclavicular distance
is maintained (Figure 19).
• Type III: Complete disruption of the AC ligaments, CC ligaments, and muscle attachments.
The joint space is widened, and the
Reprinted from Injury, Volume 34, Siddiqui AA, Turner SM,
Posterior sternoclavicular joint dislocation: the value of intraoperative ultrasound, pages 448-53, Copyright © 2003, with
permission from Elsevier.
Emergency Medicine Practice®
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October 2007 • EBMedicine.net
coracoclavicular distance is increased by 25100%.58 The clavicle is displaced upward by the
pull of the trapezius, and the shoulder is
displaced downward by the effect of gravity
(Figure 20).
• Type IV: Complete rupture of the AC and CC
ligaments with displacement of clavicle posteriorly through the trapezius.
• Type V: Complete rupture of the AC and CC
ligaments with an exaggerated superior displacement of the clavicle. The coracoclavicular
distance is increased 100-300%.58
• Type VI: Subcoracoid displacement of the
clavicle.
instability. It is helpful to visualize both shoulders
simultaneously to assess for symmetry. Type I and II
injuries are associated with mild tenderness and
swelling over the ACJ margin and minimal deformity.
A full range of motion is often possible, although
painful. Patients with Type III, IV, V, and VI injuries
usually have severe pain and will hold the arm tightly
adducted. In Type III injuries, the shoulder hangs
downward and the clavicle rides high, producing a
visible clinical deformity. In Type IV injuries, the
clavicle may be palpable posteriorly, and in Type V
injuries, the clavicle may be palpable subcutaneously
above the acromion. In Type VI injuries, the shoulder
assumes a flattened clinical appearance.
The energy settings used for the three-view
shoulder trauma series usually over penetrate the ACJ.
Therefore, specific ACJ views that use less intensity
should be ordered. The recommended projections
include an AP view of both shoulders on a single wide
film, an axillary lateral view, and a 15-degree cephalic
tilt view.47,59 The axillary lateral view is very important for identifying associated fractures and any
posterior dislocation of the clavicle. The normal
coracoclavicular distance varies between 11 mm and 13
mm. A difference of more than 5 mm between the
injured and uninjured sides is diagnostic of complete
coracoclavicular disruption. Type I injuries have
essentially normal radiographs. Type II injuries
(Figure 19) show widening of the joint and a slight
upward or posterior displacement of the clavicle but a
normal coracoclavicular distance. Type III (Figure 20),
IV, and V injuries have a widened joint, an increased
coracoclavicular distance, and either superior or
posterior displacement of the clavicle. Historically,
stress views of the ACJ have been recommended to
differentiate between Type II and III injuries. To study
this recommendation, Bossart et al presented 83 pairs
of radiographs, taken with and without weights, in a
blinded manner to a staff radiologist. In only three
cases (4%) did weights cause the injured coracoclavicular distance to increase and thereby unmask a grade III
injury not evident on plain radiographs. In several
cases, the weights actually caused the injured and
uninjured CC distance to decrease; the authors concluded that the use of weighted radiographs lacks
efficacy for unmasking grade III ACJ injuries and
recommended that the routine use of this technique be
abandoned in the ED.58,60
Clinical
Always examine patients while they are sitting or
standing because the supine position can mask ACJ
Figure 19. Type II Injury Of The Acromioclavicular
Joint
Courtesy of Dr. Daya.
Figure 20. Type III Injury Of The Acromioclavicular Joint
Management And Disposition
Type I and II injuries should be immobilized in a sling
for comfort and to protect against further injury.
These patients should be referred for follow-up with
their primary care physician. Once pain has subsided
(one to three weeks), the patient can begin range-ofmotion and strengthening exercises with a return to
sports when pain-free function has been achieved.59
Type IV, V, and VI injuries require immediate orthopedic consultation. The management of Type III injuries
has changed dramatically over the last two decades.
Courtesy of Dr. Daya.
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Most studies have concluded that conservative
treatment provides equal or, in some cases, better
functional results than surgical intervention. In
addition, surgical patients have longer recovery times
and higher complication rates.59,61-64
Figure 21. Subcoracoid Anterior GHJ Dislocation
Complications
The most common complications following ACJ
injuries are residual symptomatic instability and
tenderness over the joint due to secondary degenerative changes.56,58,59 Acromioclavicular arthritis
typically presents as an impingement syndrome with
shoulder pain between 120 and 180 degrees of
abduction.
Glenohumeral Dislocations
The glenohumeral joint (GHJ) is the most commonly
dislocated major joint in the body. The lack of intrinsic bony stability in conjunction with its wide range of
motion predisposes the joint to dislocations. Anterior
dislocations account for 95-97% of all glenohumeral
dislocations. Posterior dislocations account for most
of the remainder, while inferior and superior dislocations are rare.
Courtesy of Dr. Daya.
the acromion process is prominent, and the normally
rounded shoulder assumes a “squared-off” appearance. The coracoid process is indistinct, and the
anterior shoulder appears full. The patient cannot
adduct or internally rotate without pain. A neurovascular examination must be performed to identify
associated injuries of the brachial plexus, axillary
nerve, radial nerve, or axillary artery. The reported
incidence of axillary nerve injuries after anterior
glenohumeral dislocation ranges from 5% to 54%, and
they are more frequent in patients over 50 years of
age.67,68 Axillary nerve function can be assessed by
testing for sensation over the lateral aspect of the
shoulder and by testing motor function of the teres
minor and deltoid muscles. Deltoid function can be
tested by having the patient attempt shoulder abduction while the examiner simultaneously feels for
muscle contraction. Motor testing is recommended,
since sensory testing may be inaccurate due to the
presence of overlapping cutaneous nerve root dermatomes.
The trauma series of radiographs will confirm the
clinical diagnosis and identify the position of the
humeral head. Associated fractures may be present in
up to 50% of cases. The most common of these is a
compression fracture (Figure 22) 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, is reported to be present in 11-50% of all
anterior dislocations. The actual incidence is probably
much higher, since minor compression fractures are
difficult to visualize on plain radiographs. A corresponding fracture of the anterior glenoid rim
(Bankart’s Fracture) is present in approximately 5% of
cases.6 Avulsion fractures of the greater tuberosity are
present in 10-15% of cases (Figure 23).6,67
Anterior Dislocations
Pathophysiology And Classification
The most common mechanism of injury of anterior
dislocations consists of an indirect force transferred to
the anterior capsule from a combination of abduction,
extension, and external rotation. In younger individuals, the injury is usually sustained during athletic
activities involving rapid movements; a characteristic
pathological feature is avulsion of the anteroinferior
glenohumeral ligament with capsulolabral detachment (Bankart lesion).65 In older patients, a fall onto
the outstretched arm is the more common mechanism
of injury and there is often an accompanying rotator
cuff tear.53,65
Anterior dislocations can be classified according
to the anatomic position of the dislocated humeral
head.66 After dislocation, the humeral head can
assume a subcoracoid, subglenoid, subclavicular, or
intrathoracic position. The subcoracoid (Figure 21) is
the most common type of anterior dislocation. The
head is displaced anteriorly and rests on the scapular
neck inferior to the coracoid process. The second
most common type is the subglenoid dislocation, in
which the head is anterior and inferior to the glenoid
fossa. The subcoracoid and subglenoid types account
for 99% of all anterior dislocations. Subclavicular and
intrathoracic dislocations are extremely rare and
involve the addition of impact forces that push the
humeral head medially.
Clinical
Clinical presentation is that of severe pain with the
dislocated arm held in slight abduction and external
rotation by the opposite extremity. The lateral edge of
Emergency Medicine Practice®
Management And Disposition
Perform closed reduction of the dislocation
14
October 2007 • EBMedicine.net
expeditiously because neurovascular complications
increase with time.68 It is recommended that radiographic documentation of the type of dislocation and
any associated fractures be obtained before attempting
reduction. The role of pre-reduction as well as postreduction radiographs have been the subject of several
recent studies aimed at reducing radiograph utilization and shortening the time spent in the ED; see the
Controversies And Cutting Edge section.
Good muscle relaxation is often the key to a
successful reduction. Reductions can also be accomplished without the use of any analgesia if the time
from injury to reduction is short or if the dislocation is
a recurrent one. Muscle relaxation and analgesia can
be achieved through procedural sedation. The intraarticular injection of a local anesthetic agent can be
used as an alternative to sedation analgesia. Enter the
joint under sterile technique 2 cm inferior to the
lateral edge of the acromion using an 18- or 20-gauge
needle. Aspirate any associated hemarthrosis and
then inject 20 mL of 1% lidocaine over 30 seconds.
The patient is then allowed to relax for 15 minutes
before reduction is attempted. The published studies
to date have all used lidocaine, although it would be
reasonable to expect similar results with long acting
local anesthetic agents such as bupivicaine. A recent
systematic literature review revealed six randomized,
controlled trials comparing intravenous sedation to
intra-articular lidocaine.69 Outcomes in these studies
included success rates, complications, and time spent
in the ED.70-75 Although the reduction techniques
were not controlled in these studies, none showed a
statistical difference in the reduction success rates,
which averaged 92% for both the intra-articular
lidocaine and intravenous sedation groups.69 Complication rates were quite different, averaging 0.9% in the
intra-articular lidocaine group (septic arthritis,
abscess, cellulitis, allergy, or failure of reduction) and
16.4% in the intravenous sedation group (potential
Figure 22. Anterior Subglenoid GHJ Demonstrating
Mechanism Of Injury Of The Hill-Sachs Deformity
Due To A Posterolateral Impaction Fracture Of The
Humeral Head
Courtesy of Dr. Daya.
Figure 23. Anterior GHJ Dislocation With Associated
Fracture Of The Greater Tuberosity
Key Points For Shoulder Girdle
Fractures And Dislocations
1. A thorough neurovascular exam is essential and
must be repeated after any manipulation.
2. The three-view trauma series leads to an accurate
radiographic diagnosis of most fractures and
dislocations; however, specialized views (e.g., the
apical oblique and 15-degree cephalic tilt view)
may be useful or necessary in some instances.
Think about the presence of unfused epiphyses in
adolescents and young adults and consider
comparison films on a selective basis.
3. Most fractures can be treated conservatively with
good functional outcomes.
4. Early initiation of passive pendular range-ofmotion exercises can reduce the risk of adhesive
capsulitis when the shoulder is immobilized for
any reason.
Courtesy of Dr. Daya.
EBMedicine.net • October 2007
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Emergency Medicine Practice®
respiratory depression, cardiac compromise, allergy,
or failure of reduction). In two studies, the time spent
in the ED was significantly shorter for the intraarticular lidocaine group and there was as much as a
62% cost savings versus the intravenous sedationanalgesia group.71,74
Reduction can be accomplished using various
techniques, most of which involve traction, leverage,
or scapular manipulation principles.76 Over a dozen
techniques have been described for reducing a shoulder dislocation.69 Most of these have only been
described in case series or consecutive prospective
cohorts. There is only one randomized trial in the
literature which compared the Kocher and Milch
techniques; it found no statistical differences in the
success rates between the two techniques.77 Due to
insufficient data at this time, no specific recommendation can be made regarding the optimal reduction
technique.69 The ideal method should be simple,
quick, effective, require little assistance, and cause no
additional injury to the shoulder. It is wise to be
familiar with several techniques of reduction, since
none is uniformly successful.
any gentle external pressure or rotation as needed
until reduction is accomplished.
Leverage Techniques
The most commonly recommended leverage technique is the external rotation method of Liedelmeyer
(Figure 26).80 With the patient in the supine position,
the involved arm is slowly and gently adducted to the
side. The elbow is flexed to 90 degrees and slow,
gentle external rotation is applied to achieve reduction. Success rates reported with the external rotation
method range from 78% to 90%.69
Scapular Manipulation
Scapular manipulation accomplishes reduction by
Figure 24. Traction-Countertraction Reduction
Technique
Traction Techniques
Gentle traction in various directions (forward flexion,
abduction, overhead, lateral) is used to overcome the
muscle spasm that holds the humeral head in its
dislocated position.76 In the Stimson technique, the
patient is placed prone with the dislocated arm
hanging over the edge of the examining table. A 10or 15-pound weight attached to the wrist or lower
forearm provides traction in forward flexion. Reduction usually occurs over 20-30 minutes. Success rates
reported with the Stimson method range from 91 to
96%. This is an excellent technique in the busy ED
because it saves time and resources.69
In the traction-countertraction method, traction is
applied along the abducted arm while an assistant
using a folded sheet wrapped across the chest applies
counter-traction (Figure 24). The forward elevation
maneuver of Cooper and Milch is also simple and safe
(Figure 25). The arm is initially elevated 10-20
degrees in forward flexion and slight abduction.
Forward flexion is continued until the arm is directly
overhead. Abduction is then increased, and outward
traction is applied to complete the reduction.78
Reported success rates with this technique range from
70% to 89%.69
Another simple and very effective traction technique with a reported success rate of 97% is the
Snowbird technique.79 In this method, the patient is
seated in a chair and the affected arm is supported by
the patient’s unaffected extremity. A three-foot loop
of four-inch cast stockinet is then placed along the
proximal forearm of the involved extremity with the
elbow at 90 degrees. The patient is then assisted or
instructed to sit up and the physician’s foot is placed
in the stockinet loop to provide firm downward
traction. The physician’s hands remain free to apply
Emergency Medicine Practice®
Reprinted with permission from Rosen’s Emergency Medicine, sixth
edition, Marx, Hockberger, and Walls, “Shoulder,” page 689,
Copyright Elsevier 2006.
Figure 25. Milch Technique
Reprinted from www.faculty.washington.edu.
16
October 2007 • EBMedicine.net
repositioning the glenoid fossa rather than the
humeral head. The patient is placed in the prone
position with the affected arm hanging off the table as
for the Stimson technique. After the application of
downward traction (manual or hanging weights), the
scapula is manipulated (Figure 27) by rotating the
inferior tip medially while simultaneously stabilizing
the superior and medial edges with the opposite
hand.81 Success rates range from 79% to 96%. McNamara described a seated modification of the scapular
method in which traction is applied in the forward
horizontal position while an assistant manipulates the
scapula.82 Scapular manipulation can be difficult in
obese individuals, in whom it is difficult to palpate
and grasp the inferior tip of the scapula.
The neurovascular examination must be repeated
after any attempt at reduction. It is also generally
recommended that radiographs be repeated to confirm reduction and to identify any associated fractures
not apparent on pre-reduction films.
Once reduced, immobilize the affected extremity.
Figure 26. External Rotation Technique
Reprinted with permission from Rosen’s Emergency Medicine, sixth
edition, Marx, Hockberger, and Walls, “Shoulder,” page 689,
Copyright Elsevier 2006.
Clinical Pathway: Approach To Clavicle Fractures In The ED
Clavicle fractures
Is there:
• An open fracture?
• A fracture with neurovascular injuries?
• Skin tenting?
• Interposition of soft tissues?
NO
Is it a Type II lateral clavicle fracture?
YES
Immediate orthopedic consultation
(Class I)
YES
Pain control and immobilization,
then urgent orthopedic
consultation (within 72 hours)
(Class I)
YES
Pain control and immobilization,
then early orthopedic referral
(Class III)
NO
Is it:
• Severely comminuted?
• A displaced fracture of the middle third (defined
as over 20 mm initial shortening)?
NO
Pain control and immobilization, then
primary care physician follow-up
(Class II)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May
be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s
individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2007 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB
Practice, LLC.
EBMedicine.net • October 2007
17
Emergency Medicine Practice®
all glenohumeral dislocations.84 The 45-degree
angulation of the scapula on the thoracic cage positions the glenoid fossa posterior to the humeral head
and serves as a partial buttress against posterior
dislocation. Unfortunately, over 50% of posterior
dislocations are missed on initial evaluation, and
many remain unrecognized for weeks or months.85,86
A posterior dislocation can result from several
distinct mechanisms of injury. Convulsive seizures
(epileptic or after electrical shock) have been associated with unilateral or bilateral posterior dislocations
because the larger and stronger internal rotator
muscles (latissimus dorsi, pectoralis major, teres
major, subscapularis) overpower the weaker external
rotators (teres minor, infraspinatus).85 A posterior
dislocation can also occur after a fall onto the outstretched hand with the arm held in flexion, adduction, and internal rotation or after a direct blow to the
anterior aspect of the shoulder. Classification (subacromial, subglenoid, subspinous) is based on the
final resting position of the humeral head. The
subacromial variety accounts for 98% of all posterior
dislocations.84
Figure 27. Scapular Manipulation Technique
Clinical
Early diagnosis is essential to prevent long-term
functional and therapeutic complications. The patient
will hold the affected arm across the chest in adduction and internal rotation. The injury can be relatively
painless in some cases.85 The normal shoulder
contour is replaced by a flat, squared-off appearance
Reprinted from www.faculty.washington.edu.
Discharge patients with adequate analgesia and
appropriate follow-up. Primary dislocations and
complicated cases (associated fracture, rotator cuff
tear, axillary nerve injury) should receive prompt
orthopedic follow-up. In uncomplicated cases,
immobilize the shoulder for three to six weeks in
younger patients and one to two weeks in patients
older than 40 years of age.6 If immobilization is used,
early initiation of pendular shoulder exercises can
help reduce the risk of adhesive capsulitis. This
should be followed by a meticulous rehabilitation
program aimed at restoring the static and dynamic
stabilizers of the glenohumeral joint.6
Figure 28. Light Bulb Or Drumstick Sign (Posterior
GHJ Dislocation)
Complications
Complications include the aforementioned fractures
and neurovascular injuries. Most axillary nerve
injuries are neuropraxic, and the prognosis for recovery of function is good.68 Rotator cuff tears may be
present in 10-15% of cases.83 Rotator cuff tears are
more common in primary dislocations in individuals
over the age of 40. In this setting, failure to abduct the
arm is often initially misdiagnosed as an axillary
nerve injury. Most of these individuals require tendon
and capsular repair to restore shoulder stability.83
Recurrence is also a common complication after
anterior dislocation, especially in patients less than 30
years of age.66
Posterior Dislocation
Pathophysiology
Posterior dislocations are rare and account for 2% of
Emergency Medicine Practice®
Courtesy of Dr. Daya.
18
October 2007 • EBMedicine.net
the humeral head and posterior glenoid rim. CT may
be helpful in some instances.87
and the humeral head may be palpable posteriorly
beneath the acromion process. Abduction is severely
limited, and external rotation is completely blocked.
Failure to diagnose is often due to an over reliance on
radiological findings and an under reliance on the
clinical examination. The most common misdiagnosis
is adhesive capsulitis.84,86
The true or standard AP radiographs can appear
deceptively normal with posterior dislocations. The
common inability to diagnose posterior dislocation in
the frontal plane has led to the description of several
characteristic radiographic findings. The humeral
head is often profiled in internal rotation and takes on
a “light bulb” or “drumstick” appearance (Figure 28).
Standard AP films also show loss of the half-moon
elliptical overlap of the humeral head and glenoid
fossa as well as an increase in the distance between
the anterior glenoid rim and the articular surface of
the humeral head (“rim sign”). A true AP film will
show abnormal overlap of the glenoid fossa with the
humeral head (Figure 29). Finally, an impaction
fracture (Figure 30) of the anteromedial humeral head
(reverse Hill-Sachs deformity) is invariably present.
This may produce a curvilinear density on the frontal
projection parallel to the articular cortex of the
humeral head (“trough sign”). Orthogonal views
such as an axillary lateral, transscapular “Y,” or apical
oblique (Figure 31) are essential to clinch the diagnosis. These views can identify associated fractures of
Management And Disposition
Obtain orthopedic consultation for all patients with
posterior dislocations. Closed reduction may be
attempted in the ED under procedural sedation. The
technique of reduction incorporates axial traction in
line with the humerus, gentle pressure on the
Figure 30. Impaction Fracture Of Anteromedial
Humeral Head (Reverse Hill Sach’s), Seen With
Posterior GHJ Dislocation
Figure 29. Abnormal Overlap Of Glenoid Rim And
Humeral Head On A True AP View, Seen With
Posterior GHJ Dislocation
Courtesy of Dr. Daya.
Courtesy of Dr. Daya.
Courtesy of Dr. Daya.
EBMedicine.net • October 2007
Figure 31. Scapular “Y” View Showing Posterior GHJ
Dislocation
19
Emergency Medicine Practice®
posteriorly displaced head, and slow external rotation.
If this fails, reduction with the patient under general
anesthesia is indicated. Once reduced, the shoulder is
immobilized in external rotation with slight abduction.86 Cases that were missed initially and present as
a chronic or “locked posterior dislocation” should be
discussed with the orthopedist since they often
require semi-elective open reduction and internal
fixation or arthroplasty.86,87
acromion, coracoid, clavicle, greater tuberosity,
humeral head, and glenoid rim are frequently present.
Management And Disposition
When possible, obtain orthopedic consultation before
attempting closed reduction in the ED; it should then
be performed under procedural sedation using a
traction-countertraction maneuver. Apply traction in
line with the humeral shaft while an assistant applies
countertraction across the shoulder. Gentle abduction
usually reduces the dislocation, and the arm can then
be brought down into an adducted position. Multiple
attempts may be necessary and occasionally buttonholing of the capsule will prevent closed reduction,
necessitating open reduction. A single operator
technique has been described by Nho et al.90
Complications
The most common complications are associated
fractures of the glenoid rim, greater tuberosity, lesser
tuberosity, and humeral head. The subscapularis
muscle may be avulsed from its insertion site on the
lesser tuberosity. Neurovascular injuries are uncommon because the anterior location of the neurovascular bundle protects it from injury. Recurrent posterior
dislocations occur in 30% of patients and predispose
the joint to degenerative changes.
Figure 32. Inferior GHJ Dislocation Demonstrating
The Scapula Spine Parallel To The Humeral Shaft
Inferior Dislocation (Luxatio Erecta)
Pathophysiology
Luxatio erecta is a rare type of glenohumeral dislocation in which the superior aspect of the humeral head
is forced below the inferior rim of the glenoid fossa.
Less than 1% of all shoulder dislocations are of this
variety and the mechanism of injury involves either
indirect or direct forces.88,89 Most inferior dislocations
result from indirect forces that hyperabduct the
affected extremity. This causes impingement of the
humeral head against the acromion process. Further
levering of the humeral shaft against the acromion
ruptures the capsule, dislocating the head inferiorly.
Application of a direct axial load to an abducted
shoulder can also disrupt the weak inferior glenohumeral ligament and drive the humeral head
downward.
Clinical
Typically, the patient presents with the arm locked
overhead in 110-160 degrees of abduction. The elbow
is usually flexed with the forearm resting on top of the
head. The inferiorly displaced humeral head may be
palpable along the lateral chest wall and any
attempted movement is very painful. A completed
neurovascular examination is essential to evaluate for
associated injuries.
Luxatio erecta cases are often mistakenly diagnosed and treated as subglenoid anterior dislocations,
since the radiographic features of these two clinical
entities are remarkably similar. Standard AP radiographs demonstrate the superior articular surface
inferior to the glenoid fossa. In addition, the humeral
shaft characteristically lies parallel to the spine of the
scapula on the AP view (Figure 32).89 This radiographic feature is useful in distinguishing luxatio
erecta from a subglenoid anterior dislocation because
the humeral shaft lies perpendicular to the spine of
the scapula in the latter. Associated fractures of the
Emergency Medicine Practice®
Reprinted from www.learningradiology.com.
Cost- And Time-Effective Strategies
1. The use of intra-articular 1% lidocaine to facilitate
analgesia and relief of muscle spasm in anterior
glenohumeral joint dislocations results in shorter
ED length of stay and substantial cost savings
when compared to procedural sedation.
2. The routine use of weighted views to diagnose
grade III ACJ injuries lacks efficacy, adds cost, and
is unnecessary.
3. Recent studies suggest that post-reduction radiographs may not be necessary following successful reduction of anterior glenohumeral dislocations. In selected cases, pre-reduction radiographs
may also be unnecessary.
20
October 2007 • EBMedicine.net
Complications
Neuropraxic lesions of the brachial plexus are very
common. Aneurysm or thrombosis of the axillary
artery as well as thrombosis of the axillary vein have
also been associated with luxatio erecta.91,92 Given the
proximity of the two structures, arteriography should
be strongly considered any time a brachial plexus
injury is observed. In a 1990 case report and review of
the literature, Mallon et al reported that 12% of cases
were associated with rotator cuff tears and 37% of
cases had a fracture of some type. Greater tuberosity
avulsion fractures occur in 31% of cases, and fractures
of the glenoid, acromion, surgical neck, humeral head,
and scapular body have also been reported.93 Adhesive capsulitis is a common long-term complication of
luxatio erecta.
Figure 33. Immobilization Using A Sling (A) Or In
External Rotation (B) Following Reduction
A
Controversies And Cutting Edge
Cutting Edge
B
Once an anterior shoulder dislocation is reduced, the
standard teaching has been immobilizing the shoulder
in internal rotation using a sling (Figure 33A) to allow
for the healing of the injured soft tissues. The wisdom
of this has recently been questioned by cadaveric
studies from Japan and Australia which demonstrated
that immobilization in external rotation (Figure 33B)
allowed for better approximation of the injured soft
tissues (Bankart lesion) to the glenoid rim following
an anterior shoulder dislocation.94,95 The potential
benefits of immobilization in external rotation have
been subsequently confirmed through two clinical
studies. In the first study, Itoi et al obtained MRI
images in both internal (mean 29 degrees) and external (mean 35 degrees) rotation following reduction of
an anterior dislocation in 19 patients (13 recurrent, 6
acute). They noted that separation and displacement
of the labrum were both significantly less when the
arm was immobilized in external rotation as compared to internal rotation (P = 0.0047 and P = 0.0017,
respectively).96 This preliminary study was then
followed by a prospective, randomized trial comparing these two methods of immobilization following
reduction in 40 patients with first time anterior
dislocations.97 The authors reported that three weeks
of immobilization in 10 degrees of external rotation
was associated with a zero recurrence rate at 13-15
months compared to 30% with sling immobilization in
internal rotation.97 A larger confirmatory study with
longer follow-up intervals would be helpful, but, for
now, it appears that immobilization in external
rotation (Figure 33B) may be of more benefit than
immobilization in internal rotation in patients with a
first anterior shoulder dislocation.98
Courtesy of Dr. Daya.
clinical diagnosis and to assess for the presence of any
associated fractures. Furthermore, it has been recommended that patients receive post-reduction radiographs to confirm reduction and exclude fractures
caused by the reduction technique. The need for preand post-reduction radiographs in suspected shoulder
dislocations has been challenged by several authors in
recent years.99-104 Reduction in the number of radiographs should decrease costs and shorten ED
throughput times. Hendey et al retrospectively
reviewed the radiographic findings in 131 patients
with 175 dislocations to determine the utility of postreduction radiographs.100 They noted that prereduction radiographs demonstrated all associated
fractures except for 14 new Hills-Sachs deformities
which they deemed to be clinically insignificant. In a
subsequent prospective study of 104 patients, these
same authors reported that physician clinical confidence with regards to a successful reduction (presence
of a palpable clunk, decrease in pain, and improvement in the range of motion) was well correlated with
findings on the post-reduction radiographs.101 Shuster et al investigated the need for pre-reduction
radiographs at a rural community hospital that serves
Controversies
Most health care practitioners have traditionally been
taught that pre-reduction radiographs are necessary in
all suspected shoulder dislocations to confirm the
EBMedicine.net • October 2007
21
Emergency Medicine Practice®
an active skier and snowboarder population. In one
study, they found that when the emergency physician
was clinically confident of the diagnosis (68% of
cases), they were 100% accurate.102 In a follow-up
study, they demonstrated that implementation of
voluntary guidelines based on physician certainty
allowed for the elimination of pre-reduction radiographs in 88.9% of cases.103
Decreasing the need for pre- and post-reduction
radiographs was recently prospectively evaluated by
Hendey and colleagues using a clinical decision
algorithm based on mechanism of injury, history of
prior dislocations and physician’s certainty of joint
position.104 The algorithm reduced x-ray utilization
by 46%. In addition, the mean ED times were significantly shorter for patients managed without radiographs and the reduction in ED utilization was not
offset by an increase in follow-up office radiographs.
The findings of most of these studies are very subjective and one cannot assume that all doctors will have
Risk Management Pitfalls
6. Failure to initiate passive shoulder exercises
early during the immobilization phase for
shoulder injuries.
One of the most dreaded complications after any
shoulder injury with immobilization is adhesive
capsulitis. This can be avoided by minimizing the
duration of immobilization when possible and
initiating stretching and pendular shoulder
exercises early.
1. Failure to obtain a CT to evaluate the SCJ joint.
Standard AP, oblique, and specialized (40-degree
cephalic tilt) views of the SCJ are often difficult to
interpret because of overlapping rib, sternum, and
vertebral shadows. These dislocations and
associated injuries are best visualized by CT.15
2. Failure to search for associated injuries with
retrosternal SCJ dislocations.
Up to 25% of posterior dislocations may be
complicated by life-threatening injuries to
intrathoracic and superior mediastinal structures.
7. Failure to diagnose a posterior glenohumeral
dislocation.
Over 50% of posterior dislocations are missed on
initial evaluation, and many might go unrecognized (“locked posterior dislocations”) for weeks
and months. This can be avoided by a careful
clinical examination which will show limited
abduction and blocked external rotation. Include
posterior dislocation in the differential diagnosis
of any shoulder injury.
3. Failure to diagnose an axillary nerve injury
following an anterior glenohumeral dislocation.
The incidence of axillary nerve injuries after
anterior glenohumeral dislocation ranges from 5%
to 54%.68,86 Axillary nerve function can be
assessed by testing for sensation over the lateral
aspect of the shoulder (the “regimental badge”
region) and by testing motor function of the
deltoid muscle. Motor testing is more accurate
because sensory testing can be misleading due to
the presence of overlapping cutaneous nerve root
dermatomes.
8. Misdiagnosing luxatio erecta as an anterior
subglenoid dislocation.
It is important to evaluate the relationship
between the spine of the scapula and the longitudinal axis of the humerus to avoid missing an
inferior glenohumeral dislocation. In luxatio
erecta, the scapula spine and humerus are parallel
to each other whereas they are perpendicular to
each other in subglenoid anterior dislocation.
Associated tears of the rotator cuff are very
common with luxatio erecta.
4. Failure to refer Type II lateral clavicle fractures
as well as severely comminuted or displaced
midclavicular fractures to an orthopedic
surgeon.
Although most clavicle fractures will heal without
surgical intervention, these fractures have a high
incidence of non-union and may benefit from
surgical repair.
9. Failure to refer young individuals to an orthopedic surgeon following a primary traumatic
anterior dislocation.
Recurrence is a common complication after
anterior dislocation in patients under 30 years of
age. Such individuals may benefit from orthopedic follow-up and arthroscopic repair of associated Bankart lesions.
5. Failure to recognize a posterolateral compression
fracture of the humeral head (Hill-Sachs deformity) in conjunction with an anterior glenohumeral dislocation.
Hill-Sachs deformities are very common following
anterior dislocations and appear to be a predisposing factor for recurrence.
Emergency Medicine Practice®
10. Attempting reduction of two-part proximal
humeral fracture dislocations in the ED.
Forced reduction of these injuries can lead to
separation of the fracture fragments. It is best to
seek orthopedic consultation.
22
October 2007 • EBMedicine.net
the same clinical acumen. Radiographs of the
shoulder are easily available and present little or no
risk to the patient. Unfortunately, clinical and diagnostic errors in this area may lead to malpractice
claims. For these reasons, imaging of suspected
shoulder dislocations remains advisable in most cases,
with the possible exception of some patients presenting with a history of recurrent dislocations in the
absence of trauma.
reference, where available. In addition, the most
informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*)
next to the number of the reference.
1. Simon RR, Koenigsknecht SJ. Emergency orthopedics:
the extremities, ed 4, Norwalk, 2001, McGraw-Hill.
(Textbook)
2. Tibone JE. Shoulder problems of adolescents: how
they differ from those of adults. Clin Sports Med
1983;2:423-427. (Review)
Case Conclusion
3. Neer CS, Rockwood CA. Fracture and dislocations of
the shoulder. In Rockwood CA, Green DP, editors:
Fractures in adults, ed 4, Philadelphia, 1996, JB Lippincott. (Textbook Chapter)
The quarterback was diagnosed with a Type III ACJ injury
based on a widening of the acromioclavicular and coracoclavicular distances. He was eventually discharged home
with his family with orthopedic follow-up within 72 hours
to discuss operative vs. non-operative treatment. You
advise your medical student that a study by Bossart and
colleagues showed the use of weighted radiographs to lack
efficacy for unmasking Type III ACJ injuries and that the
routine use of this technique has been abandoned in the ED.
On arrival, the wide receiver was noted by the trauma
team to be in severe respiratory distress, and a retrosternal
dislocation of the clavicle was clinically suspected. This
was confirmed through a CT scan and the patient was
transferred by the orthopedic surgeon along with cardiothoracic surgery service to the operating room for a closed
reduction.
5. Cole PA. Scapular fractures. Orthop Clin North Am
2002;33:1-18. (Review)
Summary
8. Kanowitz A, Dunn TM, Kanowitz EM, et al. Safety
and effectiveness of fentanyl administration for
prehospital pain management. Prehosp Emerg Care
2006;10:1-7. (Retrospective; 2,129 patients)
4. Yeh GL, Williams GR. Conservative management of
sternoclavicular injuries, Orthop Clin North Am
2000;31:189-203. (Review)
6. Wen DY. Current concepts in the treatment of anterior
shoulder dislocations. Am J Emerg Med 1999;17:401-7.
(Review)
7. McKoy BE, Bensen CV, Hartsock LA. Fractures about
the shoulder: conservative management, Orthop Clin
North Am 2000; 31:205-16. (Review)
Shoulder girdle fractures and dislocations are commonly encountered in the ED. Diagnosis and management of these injuries is best accomplished by a
thorough clinical assessment supplemented by
radiological studies when needed. The evidence
supporting many of our current management strategies is limited primarily to prospective and retrospective observational studies. Many researchers have
begun to question the traditional diagnostic and
treatment approaches to these injuries, such as
whether immobilization is necessary following the
successful reduction of anterior glenohumeral dislocation and, if so, for how long and in what position.
Prospective, randomized trials will hopefully allow us
to move away from historical approaches towards
more evidence-based treatment approaches.
9. Brown JC, Klein EJ, Lewis CW, et al. Emergency
department analgesia for fracture pain. Ann Emerg
Med 2003;42:197-205. (Retrospective; 2828 patients)
10. Szalay EA, Rockwood CA. Injuries of the shoulder
and arm. Emerg Med Clin North Am 1984;2:279-294.
(Review)
11. Brems-Dalgaard E, Davidsen E, Sloth C. Radiographic
examination of the acute shoulder. Eur J Radiol
1990;11:10-14. (Retrospective; 125 patients)
12. De Smet AA. Axillary projection in radiography of the
nontraumatized shoulder. Am J Roentgenol
1980;134:511-514. (Retrospective observational; 239
patients)
13. Kornguth PJ, Salazar AM. The apical oblique view of
the shoulder: its usefulness in acute trauma. Am J
Roentgenol 1987;149:113-116. (Retrospective; 511
patients)
References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than
a case report.
To help the reader judge the strength of each
reference, pertinent information about the study, such
as the type of study and the number of patients in the
study, will be included in bold type following the
EBMedicine.net • October 2007
14. Sloth C, Just SL. The apical oblique radiograph in
examination of acute shoulder trauma. Eur J Radiol
1989;9:147-51. (Prospective observational; 125
patients)
15. Ernberg LA, Potter HG. Radiographic evaluation of
the acromioclavicular and sternoclavicular joints. Clin
Sports Med 2003;22:255-275. (Review)
23
Emergency Medicine Practice®
*31. Zlowodzki M, Bhandari M, Zelle BA, et al. Treatment
of scapula fractures: systematic review of 520 fractures
in 22 case series. J Orthop Trauma 2006;20:230-233.
(Systematic review)
16. Robinson CM. Fractures of the clavicle in the adult:
epidemiology and classification. J Bone Joint Surg Br
1998;80:476-84. (Retrospective; 1000 patients)
17. Nowak J, Mallmin H, Larsson S. The etiology and
epidemiology of clavicular fractures: a prospective
study during a two-year period in Uppsala, Sweden.
Injury 2000;31:353-8. (Prospective observational; 185
patients)
32. Brown CV, Velmahos G, Wang D, et al. Association of
scapular fractures and blunt thoracic aortic injury: fact
or fiction? Am Surg 2005;71:54-57. (Retrospective; 392
patients)
33. Ada JR, Miller ME. Scapular fractures: analysis of 113
cases. Clin Orthop Relat Res 1991;269:174-180.
(Prospective observational; 113 patients)
*18. Zlowodzki M, Zelle BA, Cole PA, et al. Treatment of
acute mid-shaft clavicle fractures: systematic review
of 2144 fractures: on behalf of the Evidence-Based
Orthopaedic Trauma Working Group. J Orthop Trauma
2005;19:504-7. (Systematic review)
34. Harris RD, Harris JH. The prevalence and significance
of missed scapular fractures in blunt chest trauma.
Am J Roentgenol 1988;151:747-50. (Retrospective; 100
patients)
19. Anderson K. Evaluation and treatment of distal
clavicle fractures. Clin Sports Med 2003;22:319-326.
(Review)
35. Zuckerman JD, Koval KJ, Cuomo F. Fractures of the
scapula, American Academy of Inst Course Lect
1993;42:271-281. (Review)
20. Kendall KM, Burton JH, Cushing B. Fatal subclavian
artery transection from isolated clavicle fracture. J
Trauma 2000;48:316-8. (Case report)
21. Taitsman LA, Nork SE, Coles CP, et al. Open clavicle
fractures and associated injuries. J Orthop Trauma
2006;20:396-9. (Retrospective case series)
36. Court-Brown CM, Garg A, McQueen MM. The
epidemiology of proximal humeral fractures, Acta
Orthop Scand 2001;72:365-371. (Prospective observational; 1015 patients)
22. Andersen K, Jensen PO, Lauritzen J. Treatment of
clavicular fractures. Acta Orthop Scand 1987;57:71-4.
(Prospective randomized trial; 79 patients)
37. Neer CS. Displaced proximal humeral fractures. Part
I. Classification and evaluation. By Charles S. Neer, I,
1970. Clin Orthop Relat Res 1987;223:3-10. (Review)
23. Stanley D, Norris SH. Recovery following fractures of
the clavicle treated conservatively. Injury 1988;19:1624. (Prospective non-randomized controlled, 140
patients)
38. Williams GR, Wong KL. Two-part and three-part
fractures: open reduction and internal fixation versus
closed reduction and percutaneous pinning, Orthop
Clin North Am 2000;31:1-21. (Review)
24. Bezer M, Aydin N, Guven O. The treatment of distal
clavicle fractures with coracoclavicular ligament
disruption: a report of 10 cases. J Orthop Trauma
2005;19:524-528. (Case series)
39. Handoll HH, Gibson JN, Madhok R. Interventions for
treating proximal humeral fractures in adults.
Cochrane Database Syst Rev 2004;4:CD000434. (Systematic review)
25. McKee MD, Wild LM, Schemitsch EH. Midshaft
malunions of the clavicle.
J Bone Joint Surg Am 2003;85:790-797. (Case series)
40. McLaurin TM. Proximal humerus fractures in the
elderly are we operating on too many? Bull Hosp Jt Dis
2004;62:24-32. (Review)
26. Hill JM, McGuire MH, Crosby LA. Closed treatment
of displaced middle-third fractures of the clavicle
gives poor results. J Bone Joint Surg Br 1997;79:537-539.
(Retrospective; 52 patients)
41. Ferkel RD, Hedley AK, Eckardt JJ. Anterior fracturedislocation of the shoulder: pitfalls in treatment, J
Trauma 1984;24:363-7. (Case report)
42. Burgos Flores J, Gonzalez-Herranz P, Lopez-Mondejar
JA, et al. Fractures of the proximal humeral epiphysis,
Int Orthop 1993;17:16-9. (Prospective observational; 22
patients)
27. Nordqvist A, Peterson CJ, Redlund-Johnell I. Midclavicle fractures in adults: end result study after
conservative treatment. J Orthop Trauma 1998;12:572576. (Retrospective; 225 patients)
43. Williams DJ. The mechanisms producing fractureseparation of the proximal humeral epiphysis, J Bone
Joint Surg Br 1981;63:102-7. (Case report)
28. Nowak J, Holgersson M, Larsson S. Sequelae from
clavicular fractures are common: a prospective study
of 222 patients. Acta Orthop 2005;76:496-502. (Prospective observational; 222 patients)
44. Young SJ, Barnettt PL, Oakley EA. Fractures and
minor head injuries in children II. Med J Aust
2005;182:588-592. (Review)
29. Bowen RE, Mah JY, Otsuka NY. Midshaft clavicle
fractures associated with atlantoaxial rotatory
displacement: a report of two cases. J Orthop Trauma
2003;17:444-447. (Case report and review)
45. DePalma AF. Surgery of the shoulder, ed 3, Philadelphia,
1983, JB Lippincott. (Textbook)
46. Ferrera PC, Wheeling HM. Sternoclavicular joint
injuries. Am J Emerg Med 2000;18:58-61. (Case series)
30. Crook TB, Eynon CA. Traumatic atlantoaxial rotatory
subluxation. Emerg Med J 2005;22:671-672. (Case
report)
Emergency Medicine Practice®
24
October 2007 • EBMedicine.net
63. Bannister GC, Wallace WA, Stableforth PG, et al. A
classification of acute acromioclavicular dislocation: a
clinical, radiological and anatomical study.
Injury 1992;23:194-196. (Prospective randomized trial;
48 patients)
47. Garretson RB, Williams GR Jr. Clinical evaluation of
injuries to the acromioclavicular and sternoclavicular
joints. Clin Sports Med 2003;22:239-254. (Review)
48. Ono K, Inagawa H, Kiyota K, et al. Posterior dislocation of the sternoclavicular joint with obstruction of
the innominate vein: case report. J Trauma
1998;44:381-3. (Case report and review)
64. Phillips AM, Smart C, Groom AF. Acromioclavicular
dislocation. Conservative or surgical therapy. Clin
Orthop Relat Res 1998;353:10-17. (Review)
49. McKenzie JM. Retrosternal dislocation of the clavicle.
J Bone Joint Surg Br 1963;45:138-41. (Case report)
65. Chalidis B, Sachinis N, Dimitriou C, et al. Has the
management of shoulder dislocation changed over
time? Int Orthop 2007;31:385-9Epub 2006 Aug 15
(Prospective; 308 patients)
50. Siddiqui AA, Turner SM. Posterior sternoclavicular
joint dislocation: the value of intra-operative ultrasound. Injury 2003;34:448-53. (Case report)
66. Kroner K, Lind T, Jensen J. The epidemiology of
shoulder dislocations. Arch Orthop Trauma Surg
1989;108:288-290. (Prospective observational)
51. Buckerfield CT, Castle ME. Acute traumatic retrosternal dislocation of the clavicle, J Bone Joint Surg Am
1984;66:379-85. (Case series and review)
67. Perron AD, Ingerski MS, Brady WJ, et al. Acute
complications associated with shoulder dislocation at
an academic emergency department. J Emerg Med
2003;24:141-5. (Retrospective; 190 patients)
52. Tyer HD, Sturrock WD, Callow McC. Retrosternal
dislocation of the clavicle. J Bone Joint Surg Br
1963;45:132-137. (Case report)
53. Nordqvist A, Petersson CJ. Incidence and causes of
shoulder girdle injuries in an urban population, J
Shoulder Elbow Surg 1995;4:107-12. (Prospective
observational)
68. Perlmutter GS. Axillary nerve injury. Clin Orthop
1999;368:28-36. (Review)
*69. Kuhn JE. Treating the initial anterior shoulder
dislocation – an evidence-based medicine approach.
Sports Med Arthrosc Rev 2006;13:192-198. (Systematic
review)
54. Kocher MS, Feagin JA Jr. Shoulder injuries during
alpine skiing. Am J Sports Med 1996;24:665-669.
(Retrospective; 3247 patients)
70. Suder PA, Mikkelsen JB, Hougaard K, et al. Reduction
of traumatic secondary shoulder dislocations with
lidocaine. Arch Orthop Trauma Surg 1995b;114;233-236.
(Prospective comparative trial; 52 patients)
55. Richards RR. Acromioclavicular joint injuries. Inst
Course Lect 1993;42:259-269. (Review)
56. Turnbull JR. Acromioclavicular joint disorders. Med
Sci Sports Exerc 1998;30:S26-32. (Review)
71. Matthews DE, Roberts T. Intraarticular lidocaine
versus intravenous analgesia for the reduction of
acute anterior shoulder dislocations: a prospective
randomized study. Am J Sports Med 1995;23:54-8.
(Prospective randomized trial; 30 patients)
57. Rockwood C, Williams G, Young C. Disorders of the
acromioclavicular joint. In: Rockwood C, Matsen FL,
Wirth M, Loppitt S, eds. The shoulder, Philadelphia,
2004, Saunders. (Textbook)
72. Gleeson AP, Graham CA, Jones I, et al. Comparison of
intra-articular lignocaine and a suprascapular nerve
block for acute anterior shoulder dislocation. Injury
1997;28:141-2. (Prospective comparative trial; 20
patients)
58. Clavert P, Moulinoux P, Kempf JF. Technique of
stabilization in acromioclavicular joint dislocation.
Techniques in shoulder and elbow surgery 2003;6:1-7.
(Review)
59. Clarke HD, McCann PD. Acromioclavicular joint
injuries, Orthop Clin North Am 2000;31:177-87.
(Review)
73. Kosnik J, Shamsa F, Raphael E, et al. Anesthetic
methods for reduction of anterior shoulder dislocations: a prospective randomized study comparing
intraarticular lidocaine with intravenous analgesia
and sedation. Am J Emerg Med 1999;17:566-570.
(Prospective randomized trial; 49 patients)
*60. Bossart PJ, Joyce SM, Manaster BJ, et al. Lack of
efficacy of weighted radiographs in diagnosing acute
acromioclavicular separation, Ann Emerg Med
1988;17:20-4. (Prospective randomized trial)
74. Miller SL, Cleeman E, Auerbach J, et al. Comparison
of intra-articular lidocaine and intravenous sedation
for reduction of shoulder dislocations: a randomized,
prospective study. J Bone Joint Surg Am 2002;84:2135-9.
(Prospective randomized trial; 30 patients)
*61. Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular
dislocation. A prospective, controlled, randomized
study.
J Bone Joint Surg Am 1986;68:552-5. (Prospective
randomized trial; 84 patients)
75. Orlinsky M, Shon S, Chiang C, et al. Comparative
study of intra-articular lidocaine and intravenous
meperidine/diazepam for shoulder dislocations. J
Emerg Med 2002;22:241-245. (Prospective comparative
trial; 54 patients)
62. Bannister GC, Wallace WA, Stableforth PG, et al. The
management of acute acromioclavicular dislocation. A
randomized prospective controlled trial.
J Bone Joint Surg Br 1989;71:848-50. (Prospective
randomized trial; 60 patients)
EBMedicine.net • October 2007
25
Emergency Medicine Practice®
76. Riebel GD, McCabe JB. Anterior shoulder dislocations:
a review of reduction techniques. Am J Emerg Med
1991;9:180-188. (Review)
91. Gardham JR, Scott JE. Axillary artery occlusion with
erect dislocation of the shoulder. Injury 1979;11:155158. (Case report)
77. Beattie TF, Steedman DJ, McGowan A, et al. A
comparison of the Milch and Kocher techniques for
acute anterior dislocation of the shoulder. Injury
1986;17:349-352. (Prospective randomized; 111
patients)
92. Lev-El A, Adar R, Rubinstein Z. Axillary artery injury
in erect dislocation of the shoulder. J Trauma
1981;21:323-235. (Case report)
93. Mallon WJ, Bassett FH, Goldner RD. Luxatio erecta:
the inferior glenohumeral dislocation. J Orthop Trauma
1990;4:19-24. (Case series and review)
78. Janecki CJ, Shahcheragh GH. The forward elevation
maneuver for reduction of anterior dislocation of the
shoulder. Clin Orthop 1982;164:177-180. (Case series)
94. Itoi E, Hatakeyama Y, Urayama M, et al. Position of
immobilization after dislocation of the shoulder. A
cadaveric study. J Bone Joint Surg Am 1999;81:385-390.
(Prospective, 10 patients)
79. Westin CD, Gill EA, Noyes ME, et al. Anterior
shoulder dislocation: a simple and rapid method for
reduction. Am J Sports Med 1995;23:369-371. (Prospective observational; 78 patients)
95. Miller BS, Sonnabend DH, Hatrick C, et al. Should
acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J
Shoulder Elbow Surg 2004;13:589-92. (Prospective, 10
patients)
80. Danzl DF, Vicario SJ, Gleis GL, et al. Closed reduction
of anterior subcoracoid shoulder dislocation: evaluation of an external rotation method. Orthop Rev
1986;15:311-315. (Prospective observational; 78
patients)
96. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint.
A study with use of magnetic resonance imaging. J
Bone Joint Surg Am 2001;83:661-7. (Prospective, 19
patients)
81. Kothari RU, Dronen SC. Prospective evaluation of the
scapular manipulation technique in reducing
anterior shoulder dislocations. Ann Emerg Med
1992;21:1349-1352. (Prospective observational; 48
patients)
*97. Itoi E, Hatakeyama Y, Kido T, et al: A new method of
immobilization after traumatic anterior dislocation of
the shoulder: a preliminary study, J Shoulder Elbow
Surg 2003;12:413-415. (Prospective randomized trial;
40 patients)
*82. McNamara RM. Reduction of anterior shoulder
dislocations by scapular manipulation. Ann Emerg
Med 1993;22:1140-1144. (Prospective observational; 54
patients)
98. Smith TO. Immobilization following traumatic
anterior glenohumeral joint dislocation: a literature
review. Int J Care Injured 2006;37: 228-237. (Review)
83. Nevasier RJ, Nevasier TJ, Nevasier JS. Anterior
dislocation of the shoulder and rotator cuff rupture.
Clin Orthop Relat Res1993;291:103-106. (Prospective
observational; 37 patients)
99. Harvey. Are postreduction anteroposterior and
scapular Y views useful in anterior shoulder dislocations? Am J Emerg Med 1992;10:149-151. (Retrospective)
84. Heller KD, Forst J, Forst R, et al. Posterior dislocation
of the shoulder: recommendation for a classification.
Arch Orthop Trauma Surg 1994;113:228-231. (Review)
100. Hendey GW, Kinlaw K. Clinically significant abnormalities in postreduction radiographs after anterior
shoulder dislocation. Ann Emerg Med 1996;28:399-402.
(Retrospective; 131 patients)
85. Perrenoud A, Imhoff AB. Locked posterior dislocation
of the shoulder. Bull Hosp Jt Dis 1996;54:165-168. (Case
series)
101. Hendey GW. Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med 2000;36:108-13. (Prospective
observational; 104 patients)
86. Perron AD, Jones RL. Posterior shoulder dislocation:
avoiding a missed diagnosis. Am J Emerg Med
2000:18:189-191. (Case report)
87. Wadlington VR, Hendrix RW, Rogers LF. Computed
tomography of posterior fracture-dislocations of the
shoulder: case reports. J Trauma 1992;32:113-115. (Case
report)
102. Shuster M, Abu-Laban R, Boyd J. Prereduction
radiographs in clinically evident anterior shoulder
dislocations. Am J Emerg Med 1999;17:653-658.
(Prospective; 97 patients)
88. Grate I. Luxatio erecta: A rarely seen, but often missed
shoulder dislocation. Am J Emerg Med 2000;18:317-321.
(Case Report)
103. Shuster M, Abu-Laban R, Boyd J, et al. Prospective
evaluation of a guideline for the selective elimination
of pre-reduction radiographs in clinically obvious
anterior shoulder dislocations. Can J Emerg Med
2002;4:257-262. (Prospective; 63 patients)
89. Davids JR, Talbott RD. Luxatio erecta humeri. A case
report. Clin Orthop Relat Res 1990;252:144-149. (Case
report)
*104. Hendey GW, Chally MK, Stewart VB. Selective
radiography in 100 patients with suspected shoulder
dislocation. J Emerg Med 2006;31:23-28. (Prospective;
100 patients)
90. Nho SJ, Dodson CC, Bardzik KF, et al. The two-step
maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior
dislocation to reduction).
J Orthop Trauma 2006;20:354-357. (Case report)
Emergency Medicine Practice®
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October 2007 • EBMedicine.net
CME Questions
6. Which of the following is the most appropriate
management with regard to dislocations of the
sternoclavicular joint?
a. All Grade II injuries should be managed by
closed reduction
b. All Grade I injuries should be referred to an
orthopedist
c. If traction alone does not reduce a posterior
dislocation, concurrent clavicular
manipulation may be helpful via sterile skin
prep and a sterile towel clip
d. Posterior dislocations are best managed in
the operating room by a thoracic surgeon
e. Occasionally, posterior dislocations are true
orthopedic emergencies
1. Urgent (within 72 hours) orthopedic consultation is recommended for which type of clavicle
fracture?
a. Type III lateral clavicle fracture
b. Greenstick fracture
c. Type II lateral clavicle fracture
d. Minimally displaced mid-clavicular fracture
e. Type I lateral clavicle fracture
2. Which of the following has been associated with
an increased risk of nonunion with a midclavicular fracture?
a. Male gender
b. Younger age
c. Less than 10 mm of shortening
d. Absence of comminution
e. Greater than 20 mm of shortening
7. The normal coracoclavicular distance in a
standing adult is:
a. 5-7 mm
b. 11-13 mm
c. 13-15 mm
d. 17-19 mm
e. 20-22 mm
3. The most common mechanism of injury for
patients with a scapula fracture is:
a. Fall
b. Motor vehicle accident
c. Motorcycle accident
d. Pedestrian struck by auto
e. Assault
8. How would you classify an ACJ injury that
radiographically shows a posteriorly displaced
clavicle with a widened coracoclavicular
distance?
a. Type I
b. Type II
c. Type III
d. Type IV
e. Type V
4. The risk of avascular necrosis of the humeral
head is highest with which type of proximal
humerus fracture?
a. Displaced two-part fracture
b. Displaced three-part fracture
c. Minimally displaced two-part fracture
d. Displaced four-part fracture
e. Hill-Sachs deformity (anteromedial impression fracture)
9. Which of the following is the most common
type of anterior glenohumeral dislocation?
a. Subglenoid
b. Subcoracoid
c. Intrathoracic
d. Subclavicular
e. Subspinous
5. The trauma series of the shoulder is best
described by which of the following three
radiographic views?
a. True AP, scapular Y, apical oblique
b. True AP, scapular Y, axillary
c. 40-degree cephalic tilt, true AP, axillary
d. Internal AP, external AP, scapular Y
e. 40-degree cephalic tilt, apical oblique, axillary
10. Which of the following muscles is innervated by
the axillary nerve?
a. Teres major
b. Subscapularis
c. Trapezius
d. Deltoid
e. Supraspinatus
11. Axillary vein thrombosis has been reported in
association with which of the following
injuries?
a. Posterior subacromial dislocation
b. Anterior subcoracoid dislocation
c. Posterior subspinous dislocation
d. Anterior subglenoid dislocation
e. Inferior glenohumeral dislocation
EBMedicine.net • October 2007
27
Emergency Medicine Practice®
Physician CME Information
12. Which of the following is not a complication
associated with anterior glenohumeral
dislocations?
a. Compression fracture of the posterolateral
aspect of the humeral head (Hill-Sachs
deformity)
b. Avulsion of the anteroinferior glenohumeral
ligament with capsulolabral detachment
(Bankart lesion)
c. Avulsion of the subscapularis muscle
d. Fracture of the anterior glenoid rim
(Bankart’s Fracture)
e. Axillary nerve neuropraxia
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also: Anonymous. Guidelines for
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tiveness of community-wide
Level of Evidence:
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1992;268(16): 2289-2295.
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