Chapter 28- injuries of the shoulder girdle Flashcards
What does the shoulder girdle consist of
Clavicle and scapula
What is the typical history of a clavicle fracture
- Common in children and adults
- Occur following a fall onto the shoulder or outstretched arm
- May also occur due to direct trauma
Signs of clavicle fracture
- tenderness and swelling/ deformity over the fracture- usually at the junction of middle and outer third of the clavicle
- Affected arm supported by the other hand
- Decreased range of motion of whole arm
What xrays should be sone in suspected clavicle fracture
- Plain AP Xray and another at 45 degree tilt
Treatment of clavicle fracture
- Support the weight of the arm in a shoulder immobilzer which supports the elbow and the arm for 6 weeks
- Patients usually feel the most comfortable in a figure of 8 splint
When is surgery indicated in a clavicle fracture
- bony spikes threatening or piercing overlying skin
- open fractures
- Compression/ laceration of subclavian vessels or brachial plexus
- 1.5 cm displacement, no cortical contact and comminution
typical history of acromio-clavicular joint injuries
- compression to lateral part of the shoulder
- Patient will complain of pain over the outer end of the clavicle and pain on movement of the arm
signs on examination of acromiclavicular injuries
- swelling, tenderness and a visible/ palpable step over the outer end of the clavicle
- Reduced range of movement of the shoulder and the arm
What are the two ligaments joining the clavicle to the acromion?
conoid and trapezoid ligaments
name and describe the grades of acromio-clavicular joint injuries
Grade 1: sprain- local tenderness over the joint but no displacement, both the capsule and ligaments are intact
Grade 2: Subluxation- Joint capsule is torn but the ligaments remain intact/ stretched
Grade 3: dislocation- capsule and ligaments are torn allowing outer end of the clavicle to displace superiorly
Grade 4, 5, 6: Occasionally the end of the clavicle can displace very widely either inferiorly, superiorly or posteriorly
Treatment of acromio-clavicular joint injuries
Grade 1: Treat symptomatically for pain with arm sling and analgesics/ anti-inflammatory agents
Grade 2: Relieve the weight of the arm on the AC joint by supporting the arm in a shoulder immobilizer. Analgesia and anti-inflammatories until the pain has subsided
Grade 3: Treat as grade 2
Displacement greater than 3- surgery is reccommended
typical history in the sternoclavicular dislocation
- Anterior dislocation caused by a fall on the shoulder
- Posterior dislocation is due to direct blow to clavicle
- Patient presents with pain over the sterno-clavicular joint accentuated by movement of the arm
Findings on examination of sterno-clavicular dislocations
- Anterior:
- fullness or bump over the affected SC joint
- Under anaesthesia, medial end of the clavicle can be balloted back and forth or sprung like a piano key. *decrease range of movement of the arm due to pain, especially adduction and elevation
- Posterior:
- Depression/ step over the affected SC joint
- Medial end of clavicle displaced posteriorly and can compress vascular structures in the mediastinum
What investigations should be done in suspected Sternoclavicular dislocations
- Xray: serendipity view
- CT scan (gold standard)
Treatment of sternoclavicular dislocations
- anterior: Reduce by putting pressure on medial end of clavicle and retraction to the scapula. Figure of 8 may help to keep the reduction
- Posterior: Refer for reduction. If this is not possible; sandbag placed under the shoulders and a sharp pointed towel clip used to grasp the end of the clavicle and pull it forward. If unstable – surgery
typical history of fracture to the scapula
direct, high energy trauma to chest wall
Examination findings and treatment of fractures to the blade of scapula
- Pain, swelling and bruising over the chest wal in the region of the scapula
- Decreased range of movement of the shoulder
- Treated symptomatically for pain with analgesia, shoulder immobilizer and anti-inflammatory agents
Examination findings and treatment of fractures to the glenoid and neck
- arthritic change if involvement of articular surface
- Pain and limitation of movement of the shoulder joint
- Should be evaluate by specialist for possible operative management
Examination findings and treatment of fractures to the spine of the scapula
- pain and bruising psoteriorly over the spine of the scapula
- Treat symptomatically
Examination findings and treatment of fractures to the acromion of the scapula
- Pain and swelling over the acromion, outer end of the clavicle and the AC joint area
- Depression of the fracture fragment may cause impingement of the rotator cuff
- If displaced require surgery
- Late problems may be treated with acromioplasty
Examination findings and treatment of fractures to the coracoid
- Avulsion fractures result in pain on contracting the biceps
- Displacement of >1cm - should be surgically replaced and fixed with a screw
What may a fracture of the blade of the scapula indicate
- Severe intra-thoracic, thoracic spine and other injuries in 80 percent of patients
How does one delineate articular involvement in fractures of the glenoid
CT scan
What XRay view should be requested for neck and glenoid fractures
Lateral scapular view
Typical history of anterior shoulder dislocation/ subluxation
- Forcible abduction/ external rotation
- Anterior subluxation seen in throwing activities –> dead arm syndrome
- Traction on brachial plexus may cause temporary numbness of the arm
- Patient presents with pain and inability to move the shoulder in any direction
Findings on examination of anterior shoulder dislocation
Flattened/ hollow contour of shoulder Arm supported by the patient Fullness below the coracoid anteriorly Painful limitation of all shoulder movements Squaring of shoulder
How do you test function of axillary nerve (should be done in any anterior dislocation of the shoulder)
Test deltoid contraction and sensation over the deltoid muscle
Which Xray views should be requested in anterior dislocation of the shoulder
- AP view
- Lateral scapula view
- Modified axillary view
what methods are available to reduce anterior dislocation of the shoulder
- Kocher manoeuver
- Hippocratic method
- Modified Milch
complications of anterior shoulder dislocation
recurrent dislocation
Rotator cuff tears
injury to the axillary nerve
Typical history of posterior shoulder dislocation
- Forced internal rotation or blow to the front of the shoulder
- Seen following epileptic fits or electric shocks
- Painful limitation of active and passive movement, particularly external rotation
Examination findings of posterior shoulder dislocation
- shoulder contour does not look abnormal
- Fullness posteriorly in thin patient
- Inability to abduct and externally rotate actively and passively
Signs of Posterior shoulder dislocation on AP xray
- Empty glenoid sign
- Light bulb shape of the humeral head
Treatment of posterior shoulder dislocation
-Manipulation under anaesthesia or sedationand adequate muscle relaxation, and immobilization of the arm in external rotation
