EM Ortho 7: Shoulder and Clavicle

Question 1

remarks on sternoclavicular joint

Answer 1

The joint is remarkably stable, due to strong surrounding ligaments
as a result, most injuries are simple sprains, while dislocations and fractures and uncommon

Question 2

remarks on clavicle

Answer 2

the medial clavicular epiphysis is the last epiphysis of the body to appear radiographically (18 y) and the last to close (22-25y).

because of this, an apparent sternoclavicular joint dislocation in children and young adults is typically a Salter-Harris type I or II fracture, with either anterior or posterior displacement of the clavicular metaphysis that requires orthopedic consultation and ff up for optimal healing and remodeling

Question 3

the major symptom of sternoclavicular dislocation

Answer 3

severe pain, exacerbated by arm motion and lying supine

Question 4

remarks on pain at the sternoclavicular joint in nontrauma patients

Answer 4

should raise suspicion for septic arthritis, especially in injection drug users

Question 5

imaging in sternoclavicular dislocation

Answer 5

ROUTINE RADIOGRAPHS
-low sensitivity for detecting dislocation
- but is immediately needed to exclude a pneumothorax, pneumomediastinum, and hemopneumothorax

CT
- imaging of choice
- recommended in any posterior dislocaiton with concern for injury to the mediastinal structures

Question 6

management of anterior sternoclavicular dislocations

Answer 6

if uncomplicated, may be discharged without an attempted reduction, bec this injury has little or no impact on function.
clavicular splinting, ice, analgesics, sling, and orthopedic referral are required

closed reduction can be performed within 10 days of injury.
even with reduction, the joint is usually unstable and redislocates (50%) when pressure is released. refer to an orthopedist

Question 7

management of posterior sternoclavicular dislocations

Answer 7

may be associated with life-threatening injuries to adjacent structures, including pneumothorax or compression/laceration of surrounding great vessels, trachea, or esophagus

orthopedic consultation is necessary for closed or open reduction

Question 8

remarks on clavicle in terms of fractures

Answer 8

midportion of the clavicle is the thinnist, having no accompanying ligamentous or muscular attachments.

fracutre is m/c in middle 1/3 of clavicle

fractures result from a direct blow to the shoulder, buckling the clavicle

Question 9

clinical picture of clavicular fracture

Answer 9

The arm is slumped inward and downward, and range of motion is limitied

the fracture can often be palpated, and crepitus may be present

Question 10

nonoperative management of middle 1/3 clavicular fractures

Answer 10

immobilization with either a sling or figure-of-eight for 4-8 weeks, until the fracture is no longer painful

encourange daily ROM of the elbow immediately and of the shoulder as soon as pain allows (3-5 days)

primary care or orthopedic ff up in 1-2 weeks after injury in conservative treatement

Question 11

middle clavicle fracture nonunion risk factors

Answer 11

initial shortening >2cm
displaced fracture >100%
comminuted fracture
significant trauma
female
elderly

refer to an orthopedist within a few days

Question 12

management of distal clavicular fractures

Answer 12

Type I (distal to coracoclavicular ligaments with intact ligaments) and III (intra-articular) can be managed conservatively with sling immobilization and PC ff up in 1-2 weeks

type II fractures may require operative intervention to avoid nonunion

Question 13

Remarks on proximal clavicular fractures

Answer 13

often high-mechanism injuries and can be associated with intrathoracic trauma

CT can diagnose the fracture and identify additional injuries

Question 14

Management of proximal clavicular fractures

Answer 14

initial mgt includes sling immobilization

EMERGENT referral is required when posteriorly displaced fragments compromise mediastinal structures.

refer all other proximal 1/3 fractures to orthopedics within 1-2 weeks