shoulder Flashcards
Discuss clavicle fractures
Accounts for 3-5% of all fracture with a 2:1 male to female ratio and is the most commonly fractured bone in children.
Fractures of the medial third are uncommon (5%) and occur as a result of a direct blod to the anterior chest.
Fractures of the middle third are the most frequent (80%)- usually involves a diret force applied to the lateral aspect of the shoulder as a result fo a fall sport injury or MVC.
Fractures of the lateral 3rd (15%) result from a direct blow to the top of the shoulder and are further classified into three types
1) stable and minimally dispalced as the coracocalvicular ligament remains intact
2) associated with torn coracoclavicular ligament and have a tendencey to displace becuase the proximal fragment lacks stabilising forcese
3) Involve the articular surface
Discuss indications for orthopaedic review of clavicle fractures for ORIF
Absolute
- open fractures
- displaced fracture with skin tenting
- associated vascular injury
- floating shoulder (clavicle and scapular neck fracture)
- symptomatic nonunion
- Symptomatic malunion
Relative and controversial indications
- displaced with >2cm shortening
- bilateral displaced clavicle
- brachial plexus injury (questionable as 66% have spont return)
- closed head injury
Discuss complications associated with clavicle fractures
Delayed union
non union
Symptomatic malunion
Vascular complications of the medial third resemble those associated with posterior sternoclavicular dislocations
Pleuea, axillary vessels and brachial plexus injury are rare but possible
Describe proximal humerus fractures
Occur primarily in the older population in whom structural changes weaken the proximal humerus predisposing it to injury
Most injuries are associated with minimal displacement and are adequately managed with conservative management severe displacment requires fixation
Describe the Neer classification of proximal humeral fractures
Two main components of the classification are the number of fracture parts and the displacement
The four parts are
- the humeral head
- the greater tuberosity
- the less tuberosity
- the humeral shaft
A fracture part is considered displaced if angulation exceeds 45 degrees or if the fracture is displaced by more than 1 cm
One part fracture
- fracture line involve 1-4 parts
- non of the parts are displaced (ie <1cm and <45 degrees)
- account for 70-80% of all prixmal humeral fracture
Two part: 2-4 parts with one part displaced
1) surgical neck most common
2) greater tuberosity
- frequently seen in the setting of anterior shoulder dislocation
3) anatomical neck
4) lesser tub
3 part
-2 parts are dispalced
4 part
-fracture lines invovle more than 4 parts and three are dispalced
Describe management of proximal humeral shaft fractrure s
Minimally displcaed fractures constitute up to 80-85% of all cases
In these instances limited displacement or angulation is present and the fracture segments are held together by the capsule periosteum and surrounding muscles.
Initial therapy is adequate analgeisa and sling
Early physio
2-4 part fracture often require surgical fixaction however prospective and retrospective observationla studies failed to show significant funcitonal difference between operative and nonoperative treatment of dispalced 2 and 3 part fracture
There is evidence for 4 part fractures
Complications
- adhesive capsulitis
- AVN
- Neurovascular compromise (axillary, brachail and axiallary artery)
- malunion, non union
- axilary nerve and brachial plexus injury
Discuss sternoclavicular dislocation
Infrequent and account for <1% of all dislocations
Signifiacnt forces are required to dislcoate the strong ligamentous stabilizers of this joint.
Major cause is MVC
most are anterior dislocations
Posterior dislocation though rare can be associated with life threatening injuries wihtin the superior mediastinum
Grade 1 - sprain
Grade 2 subluxation due to disruption of sternoclacicular ligament and capsule
Grade 3 complete rupture of the sternoclavicualr and costoclavicular liagements dislocation
Discuss management of sternoclavicular dislocation
Treatment of grade 1 injuries include sling immobilization for comfort and primary care follow-up.
Grade 2 should be immobilized with a sling and patient referred for orthopaedic follow-up
Grade 3 should be managed by closed reduction and rarely open reduction
Anterior dislocations can be redueced in the ED with proper analgesia
Posteiror dislocations constitute a true orthopaedic emergency and should be reduced expeditiously
-ideally in theater
-may need emergent if airway or vascular compromise
Complications
- Primarily cosmetic for anterior
- posterior may be associated with life threatening injuries include intrathoracic and superior mediastinal strutures.
- Compression or laceration of great vessles, tracheo-oesophageal fistual, tracheal compression, pneumo, thoracic outlet syndrome and brachail blexus injuries
Discuss AC joint injuries
Primarily found in young men as a result of MVC bicycle accidents or paricipation in contact spots.
The weak AC ligament rupture first with more force the coracoclavicular ligaments rupture
Patient should be exmained while upright as the supine position may mask ACJ instability
Discuss Rockwood classification of ACJ injury
Type 1 - sprain nil ruptured ligament
Type 2
- AC ligament ruptured
- CC ligament intact
- joint capsule intact
- Deltoid muscle intact
- trapezius muscle intact
Type 3 - coracoacromial distance <25mm AC ligament ruptured CC ligament ruptured Joint capsule ruptured Deltoid muscle ruptured Trap muscle ruptured
Type 4 – type 3 with posterior displcaement of calvicle
Type 5 – >25mm of distance between the coracoacromail distance
Type 6 inferior displacement
Discuss clinical features of ACJ injury
Patient should be exmained while upright as the supine position may mask ACJ instability
Type 1 and 2 injuries are associated with mild tenderness and swelling over the ACH maring with minimal deformity and full ROM (although painful)
Type 3-6 are characterized by severe pain and patients hold the arm tightly adducted to reduce traction stress across the joint
The recommended projection include routine AP and axillary lateral view
THe normal coracoclavicular distance range from 11-13 mm a difference of more than 5mm between the effected and unaffected shoulder is diagnostic
Discuss management of ACJ injuries
TYpe 1 and 2 should be immobilised in a sling for comfort and to remove stress on injured ligaments. When pain has subsided gradual ROM and strengthening exercises can begin
The management of type 3 is variable with most favouring non operative management. Young serious athletes, those with severe displacement >2cm and those who do reptitive overhead actitivites may be candidates for surgical intervention
Type 4-6 require early surgical intervention
Complications
- chronic joint instability
- joint tenderness due to secondary degnerative changes
Discuss anterior shoulder dislocations
Usually occurs wiht activities involving rapid movements with teh arm elevated abducted and eternally rotated.
A characteristic pathologic feature is an avulsions of the anteriorinferior glenohumeral ligament with capsulolabral detachement (Bankart’s lesion)
Discuss Hill-Sachs fractures
Compression fracture of the posterolateral aspect of the humeral head caused by forceful impingement against the anterior rim of the glenoid fossa. Hills Sachs are not clinically significant unless they are large enoguht to cause recurrent shoulder instability or painfyul clicking or catching
DIscuss management of anterior shoulder dislocations as well as 5 reduction techniques
Prompt reduction in the ED as the risk of clinically significant neurovascular injury increases with time out of joint as well as increasing difficulty with reduction
Analgesia
Procedural sedation
Intra-articular lignocaine
Reduction techniques
1) Stimson
- patient placed prone with dislocated shoulder hanging over the edge - attach 10-15 pound weight to wrist or lower forearm - reduction usually occurs in 20-30 inutes
2) Traction countertraction
3) External rotation method
- patient seated or supine
- arm is slowly and gently adduted to the side
- The elbow is flexed to 90 degrees and slow gentle external rotation si applied to achieve reduction
4) cunningham
- patient sits without slouching in a hard backed chaird
- adduct the affected arm to the body and place elbow in full felxion resting against operators shoulder
- operator then provides traction by placing their wrist on patient forearm while asking the patient to shurg shoulders superiorly and posteriorly
- the operator adds massage down through the trapezious delotoid and bicpes
5) modifired kockers
-traction at the flexed elbow
-externally rotate to 90 degrees stopping for muscle spasm
if not reduced then a
-adduct the arm and touch other shoulder
Not recommended (due to high incidence of associated complications)
- Hippocratic
- Kocker maneuver
Post reduction sling for 1-2 weeks
for ortho follow-up if primary dislocation or complicated
