Shoulder Trauma

Question 1

Examples of shoulder trauma

Answer 1

-Dislocations
-Rotator cuff tears
-Proximal humerus fractures
-Humerus shaft fracture

Question 2

General principles of shoulder injury

Answer 2

-To permit it’s wide range of movement(ROM), the shoulder is mechanically unstable by design.
-This full ROM is not necessary required to achieve a ‘functional’ shoulder.
-Bony congruency is poor, so soft tissues are important for stability
=Labrum
=Rotator cuff

Question 3

Epidemiology and types of shoulder dislocations

Answer 3

-Very common due to poor bony congruency

-Risk factors: sports, loose ligaments, Ehlers-Danlos syndrome, male adolescence and 40 rs, older women

-Anterior; 90-95%, teenagers (90% <20): excessive extension and lateral rotation
-Posterior, 5-10%, seizures and electrocution (or high energy trauma)
-Inferior, 0.5%, high energy >anyone

Question 4

Presentation of dislocation

Answer 4

-Characteristic posturing of joint (external rotation and slight abduction)
-Pain on movement, apprehensive about motion of affected joint
-Inability to move joint/ incomplete range of motion
-Tenderness and swelling

Question 5

Investigation of anterior dislocation

Answer 5

-Examination:
=Look: loss of shoulder contour
=Feel: (humeral head palpable inferior to the corocoid process)
=Move: mechanical block to IR

-Imaging - XR:
=Humeral head in a ‘subcoracoid position’
+/- Hill-Sachs lesion (posterolateral humeral head depression fracture as impaction with anterior glenoid rim)
+/- (bony) Bankart lesion (anteroinferior aspect of glenoid labral complex)
-MRI

Question 6

Management of anterior dislocations

Answer 6

-Acute
=Reduce (Kocher manoeuvre: traction in external rotation -> adduction -> internal rotation) relaxed patient
=Sling 1/52 -> arm internally rotated and adduct
=Physiotherapy

-Recurrent
=Surgery- many options: primary stabilisation via anatomic Bankart’s repair (over simple arthroscopic lavage or non-operative treatment) for young, high-risk patients with a first-time shoulder dislocation
=Bone block

Question 7

Investigation of posterior dislocation

Answer 7

-Examination:
=Look: loss of shoulder contour; internally rotated arm.
=Feel: (humeral head palpable posteriorly)
=Move: mechanical block to ER

-Imaging - XR:
=Humeral head looks like a ‘lightbulb’, dislocated posteriorly
=Anterior surface of humeral head has impacted onto posterior rim of glenoid, creating a reverse Hill-Sachs lesion (rim sign: widened glenohumeral joint space, trough line: dense vertical line in medial humeral head)
=Ensure an axillary view is available
=50% missed in AE

Question 8

Management of posterior dislocations

Answer 8

-Reduction (often challenging)
-Immobilisation in external rotation for4-6/52
-Physiotherapy
-(Surgery for recurrent dislocations)

Question 9

Describe inferior dislocations (Luxatio Erecta)

Answer 9

-Characteristic appearance, with the arm fixed in high abduction (humeral head in axillary fossa)
-High energy impact
-Commonly associated with:
=Neurovascular injury
=Rotator cuff tears
=Fracture

Question 10

Investigation and management of inferior dislocation

Answer 10

-Most require an MRI (after reduction)

-Reduction and immobilisation (brief)
-Many require surgical intervention due to soft tissue injury or fracture

Question 11

Overview of proximal humerus fracture

Answer 11

-Usually 2ary to osteoporosis (older patients)
-Associated with
=Axillary nerve injury
=Avascular necrosis of the humeral head
-Classified using the Neer Classification
-Treatment nuanced; however, many can be treated conservatively with a collar-and-cuff(not a sling!): leave elbow free to pull shoulder down to realign bones

Question 12

Rotator cuff muscles and actions

Answer 12

-Supraspinatus; abduction of arm
-Infraspinatus: lat/ external rotation
-Teres Minor: lat/ external rotation (adduction)
-Subscapularis: med/ internal rotation (adduction)

Question 13

Types of rotator cuff tears

Answer 13

-Acute tears in young patients (least common), due to trauma:
=Falls
=Shoulder dislocations

-Chronic, degenerative tears -> elderly (most common). Risk factors >60

Question 14

Presentation of rotator cuff tears

Answer 14

-Pain
=Worse with overhead activities (worse on abduction)
=At night (poor prognostic indicator)
=Commonly localities to anterior lateral shoulder near deltoid insertion
-Weakness (resisted external rotation (infraspinatus), abduction and elevation (supraspinatus), or isolated internal rotation (subscapularis).

-Wasting
-Reduced active ROM, with preserved passive ROM
=Pain in first 60 degrees of abduction
=Tenderness over anterior acromion
-Special tests
=Jobe / Empty Can (supraspinatus)
=ER (external rotation) lag sign (infraspinatus)
=Horn blowers (teres minor)
=Goebers/ Lift off (subscapularis)!!
=Scarf test (acromio-clavicular joint)

Question 15

Investigation of rotator cuff tears

Answer 15

-MRI is diagnostic
-USS also helpful, but user dependent
-XR commonly performed (trauma, tumour, infection)

Question 16

Management of rotator cuff tears

Answer 16

-Acute:
=Rotator cuff repair (generally arthroscopic)- better in young acute tears

-Chronic:
=First line: NSAIDs, subacromial steroid injection, physiotherapy
=If this fails: consider surgery

Question 17

Types of rotator cuff injury

Answer 17

1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy