Shoulder Trauma

Question 1

Proximal humeral shaft fractures are (common/uncommon) and causes include….

Answer 1

Proximal humeral shaft fractures are common

Causes - FOOSH, low energy injuries to osteoporotic bone or falling directly onto the shoulder

Question 2

What is the most common fracture pattern seen in humeral shaft fractures?

Why is this the most common?

Answer 2

Fracture of the surgical neck with medial displacement of the humeral shaft

This is due to the pull of the pectoralis major muscle

Question 3

How are the following humeral shaft fractures best managed?

• minimally displaced
• persistently displaced fractures
• splitting head fractures

Answer 3

Minimally displaced - manage conservatively with a sling

Persistently displaced - may require internal fixation (pain, stiffness and failure of fixation can occur)

Splitting head fractures - usually require shoulder replacement, unless the patient is young and has very good bone quality

Question 4

(Anterior/Posterior) shoulder dislocations are much more common

Answer 4

Anterior shoulder dislocations are much more common

Question 5

What is a Bankart lesion?

Answer 5

Detachment of the anterior glenoid labrum and capsule

Question 6

What causes shoulder dislocations?

Answer 6

Excessive external rotational force, or onto the back of the shoulder

Can also be caused by seizures

Question 7

What is a Hill-Sachs Lesion?

Answer 7

Same process as a Bankart lesion (posterior surface of humeral head coliding with anterior surface of glenoid labrum) but there is an impaction fracture of the humeral head

Question 8

What nerve can be stretched and damaged as a result of shoulder dislocation?

What space does this nerve pass through?

Answer 8

The axillary nerve can be damaged

It passes through the quadrilateral space

Question 9

What is the principle clinical sign if a patient has damaged their axillary nerve?

Answer 9

Loss of sensation in the regimental badge area

Question 10

What is the difference between the surgical neck and the anatomical neck?

Answer 10

Surgical neck is below the tubercles

Anatomical neck is just below the articular surface of the bone

Question 11

What is the general mainstay of treating a dislocated shoulder?

Answer 11

Closed reduction under sedation/anaesthetic

Neurovascular assessment needs to be performed both before and after reduction

Following this, the patient’s arm is held in a sling for 2-3 weeks while the detached capsule to heal

Question 12

What is the classical radiographic appearance of a posteriorly dislocated shoulder on Xray?

Answer 12

Lightbulb sign - excessively rotated humeral head appears more symmetrical, like a lightbulb (visualised on an AP Xray)

(NB - PA is standard Xray protocl…)

Question 13

What nerve is at risk in a humeral shaft fracture?

How would damage to this nerve present clinically?

Where would sensation be lost?

Answer 13

The radial nerve is at risk

Damage to this nerve would present with wrist drop

There would be a loss of sensation in the first dorsal web space

Question 14

How are humeral shaft fractures typically managed? What is the rate of union?

Up to what degree of angulation can be tolerated in a humeral shaft fracture before it is managed otherwise?

Answer 14

Humeral shaft fractures are typically managed non-operatively and are treated with a functional humeral brace which compresses the fragments into alignment and provides stability

Union rates are 90%

Up to 30 degrees of angulation (!!!) can be tolerated due to mobility of the shoulder and elbow joints