SHOULDER (Dislocations of the shoulder region (Sternoclavicular joint…
Dislocations of the shoulder region
TOP LEFT = subglenoid
BOTTOM = subclavicular
TOP RIGHT = subcoracoid (most common)
N = normal position, D = dislocated
• Uncommon injury.
• Mechanism. Indirect force to lateral shoulder or direct impact on medial end of clavicle.
• Types. Usually dislocates anteriorly; posterior dislocation is rare. The deformity is at the medial clavicle.
• Complications. Tracheal and oesophageal compression may occur with posterior dislocation. Careful assessment is required.
• Anterior dislocation. Treated symptomatically with a sling, analgesia, and early mobilization.
• Posterior dislocation with tracheal compression. Requires closed reduction or open if this fails (with cardiothoracic surgical help).
Acromioclavicular joint (ACJ)
• Usually an injury of second to fourth decade, more common in males.
• Mechanism. Fall or direct impact on to the point of the shoulder.
• Rockwood classification. Six types with increasing numbers relating to increasing severity of ligamentous disruption (acromioclavicular and coracoclavicular) and displacement.
• Type I. Sprained acromioclavicular ligament (no displacement).
• Type II. Acromioclavicular ligaments disrupted, ACJ subluxed.
• Type III. Acromioclavicular and coracoclavicular ligaments disrupted (>100% displacement).
• Type IV. Both ligaments disrupted with posterior displacement.
• Type V. All ligaments torn and massively displaced.
• Type VI. All ligaments torn and inferior displacement (very rare).
• Types I and II (and some III). Broad arm sling and early mobilization when pain allows. Persistent pain or functional limitation is treated by reconstruction of the coracoacromial ligament.
• Type III and above. Acute repair indicated. Soft tissue reconstruction better than hook plate.
Anterior dislocation of the glenohumeral joint
Traumatic event, leading to forced abduction and external rotation (fall on to the outstretched arm).
• Young. Ninety per cent have traumatic injury to bony and/or soft tissue restraints in the shoulder—the Bankart lesion (anteroinferior glenoid labrum tear, with or without a glenoid rim fracture), Hill–Sachs lesion (impression fracture as the anterior glenoid impacts on humeral head).
• Rotator cuff tears. Approximately 30% of those >40y and 80% of those >60y will have a tear.
• Greater tuberosity fractures. Common over the age of 50y.
• History of injury and whether had previous dislocations.
• The shoulder looks ‘square’ as the deltoid is flat and a sulcus can be visible where the humeral head may be.
• The patient supports the arm which is abducted and very painful.
• Assess neurovascular status (axillary nerve).
• X-rays (AP and axillary or scapular ‘Y’ lateral views) show the humeral head anterior and inferior to the glenoid. Used to exclude a fracture of the humerus or glenoid.
• Reduce as an emergency in A&E.
• Give IV morphine 5–10mg + inhaled N2O (IV midazolam 5mg is usually unnecessary).
• Simplest, extremely reliable method is gentle, continued straight line traction with the arm abducted about 10–20° from the trunk. May take 10–15min, but patience is the key, not force.
• Avoid rotation (such as in a ‘Kocher's manoeuvre’) as this is dangerous and may cause fracture of the humerus.
• Countertraction can be placed across the trunk with a broad sheet.
• Alternative technique is patient prone on the trolley, arm hanging freely down and weighted (e.g. 3L bag of saline) (‘Stimson's technique’).
• If there is an associated humeral neck fracture, then the reduction should be done under GA.
• Place the arm in a collar and cuff sling under the clothes. Repeat the X-ray to confirm reduction and that there has been no iatrogenic fracture.
• Always document the neurological status (axillary nerve) before and after reduction.
• Follow-up in clinic mandatory to assess for associated injuries.
Posterior dislocation of the glenohumeral joint
Rare. Due to forced internal rotation or direct blow to the anterior shoulder (e.g. after an epileptic fit or electric shock). Common to be missed.
• The arm is held internally rotated and no external rotation is possible.
• The humeral head should be palpable posteriorly.
• AP X-rays may show the humeral head as a ‘light bulb’ shape (internally rotated), but this is not diagnostic of posterior dislocation.
• Lateral X-ray shows the dislocation.
• In-line traction method (as above), but consider GA if difficult—avoid excessive force.
• May be very unstable; occasionally the ‘broomstick’ plaster may be used.
Recurrent dislocation of the shoulder
• Usually due to a Bankart lesion or capsular redundancy (stretched and floppy).
• Commonest in young age of first dislocation (90% recurrence if <20y, 60% if 20–40y, <10% if older than 40y).
TREATMENT - surgery
• Repair and fixation of the anterior ‘Bankart lesion’.
• May be done open or arthroscopically.
• Capsular laxity is treated by capsular shift, an overlapping ‘pants-over-vest’ procedure to improve proprioceptive joint sensation.
Fractures of the ribs and sternum
• Single rib fractures occur as a result of direct injury such as a fall.
• Fractures of the lower ribs can occur with coughing.
• Sternal fractures occur with direct injury, e.g. contact with steering wheel or by restraint by a seat belt.
• High velocity (RTA) or large crush injuries can result in a ‘stove-in’ chest with a flail segment, i.e. multiple rib fractures, each fractured at two sites.
• Single rib fracture. Symptomatic with analgesia.
• Multiple rib fracture. If ≥3 ribs involved, should admit for observation overnight, but treatment symptomatic with analgesia and chest physiotherapy.
• Sternal fracture. Symptomatic treatment, but observe for associated injuries (see below).
• Flail chest or extensive multiple rib fractures. Potentially life-threatening injury and may present with severe respiratory distress.
• Flail segments move paradoxically, preventing adequate ventilation.
• Multiple fractures restrict respiratory effort, severely impairing ventilation.
• Treat with high flow O2 and analgesia. CPAP and even IPPV may be required.
Incidence of complications rises dramatically if the injury involves:
• >3 ribs.
• First, second, or third ribs.
They are all indicators of high energy transfer injury.
• Bleeding into the pericardial cavity causes severe haemodynamic shock and may be the cause of a cardiac arrest at presentation.
• Diagnosis is by high clinical suspicion, muffled heart sounds, raised JVP, and no signs of a tension pneumothorax.
• Treat by immediate pericardiocentesis with transfer to cardiothoracic unit for repair of the defect.
• Usually due to direct pleural injury by bone fragments during injury.
• Often associated with haemothorax.
• Signs are respiratory distress, absent breath sounds, hyperresonant percussion note (pneumothorax), or shock.
• Tension pneumothorax is life-threatening and requires immediate decompression via a 16G needle placed into the second anterior intercostal space, followed by definitive chest drain placement.
• If in any doubt, always treat first on clinical grounds rather than wait for investigations (X-rays, etc.).
FRACTURES AROUND THE SHOULDER
Fall or direct blow to lateral shoulder (5–10% of all fractures).
• Occurs in the middle (75%), lateral (20%), or medial (5%) third.
• The pattern of lateral third fractures depends on relationship and integrity of the coracoclavicular ligaments, and involvement of the acromioclavicular joint.
• Medial third fractures are assessed with displacement and involvement of sternoclavicular joint in mind.
• Middle third. Virtually all can be treated conservatively with a broad arm sling (not a collar and cuff). Indications for ORIF (plate and screws) are open fractures, significant neurovascular injuries, skin tenting, floating shoulder. Fractures with >100% displacement and 2cm of shortening have better outcomes with ORIF.
• Lateral third. Undisplaced can be treated non-surgically; however, the presence of displacement suggestive of coracoclavicular ligament disruption will require fixation with either plate and screw constructs, hook plate, or ligament reconstruction (Weaver–Dunn procedure).
• Medial third. Most are undisplaced and treated conservatively in a sling. Displacement, especially posterior, into the root of the neck may warrant surgery.
• Metalwork. Failure or subcutaneous irritation.
• Non-union. Associated with displacement and shortening.
• Acute complications. Neurovascular injury (including brachial plexus injury), neurovascular compression (costoclavicular syndrome), pneumothorax from bony penetration of the pleura.
Direct trauma, usually a high velocity injury such as an RTA. Always have a high clinical suspicion of other possible injuries such as rib fracture, pulmonary contusion, and pneumo/haemothorax; 20–40% have ipsilateral clavicle fractures.
• Simple (no involvement of the glenoid (glenohumeral joint)). Adequate analgesia (very painful injury; may require HDU admission) and early mobilization.
• Complex (involving the glenoid and glenoid neck). May need ORIF after further imaging such as CT/MRI scanning.
• Floating shoulder will require ORIF of clavicle.
Young—high energy injury; elderly—low energy falls. Full neurovascular assessment (especially axillary nerve) is essential, alongside pre-injury function (aids management decision).
The Neer classification
Based on Codman's fracture lines along old physeal scars; four segments or parts. A fracture part is considered when it is >1cm displaced or >45° angulated. Thus defined as 1-, 2-, 3-, or 4-part fractures.
• Undisplaced or impacted. Collar and cuff with early pendular mobilization.
• Displaced. Usually requires ORIF by ‘locking’ plate, proximal humeral intramedullary nails or cannulated screws, and K wires with or without tension band wiring.
• Severely comminuted fractures (4-part), especially including fracture dislocations, have a high rate of avascular necrosis; usually treated with hemiarthroplasty and soft tissue reconstruction of the rotator cuff to the prosthesis.
Non- and mal-union, avascular necrosis of the humeral head, and osteoarthritis of the shoulder joint are the commonest. High velocity injuries may also cause neurovascular injuries, particularly of the brachial plexus.
Paediatric humeral fractures
• Usually occur at the surgical neck or through and around the proximal humeral epiphysis.
• May be indicative of a non-accidental injury.
• Most require no treatment apart from collar and cuff with mobilization as for adults. Remodelling potential is good in this area.