TRAUMATIC SHOULDER CONDITIONS John W. Gibbs, DO Orthopaedic Surgeon Rochester Regional Health Orthopaedics at Red Creek
Traumatic Shoulder Conditions Fractures Dislocations Separations Tendon Tears Labral Tears
Fractures
Fractures Proximal Humerus Clavicle Scapular
Proximal Humerus Fractures Anatomy Head Greater Tuberosity Lesser Tuberosity Shaft
Proximal Humerus Fractures Comprise 4-5% of all fractures Comprise 45% of all humerus fractures High energy vs. Low Energy More common in Females (2:1 over males) Osteoporosis
Proximal Humerus Fractures Mechanism Low Energy (most common) Fall from a standing height Outstretched arm Elderly, osteoporotic High Energy MVC More severe fractures
Proximal Humerus Fractures Treatment Non-operative 85% of all proximal humerus fxs Immobilizer / sling Early mobilization 7-10 days Operative Considerations Displacement / Angulation Age Activity level Bone quality Associated injury
Clavicle Fractures Mechanism Fall onto the shoulder Most common (87%) Direct clavicle impact (7%) Fall onto outstretched hand (8%)
Clavicle Fractures Classification Middle third (80%) Most common Distal third (15%) Proximal third (5%)
Clavicle Fractures Treatment Majority non-operative Distal third Sling Beware “Z” configuration Risk nonunion Distal third Medial to CC ligaments
Scapula Fractures Relatively uncommon Associated injuries (<1% of all fractures) Associated injuries
Scapula Fractures Glenoid Associated with dislocation Body High energy
Scapula Fractures Treatment Body Glenoid Most non-operative Consider operative
Dislocations / Separations
Dislocations / Separations Glenohumeral Dislocation Acromioclavicular Separation
Dislocations Glenohumeral Dislocation Most commonly dislocated major joint 45% of all dislocations Anterior Most common 8-9 times greater than posterior Posterior 2nd most common Superior / Inferior rare Inferior Dislocation: Luxatio Erecta
Glenohumeral Dislocations Treatment Reduction Immobilizer Considerations Non-operative vs operative management Age Activity level Associated injuries
Separations Acromioclavicular Separation Males 10:1 over females Fall onto point of the shoulder
Separations Acromioclavicular Separation Treatment Non-operative Type I & II Most Type III Operative Some Type III Type IV, V, VI
Acromioclavicular Separations Classification considerations: AC & CC ligaments
Acromioclavicular Separations
Tendon Tears
Traumatic Tendon Tears Rotator Cuff Long head Bicep Pectoralis major
Traumatic Tendon Tears Rotator Cuff Supraspinatus Infraspinatus Teres Minor Subscapularis
Traumatic Tendon Tears Rotator Cuff Functional Loss High suspicion for tear with shoulder dislocation in older patient
Traumatic Tendon Tears Long head Bicep Distal migration of bicep muscle belly vs. proximal migration Functional deficit Supination 21% loss Elbow Flexion 8% loss
Traumatic Tendon Tears Long head Bicep Treatment options Non-operative Operative Bicep Tenodesis
Traumatic Tendon Tears Pectoralis major
Labral Tears
Labral Tears Many ways to tear your labrum
Labral Tears Overlapping signs / symptoms with other shoulder conditions Achy, dull pain Possible traumatic history Hanging by arms (Crossfit, Tough Mudder) Swinging arms (kettlebell) Ballistic shoulder activity Mechanical symptoms Clicking, popping, catching Associated neurologic symptoms Numbness, tingling
Labral Tears Treatment Wide spectrum of clinical presentation Analogous to varied meniscal tear presentation Non-operative Older, sedentary patients Degenerative tears Tend to get stiff from operative repair Operative Younger, active patients
Traumatic Shoulder Conditions Younger patients Older patients Tend to regain mobility Potential laxity / instability issues Tend to stay stiff Risk for Adhesive Capsulitis Consider associated / missed injuries
Case Presentation - 1 35 y/o male, chiropractor, body builder bench press, pain anterior shoulder region, divot in his infraclavicular region Able to continue bench press and weight lifting Weakness with incline bench press Presents to office 6 weeks s/p injury Diagnostic / Treatment options:
Case Presentation - 1 Diagnostic / Treatment options: Clinical diagnosis Clavicular head pectoralis major tear MRI Clavicular head pectoralis major origin avulsion Treatment Non-operative vs. operative Functional Cosmetic concerns
Case Presentation - 2 62 y/o female, retired nurse, active grandmother Slipped on the ice @ grocery store, pain in shoulder region, unable to elevate arm Seen at urgent care: no fracture, anterior dislocation Urgent care unable to reduce shoulder Shoulder reduced at Unity ED Presents to office 1 week s/p injury Diagnostic / Treatment options:
Case Presentation - 2 Diagnostic / Treatment options: Xrays repeated at office: maintained reduction Active elevation to 45 degrees / Abduction to 20 degrees Significant weakness with external rotation MRI: Supraspinatus & Infraspinatus complete tendon tear with retraction Operative intervention
Case Presentation - 3 60 y/o male, orthopaedic surgeon, active, cyclist, golfer Struck from behind by motor vehicle while riding bicycle Landed on point of shoulder, dominant arm Seen at urgent care: AC separation, Type III Self-diagnosed Presented to office with literature and requested surgery Active elevation to 45 degrees / Abduction to 20 degrees Distal clavicle prominent Primary form of cardiovascular exercise: cycling Diagnostic / Treatment options:
Case Presentation - 3 Diagnostic / Treatment options: MRI confirms Type III AC separation Coraco-clavicular ligaments disrupted Supraspinatus: low-grade partial thickness tearing Non-operative vs. operative considerations Shoulder fatigueability and scapular dysfunction AC arthritis Continued deterioration of rotator cuff Elected for AC repair Returned to all activities and operating
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