INJURIES AROUND THE SHOULDER BY : DR SANJEEV

INTRODUCTION : Shoulder joint consists : Glenohumeral joint Acromioclavicular joint Sternoclavicular joint

Clavicle - First bone to ossify - 5th week. - Ossify from two primary centres - Bone in the body lying horizontal - Connects the shoulder to the trunk. - Medial 1/3 protects the brachial plexus and the vessels.

FRACTURE CLAVICLE Mechanism of injury : Direct ( 91 %) - due to fall on the point of the shoulder Direct trauma ( 8%) – due to RTA Indirect ( 1 %) – fall on the outstretched hands Sites : At the junction of middle and outer third (85%) Distal 1/ 3rd – 10% Medial 1/ 3rd - 5%

Cont.. Fracture distal third clavicle                                                            © 2009 Nucleus Medical Art,

CLASSIFICATION (ALLMAN`S) Group 1 : Middle 1/3rd of the shaft Group 2 (lateral 3rd ) : Type A : coracoclavicular ligament intact Type B : coracoclavicular ligament rupture Type C : intra-articular extension

Clinical feature : Pain Swelling Deformity Inability to raise the shoulder Radiological : AP view Lordotic view

Treatment Conservative methods Cuff and collar sling                                                                                                                                                        Figure 1 Child with collar and cuff sling.

Cont.. Strapping and sling suspension Figure of 8 bandaging

Complications. Ulnar nerve (commonest nerve )due to compression between clavicle and 1st rib. . Early: subclavian vessels or brachial plexus injury, Late: Shoulder stiffness Malunion

Injuries of the Acromioclavicular joint (A C JOINT) Is a diarthrodial joint with a fibrocartilaginous disc between two bones Incidence :-12 %,common (young) male :female ratio is 5: 1 Mechanism of injury - Direct fall on the shoulder - Indirect : fall on the outstretched hand

Clinical feature Pain Swelling Difficulty in raising the arm up Supports the affected shoulder by holding the elbow with unaffected hand O / E: Tenderness Lateral end of clavicle is prominently felt

Classification Type – 1 : minor sprain to AC ligament Type – 2 : rupture of ACL, sprain of CCL Type – 3 : both ACL and CCL rupture , clavicle is displaced upwards Type – 4 :same as type 3 , clavicle(upward and posterior displacement ) Type - 5 : type 3 with severe displacement of the clavicle towards base of the neck Type – 6 : inferior dislocation with clavicle towards base of the neck.

Radiology AP view with 15 degree cephalic tilt to prevent overlap of the spine of scapula on routine AP view Lateral view – axillary view of the shoulder MANAGEMENT : Type -1 :rest , ice bags , NSAIDS, Type – 2: Sling (10-14 days) , adhesive strapping ,cast, Surgery :if persisting pain

Type – 3 : Conservative : Reduction Retention with sling and cast Surgical : AC repair CC repair Type 4,5,6 : Open reduction Internal fixation Repair reconstruction

Complication CC ossification Infection Joint stiffness

ANTERIOR DISLOCATION OF SHOULDER Classification Traumatic injuries : Sprains Acute subluxation Acute dislocation Recurrent dislocation Unreduced dislocation

Anterior shoulder dislocation Fig: 1

Anterior shoulder dislocation Fig : 2

Cont.. Atraumatic injuries : Voluntary Involuntary Congenital Based on anatomical location of humaral head : Subcoracoid Subglenoid Subclavicular Intrathoracic

Pathoanatomy Stretching or tearing of capsule. Labral damage: (Bankart lesion) Avulsion of anteroinferior labrum. Hill Sachs lesion Posterior defect due to impression of anterior edge of the glenoid. Rotator cuff tear

Mechanism of injury Direct force - blow from the posterior aspect of the shoulder Indirect force – due to abduction +external rotation +extension injury (common) C / F : Pain – severe Arm is held in abduction and external rotation Adduction – restricted Normal contour of shoulder is lost and there is anterior shoulder fullness

Fig : Injured shoulder held in slight abduction and external rotation.

Cont.. Clinical tests for diagnosis : Posterior aspect is flat Coracoid process is not identified Axillary nerve injury may be present

Investigations X ray shoulder : AP and axillary views (Special views) CT (defect in the head) MRI (bone and soft tissue) Arthrography : (rotatory cuff tear)

Clinical evaluation- History: Injured shoulder held in slight abduction and external rotation. On examination Friction at the shoulder due to acromion. Palpable mass below the clavicle. Test the deltoid.

Fig : Palpable mass below the clavicle

Duga’s test: inability to touch opposite shoulder. Anterior dislocation… Duga’s test: inability to touch opposite shoulder. Callway’s test: vertical circumference of axilla is increased. Apprehension test: abduction, extension and external rotation reproduces pain.

Management. Non operative- Traction -countertraction. Hippocratic technique: close reduction using foot on the axilla, head is levered using foot as a fulcrum. Kocher maneuver: TEA I ( more chances of #)

Fig : Traction -countertraction

Fig : Hippocratic technique: close reduction using foot on the axilla, head is levered using foot as a fulcrum.

Fig : Kocher maneuver

Milch technique: patient supine, limb abducted and externally rotated, thumb pressure in applied by the physician to push the head into place Stimson technique: prone position, weight is hung from the wrist to distract the shoulder joint. After 10 to 15 mins it can be easily reduced

Fig : Stimson technique :prone position, weight is hung from the wrist to distract the shoulder joint. After 10 to 15 mins it can be easily reduced

Operative management (more than 3 episodes) Indications Soft tissue interposition Displaced greater tuberosity fracture Glenoid rim fracture. Role of arthroscopy. Post operative immobilization for 1 to 3 weeks

Complications Recurrence( most common) Unreduced dislocation Traumatic osteoarthritis Axillary nerve damage Soft tissue injuries

Anterior shoulder dislocation Fig: 1

Fig : Palpable mass below the clavicle

Anterior shoulder dislocation Fig :

Fig : Injured shoulder held in slight abduction and external rotation.

Fig : Stimson technique :prone position, weight is hung from the wrist to distract the shoulder joint. After 10 to 15 mins it can be easily reduced

Fig : Traction -countertraction

Fig : Hippocratic technique: close reduction using foot on the axilla, head is levered using foot as a fulcrum.

Fig : Palpable mass below the clavicle

Fig : Kocher maneuver

Anterior shoulder dislocation Fig :