1. SHOULDER
The shoulder joint is a unique and complex articulation unit. It has the largest range of motion of any appendicular joint in the body and can be moved through a space that exceeds a hemisphere in extent.

2. Anatomy
The shoulder girdle connects the upper extremity to the axial skeleton.
It consists of three bones and three joints:
clavicle
humerus
scapula
acromioclavicular
glenohumeral
sternoclavicular

4. CLINICAL FEATURES Pain ,Stiffness, instability ,weakness
Physical exmamination:
Palpation beginning at the SCJ and moving laterally along the clavicle to the ACJ. Next, the scapula, glenohumeral joint, and humerus are palpated. Any point tenderness, crepitus,swelling, or deformity should be noted.

5. Note to:
deformity, ecchymosis, laceration, swelling, or hematoma, the masses of the trapezius swelling, or hematoma, deltoid, infraspinatus, and supraspinatus muscles should be compared with the unaffected side to detect any atrophy

6. Active and passive ranges of motion should be tested:
Active range of motion is best determined with the patient in the sitting position.
Passive range of motion is best evaluated with the patient in the supine position.

7. Examination of the neurovascular function:
sensory and full motor examination:
The radial pulse should also be checked, although collateral circulation may preserve this in the presence of a vascular injury.
The presence of pallor, paresthesias, or an expanding hematoma should raise suspicion for a vascular injury.

9. DIAGNOSTIC STRATEGIES
Radiology:
True anteroposterior (AP) (45­ degree lateral)
Transscapular lateral (“Y” view)
axillary lateral view

11. transscapular view define:
Axillary view define :
relationship of the humeral head with the glenoid fossa
lesions of the coracoid process, humeral head, and glenoid rim.
transscapular view define:
scapula is projected as a Y, with the body forming the lower limb and thecoracoid and acromion processes forming the upper limbs.
anterior and posterior glenohumeral dislocations.

12. The apical oblique view (obtained by having the patient stand bending forward, and angling the central ray 45 degrees caudally) shows:
the glenohumeral joint in a unique coronal projection
Hill­-Sachs lesions in shoulder dislocations
displacement and angulation of proximal humerus fractures

14. Clavicle fracture:
The clavicle accounts for 5% of all fractures and is the most commonly fractured bone in children.
Clavicular fractures are classified anatomically and mechanistically into three groups :
Medial third Fx(5%): mechanism of injury:
Direct blow to the anterior chest.

15. Middle third Fx (80%)
mechanism of injury involves a direct force applied to the lateral aspect of the shoulder as a result of a fall, sporting injury, or motor vehicle col­lision (MVC)

17. Lateral third Fx (15%): Types of this Fx:
Result from a direct blow to the top of the shoulder.
Types of this Fx:
stable and minimally displaced because the coracoclavicular ligament remains intact.
associated with a torn coracoclavicular ligament and have a tendency to displace because the proximal fragment lacks any stabilizing forces.
injuries involve the articular surface.

19. Clinical Features Pain over the fracture site
Ecchymosis, crepitus palpable, visible deformity
Tenting of the skin
Neurovascular injury
Pneumothorax and pulmonary injuries are also rare unless an open or medial third fracture is present.

20. Management pain control, immobilization, and proper follow­up care.
simple sling or sling and swathe
Figure-­of-­eight splint  
Velpeau sling

22. Disposition Immediate orthopedic consultation include: Open fractures
Skin tenting
Fractures associated with neuro vascular injuries
Interposition of soft tissues

23. Urgent orthopedic consultation (before 72 hours) :
Type II lateral clavicle fractures
Severely comminuted or displaced fractures of the middle
third (defined as over 20 mm of initial shortening)
Early passive shoulder range ­of­ motion exercises are encouraged to reduce the risk of adhesive capsulitis.
Younger children generally require shorter periods of immobilization (2 to 4 weeks) than adolescents and adults (4 to 8 weeks).

24. Greenstick fractures of the mid clavicle are common in children
Greenstick fractures of the mid clavicle are common in children.Most of these fractures are nondisplaced and heal uneventfully. Initial radiographs may appear normal despite sug­gestive clinical findings. In these instances, the arm should be immobilized in a simple sling and the radiographic evaluation repeated in 7 to 10 days if pain persists, to evaluate for early callus formation.

26. AARD An uncommon but important association is that between
clavicle fractures and atlantoaxial rotatory displacement.
Most cases occur in girls younger than 10 years.
Early diagnosis is important because delayed diagnosis can lead to a chronic deformity requiring sur­gical correction.

27. AARD should be suspected if the child has a
clavicle fracture and demonstrates a “cocked-­robin” position with the head bent toward the fractured side but rotated in the opposite direction.
The injury is best demonstrated by CT scan and, if
recognized early, can be treated with a soft cervical collar or halotraction.

28. Scapula
  Fractures of the scapula are rare.
In general, considerable force and energy are required to fracture the body & neck of the scapula.
Most fractures, including fractures with severe comminution and displacement.The most important aspect of scapula fractures is the high incidence of associated injuries to the ipsilateral lung,chest wall,and shoulder girdle complex.

29. Diagnosis of fractures scapula
True AP veiw:body of scapula.
Lateral trans scapular veiw:evaluation of displacement of body of scapula and glenoid.
Lateral axillary veiw:fractures of acromion, coracoid process. :

30. :

31. Management Analgesia Immobilization: sling for 2 to 4 weeks
close radiographic follow ­up for assessment for delayed displacement.
Displaced acromial fractures that impinge on the glenohumeral joint require surgical management.
Fractures of the body and spine and nondisplaced fractures require no further therapy.

32. Proximal Humerus Neer’s classification system:

33. Major categories of humerual fracture
Minimal displacement
Two ­part displacement
Three ­part dis placement
Four ­part displacement

36. Management Most nondisplaced fractures heal over 4 to 6 weeks.
In two ­part, three ­part, and four ­part displaced an orthopedic surgeon should be consulted, because many of these injuries require operative repair.

37. Fracture-­dislocation injuries are best managed in consultation with an orthopedic surgeon before attempts at reduction (except in cases of neurovascular compromise or unavailability of an orthopedic surgeon).

38. Proximal Humeral Epiphysis
The most common mechanism of injury involves a fall onto the outstretched hand.
The fracture is most common in adolescent boys.

39. Management Early orthopedic consultation should be obtained
Children younger than 6 years:
Salter I epiphyseal injuries
sling and swathe and analgesic agents

40. Chil­dren older than 6 years
Salter II epiphyseal injury
Salter II injuries with more than 20 degrees of angulation may
benefit from reduction.
After reduction, unstable injuries should be immobilized in a
shoulder spica cast, whereas stable lesions can be immobilized
with a sling and swathe.
Fractures of the proximal humeral epiphyses generally heal in 3 to 5 weeks.

42. Types of SCJ dislocation:
Dislocations:
Sternoclavicular:
The most common mechanisms are MVCs and injuries sustained in contact sports.
The SCJ can dislocate in an anterior or a posterior direction.
Types of SCJ dislocation:
Mild sprain secondary to stretching of the sternoclavicular and costoclavicular ligaments.
subluxation of the joint (anterior or posterior) secondary to rupture of the sternoclavicular ligament but the costoclavicular ligament remains intact.
Complete rupture of the sternoclavicular,costoclavicular ligaments.

43. Diagnostic Strategies
Standard AP, oblique, and specialized (40 ­degree cephalic tilt) views
CT scan
Ultrasound imaging

44. Management
Grade I Immobilization (simple sling for1-2 weeks), analgesia
Grade II immobilized with a sling or soft clavicular (figur-of-­eight) splint(3-6weeks)
The patient referred for orthopedic follow­up care.
All grade III injuries should be managed by closed reduction.
Anterior dislocations may be reduced in the ED after orthope­dic consultation and intravenous analgesia.

46. Most reductions are unstable.
Because the deformity is primarily cosmetic and not functional, the current treatment of choice for recurrent anterior dislocations is benign neglect.
Posterior dislocations constitute true orthopedic emergencies and should be reduced expeditiously.

47. Acromioclavicular Joint dislocation
The most common mechanism of injury involves a fall or direct
blow to the point of the shoulder with the arm adducted.
Classification is based on the degree of damage sustained by the acromioclavicular and coracoclavicular ligaments.

48. Classification of ACJ Dislocation
Type I sprain of the acromioclavicular ligaments with no separation of the acromion and clavicle.
TypeII: disruption of the acromioclavicular ligaments.
The joint space is widened, and the clavicle is displaced slightly upward. There are minor tears in the attachments of the deltoid.
and trapezius muscles, but the coracoclavicular ligament remains intact
A type III: complete disruption of the AC ligaments,
coracoclavicular ligament,muscle attachments. The joint space is widened, the coracoclavicular distance is increased by 25 to 100%.

49. Type IV and V injuries, the ligamentous and muscle disruptions are similar to the disruptions encountered in type III injuries, but the clavicle is displaced either posteriorly into the trapezius (type IV) or superiorly in an exaggerated fashion (coracoclavicular distance increased to 300%; type V)
In the rare type VI injury, the clavicle is displaced inferiorly.

50. Clinical Features
  Patients should be examined while they are in the sitting or standing position because the supine position can mask ACJ instability.
Type I and type II: mild tenderness and swelling over the ACJ
margin, with minimal deformity. A full range of motion often
is possible, although painful.
Type III, IV, V, and VI: severe pain and adduction of arm.
Type IV injuries, the clavicle may be palpable posteriorly.

52. Diagnostic Strategies
AP view
Axillary lateral view: fractures and posterior dislocation of clavicle
15 ­degree cephalic tilt view.
The normal coracoclavicular distance:11 to 13 mm.
A difference of more than 5 mm between the injured and uninjured sides is diagnostic of a complete coracoclavicular disruption.­
Type I the radiographic appear­ance is essentially normal.

53. Type II radiographic features:
widening of the joint
a slight upward or posterior displacement of the clavicle
a normal coracoclavicular distance
Type III, IV, and V radiographic features:
widened joint
an increased coracoclavicular distance
either superior or posterior displacement of the clavicle

55. Management 
Type I and II: sling for comfort and to protect against further injury.
When pain has subsided (1 to 3 weeks), range-­of-­motion and strengthening exercises can begin, return to sports when pain­free function has been achieved.
Type III: sling immobilization,early orthopedic referral(within 72 h)
Type IV, V, and VI: early surgical treatment.

56. Surgical indication Young patient severe displacement (more than 2 cm)

57. Glenohumeral Dislocations
The glenohumeral joint is the most commonly dislo­cated major joint in the body.
Anterior Dislocations
The most common mechanism of injury consists of an indirect force transferred to the anterior capsule from a combination of abduction,extension, and external rota­tion.
characteristic pathologic:avulsion the anteroinferior glenohumeral ligament with capsulolabral detachment (Bankart’s lesion).

58. Types of anterior dislocation

59. Clinical Features severe pain
the dislocated arm held in slight abduction and external rotation by
the opposite extremity.
The lateral edge of the acromion process is prominent, and the normally rounded shoulder assumes a“squared­-off” appearance.
The coracoid process is indistinct, the anterior shoulder appears full.

60. Diagnostic Strategies:
Radiology:
Associated fractures may be present in 50% of cases.
The most common of these is a compres­sion fracture of the posterolateral aspect of the humeral head caused by forceful impingement against the anterior rim of the glenoid fossa.
This defect in the humeral head, or Hill-­Sachs defor­mity(11-50%)
The defect is best visualized on an internal rotation AP view of the glenohumeral joint.

62. Radiography: before reduction
Management
Radiography: before reduction
Ideal method of reduction:simple, quick, and effective.
Analgesia and muscle relaxation with procedural sedation.
Local anesthetic agent intra ­articular with
injection(Lidocain,Bupivacaine).
This technique is especially useful when procedural sedation is contraindicated.

63. Technique Stimson or hanging weight technique
traction-counter-traction method
Snowbird technique
external rotation method of Leidel-meyer
Milch technique
Scapular manipulation

69. After reduction Neurovascular Examination Post reduction radiography
Immobilization:(sling & swathe velpeau bandage)
Duration of immobilization:
In younger patients:3-4 weeks
In older patients>40 years :1-2 weeks
Orthopedic follow-up care:
Primary disloctaion
Complicated cases
Patients discharged with analgesia

72. Anterior Subluxation (Dead arm syndrome) In young athletic adults
The patient reports sudden sharp shoulder pain and weakness that occurred while performing an abduction and external rotation maneuver. Radiography:Normal
confirm the diagnosis: apprehension sign
A lax or redundant anterior capsule is thought to be responsible for this syndrome
Treatment: referred for ortho­pedic follow-­up care(capsulorrhaphy)

74. Posterior Dislocation
rare(2 to 5% )
More than 50% are missed on initial evaluation, and many
remain unrecognized (“locked posterior dislocations”) for weeks
or months.
mecha­nisms of injury:
Convulsive seizures (epileptic or after electrical
shock) have been associated with unilateral or bilateral posterior
dislocations.
fall onto the outstretched hand with the arm held in flexion,
adduc­tion, and internal rotation

75. Types of posterior dislocation
subacromial (most common)
subglenoid
subspinous
Clinical Features
The patient hold the affected arm across the chest in adduction and internal rota­tion.
Usually painful, but may be painless.
Abduction is severely limited.
External rotation is completely blocked.

76. Diagnostic Strategies
Radiography:
True or standard AP radiographs can appear deceptively normal with posterior dislocations.
characteristic radiographic features in Standard AP films:
loss of the half moon elliptic overlap of the humeral head and glenoid fossa.
The distance between the anterior glenoid rim and the articular surface of the humeral head is increased (Rim sign).
The humeral head is profiled in internal rotation and takes on a “lightbulb” or “drumstick” appearance.
A true AP film shows abnormal overlap of the glenoid fossa with the humeral
head.
An impaction fracture of the anteromedial humeral head (reverse Hill-­Sachs deformity) is invariably present ( trough sign)

77. Figure   Anteroposterior (A) and transscapular (B) radiographic  views of a posterior glenohumeral dislocation. Note the “lightbulb” or  “drumstick” appearance of the humeral head. 

81. Management In the ED Closed reduction with procedural sedation.
The technique of reduction:
Internal rotation and lateral traction to disimpact the humeral head from the glenoid rim.
The humeral head can also be disimpacted with use of the “lever principle”.
If this technique fails, reduction with the patient under general anesthesia is indicated.
After reduction the shoulder should be immobilized in external rotation with slight abduc­tion.
Refer for orthopdist:
missed initially
chronic
“locked” posterior dislocations(open reduc­tion and internal fixation or arthroplasty).

82. Inferior Glenohumeral Dislocation (Luxatio Erecta)
Rare(Less than 0.5%)
mechanism of injury: indirect or direct forces.
Most inferior dislocations result from indirect forces that hyperabduct the affected extremity.

84. Clinical Features
The patient has the arm locked overhead in 110 to 160 degrees of abduction.
The elbow usually is flexed, and the forearm typically rests on top of the head.

85. Diagnostic Strategies
Radiology:
Many cases of luxatio erecta are mistakenly diagnosed and treated as subglenoid anterior dis­locations because the radiographic features of these two clinical entities are remarkably similar.
Standard AP radiographs show:
the superior articular surface inferior to the glenoid fossa
the humeral shaft paralled to the spin of the scapula
In subglenoid anterior dislocation:
Latter the humeral shaft lies parallel to the chest wall.

87. Management
Reduction by traction-countert-raction maneuvers under procedural sedation.
open reduction “buttonholing” of the capsule will prevent closed
reduction
Refer to orthopedic
An alternative approach is the two-­step closed reduction maneuver:
single operator
fewer attempts
minimal force
local analgesia
minimal procedural sedation.