1. Injuries to the Shoulder

2. I. Anatomy

3. A. Bones 1. Humerus

4. 2. Scapula a. Coracoid Process b. Acromion Process c. Glenoid Fossa

5. 3. Clavicle

6. 4. Sternum

7. B. Ligaments 1. Sternoclavicular ligament—Only place of direct attachment of upper extremities to the trunk. 2. Coracoclavicular ligament 3. Acromioclavicular ligament 4. Capsular ligament—Over the head of the humerus to the glenoid fossa.

8. C. Joints 1. Glenohumeral Joint—Lets you raise your arm only about 30 degrees by itself. 2. Acromioclavicular Joint (A/C)—Allows for rotation. 3. Coracoclavicular Joint (C/C)—Provides stability. 4. Sternoclavicular Joint (S/C)—Attaches upper extremities to trunk. 5. Scapulothoracic Joint—Not a true joint as no bone to bone contact.

9. II. Clavicle Fractures

10. A. Mechanisms of Injury (How the injury occurs) 1. Falling on an outstretched arm. 2. Falling on the point of the shoulder. 3. Direct blow to the clavicle.

11. B. Evaluation: 1. History a. Athlete will be able to relate one of the previous mechanisms. b. Will relate a pop or snap. c. Will tell you about it immediately as it causes severe pain. d. Will not try to participate or move arm.

12. 2. Inspection a. Will support the injured side with the good hand and turn their head towards the injured side to relieve some pain. Look for this posture. b. Localized swelling around fracture site. c. May see a deformity (as the bones separate).

13. 3. Palpation a. Pinpoint tenderness over the fracture site. b. You should be able to feel a deformity. c. You may feel grinding and popping (crepitation).

14. 4. Manipulation— Clavicle wiggle—Use only when in doubt of fracture.

15. 5. Treatment a. Apply sling for comfort, local ice, see an MD, and watch for shock. b. MD will put in figure 8 harness for 4-6 weeks.

16. 6. Greenstick Fracture a. Is a specific type of fracture where the bone breaks on one side only, not all the way through. b. You see this fracture often in the clavicle in the younger athlete.

17. III. Acromioclavicular Joint Sprains (shoulder separation)

18. A. Mechanism of Injury 1. Fall on outstretched arm. 2. Fall on point of elbow. 3. Fall on point of shoulder.

19. B. Severity of Injury 1. Grade I—stretching but not tearing of the A/C ligament. 2. Grade II—some tearing of A/C ligament and stretching of C/C ligament. 3. Grade III—complete tear of both A/C and C/C ligaments (Requires surgery).

20. C. Evaluation

21. 1. History a. Relates mechanism of injury. b. May feel pop or snap. c. Gradual or immediate inability to abduct the arm.

22. 2. Inspection a. Localized swelling. b. With grade II or III, you may see some deformity as the end of the clavicle raises up.

23. 3. Palpation a. Tender at the end of clavicle at shoulder. b. You may be able to feel deformity in Grade II-III.

24. 4. Functional testing a. Have them actively raise their arm up from their side. They will have limited arm abduction. b. The more severe the sprain, the more limited it will be.

25. 5. Manipulation a. Clavicle wiggle—Hold clavicle and wiggle it front to back. b. If tender at the joint then ligaments have been damaged. c. If movement then more significant grade of injury.

26. 6. Treatment a. Local ice b. Sling c. MD

27. 7. Recovery time (out of sport time…not healing time) a. Grade I—7-10 days b. Grade II—up to 4 weeks c. Grade III—6-8 weeks with surgery, 4-6 without surgery (but will likely fail and still have to do surgery)

28. IV. Subluxation/Dislocation of Glenohumeral Joint A. The stability of the joint is provided by the capsular ligament only. Once stretched it stays that way. B. The muscles provide for movement but provide for little strength/stability.

29. C. Direction shoulder goes out: 1. Anterior or anterior/inferior—Most common 2. Posterior—More complicated/less likely for repair to work. On posterior side ligament is paper thin and see-through so it is difficult to heal.

30. 3. MDI (multi-directional instability) a. Hard to stabilize. b. Miserable success rate. c. Most MD’s won’t repair. d. Often known as voluntary luxators--people who are more flexible are more likely to have this problem. i.e. when arms extended, elbows greater than 180 degrees. They can touch thumb to forearm. Index finger back to 90 degrees or less.

31. D. Mechanism of Injury 1. Anterior—arm being forced into a position of abduction and external rotation. 2. Posterior—Direct longitudinal force on extended arm.

32. E. Evaluation 1. History a. Subluxation—soreness, worsens with use, no injury moment, no pop/snap. b. Dislocations—relates injury mechanism, distinct pop and clunk, doesn’t want to move or cannot move it.

33. 2. Inspection a. Subluxation—You don’t really see anything. b. Dislocations 1. If it relocates, swelling in/around shoulder…in the hollow in front of shoulder especially. 2. If it stays out, there is a depression where the humerus was and a lump where the humerus went.

34. 3. Palpation a. Subluxation—Tenderness across front, a little tender across back. b. Dislocation—Very tender where lump is, tender at the back and the depression.

35. 4. Functional Test a. Subluxation—by history, increasing pain with activity. b. Dislocation—None or inability to actively move arm.

36. 5. Manipulation a. Subluxation—Positive apprehension sign. b. Dislocation—Positive apprehension sign. c. Apprehension sign—abduct and rotate shoulder…eyes get big and they move out of position if it is dislocation.

37. 6. Treatment for Subluxation/Dislocations a. Ice, rest, re-strengthening. b. If re-occurs, will likely need surgery. c. Reoccurrence rate in 17-25 year old athlete is 90-95%.