1. Shoulder Trauma & Disorders
Turhan Özler MD.
Assistant Professor
Yeditepe University Faculty of Medicine
Department of Orthopaedics & Traumatology

2. Clavicle Fractures

3. Clavicle Fractures Mechanism Fall onto shoulder (87%) Direct blow (7%)
Fall onto outstretched hand (6%)

4. Clavicle Fractures Clinical Evaluation Radiographic Exam
Inspect and palpate for deformity/abnormal motion
Thorough distal neurovascular exam
Auscultate the chest for the possibility of lung injury or pneumothorax
Radiographic Exam
AP chest radiographs.
Clavicular 45deg A/P oblique X-rays
Traction pictures may be used as well

5. Clavicle Fractures Allman Classification of Clavicle Fractures
Type I Middle Third (80%)
Type II Distal Third (15%)
Type III Medial Third (5%)

6. Clavicle Fracture Closed Treatment Operative intervention
Sling or 8 bandage immobilization for usually
3-4 weeks with early ROM encouraged
Operative intervention
Fractures with neurovascular injury
Fractures with severe associated chest injuries
Open fractures
Group II, type II fractures
Cosmetic reasons, uncontrolled deformity
Nonunion

7. Clavicle Fractures Associated Injuries Brachial Plexus Injuries
Contusions most common, penetrating (rare)
Vascular Injury
Rib Fractures
Scapula Fractures
Pneumothorax

8. Shoulder Dislocations

9. Shoulder Dislocations
Epidemiology
Anterior: Most common
Posterior: Uncommon, 10%, Think Electrocutions & Seizures
Inferior (Luxatio Erecta): Rare, hyperabduction injury

10. Shoulder Dislocations
Clinical Evaluation
Examine axillary nerve (deltoid function, not sensation over lateral shoulder)
Examine M/C nerve (biceps function and anterolateral forearm sensation)
Radiographic Evaluation
True AP shoulder
Axillary Lateral
Scapular Y
Stryker Notch View (Bony Bankart)

11. Shoulder Dislocations
Anterior Dislocation Recurrence Rate
Age 20: 80-92%
Age 30: 60%
> Age 40: 10-15%
Look for Concomitant Injuries
Bony: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater Tuberosity Fracture
Soft Tissue: Subscapularis Tear, RCT (older pts with dislocation)
Vascular: Axillary artery injury (older pts with atherosclerosis)
Nerve: Axillary nerve neuropraxia

12. Shoulder Dislocations
Anterior Dislocation
Traumatic
Atraumatic
(Congenital Laxity)
Acquired
(Repeated Microtrauma)

13. Shoulder Dislocations
Posterior Dislocation
Adduction/Flexion/IR at time of injury
Electrocution and Seizures cause overpull of subscapularis and latissimus dorsi
Look for “lightbulb sign” and “vacant glenoid” sign
Reduce with traction and gentle anterior translation (Avoid ER arm  Fx)

14. Shoulder Dislocations
Inferior Dislocations
Luxatio Erecta
Hyperabduction injury
Arm presents in a flexed “asking a question” posture
High rate of nerve and vascular injury
Reduce with in-line traction and gentle adduction

15. Shoulder Dislocation Treatment Nonoperative treatment
Closed reduction should be performed after adequate clinical evaluation and appropriate sedation
Reduction Techniques:
Traction/countertraction- Generally used with a sheet wrapped around the patient and one wrapped around the reducer.
Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial traction
Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be used
Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral head
Scapular manipulation

16. Shoulder Dislocations
Postreduction
Post reduction films are a must to confirm the position of the humeral head
Pain control
Immobilization for 7-10 days then begin progressive ROM
Operative Indications
Irreducible shoulder (soft tissue interposition)
Displaced greater tuberosity fractures
Glenoid rim fractures bigger than 5 mm
Elective repair for younger patients

17. Proximal Humerus Fractures

18. Proximal Humerus Fractures
Epidemiology
Most common fracture of the humerus
Higher incidence in the elderly, thought to be related to osteoporosis
Females 2:1 greater incidence than males
Mechanism of Injury
Most commonly a fall onto an outstretched arm from standing height
Younger patient typically present after high energy trauma such as MVA

19. Proximal Humerus Fractures
Clinical Evaluation
Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation
Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

20. Proximal Humerus Fractures
Neer Classification
Four parts
Greater and lesser tuberosities,
Humeral shaft
Humeral head
A part is displaced if >1 cm displacement or >45 degrees of angulation is seen

21. Proximal Humerus Fractures
Treatment
Minimally displaced fractures- Sling immobilization, early motion
Two-part fractures-
Anatomic neck fractures likely require ORIF. High incidence of osteonecrosis
Surgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF
Three-part fractures
Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement requires ORIF.
Four-part fractures
In general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)

23. Shoulder Impingment What is it?
Rotator cuff impingement syndrome is a clinical diagnosis that is caused by mechanical impingement of the rotator cuff by its surrounding structures.
Patients with impingement syndromes may present with various signs and symptoms on physical examination depending on the degree of pathology and the structures involved.

24. Shoulder Impingment Subacromial Impingement Subcoracoid Impingement
Secondary Extrinsic Impingment
Posterosuperior glenoid impingement
Anterosuperior glenoid impingement

25. Subacromial Impingement
Narrowing of the space between the humeral head and the coracoacromial arch (supraspinatus outlet);
Causing entrapment of the supraspinatus tendon and subacromial bursa.
Repeated trauma to these structures will lead to tendon degeneration/tear and bursitis.
Patients complain of pain and tenderness over anterior or anterolateral aspect of the shoulder joint.

26. Subacromial Impingement
Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal arch.

27. Subacromial Impingement
Stage 1 disease consists of edema and hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under conservative treatment.

28. Subacromial Impingement
Stage 2 disease shows progressive inflammatory changes of the rotator cuff tendons and the subacromial-subdeltoid bursa, and can be treated by removing the bursa and dividing the coracoacromial ligament after failed conservative management.

29. Subacromial Impingement
Stage 3 disease manifests as partial or complete tears of the rotator cuff and secondary bony changes at the anterior acromion, the greater tuberosity or the acromioclavicular joint.

30. Subacromial Impingement
Abnormal acromial shape or position
Subacromial enthesophytes
Os acromiale
Thickened coracoacromial ligament
Acromioclavicular joint undersurface osteophytes

31. SLAP LESIONS

32. Outline Anatomy of the Glenoid Labrum Function of the Labrum
Definition of SLAP lesions
Classification of SLAP lesions
Etiology of SLAP Lesions
Diagnosis
Management

33. Anatomy of the Glenoid Labrum
Labrum, Capsule, Biceps tendon and Subscapularis muscle are derived from the same embryological cells.
Labrum is a fibrocartilaginous tissue with sparse elastin fibers.
Acts as a transition between the hyaline cartilage of the glenoid and the fibrous joint capsule. Inferiorly, the labrum blends with the articular cartilage of the glenoid.
Funtions as a stabilizing and load-sharing structure and serves as a site for ligamentous attachment.

34. Glenoid Labrum

35. Biceps Anchor
Broad origin from the supraglenoid tubercle AND the superior labrum at the 12 o-clock position.
Supraglenoid tubercle is 5 mm medial to the superior edge of the glenoid rim.
It has a variable origin, with some reports of 100% origin from the labrum alone.

36. Relation of Biceps & Labrum

37. Biceps Anchor
Edge of Labrum

38. Function of the Labrum Site for Ligamentous attachment.
Origin of long head of biceps tendon.
Increases Glenohumeral contact by 25%, thereby contributing to the stability of the joint.

39. Normal Variations in Superior Labral Morphology
Mileski, Snyder, Davidson
Triangular Labrum
“Bumper” Labrum
Meniscoid Labrum
Sub-labral Foramen
Buford Complex

40. Biceps
Glenoid Cartilage
Triangular Labrum

41. Biceps
Glenoid
Humeral Head
“Bumper” Labrum

42. Biceps
Labrum
Rim of Glenoid
Meniscoid Labrum

43. A Normal Variant found in 1.5% of shoulders.
Cord-like Middle Glenohumeral Ligament with apparently deficient labral tissue below it.
MGHL
Humeral Head
Glenoid
The Buford Complex

44. Definition of SLAP lesions
Term SLAP coined by Snyder et al.
Superior Labrum Anterior and Posterior (to the biceps anchor)
Refers to lesions of the superior labrum

45. Classification…..by Snyder

46. Additions to Snyder’s 4 types
Type 5: SLAP tear that extends to the inferior aspect of the labrum. Type 6: Superior Labral flap. Type 7: SLAP tear that extends into the capsule.

47. Etiology of SLAP Lesions
There is controversy regarding the actual mechanism/s resulting in SLAP lesions.
Theories include:
Primary shoulder instability leading to internal impingement of the labrum.
Traction injury from biceps during the deceleration phase of throwing.
Traction/twisting injury from biceps during the late cocking phase of throwing (abduction and external rotation)
Compression injury from a FOOSH.

48. Etiology of SLAP Lesions
Likely, each theory has it’s own merit for a given SLAP pattern, as there are biomechanical or clinical studies supporting each one.