1. INJURIES AROUND THE SHOULDER
BY : DR SANJEEV

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

3. 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.

4. 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%

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

6. 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

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

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

9. Cont..
Strapping and sling suspension
Figure of 8 bandaging

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

11. 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

12. 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

13. 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.

14. 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

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

16. Complication
CC ossification
Infection
Joint stiffness

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

18. Anterior shoulder dislocation
Fig: 1

19. Anterior shoulder dislocation
Fig : 2

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

21. 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

22. 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

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

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

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

26. 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.

27. Fig :
Palpable mass below the clavicle

28. 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.

29. 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 #)

30. Fig :
Traction -countertraction

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

32. Fig :
Kocher maneuver

33. 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

34. 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

35. 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

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

37. Anterior shoulder dislocation
Fig: 1

38. Fig :
Palpable mass below the clavicle

39. Anterior shoulder dislocation
Fig :

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

41. 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

42. Fig :
Traction -countertraction

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

44. Fig :
Palpable mass below the clavicle

45. Fig :
Kocher maneuver

46. Anterior shoulder dislocation
Fig :