ORTHOPAEDICS
Upper Limb Injuries: The Shoulder and Upper Arm
SHOULDER
Examination of the Shoulder and Upper Arm
Inspection
Patient should be observed standing/sitting in comfortable position; note level of shoulders + presence/absence of swellings or
wasting
Deltoid wasting accompanies many shoulder conditions, as does wasting of posterior scapular muscles (supraspinatus and
infraspinatus)
Palpation
Landmarks: tip of acromion, sternoclavicular joint, coracoid process, spine of scapula
Greater tuberosity of humerus also normally palpable
Tenderness commonly found over trapezius area, and in capsulitis may be localized to greater tuberosity
Increased temperature and boggy swelling may accompany infective conditions or rheumatoid arthritis
Movements
Abduction, flexion, internal and external rotation should be tested
Abduction: observe from behind
External rotation tested with elbow pressed into side of the body
Measurement
Measure girth of upper arm (index of deltoid/biceps/triceps wasting)
Neurology
Damage to axillary nerve may produce patch of anaesthesia over belly of deltoid
Shoulder complications may be associated with brachial plexus injury
Circulation
Blood supply in arm may be impaired due to pressure on axilla.
Axillary vein thrombosis = uncommon; usually affects young men swelling and discoloration of whole arm
Lymphatics
Lymphatic glands in axilla/ supraclavicular fossa may be enlarged from shoulder disease, particularly infective conditions.
Congenital Conditions: Sprengel’s Shoulder
Sprengel’s shoulder: scapula is higher and smaller than usual, and is rotated into abduction. There may be ligamentous and bony bar
connecting the upper medial border to the cervical spine (=the omovertebral bar)
- Occasionally worth resecting improvement in appearance.
- Sprengel’s condition often associated with Klippel-Feil Syndrome
Developmental Conditions
Rarely, recurrent dislocation of shoulder is due to developmental defect of the glenoid/ humeral head.
Constitutional laxity = occasional cause of recurrent dislocation of the shoulder.
Traumatic conditions
Fractured clavicle
One of the most common # in childhood and early adult life; usually caused by fall onto the shoulder or FOOSH.
Fracture rarely open.
In child, # usually greenstick (one side of bone broken and other bent).
Clinical Features:
- Pain in the shoulder region
- Patient supports weight of arm with his/her other arm
- Bone typically breaks in middle of clavicle, or at the junction of the middle and outer 1/3
- Outer fragment pulled downwards and forwards by weight of the arm
Complications: Rare;
- Brachial plexus/subclavian A or V may be injured
- Occasionally, dome of pleura may be penetrated by bony fragment, producing a PNTX.
- Non-union very rare: more likely after internal fixation.
Treatment:
- For most clavicular #s, adequate treatment consists of supporting the weight of the arm in a broadarm sling
- More severely displaced #s, attempt sometimes made to secure a partial reduction by figure-of-8 bandage: this is not effective
device/ may be uncomfortable.
- Occasionally, displacement may be sufficiently severe to warrant internal fixation, especially if # at the lateral end.
- Small plate/tension band wiring may be used.
- Majority of clavicular # heal well, give excellent function and after remodeling are cosmetically satisfactory.
- 3 weeks of support usually sufficient, and subsequent recovery of function is usually rapid.
,Fractures and Dislocations around the Shoulder
Dislocation of the Sternoclavicular Joint
Uncommon; usually the medial end of the clavicle dislocates forward and the deformity is obvious.
Posterior dislocation rare; may lead to tracheal compression. Requires open reduction to relieve tracheal compression
Treatment usually symptomatic.
Clavicular Fracture
Caused by falls on outstretched hand or point of shoulder.
Bone usually breaks between the middle and outer third.
Fractures of the outer end may be associated with fractures of the coracoid and damage to the coraco-clavicular ligament.
Signs and symptoms: pain in shoulder region; supports weight of arm with other hand; proximal portion drawn upwards by
sternomastoid. Distal part droops due to weight of arm. Tenderness over site.
Investigations: Radiograph.
Treatment: support arm in triangular sling. With displaced # - 3 weeks support usually sufficient. Rarely, displacement sufficient to
warrant internal fixation (especially if skin over # is in danger of necrosis)
Complications: rare; occasional injury to brachial plexus or axillary artery may occur.
Acromioclavicular Joint
Subluxation: seen in rugby players; present with lump over joint. Treat- rest in a sling until symptoms subside. Lump often persists.
Dislocation: complete dislocation only occurs when the coraco-clavicular ligament is disrupted. The clavicle is elevated and the point of
shoulder lowered. Tenderness and bruising occur.
Radiographs show a gap between coracoid process and clavicle.
Treatment usually conservative with a sling, but dependent on percentage displacement, reconstruction may be required.
Subluxation and Dislocation of the Acromioclavicular joint
Subluxation and dislocation of the acromioclavicular joint = uncommon; usually caused by fall onto shoulder (often a sporting injury).
Subluxations of the joint = associated with tearing of superior and inferior acromioclavicular ligaments, but with coracoclavicular
ligament remaining intact.
Complete dislocation also involves rupture of superior and inferior acromioclavicular ligaments, but in addition the coracoclavicular
ligament is also ruptured.
In both subluxations and complete dislocations, the displacement is difficult to reposition, but function is usually good even without full
correction.
Clinical Features:
- Outer end of clavicle abnormally prominent and tender, usually with some additional swelling
- Shoulder movements restricted
- Injury frequently missed on X-rays, but displacement may be more obvious if patient holds a weight in the hand
Treatment:
- Broad sling often sufficient; sometimes supplemented by strapping over the acromioclavicular joint
- Subluxation will usually persist, but function likely to be normal.
- Rarely, if pain persists, surgical repair/reconstruction of the coraco-clavicular ligament is indicated.
- The repair may be protected by driving a screw across the clavicle, and into the coracoid process, or a threaded pin or figure-
of-8 wire may be passed across the acromio-clavicular joint.
- Subluxation may recur when these devices are removed, but long-term appearance may be improved.
Scapular Fracture
Usually caused by direct violence. There may be extensive cruising.
Treatment: rest, analgesia, collar and cuff. Mobilize when pain allows.
CT if suspect glenoid involvement.
Fractures of acromion and scapula
Acromion/scapula # often caused by direct blow/ fall; rarely
displaced.
Usually of little significance
Scapula # may be associated with rib #s.
Treatment: simple support in broad sling + early movement
when pain allows.
Dislocation of the Shoulder
95% shoulder dislocations are anterior; caused by fall on
outstretched hand
In younger patients, capsule is strong and doesn’t tear. The
glenoid labrum and capsule are avulsed from the bone,
enabling recurrent dislocations to occur.
In older patients, the capsule is torn – this heals following
reduction; recurrent dislocation less common in older patients.
Posterior dislocations rare: lateral radiograph required for
diagnosis.
Signs and Symptoms: fall on outstretched hand; pain; patient supports arm; arm abducted; loss of normal contour of shoulder.
Check for axillary nerve damage – anaesthesia over skin at insertion of deltoid (badge patch area)
Investigations: Radiograph: humeral head not in contact with glenoid; check for associated # of humeral head and neck.
Treatment: Reduction under GA or IV sedation; two methods to reduce shoulder
, - Kocher’s method: flex elbow to right angle; apply gentle traction in line of humerus; rotate humerus externally using forearm
as lever; adduct humerus across trunk then internally rotate humerus
o Not done in elderly; risk of iatrogenic #
- Hippocratic method: place foot in axilla and pull down on arm; use toes to slip head back into position; confirm position with
radiograph. Immobilize arm in sling for 3 weeks.
Complications:
- Early: axillary nerve damage and associated #s
- Late: stiffness and recurrent dislocations.
- Complete rotator cuff tear in elderly
Recurrent Shoulder Dislocation
Recurrent shoulder dislocations usually follow the following at the time of the original dislocation:
- Bankart lesion: damage to glenoid labrum
- Hills-Sachs lesion: damage to humeral head – radiograph may reveal depression on humeral head
Dislocation occurs on movement of arm, especially if raised and externally rotated.
Treatment:
- Operation: Bankart’s operation – torn glenoid labrum reattached to bone.
- Reconstruction of anterior labrum is Gold Standard; should be carried out arthroscopically.
- Open reconstruction now rare.
Dislocation of the shoulder = common injury, following fall on arm/shoulder; t usually occurs in an anterior direction (Sub-coracoid),
or occasionally posteriorly/inferiorly.
Clinical Features:
- Diagnosis is usually easy in the typical anterior dislocation because of the flattening of the deltoid muscle, which produces a
loss in the curved contour of the shoulder, which therefore becomes ‘squared off’
- The injury is painful and the patient supports the arm against all movement
- Humeral head may be palpable below the coracoid, or in the axilla
- Posterior dislocation: more difficult to diagnosed because the abnormality in contour of the shoulder is less obvious, and X-ray
appearances may be misleading: the rotation of the upper end other humerus produces a ‘light-bulb’ appearance. Dislocation is
best seen on an axillary view if this can be obtained.
- Inferior dislocation (luxation erect) = rare; characterized by fact that arm lies in vertical position alongside the patient’s head. If
there is ever doubt re: possible shoulder joint dislocation, CT scan should be performed.
Complications
- Occasionally, the circumflex (axillary) nerve is damaged paralaysis of the deltoid. This can be checked by testing sensation
over insertion of the deltoid
- Recovery usual
- Brachial plexus/ axillary artery may also be damaged.
Treatment = reduction ASAP; many methods:
1) Patient lies down with arm handing over side of couch; with analgesic injection, muscles gradually relax, allowing the operator
to slip the humeral head back into the joint.
2) Hippocratic method: patient given pain relief and encouraged to relax. With patient supine, surgeon pulls arm down whilst
applying counter-traction in the axilla with his/her foot. This allows reduction of humeral head into the socket.
3) Kocher’s method: elbow is flexed and traction is applied to the arm; the arm is then externally rotated, adducted across the
chest and flexed at the shoulder, and then internally rotated until the forearm touches the chest. There is risk of fracturing the
humerus, and the other methods are generally preferred.
After reduction, X-ray is taken to confirm position and arm is immobilised for 3 weeks in broad sling. Patient is then encouraged to
progressively mobilized the shoulder.
Recurrent dislocation of the shoulder
Occasionally follows one or more traumatic dislocations; more frequent if first shoulder dislocation occurred when the patient was
young.
After several dislocations, defect may be visible in the head (Hill Sachs lesion) or the edge of the glenoid on lateral X-ray film, and at
operation, the cartilaginous glenoid labrum and capsule may be found to be avulsed from the anterior margin of the glenoid (Bankart
lesion)
Treatment:
- Prior to surgical treatment, must confirm direction of dislocation
- Operations to stabilize shoulder are either undertaken as open/arthroscopic (keyhole) procedures.
- In both situations, they involve repairing the damaged capsule and labrum to the glenoid.
Impingement Syndrome of the Shoulder
Mechanical impingement of rotator cuff muscles on the under-surface of the acromion can cause inflammation and pain with overhead
activities.
The insertion of supraspinatus = relatively avascular area susceptible to repeated trauma and degeneration.
Pain may be felt in mid-arc of abduction, with positive impingement tests – shoulder forward flexed 90° and internal rotation impacts
supraspinatus tendon between acromion and greater tuberosity.
Investigations: Radiographs to exclude arthritis, sclerosis of acromion and tuberosity. USS – cuff inflammation and tendinosis. MRI.
Treatment: modification of activity. NSAIDs. Physiotherapy. Subacromial steroid injection. If symptoms persist, athroscopic subacromial
decompression may be required.
Frozen Shoulder
Thought to be due to fibrosis of capsule of shoulder joint.
