Transcript Injuries of the shoulder, upper arm and elbow

Injuries of the shoulder
Dr. Ammar Talib Al- Yassiri
College of Medicine / Baghdad
University
Objectives
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FRACTURES OF THE CLAVICLE
FRACTURES OF THE SCAPULA
ACROMIOCLAVICULAR JOINT INJURIES
STERNOCLAVICULAR DISLOCATIONS
DISLOCATION OF THE SHOULDER
FRACTURES OF THE CLAVICLE
• In children
– fractures easily
– unites rapidly.
• In adults
– much more troublesome
– common.
• Fractures of the midshaft > lat.
Fractures>med.fractures
Mechanism of injury
• A fall on the shoulder or the outstretched
hand
• In the common mid-shaft fracture
• In fractures of the outer end
Clinical features:
• The arm is clasped to the chest
• A subcutaneous lump
• it is prudent to feel the pulse and gently to
palpate the root of the neck
• Outer third fractures are easily missed or
mistaken for acromioclavicular joint injuries.
Imaging:
• requires at least an AP view and another taken
with a 30 degree cephalic tilt.
• middle third of the bone
• Fractures of the outer third may be missed
• medial third fractures it is also wise to obtain
x-rays of the sterno-clavicular joint
Classification:
• Clavicle fractures are usually classified on the
basis of their location:
– Group I (middle third fractures),
– Group II (lateral third fractures) and
– Group III (medial third fractures).
Treatment:
• MIDDLE THIRD FRACTURES:Non-operative
management (sling for 1-3 WKs)
• LATERAL THIRD FRACTURES
– minimally displaced : sling for 2–3 weeks
– Displaced lateral third fractures: surgery
• MEDIAL THIRD FRACTURES: non operatively
Complications
• EARLY
– Injury to the vital structures,
• a pneumothorax,
• damage to the subclavian vessels and
• brachial plexus injuries are all very rare.
• LATE
– Non-union:
• Risk factors
– increasing age,
– displacement,
– comminution
– female sex.
• Symptomatic non-unions are generally treated with plate fixation and bone grafting
if necessary.
– Malunion : All displaced fractures heal in a nonanatomical position with some
shortening and angulation, however most do not produce symptoms.
– Stiffness of the shoulder This is common but temporary; it results from fear of
moving the fracture.
FRACTURES OF THE SCAPULA
• Mechanisms of injury
– The body of the scapula
– The neck of the scapula
– The coracoids process
– Fracture of the acromion
– Fracture of the glenoid fossa
Clinical features
• The arm is held immobile
• severe bruising over the scapula or the chest
wall.
• fractures of the body of the scapula are often
associated with severe injuries to the chest,
brachial plexus, spine, abdomen and head.
• Careful neurological and vascular
examinations are essential
• X-Ray:
– a comminuted fracture of the body of the scapula,
– a fractured scapular neck with the outer fragment
pulled downwards by the weight of the arm.
– Occasionally a crack is seen in the acromion or the
coracoid process.
– CT is useful for demonstrating glenoid fractures or
body fractures
Treatment
• Body fractures:
• Isolated glenoid neck fractures
• Intra-articular fractures if displaced, >1/3 of the glenoid
surface and is displaced by >5 mm surgical fixation should be
considered.
• Fractures of the acromion
– Undisplaced fractures are treated non-operatively.
– Displaced fracture require operative intervention to
restore the anatomy.
• Fractures of the coracoid process
– distal to the coracoacromial ligaments (conservative)
– proximal to the ligaments (operative)
• Combined fractures ‘floating shoulder’ At least one of the
injuries (and sometimes both) will need operative fixation
ACROMIOCLAVICULAR JOINT INJURIES
• Mechanism of injury: A fall on the shoulder
with the arm adducted
• Pathological anatomy and classification:
– Type I
– Type II
– Type III
– Type IV
– Type V
– Type VI
Clinical features:
• point to the site of injury
• area may be bruised.
• If there is tenderness but no deformity, the
injury is probably a sprain or a subluxation.
• With dislocation the patient is in severe pain
and a prominent ‘step’ can be seen and felt.
• Shoulder movements are limited.
X-ray:
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anteroposterior,
cephalic tilt and are advisable.
axillary views
a stress view is sometimes helpful in
distinguishing between a Type II and Type III
injury:
Treatment:
• Sprains and subluxations the arm is rested in a
sling until pain subsides (usually no more than a
week) and shoulder exercises are then begun.
• conservative treatment for a straight forward
Type III injury.
• Operative repair should be considered only for
– patients with extreme prominence of the clavicle,
– those with posterior or inferior dislocation of the
clavicle and
– those who aim to resume strenuous overarm or
overhead activities.
STERNOCLAVICULAR DISLOCATIONS
• Mechanism of injury:
– uncommon injury
– lateral compression of the shoulders;
– rarely, it follows a direct blow to the front of the
joint.
– Anterior dislocation is much more common than
posterior.
– The joint can be sprained, subluxed or dislocated.
Clinical features:
• Anterior dislocation
– prominent bump over the sternoclavicular joint.
– painful
– no cardiothoracic complications.
• Posterior dislocation, though rare, is much more
serious.
– Discomfort is marked; there may be pressure on the
trachea or large vessels, causing venous congestion of the
neck and arm and circulation to the arm may be
decreased.
• X-Ray: plain x-rays are difficult to interpret. Special
oblique views are helpful and CT is the ideal method.
Treatment:
• Anterior dislocation
• Posterior dislocation should be reduced as
soon as possible.
• After reduction, the shoulders are braced back
with a figure-of-eight bandage, which is worn
for 3 weeks.
DISLOCATION OF THE SHOULDER
• AETIOLOGY: Of the large joints, the shoulder is
the one that most commonly dislocates. This
is due to a number of factors:
– the shallowness of the glenoid socket;
– the extraordinary range of movement;
– underlying conditions such as ligamentous laxity
or glenoid dysplasia; and
– the sheer vulnerability of the joint during stressful
activities of the upper limb.
ANTERIOR DISLOCATION
• Mechanism of injury:
– Dislocation is usually caused by a fall on the hand.
– The head of the humerus is driven forward,
tearing the capsule and producing avulsion of the
glenoid labrum (the Bankart lesion). Occasionally
the posterolateral part of the head is crushed
Clinical features:
• Pain is severe.
• The patient supports the arm with the
opposite hand and is loathe to permit any kind
of examination.
• The lateral outline of the shoulder may be
flattened and,
• The arm must always be examined for nerve
and vessel injury before reduction is
attempted.
X-Ray:
• The anteroposterior x-ray will show the
overlapping shadows of the humeral head and
glenoid fossa, with the head usually lying
below and medial to the socket.
• A lateral view aimed along the blade of the
scapula will show the humeral head out of line
with the socket.
Treatment:
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In a patient who has had previous dislocations, simple traction on the arm
may be successful. Usually, sedation and occasionally general anaesthesia
is required. With
Stimson’s technique,
Hippocratic method,
Kocher’s method,
An x-ray is taken to confirm reduction and exclude a fracture.
When the patient is fully awake, active abduction is gently tested to
exclude an axillary nerve injury and rotator cuff tear. The median, radial,
ulnar and musculocutaneous nerves are also tested and the pulse is felt.
The arm is rested in a sling for about three weeks in those under 30 years
of age (who are most prone to recurrence) and for only a week in those
over 30 (who are most prone to stiffness).
Then movements are begun, but combined abduction and lateral rotation
must be avoided for at least 3 weeks.
Complications
• EARLY:
– Rotator cuff tear:
– Nerve injury: The axillary nerve is most commonly injured.
Occasionally the radial nerve, musculocutaneous nerve,
median nerve or ulnar nerve can be injured.
– Vascular injury: The axillary artery may be damaged,
particularly in old patients with fragile vessels.
– Fracture-dislocation:
• LATE
– Shoulder stiffness
– Unreduced dislocation:
– Recurrent dislocation:
POSTERIOR DISLOCATION OF THE
SHOULDER
• rare, accounting for < 2 % of all dislocations around the shoulder.
• Mechanism of injury:
– Indirect force producing marked internal rotation and adduction
– Posterior dislocation can also follow a fall on to the flexed, adducted
arm.
• Clinical features: The diagnosis is frequently missed
– The arm is held in internal rotation and is locked in that position.
– The front of the shoulder looks flat with a prominent coracoid, but
– swelling may obscure this deformity;
– seen from above, however, the posterior displacement is usually
apparent.
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• X-Ray:
–AP film (like an electric light bulb), (the
‘empty glenoid’ sign).
–A lateral film and axillary view is
essential; it shows posterior
subluxation or dislocation and
sometimes a deep indentation on the
anterior aspect of the humeral head.
• Treatment:
– The acute dislocation is reduced (usually under
general anaesthesia)
– If reduction feels stable the arm is immobilized in
a sling; otherwise the shoulder is held widely
abducted and laterally rotated in an airplane type
splint for 3–6 weeks to allow the posterior capsule
to heal in the shortest position.
– Shoulder movement is regained by active
exercises.
• Complications
– Unreduced dislocation:
• At least half the patients with posterior dislocation have
‘unreduced’ lesions when first seen up to two thirds of
posteriordislocations are not recognised initially.
• Typically the patient holds the arm internally rotated; he cannot
abduct the arm more than 70–80 degrees, and if he lifts the
extended arm forwards he cannot then turn the palm upwards.
• If the patient is young, or is uncomfortable and the dislocation
fairly recent, open reduction is indicated. Late dislocations,
especially in the elderly, are best left, but movement is
encouraged.
– Recurrent dislocation or subluxation: Chronic posterior
instability of the shoulder is discussed later