- • Fracture Clavicle
- • Malunion Clavicle
- • Nonunion Clavicle
- • ACM Joint Dislocation
- • Injuries of the Acromioclavicular Joint
- • Anterior Dislocation of the Shoulder
- • Posterior Dislocation of Shoulder
- • Recurrent Shoulder Dislocation
- • Complications of Proximal Humeral Fractures
- • Malunion Surgical Neck Fracture
- • Malunion Greater Tuberosity
- • Frozen Shoulder (Periarthritis of the Shoulder)
- • Long Thoracic Nerve Injury
CLAVICLE INJURIES
FRACTURE CLAVICLE
The term clavicle is derived from the Latin root Clavis meaning Key.
Mechanism of Injury
Direct due to fall on the point of the shoulder. This is the most common mode of injury accounting for 91 percent of the cases.
Direct trauma over the clavicle due to RTA, etc. accounts for 8 percent of the cases.
Indirect fall on the outstretched hands accounts for 1 percent of the cases.
Sites of Fracture
- Eighty percent of the fracture clavicle occurs at the junction of middle and outer third
- One percent at medial end of the clavicle
- Lateral end fracture is uncommon.
Clinical Features
Patient presents with pain, swelling, deformity and inability to raise the shoulder. Rarely patient may present with pseudoparalysis of the affected arm.
Radiology
Routine anteroposterior view of the clavicle is sufficient to make a diagnosis most of the times.
Treatment
Conservative Methods
This is the treatment of choice in fracture clavicle and consists of the following methods:
- Cuff and collar sling for undisplaced fractures
- Strapping the fracture site using dynaplast gives good results especially in children and young adults.
- Figure of ‘8’ this is popularly used and it acts by retracting the shoulder girdle, minimizes the overlap and allows more anatomical healing.
Surgery
Surgery is rarely indicated and is considered in the following situations: Open fractures, injury to neurovascular bundle, if the fracture is threatening to penetrate the skin, nonunion, fracture near acromioclavicular joint, and displaced epiphysis in children.
Fixations methods: This could be either by plate and screws, by special intramedullay rods or by K-wire.
Complications of Fracture Clavicle
- Neurovascular injury: The structures commonly injured are subclavian vessels and the medial cord of the brachial plexus through which the ulnar nerve is derived.
- Frozen shoulder: Due to periarthritis of the shoulder joint following prolonged immobilization.
ACM JOINT DISLOCATION
INJURIES OF THE ACROMIOCLAVICULAR JOINT
Acromioclavicular joint is a diarthrodial joint with a fibrocartilaginous disk between the two bones (similar to a meniscus).
Mechanism of Injury
- Direct force: This is the most common mechanism of injury as in RTA, assault, etc.
- Indirect force: It is due to fall on the outstretched hands.
Clinical Features
Patient complains of pain, swelling, and difficulty in raising the arm up. On examination there is tenderness over the lateral end of clavicle and is prominently felt.
Classification
Depending upon the severity of the tear of acromioclavicular and coracoclavicular ligaments, the injury is classified as Grades I to III.
Radiology
Routine anteroposterior view helps clinch the diagnosis while sometimes—special views are called for diagnosis (Figs 1.5 and 1.6).
Treatment
Conservative Methods
Fortunately, most of the ACM injuries are mild and hence can be effectively managed by conservative measures like rest to the part, collar and cuff sling, ice and heat packs, adhesive strapping, etc.
Surgery
Either persistent pain and more severe ligaments tears needs to be tackled surgically by repair, reinforcement or reconstruction of the ligaments or by excision of the lateral end of clavicle in more troublesome cases.
SHOULDER INJURIES
ANTERIOR DISLOCATION OF THE SHOULDER
Shoulder joint is vulnerable for dislocation more often than any other joint in the body.
Mechanism of Injury
- Direct force: A violent direct blow on the posterior aspect of the shoulder can lead to ADS. However, this is not very common.
- Indirect force: A fall on an outstretched hand with the shoulder in abduction and external rotation dislocates the shoulder anteriorly. This is the common method of dislocation.
Clinical Features
An ADS victim writhes with agonizing pain, holds the drooping, abducted and externally rotated shoulder in the opposite hand. The more unlucky ones may complain of loss of sensation on the outer aspect of the upper arm (Regiment Badge sign) due to the injury to the circumflex nerve. ADS present a spectrum of interesting, unmistakable and classical clinical signs like:
- Loss of the normal spherical counter shoulder. An inelegant flat shoulder replaces this.
- An anterior shoulder prominence.
- ADS make it possible for a ruler to be placed straight touching the acromion and the lateral epicondyle of the humerus (Hamilton's ruler test).
- Girth of the axilla is increased (Callaway's test).
- Anterior axillary fold is lower than the posterior (Bryant's test).
Radiology
Proper radiographic techniques help to elicit these above-mentioned lesions explicitly.
Management
All dislocations are emergencies and they need to be put back immediately without any delay and shoulder dislocation is no exception. Closed reduction under general anesthesia is preferred as it not only keeps the 7patient quiet but also ensures adequate muscular relaxation for smoother reduction.
Methods of Closed Reduction
As the forces dislocating the shoulder are many, likewise there is many a method to put it back into position. Our ancestors deprived of today's advanced technical gadgetries, crudely placed a foot into the axial and pulled the shoulder back into position (Hippocrates method). Nowadays, a more refined and scientific technique is in vogue (Kocher's method).
Open Reduction
Open reduction is rarely required and is reserved for specific indications like failed closed reduction.
Complications
These could be recurrent dislocation of shoulder, old unreduced dislocation of the shoulder, frozen shoulder, acute problems like injury to the axillary nerve, etc.
Recurrent Anterior Dislocation of the Shoulder (RDS)
This is a very common complication of anterior dislocation of shoulder and accounts for greater than 80 percent of dislocations of the upper extremity. Age at the time of initial dislocation is an important prognostic factor, recurrence rate being 55 percent in patients 12-to 22-year-old, 37 percent in 23 to 29 years, and 12 percent in 30-to 40-year-old.
Pathological Anatomy
Due to the initial acute dislocation there could be three classical injuries which can later lead to recurrence of the dislocation. No single deformity is responsible for recurrent dislocation of shoulder. Three important reasons have been cited and they have been called the essential lesions.
Triad of Essential Lesion
Hill-Sachs lesion: It is a posterolateral defect in the head of the humerus. This is produced due to the impact of the posterolateral part of the head of the humerus against the sharp anterior margin of the glenoid rim.
Bankart's lesion: Perthes first described this as defect in the anterior part of the glenoid labrum and the anterior capsule. If this defect does not heal properly or heals in elongated position, it results in RDS.
Erosion of anterior rim of glenoid cavity: External rotation of the shoulder in abducted position pops out the head of the humerus from the glenoid cavity due to the lax anterior capsular structures. The posterolateral defect now encounters glenoid rim and is levered out of the socket, producing dislocation. Since, no single factor is responsible for every recurrent dislocation, no single operative procedure can be applied to every patient.
Clinical Features
During the abduction activities of the shoulder, the joint may suddenly and unexpectedly give way and all the features of anterior dislocation of the shoulder mentioned earlier could be seen however with lesser intensity.
Investigations
Plain X-ray of the shoulder, CT scan, MRI, etc. helps to study the triad of lesion in RDS.
Treatment
There is no role of conservative treatment in recurrent dislocation of shoulder. Patient is advised to avoid abduction and external rotation of the shoulder. However, surgery is the treatment of choice and is indicated if the patient has more than three episodes of RDS. More than 150 operations are devised. Few are mentioned here. All the surgeries aim at correction of the essential lesions and prevent external rotation of the arm.
Arthroscopic Repair
These are the days of minimally invasive surgeries. It is possible now to carry out the Bankart's repair through athroscopy. It is less invasive leading to less morbidity and faster recovery and rehabilitation.
POSTERIOR DISLOCATION OF SHOULDER
RECURRENT SHOULDER DISLOCATION
Refer Figures 1.15 to 1.17.
COMPLICATIONS OF PROXIMAL HUMERAL FRACTURES
This is common in elderly patients and it accounts for 4 to 5 percent of all fractures.
Mechanism
- Fall on outstretched hands is the classical history.
- Blow on the lateral side of the arm is the other mode of injury.
Classification
Four segments are described with respect to proximal humerus. They are:
- Anatomical neck.
- Greater tuberosity.
- Lesser tuberosity.
- Shaft or surgical neck of the humerus.
Neer has proposed a classification for fractures of the proximal humerus based on this 4-segment concept.
How Malunion of Proximal Humerus can Happen
Due to the various displacing muscle forces acting on the proximal humerus as shown in the Figure 1.18.
Clinical Features
The patient complains of pain, swelling of the proximal arm and other features of fractures. Movements of the shoulder joint are grossly restricted.
Investigations
- Plain X-rays of the shoulder: Trauma series consists of AP, lateral, and axillary view of shoulder joint in scapular plane.
- Laminagrams to judge the articular defects.
- CT scan helps to study the fracture lines with greater accuracy.
Management
- Conservative treatment consists of rest, NSAIDs, sling, ice and heat therapy in the initial stages. Since, 80 percent of the fractures are minimally displaced, early motion of the shoulder is the mainstay of treatment to prevent stiffness of the joint. Pendulum exercises, elevation, pulley, external and internal rotation and wall climbing exercises are some of the recommended methods, in the later stages.
- Operative treatment consists of rigid internal fixation of displaced fracture of the proximal humerus in older patients with a blade-plate device and this provides sufficient primary stability to allow early functional treatment. Badly comminuted fractures need Neer's prosthetic replacement or total shoulder arthroplasty.
- Greater tuberosity fracture of the humerus: This fracture is more commonly seen in adults and is due to the fall on the joint of the shoulder. Rarely it could be due to avulsion of the supraspinatus muscle. Patient complains of pain, swelling and inability or difficulty to abduct the shoulder. Plain X-rays help to study the displacement and angulation of the tuberosity. Conservative treatment is by cuff and collar, sling, etc. suffices for undisplaced or minimally displaced fractures. Abduction splints or ORIF is reserved for displaced fractures. Malunion and frozen shoulder could be a trouble some late complications (see Figs 1.21A to E).
- Surgical neck fractures are commonly seen is frail elderly women and is due to trivial fall on the point of the shoulder. However, unlike fracture neck of femur, this fracture is frequently impacted and generally heals well by simple conservative methods take sling. Displaced fractures required closed reduction and percutaneous K-wire fixation or rarely open reduction and rigid internal fixations. Axillary nerve injury may occur and is identified by the loss of sensation in the regiment bandage area. Frozen shoulder and Malunions are another important complications (Figs 1.19 and 1.20).
MALUNION SURGICAL NECK FRACTURE
Refer Figures 1.19 and 1.20.
MALUNION GREATER TUBEROSITY
Refer Figures 1.21A to E.
FROZEN SHOULDER (PERIARTHRITIS OF THE SHOULDER)
This is a condition where there is pain and restriction of the shoulder joint movements both active and passive due to pericapsular adhesions following a brief period of immobilization of the shoulder joint.
Relevant History
- Patient is usually elderly male or female (more common)
- Pain is a predominant complaint in the initial stages
- Painful restriction of shoulder movements especially abduction and internal rotation
- There could be history of trauma to the shoulder or wrist fracture
- There could be history of diabetes
- Patient will be unable to carry out activities like buttoning the blouse, combing the hair, scrubbing the back during bath, etc.
- Difficulty in sleeping over the affected side.
Relevant Clinical Findings
- Tenderness over the affected shoulder
- Restricted abduction and internal rotation (both active and passive) (Figs 1.22A and B)
- Accessory joint play is reduced
- Resistive tests are generally pain free.
Relevant Investigations (Fig. 1.22C)
Plain X-ray may show Golding's sign (sclerosis on the outer edge of the greater tuberosity). Arthrogram is another useful investigation.
Treatment in a Nutshell
- Conservative treatment: Painkillers, physiotherapy, shoulder rehabilitation exercises, etc. Manipulations of the shoulder joint under GA could be tried.
- Surgical treatment: Arthroscopic release of the shoulder adhesions is a useful method.
LONG THORACIC NERVE INJURY
Winging of the Scapula
Highlights
- It is also called as scapula alta
- Here the medial border of the scapula is positioned laterally and posteriorly
- It is called as winged scapula because the inferior angle of the scapula protrudes backwards instead of lying flat.
Causes
- Weakness of the serratus anterior muscles
- Impingement of the long thoracic nerve
- Damaged trapezius muscle or denervation of its nerve supply
- This may be due to injury to the above structures due to repetitive lifting, fall on the shoulders, sports injuries, brachial plexus neuropathies, iatrogenic division of the long thoracic nerve, severe traumatic depression of the shoulder, fascioscapulohumeral dystrophy, fall from the bike, etc.
Relevant Clinical Findings
- Classical winged deformity
- On pushing against the wall the scapula stands out prominently (Fig. 1.23)
- There may be difficulty in lifting the arm above the head.
Treatment in a Nutshell
- Conservative treatment consists of physiotherapy, exercises and shoulder rehabilitation.
- Surgical treatment is recommended in resistant cases. The recommended procedures are pectoralis major muscle transfer in isolated serratus anterior palsy or scapulodesis in failed transfers.