Chapter 28- injuries of the shoulder girdle

Question 1

What does the shoulder girdle consist of

Answer 1

Clavicle and scapula

Question 2

What is the typical history of a clavicle fracture

Answer 2

• Common in children and adults
• Occur following a fall onto the shoulder or outstretched arm
• May also occur due to direct trauma

Question 3

Signs of clavicle fracture

Answer 3

• tenderness and swelling/ deformity over the fracture- usually at the junction of middle and outer third of the clavicle
• Affected arm supported by the other hand
• Decreased range of motion of whole arm

Question 4

What xrays should be sone in suspected clavicle fracture

Answer 4

• Plain AP Xray and another at 45 degree tilt

Question 5

Treatment of clavicle fracture

Answer 5

• Support the weight of the arm in a shoulder immobilzer which supports the elbow and the arm for 6 weeks
• Patients usually feel the most comfortable in a figure of 8 splint

Question 6

When is surgery indicated in a clavicle fracture

Answer 6

• bony spikes threatening or piercing overlying skin
• open fractures
• Compression/ laceration of subclavian vessels or brachial plexus
• 1.5 cm displacement, no cortical contact and comminution

Question 7

typical history of acromio-clavicular joint injuries

Answer 7

• compression to lateral part of the shoulder

- Patient will complain of pain over the outer end of the clavicle and pain on movement of the arm

Question 8

signs on examination of acromiclavicular injuries

Answer 8

• swelling, tenderness and a visible/ palpable step over the outer end of the clavicle
• Reduced range of movement of the shoulder and the arm

Question 9

What are the two ligaments joining the clavicle to the acromion?

Answer 9

conoid and trapezoid ligaments

Question 10

name and describe the grades of acromio-clavicular joint injuries

Answer 10

Grade 1: sprain- local tenderness over the joint but no displacement, both the capsule and ligaments are intact
Grade 2: Subluxation- Joint capsule is torn but the ligaments remain intact/ stretched
Grade 3: dislocation- capsule and ligaments are torn allowing outer end of the clavicle to displace superiorly
Grade 4, 5, 6: Occasionally the end of the clavicle can displace very widely either inferiorly, superiorly or posteriorly

Question 11

Treatment of acromio-clavicular joint injuries

Answer 11

Grade 1: Treat symptomatically for pain with arm sling and analgesics/ anti-inflammatory agents
Grade 2: Relieve the weight of the arm on the AC joint by supporting the arm in a shoulder immobilizer. Analgesia and anti-inflammatories until the pain has subsided
Grade 3: Treat as grade 2
Displacement greater than 3- surgery is reccommended

Question 12

typical history in the sternoclavicular dislocation

Answer 12

• Anterior dislocation caused by a fall on the shoulder
• Posterior dislocation is due to direct blow to clavicle
• Patient presents with pain over the sterno-clavicular joint accentuated by movement of the arm

Question 13

Findings on examination of sterno-clavicular dislocations

Answer 13

• Anterior:
• fullness or bump over the affected SC joint
• Under anaesthesia, medial end of the clavicle can be balloted back and forth or sprung like a piano key. *decrease range of movement of the arm due to pain, especially adduction and elevation
• Posterior:
• Depression/ step over the affected SC joint
• Medial end of clavicle displaced posteriorly and can compress vascular structures in the mediastinum

Question 14

What investigations should be done in suspected Sternoclavicular dislocations

Answer 14

• Xray: serendipity view

- CT scan (gold standard)

Question 15

Treatment of sternoclavicular dislocations

Answer 15

• anterior: Reduce by putting pressure on medial end of clavicle and retraction to the scapula. Figure of 8 may help to keep the reduction
• Posterior: Refer for reduction. If this is not possible; sandbag placed under the shoulders and a sharp pointed towel clip used to grasp the end of the clavicle and pull it forward. If unstable – surgery

Question 16

typical history of fracture to the scapula

Answer 16

direct, high energy trauma to chest wall

Question 17

Examination findings and treatment of fractures to the blade of scapula

Answer 17

• Pain, swelling and bruising over the chest wal in the region of the scapula
• Decreased range of movement of the shoulder
• Treated symptomatically for pain with analgesia, shoulder immobilizer and anti-inflammatory agents

Question 18

Examination findings and treatment of fractures to the glenoid and neck

Answer 18

• arthritic change if involvement of articular surface
• Pain and limitation of movement of the shoulder joint
• Should be evaluate by specialist for possible operative management

Question 19

Examination findings and treatment of fractures to the spine of the scapula

Answer 19

• pain and bruising psoteriorly over the spine of the scapula
• Treat symptomatically

Question 20

Examination findings and treatment of fractures to the acromion of the scapula

Answer 20

• Pain and swelling over the acromion, outer end of the clavicle and the AC joint area
• Depression of the fracture fragment may cause impingement of the rotator cuff
• If displaced require surgery
• Late problems may be treated with acromioplasty

Question 21

Examination findings and treatment of fractures to the coracoid

Answer 21

• Avulsion fractures result in pain on contracting the biceps
• Displacement of >1cm - should be surgically replaced and fixed with a screw

Question 22

What may a fracture of the blade of the scapula indicate

Answer 22

• Severe intra-thoracic, thoracic spine and other injuries in 80 percent of patients

Question 23

How does one delineate articular involvement in fractures of the glenoid

Answer 23

CT scan

Question 24

What XRay view should be requested for neck and glenoid fractures

Answer 24

Lateral scapular view

Question 25

Typical history of anterior shoulder dislocation/ subluxation

Answer 25

- Forcible abduction/ external rotation - Anterior subluxation seen in throwing activities --> dead arm syndrome - Traction on brachial plexus may cause temporary numbness of the arm - Patient presents with pain and inability to move the shoulder in any direction

Question 26

Findings on examination of anterior shoulder dislocation

Answer 26

``` Flattened/ hollow contour of shoulder Arm supported by the patient Fullness below the coracoid anteriorly Painful limitation of all shoulder movements Squaring of shoulder ```

Question 27

How do you test function of axillary nerve (should be done in any anterior dislocation of the shoulder)

Answer 27

Test deltoid contraction and sensation over the deltoid muscle

Question 28

Which Xray views should be requested in anterior dislocation of the shoulder

Answer 28

- AP view - Lateral scapula view - Modified axillary view

Question 29

what methods are available to reduce anterior dislocation of the shoulder

Answer 29

- Kocher manoeuver - Hippocratic method - Modified Milch

Question 30

complications of anterior shoulder dislocation

Answer 30

recurrent dislocation Rotator cuff tears injury to the axillary nerve

Question 31

Typical history of posterior shoulder dislocation

Answer 31

- Forced internal rotation or blow to the front of the shoulder - Seen following epileptic fits or electric shocks - Painful limitation of active and passive movement, particularly external rotation

Question 32

Examination findings of posterior shoulder dislocation

Answer 32

- shoulder contour does not look abnormal - Fullness posteriorly in thin patient - Inability to abduct and externally rotate actively and passively

Question 33

Signs of Posterior shoulder dislocation on AP xray

Answer 33

- Empty glenoid sign | - Light bulb shape of the humeral head

Question 34

Treatment of posterior shoulder dislocation

Answer 34

-Manipulation under anaesthesia or sedationand adequate muscle relaxation, and immobilization of the arm in external rotation