Injuries of the Shoulder Girdle

Question 1

What three anatomical joints make up the shoulder girdle?

Answer 1

The sternoclavicular joint, acromioclavicular joint, and glenohumeral joint.

Question 2

What are the two main causes of acute injuries to the shoulder girdle?

Answer 2

High energy impact (fall, road traffic accidents, sports injuries) and

Low energy fall in patients with weak bones.

Question 3

Which is the most common joint dislocation in the human body?

Answer 3

Glenohumeral shoulder dislocation.

Question 4

How are sternoclavicular dislocations classified?

Answer 4

They are divided into anterior and posterior dislocations

Question 5

Which type of sternoclavicular dislocation carries higher risk of damage to retrosternal structures?

Answer 5

Posterior dislocation.

Question 6

What structures may be damaged in posterior sternoclavicular dislocations?

Answer 6

Subclavian vessels and other retrosternal structures (e.g. great vessels, trachea, esophagus, etc.).

Question 7

anterior dislocation of the sternoclavicular joint is associated with which injuries ?

Answer 7

pneumothorax

hemothorax

rib fractures

pulmonary contusion

Question 8

posterior dislocation of the sternoclavicular joint is associated with which injuries?

Answer 8

subclavian vascular injury

pneumothorax

esophageal injury

cardiac arrhythmias

brachial plexus injury

tracheal injury

Question 9

What are three possible clinical presentations of posterior sternoclavicular dislocation due to pressure on vital structures?

Answer 9

Hoarse voice, 2) Stridor, 3) Compromised neurovascular status of the upper limb.

Question 10

what could be presentation of anterior dislocation of the SCJ?

Answer 10

Anterior dislocation causes a palpable deformity

Question 11

What radiographic investigation is required for sternoclavicular joint injury?

Answer 11

Dedicated sternoclavicular joint radiographic views of both joints.

Question 12

what are the x ray features of SCJ dislocation ?

Answer 12

joint space widening at the sternoclavicular joint

more easily identified on an angled view, on this view inferior displacement of the medial head of the clavicle is indicative of a posterior dislocation, whereas superior displacement of the clavicle indicates an anterior dislocation

Question 13

What is the management of acute anterior sternoclavicular dislocations?

Answer 13

Treatment with a simple arm sling or a collar and cuff for two weeks and early return to function.

Question 14

What is the proper management of posterior sternoclavicular joint dislocation?

Answer 14

1)Admit to trauma ward,
2) Prepare for surgery, 3) Attempt closed reduction by a team of cardiothoracic and orthopedic surgeons
4) If closed reduction fails, proceed to open reduction and surgical stabilization.

Question 15

Which demographic is commonly affected by acromioclavicular dislocations?

Answer 15

Young adults

Question 16

What are common mechanisms of injury for acromioclavicular dislocations?

Answer 16

Falls from heights or contact sports injuries.

Question 17

What are red flags in acromioclavicular dislocations requiring urgent referral?

Answer 17

Threatened skin overlying the clavicle and neurovascular compromise

Question 18

How is treatment of acromioclavicular dislocations determined?

Answer 18

Mainly by the severity of the displacement of the clavicle (up to 100% or more than 100%)

Question 19

What is the management for acromioclavicular dislocations with up to 100% displacement?

Answer 19

Immobilization in a sling and referral for orthopedic review.

Question 20

When is surgical management typically warranted for acromioclavicular dislocations?

Answer 20

When there is >100% displacement

Question 21

What are the typical complications in patients younger than 30 years with shoulder dislocations?

Answer 21

Recurrent instability.

Question 22

What complications are likely in patients older than 40 years with shoulder dislocations?

Answer 22

Acute rotator cuff tear or avulsion fracture of the greater tuberosity.

Question 23

What must be excluded during clinical examination of shoulder dislocations?

Answer 23

Brachial plexus injury, axillary nerve injury, and vascular injury.

Question 24

How does the humeral head typically displace in anterior dislocations on X-rays?

Answer 24

Medially and inferiorly.

Question 25

What radiographic sign is associated with posterior shoulder dislocations on AP view?

Answer 25

The 'light bulb' sign.

Question 26

Which radiographic views are essential to assess shoulder dislocations?

Answer 26

AP, Y-view (lateral X-ray of the shoulder), and modified axillary view

Question 27

What method should be used to relocate a dislocated shoulder?

Answer 27

Inline traction (Hippocratic method) under conscious sedation

Question 28

Explain the process of the Hippocratic method for reducing an anterior shoulder dislocation.

Answer 28

The Hippocratic method for shoulder reduction involves: 1. Position the patient supine on the examination table 2. Remove the patient's shoe on the affected side 3. Place a sheet around the patient's chest/axilla for countertraction 4. The physician places their foot (without shoe) in the patient's axilla, with the heel against the chest wall to act as a fulcrum 5. Apply gentle, steady longitudinal traction to the arm by pulling on the wrist/forearm 6. Maintain traction for 5-10 minutes to allow for muscle fatigue 7. As muscles relax, gradually increase the traction force while adducting the arm slightly 8. Apply gentle external rotation if needed 9. The humeral head should slide back into the glenoid with an audible or palpable clunk 10. Perform post-reduction neurovascular assessment 11. Obtain post-reduction radiographs to confirm proper reduction 12. Immobilize the shoulder in a sling

Question 29

What must be done after relocating a dislocated shoulder?

Answer 29

Repeat and document neurovascular assessment.

Question 30

When should orthopedic input be sought before attempting reduction of a shoulder dislocation?

Answer 30

In cases of fracture-dislocations.

Question 31

At what point should patients with dislocated shoulders be reassessed, and what should be checked for?

Answer 31

At two weeks, they should be reassessed for residual instability or traumatic rotator cuff tear (ideally with ultrasound or MRI).

Question 32

What are two other rare forms of shoulder dislocations?

Answer 32

1) Acute traumatic inferior dislocation and 2) Multidirectional instability (often due to generalized ligamentous laxity).

Question 33

What is the initial treatment for all acute shoulder dislocations?

Answer 33

Emergency room or sports field relocation followed by a course of physical therapy.

Question 34

Which patients with shoulder dislocations should be referred to an orthopedic surgeon?

Answer 34

Patients presenting with recurrent dislocations or patients younger than 20 years involved in contact sports.

Question 35

What is the standard management for most clavicle fractures?

Answer 35

Immobilization in an arm sling for 4 to 6 weeks and early gradual return to function.

Question 36

How long does full healing of clavicle fractures typically take?

Answer 36

8-12 weeks

Question 37

What are the absolute indications for surgery in clavicle fractures?

Answer 37

1.Open fracture 2.skin tenting, 3. neurovascular injury requiring repair 4. symptomatic non-unions after conservative treatment.

Question 38

What are the relative indications for surgery in clavicle fractures?

Answer 38

Multiple fractures, and patient's work or leisure requirements.

Question 39

What radiographic findings might indicate the need for surgical intervention in clavicle fractures

Answer 39

100% displacement, less than 50% apposition, and valgus or varus deformity of more than 30 degrees.

Question 40

How are proximal humerus fractures defined anatomically?

Answer 40

Fractures proximal to the surgical neckline.

Question 41

What is the standard treatment for the majority of proximal humerus fractures?

Answer 41

Conservative treatment in an arm sling or collar and cuff.

Question 42

List at least four indications for surgical intervention in proximal humerus fractures.

Answer 42

1. Open fractures, 2. fracture-dislocation, 3. displaced articular segment split fractures 4. pathological fractures 5. fractures which have failed conservative treatment.

Question 43

What radiographic findings suggest a proximal humerus fracture may have failed conservative treatment?

Answer 43

100% displacement and less than 50% apposition.

Question 44

A 25-year-old rugby player presents with pain and visible deformity at the acromioclavicular joint after a tackle. X-rays show 120% displacement. What is the appropriate management?

Answer 44

This patient will likely require surgical management due to >100% displacement at the acromioclavicular joint

Question 45

A 50-year-old presents after a fall with pain and inability to move their shoulder. X-ray shows a "light bulb" appearance of the humeral head. What is your diagnosis and initial management?

Answer 45

This is likely a posterior shoulder dislocation. Management includes obtaining complete imaging (AP, Y-view, and modified axillary view), followed by reduction under conscious sedation using inline traction, then post-reduction neurovascular assessment.

Question 46

A 65-year-old with osteoporosis presents with a displaced midshaft clavicle fracture after a simple fall. What is the typical management approach?

Answer 46

Immobilization in an arm sling for 4-6 weeks with early gradual return to function, expecting full healing in 8-12 weeks.

Question 47

A 30-year-old presents with recurrent shoulder dislocations since an initial sports injury 2 years ago. What is the appropriate management plan?

Answer 47

Refer to an orthopedic surgeon for reassessment and further treatment, as recurrent dislocations often require surgical stabilization.

Question 48

A patient presents after a motor vehicle accident with a hoarse voice, stridor, and limited arm movement. What specific joint injury should you suspect and how would you manage it?

Answer 48

Suspect a posterior sternoclavicular dislocation. Management includes obtaining dedicated sternoclavicular joint radiographic views, admission to trauma ward, and preparation for closed reduction by a team of cardiothoracic and orthopedic surgeons, with open reduction and stabilization if closed methods fail.