Shoulder and humerus injuries

Sternoclavicular sprains and dislocations

• Anatomy
  • Least bony stability but remarkably stable due to surrounding ligaments
  • Medial clavicular epiphysis is the last to ossify (18yo) and last to fuse (25yo)
  • Apparent dislocations in children and young adults are typically Salter-Harris I or II fractures with anterior or posterior dislocation of clavicular metaphysis requiring orthopaedic consult

SC joint sprain and dislocation

• Clinical features
  • Posterior dislocation
    • Direct blow or indirect force to shoulder, causing shoulder to roll forward at time of impact
  • Anterior dislocation
    • Indirect force to shoulder causing it to roll backwards at moment of impact
  • Severe pain, exacerbated by arm motion or lying supine
  • Posterior dislocations may have stridor, dysphagia or SOB

SC joint sprain and dislocation

• Diagnosis
  • Immediate CXR rules out pneumothorax, haemothorax, pneumomediastinum
  • CT is the imaging of choice to identify fracture/dislocation
  • Contrast aids diagnosis of associated superior mediastinal structure injury
• SC joint sprain
  • Ice, sling, analgesics
  • If non-traumatic, consider septic arthritis (especially in IVDU) and USS can aid in identification of a joint effusion and aspiration

SC joint sprain and dislocation

• Anterior SC joint dislocations
  • If uncomplicated – D/c without reduction as no impact on fx
    • Splinting, ice, analgesics, sling and ortho f/u
  • Closed reduction, within 10 days of injury, lie supine with towel between scapulae. Arm abducted to 90 degrees, longitudinal traction on arm with slight extension at shoulder and pressure over medial end of clavicle
  • Usually unstable and 50% redislocate anyway
• Posterior SC joint dislocation
  • Can be life-threatening
  • Ortho consult immediately for closed or open reduction
  • Open reduction should be performed in OR with trauma or vascular surgery available

Clavicle fractures

• Middle third
  • Most common. Often managed non-operatively, however, fixation may provide improved functional outcomes and  lower rates of non-union and malunion
  • Refer to ortho in ED if:
    • Severely comminuted, athletes, impact on employment and/or cosmetic concerns
  • Conservative treatment in broad-arm sling for 4-8 weeks until no longer painful with # clinic follow-up
    • 3-4 weeks young children; 4-6 weeks older children; 6-8 weeks in adults
    • Limitation of activity for 8 weeks to avoid re-fracture
    • Non-union rate for conservative Rx may be as high as 15-20%
    • Figure of 8 more uncomfortable; Collar and cuff may worsen angulation

Clavicle fractures

• Middle third
  • Can use arm as tolerated but avoid direct contact
  • Encourage daily ROM and shoulder within 3-5 days max
  • Risks for non-union
    • Initial shortening >2cm
    • Comminuted
    • Displaced >100%
    • Significant trauma
    • Female
    • Elderly

Clavicle fractures

• Distal third (Neer classification)
  • Type I – Distal to coracoclavicular ligaments and intact ligaments
    • Manage conservatively in sling with primary care follow-up in 1-2 weeks
  • Type II – Same but coracoclavicular ligaments disrupted with upward displacement of proximal aspect of clavicle
    • May require operative intervention to avoid non-union
  • Type III – Intra-articular fractures through AC joint
    • Manage conservatively in sling with primary care follow-up in 1-2 weeks

Clavicle fractures

• Proximal third
  • Often high mechanism and associated thoracic trauma
  • CT for diagnosis + associated injuries
  • Emergency referral tas any posterior displacement compromises mediastinal structures
  • Refer for ortho f/u within 1-2 weeks if not posteriorly displaced in a sling

Clavicle fractures

• Operative Rx
  • Becoming more common
  • Patient satisfaction greater (84%)
  • Reduction in non-union rate (2.2% vs. up to 20%)
  • Marginal benefit in middle third (Cochrane)
  • Possible indications
    • Open fracture of middle 1/3
    • Severe angulation or complete displacement of middle third
    • Mid-shaft fractures causing NV compromise
    • Displaced Neer Class II distal third fractures

Scapula fractures

• 2-5% mortality rate due to high trauma
• FOOSH can result in glenoid neck neck fracture
• Always assess for associated thoracic injuries given high forces required for fracture
• Rx – Sling, ice, analgesics, early ROM
• Surgery for significantly displaced articular fractures of glenoid, angulated glenoid neck fractures, acromial fractures with rotator cuff tear and coracoid fractures
• Disability more likely with glenoid, acromion or coracoid #
• Refer for ortho f/u

Scapula fractures

• Associated injuries (90%)
  • Rib fractures 52%
  • Pulmonary contusion 41%
  • Pneumothorax 32%
  • Head injury 34%
  • Spinal fracture 29%
  • Vascular injury 11%
  • Brachial plexus injury 5% (75% resolve)

Scapulothoracic dislocation

• Requires massive force to dislocate off thoracic wall with disruption to subclavian/axillary vessels and brachial plexus
• CXR shows lateral displacement of scapula (>1cm) + associated clavicle fractures, AC disruption, sternoclavicular dislocation
• Flail extremity seen in 52%
  • Complete motor and sensory loss of limb
• Ipsilateral brachial plexus injury in 90%
• Mortality rate of 10%
• Perform CT

AC joint injuries

• Anatomy
  • Coraclavicular ligaments consist of two parts:
    • Lateral trapezoid
    • Medial conoid ligament
    • Provide vertical stability
  • AC ligaments provide vertical stability
• Clinical features
  • Tenderness and deformity compared to contralateral side
• Diagnosis
  • AC radiographs require 1/3 penetration and should be ordered
  • Stress radiographs are not routinely required

AC joint injuries

• Type I – Sprain with no step-off
• Type II – AC ligaments ruptured; coracoclavicular ligaments sprained
  • XR – Slight widening of joint; clavicle elevated 25-50% above acromion
  • Mild step-off
• Type III – AC and coracoclavicular ligaments ruptured; deltoid and trapezius detached
  • Clavicle elevated 100% above acromion; coracoclavicular interspace widened 25-100%
  • Distal end of clavicle prominent and shoulder dropped
• Type IV – Ruptures of all supporting structures
  • Clavicle displaced posteriorly through trapezius
  • Axillary XR required to show posterior dislocation of distal clavicle
• Type V – Rupture of all with gross displacement of distal clavicle
  • AC joint dislocated; Coracoclavicular interspace 200-300% displaced
• Type VI – AC joint dislocated, clavicle displaced inferiorly

AC joint injuries

• Type I and II – Rest, ice, sling and early ROM within 7-14 days
• Type III – Sling immobilisation trial with surgery in selected patients based around occupation, function and age
• Type IV, V and VI – Surgical repair with very careful clinical exam and imaging to identify associated injuries

Glenohumeral joint dislocation

• Direction of dislocation determined by position of humeral head relative to centre of ‘Y’ on axillary view
• Anterior (99%)
  • Abduction, extension and external rotation leads to anterior dislocation
  • Subcoracoid is most common
  • Subglenoid, subclavicular and intrathoracic dislocation are much rarer
  • Isolated greater tuberosity fractures do not preclude relocation in ED (all other fractures do)
• Fracture-dislocations increase with age
• Can only avoid pre-reduction X-ray if no trauma with recurrent dislocations. Otherwise, crucial for relocation planning and confirmation of relocation prior to discharge

Glenohumeral joint dislocation

• Posterior <1%
  • Easily missed. Suggested by mechanism (blow to anterior shoulder, axial loading of adducted/internally rotated arm, seizure, electrocution), anterior flattening, holding in adduction and internal rotation and X-ray signs
    • Light bulb sign – Loss of humeral head tuberosities on lateral view so humeral head looks like light bulb
    • Trough line – Two parallel lines on medial cortex of humeral head = reverse Hill-Sachs lesion

Glenohumeral dislocation

• UpToDate recommendations
  • Scapular manipulation first, then external rotation technique (+- Milch)
  • If fails – traction-countertraction (modified Hippocratic) or Stimson technique
  • Specifically recommend against Kocher method and Hippocratic method
• Scapular manipulation technique
  • Upright technique – Sit up with good side against head of bed. Simultaneously push tip of scapula medially and acromion down while assist provides gentle downward traction on arm
  • Prone technique – Stimson + push tip of scapula medially (96% success rate) OR

Glenohumeral dislocation

• Reduction techniques
  • 70-96% success regardless of technique
  • External rotation technique (modified Kocher)
    • Supine, arm adducted
    • Elbow flexed 90 degrees, slowly externally rotate arm (without longitudinal traction)
    • Perform slowly to allow spasm to resolve with minimal force in external rotation
    • Reduction usually complete before reaching coronal plane but if needed can bring anteriorly and then internally rotated to opposite shoulder
    • Original article described 78% success rate, 1% risk of complication
    • UpToDate states 80-90% successful
  • Milch addition
    • Perform external rotation technique and if fails then abduct fully externally rotated arm overhead with gentle traction in line of humerus and applying direct pressure into axilla on humeral head
    • 86-100% successful
  • Stimson technique
    • Prone, arm over edge of bed, 10lb weight and inject intra-articular lignocaine
    • Takes 20-30 min
  • Traction-countertraction (modified Hippocratic)
    • Patient supine, arm abducted and elbow flexed to 90
    • Sheet tied across thorax and around assistant for counter-traction
    • Sheet around forearm of patient and waist of physician with traction + gentle internal/external rotation +- outward pressure on proximal humerus
  • Cunningham technique
    • Sit upright, move humerus into full adduction and flex elbow
    • Ask patient to shrug or bring scapulae together while massaging trapezius and deltoids then biceps belly
  • Spaso method
    • Lying supine apply vertical traction to arm and gently externally rotate
    • Can push on humeral head via armpit if necessary
  • Fares technique
    • Supine, pull arm at patients side and gradually abduct with continual up/down movements in arc of 10cm
    • If not reduced by 90 degrees abduction, external rotation is used
    • 95% successful (vs 91% for external rotation technique)
• DO NOT DO THESE
  • Kocher method
    • In-line traction on humerus while abducted to 45 degrees then externally rotated and elbow brought across chest to midline, then internally rotate
  • Hippocratic method
    • Traction-countertraction with foot in axilla
  • Both associated with high rates of fractures, brachial plexus injury and vascular injury

Glenohumeral dislocation

• Complications
  • Recurrence
    • Children and young adults recurrence >90% and early surgical repair may reduce this rate so refer first timers to ortho
  • Rotator cuff tears
    • More common in older patients
    • Weakness in external rotation after relocation suggests this and if persisting pain >2 weeks, refer to ortho for consideration
  • Humeral head bony defects (Hill-Sachs)
    • Depression fracture in posterolateral head of humerus resulting from forceful compression of humeral head against anteroinferior glenoid rim
  • Glenoid labral defects (Bankart) – Anterior labrum
  • Glenoid bony defects (Bony Bankart) – Anteroinferior
  • Neurovascular injuries (axillary nerve)
    • Axillary artery in elderly patients with absent radial pulse, axillary haematoma, bruising of lateral chest wall and axillary bruit
    • Axillary nerve in 10-25% of acute dislocations 

Hill-Sachs

Bony Bankart

Glenohumeral dislocation

• Disposition
  • Shoulder immobiliser or sling in adduction and internal rotation for 3 weeks if under 30 or 1 week if over 30 (as need early ROM)
  • Ortho f/u within 1 week (or 1-2 days if bony or soft tissue injury)
• Posterior dislocations
  • Usually indirect force with forceful internal rotation and adduction or direct blow to front of shoulder
  • Reduction
    • Supine, traction to adducted arm and assistant gently pushes humeral head anteriorly
  • Posterior glenoid rim fracture (reverse Bankart), anterolateral humeral head (reverse Hill-Sachs), humeral shaft and lesser tuberosity are common complications
  • Neurovascular and rotator cuff tears are less common
  • Immobilise and refer to # clinic

Glenohumeral dislocation

• X-ray signs of posterior dislocation (all on AP view)
  • Loss of half-moon overlap sign
  • Rim sign
    • Distance b/w articular surface of humeral head and anterior glenoid rib >6mm
  • Lightbulb sign
    • Loss of normal humeral head greater and lesser trochanters
  • Trough line sign
    • Two vertical parallel lines on medial humeral head. One being medial cortex of humeral head and the other the trough of the impaction reverse Hill-Sachs fracture

Glenohumeral dislocation

• Inferior dislocation (luxatio erecta)
  • Significant soft tissue injury and fractures
  • Hyperabduction force
  • Presents with arm fully abducted, elbow flexed and hand on or behind the head
  • Reduction – Traction in upward/outward direction with assistant applying countertraction
  • Then put in shoulder immobiliser
  • If humeral head buttonholed through inferior capsule, irreducible
  • Rotator cuff tears are common and need f/u
  • Neurovascular issues are common but almost always resolve with reduction

Glenohumeral dislocation

• Complications
  • Failed reduction in ED 5-10%
  • Rotator cuff tears are uncommon in young patients but occur in 50% of patients over 40
• Indications for operative intervention
  • Irreducible dislocations
  • Displaced greater tuberosity fractures
  • Bankart with bony fragment >20% of inferior glenoid area
  • Hill-Sachs >20% of humeral articular surface

Humerus fractures

• Neer classification
  • 4 parts: Greater tuberosity, lesser tuberosity, shaft of humerus and articular surface of humeral head
  • The displacement of a fracture segment from the proximal shaft is called a ‘part’
  • Parts NOT based on fracture lines
  • One-part fracture = No displacement at all, <1cm displacement or <45 degrees angulation
  • 50% of all proximal humeral fractures are ‘one-part’
    • Require immobilisation, ice, sling, analgesics and # clinic f/u with early ROM once pain allows to prevent adhesive capsulitis

Humeral fractures

• All other >one-part fractures require ortho consult for combination of closed reduction +- ORIF
• Any fracture involving anatomical neck risks compromise of blood supply
  • Ischaemic necrosis of articular segment may require humeral head prosthesis
• Significantly angulated surgical neck fractures have high risk of axillary neurovascular and brachial plexus injury and should be immobilised in position of presentation
• Significant greater tuberosity displacement implies rotator cuff tear with surgical repair often required for active patients
• Lesser tuberosity fractures implies possible posterior dislocation

Humeral shaft fractures

• Peaks in 3^rd and 7^th decades of life with active young men and osteoporotic older women
• Common site of pathological fractures esp. breast cancer
• Complications
  • Brachial artery injury
  • Radial nerve injury (most common) – distal third especially
  • Ulnar or median nerve injury

Humeral shaft fractures

• Fractures of middle third
  • Most common site with displacement due to actions of various muscle groups
  • No difference between surgery and conservative approach
  • <20 degrees angulation in sagittal plane, <30 degrees varus/valgus angulation and shortened <2-3cm can be managed non-operatively
  • Shoulder immobiliser
  • Hanging U-slab if traction desired (spiral fracture with shortening) with collar and cuff
  • Hanging cast with collar and cuff allows traction by gravity while U-slab negates this (somewhat) by supporting elbow
• Distal humerus fractures
  • Require emergency ortho review as complex bony and neurovascular structural involvement
  • Must assess radial, median, ulnar and anterior/posterior interosseous nerve function

Brachial plexus injuries

• Divided into supraclavicular (roots and trunks) and infraclavicular (cords and terminal nerves)
• Supraclavicular
  • C4-T1 nerve roots
  • Upper, middle and lower trunks
• Divisions beneath clavicle
• Infraclavicular
  • Lateral, posterior and medial cords
  • Terminal nerves

Brachial plexus injuries

• Frequently present with neurological impairment and neuropathic pain in affected arm
• Typically need significant swelling and soft tissue injury to neck and shoulder girdle
• Swelling in posterior triangle can be from accumulation of CSF from avulsed spinal roots
• Horner’s syndrome if adjacent sympathetic ganglion damaged
• Arm pain that is burning and constant is common, usually worse in distal parts of arm and hand in non-dermatomal distribution

Brachial plexus injuries

• Diagnosis
  • Need to map out sensory and motor deficits
  • Treatment and prognosis will depend on the location and extent of nerve damage

SLAP

• Superior labrum anterior and posterior
• Seen with repetitive overhead movements, fall on outstretched arm with tensed biceps and traction on arm
• Present with vague deep shoulder pain, popping/clicking
• May have biceps tendon tenderness and positive apprehension test
• Diagnosed on MRI or arthroscopy

Last Updated on September 1, 2021 by Andrew Crofton