Shoulder and Humerus Fractures and Dislocations PowerPoint Presentation

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Shoulder and Humerus Fractures and Dislocations Steve Lan Aug 28, 03

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Overview Common shoulder and humerus injuries seen in the ED For each injury Mechanism Physical exam Diagnostic imaging Classification Management Watch out!

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Mechanism of Injury

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Injuries to be Covered AC separation Clavicle fracture Scapula fracture Shoulder dislocation Humeral Fractures proximal mid shaft

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Shoulder Anatomy

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How bad is it doc??

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AC Separation Mechanism Downward force on tip of shoulder AC and CC ligaments disrupted Watch for associated # of clavicle, coracoid process

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Normal AC joint

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AC classification – Clinically Grade I Mild tenderness over AC joint, mild swelling Full ROM Grade II Mod/severe pain, clavicle slightly displaced up Grade III Arm kept in adduction, obvious deformity

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AC Classification Grade I Mechanism Grade II Grade III

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AC Imaging AP shoulder (cephalic tilt) Normal CC distance 1.1-1.3cm (injury if > 5mm on comparison) Axillary lat view ?Stress views - 10-15lbs tied to wrists Watch for os acromiale Secondary ossification centre on distal acromion

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AC Separation

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Management I and II Conservative (sling, ice, analgesia, physio) 6/52 before lifting III Conservative with late distal clavicle excision Refer to Ortho <72h

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Ouch!

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Clavicle Fractures Function “strut”, only bony connection to axial skeleton Mechanism direct blow > FOOSH

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Clavicle - Physical Exam Gross deformity Palpation potential injury to medial cord (Ulnar N dysfunction)

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Clavicle fracture

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Clavicle Imaging AP 30 degree cephalad view

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Is it Broke?

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Classification Proximal/middle/distal third

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Clavicle # - Middle third 80% of fractures medial portion - displaced up by sternocleidomastoid lateral portion - displaced down by weight

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Clavicle # - Middle third Management Management figure of eight vs sling (J Acta Ortho Scand 58 (1):71-4, 1987) 2-4 wks kids, 4-8 wks adults Kids: possible greenstick – immobilize and recheck in 7-10d Indication for OR (increases risk of non union) - cosmesis, tenting, open, vascular injury

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Clavicle Fracture Sling and Swathe

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Clavicle Fracture Velpeau

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Clavicle # - Distal Third 10-15% Classification I: minimal displacement II: torn CC ligament, prone to non-union III: articular surface (may mistake for 1st AC) Management conservative (J. Acta. Ortho. Scand. 64 (1):87-91, 1993 ?OR for II (BJAS 23(1): 44-6, 1992.

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Distal third #

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Clavicle # - complications Injury to brachial plexus, great vessels, lungs watch out for floating shoulder if associated with scapular surgical neck #

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Scapular Fractures Rare, high energy Males ~30 y.o. Associated with other injuries (lung, rib, clavicle)

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Scapular # Clinically If awake, arm adducted Tender, crepitus, hematoma

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Scapular # Classification Type I Body and spine Type II Acromion or coracoid process Type III Scapular neck or glenoid fossa Type I Type III Type II

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Scapular Fracture

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Scapular # - Management Conservative OR Displaced acromial # impinging on joint Associated coracoid # if CC ligament disrupted Scapular neck/glenoid fossa #

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Shoulder Dislocation Men 20-30, women 60-80 yo kids more prone to # through growth plate (joint capsule and ligaments 2-5x stronger than epiphyseal plate)

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Shoulder Dislocation - Classification Anterior (95-97%) Subcoracoid (most common) subglenoid (1/3 associated with # greater tuberosity, or # glenoid rim) subclavicular Posterior Inferior and superior

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Shoulder Dislocation Anterior dislocations Traumatic/nontraumatic Primary/recurrent

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Shoulder Dislocation Anterior

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Shoulder Dislocation Anterior Clinically Slight abduction, ext rotation Squared off, loss of coracoid process Mechanism abduction+extension+posterior force shoulder capsule torn

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Shoulder Dislocation Anterior: Exam Check brachial plexus, Axillary N

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Shoulder Dislocation - Imaging Do you want films? Recurrent dislocation vs primary, ?nontraumatic Avulsion # of greater tuberosity in 10-15% True AP Axillary view trans-scapular view Stryker Notch: West point Axillary Apical oblique view

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Anterior dislocation

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Shoulder dislocation - Management Anesthesia - conscious sedation vs intra-articular lidocaine Reduction (“know three methods well”) External rotation Scapular rotation Stimson’s Milch

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Shoulder Dislocation Reductions

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Shoulder Dislocation Reductions

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Shoulder dislocation - Management Check NV post reduction ? Repeat films (advised by Rosen) Sling and swathe, Velpeau Uncomplicated: sling x 3-4/52 if < 20 y.o., 1-2/52 if > 40 y.o. (early mobilization!) Complications: NV injury, rotator cuff tear, etc. f/u with ortho

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Shoulder Dislocation - Complications Bankart lesion primary lesion in recurrent ant instability Hill Sach lesion 35-40% of ant dislocations, predisposes to recurrent injury recurrent dislocation young adults redislocation in 55-95% skeletally mature, < 30yo: ? Early arthroscopic reconstruction (Arthroscopy 15(5) 1999: 507-12)

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Shoulder Dislocation Posterior 2-4% of shoulder dislocations Secondary to seizure, direct blow to shoulder Need to dx early to prevent long term complications

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Shoulder Dislocation Posterior: clinical features Arm held across chest Adducted Internally rotated Flat and squared off

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Shoulder Dislocation Posterior: Imaging AP may appear normal! Loss of half moon elliptical overlap of humeral head and glenoid fossa “Rim sign” – increased distance between ant glenoid rim and articular surface of humeral head “light bulb” – int rotation of humeral head “trough sign” Reverse Hill Sachs (anteromedial impaction)

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Shoulder Dislocation Posterior: Imaging

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Shoulder Dislocation Posterior: Management Conscious sedation and closed reduction Axial traction, pressure on humeral head, external rotation Complications: Missed Dx: “locked” – ORIF # glenoid rim, tuberosities, humeral head

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Shoulder Dislocation Inferior (Luxatio Erecta) Rare Arm locked overhead 110-160 deg abduction, hand resting on head AP radiograph: spine parallel to humerus Reduce with traction

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Shoulder Dislocation Inferior (Luxatio Erecta)

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Humerus Fractures Proximal Mid shaft Supra condylar

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Proximal Humerus Fractures Primarily older population FOOSH, arm pronated limits abduction Older pts #, while younger pts dislocate Both if middle aged Arm held close to body, mov’t limited by pain Tender, hematoma, bruising

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Proximal Humerus Fractures 85% minimally displaced – conservative rx Separation along old epiphyseal lines Articular surface (anatomic neck) Greater and lesser tuberosity Humeral shaft (surgical neck) Considered displaced if: > 1cm away > 45 degrees

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Proximal Humeral Fractures Neer’s Classification

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Proximal Humeral Fractures Minimal displaced 3 part #

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Proximal Humerus Fractures Management Minimally displaced # held together by capsule, periosteum, muscles Analgesia, sling and swathe x 3-4/52 2,3,4 part – consult ortho Fracture/dislocation – caution with force, don’t want to displace segments Complications: adhesive capsulitis

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Proximal Humeral Epiphysis Rare Usually Males 11-17 FOOSH # through zone of hypertrophy of epiphyseal plate Arm held close to body, swelling Classification: Salter Harris

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Proximal Humeral Epiphysis

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Proximal Humeral Epiphysis Management Potential for growth disturbance <6 yo : usually Salter I, analgesia, sling and swathe > 6 yo: usually Salter II If > 20 deg need to reduce

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Midshaft Humerus Fractures Mechanism Direct blow, severe twisting, FOOSH Obvious deformity, crepitus Shortened limb, rotated Assess radial nerve Exam shoulder and elbow

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Midshaft Humerus Fractures

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Midshaft Humerus Fractures Management Hanging arm cast (displaced) / Sugar tong (nondisplaced) F/U with ortho in 24-48h overriding #: accept up to 1 inch shortening ORIF unacceptable alignment, radial nerve involvement, segmental #, other upper extremity injuries, pathological #, limited to bedrest

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Midshaft Humerus Fractures 1 in prox to #

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Midshaft Humerus Fractures

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Midshaft Humerus Fractures Children Radial nerve injury is rare accept 1-1.5cm shortening, 15-20 deg angulation 4-6 wks in modified Velpeau or sling and swathe (compliance difficult for hanging cast)

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Supracondylar Fracture Usually < 8yo Extension (95%) vs flexion

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Supracondylar Fracture- Mechanism

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Supracondylar Fracture- clinically Mild swelling to gross deformity arm held to side, immobile, extension S-shaped configuration

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Supracondylar Fracture- Classification Gartland I - nondisplaced II - displaced with intact posterior cortex III - displaced fracture, no intact cortex A: postermedial rotation of distal fragment B: posterolateral rotation

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Supracondylar Fracture- Management If NV compromise - urgent ortho consult if no response in 60 min may attempt 1 reduction watch brachial artery and median nerve Gartland I - splint and ortho f/u 24h Gartland II - controversy but most get pinned Gartland III - closed reduction and pin

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Supracondylar Fracture- Reduction

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Spot the #

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Spot the #