Chapter 172. Shoulder and Humerus Injuries

Clinical Features

Patients with simple sprains have pain and tenderness localized to the joint, whereas patients with dislocations have severe pain, which is exacerbated by arm motion and lying supine. In anterior dislocations, the medial clavicle is visibly prominent and palpable anterior to the sternum. In posterior dislocations, the medial clavicle is less visible and often not palpable. Symptoms of hoarseness, dysphagia, dyspnea, upper extremity paresthesias, or weakness may indicate life-threatening injuries to mediastinal contents, such as pneumothorax or compression or laceration of surrounding great vessels, trachea, and esophagus.

Diagnosis and Differential

CT is the imaging test of choice. IV contrast may be needed to detect injury to adjacent mediastinal structures. Consider septic arthritis in the nontraumatic patient, especially in injection drug users.

Emergency Department Care and Disposition

Treatment for sternoclavicular sprains and uncomplicated anterior dislocations includes ice, analgesics, and sling immobilization. Attempted closed reduction is not necessary as this injury is often unstable. Posterior dislocations require immediate orthopedic consultation for open reduction and internal fixation.

Clinical Features

Patients with clavicle fractures present with pain, swelling, and tenderness over the clavicle. The scapula is a well-protected bone; therefore, fractures usually occur in association with injuries to the ipsilateral lung, thoracic cage, and shoulder girdle. Patients have pain and localized tenderness over the scapula, hold their arm in adduction, and resist any arm movement.

Diagnosis and Differential

Routine radiographs may miss some clavicle and scapular fractures. CT can confirm the diagnosis as well as identify any associated pathology.

Emergency Department and Disposition

The majority of fractures can be managed conservatively with sling immobilization, ice, and analgesics. Early range-of-motion exercises are important for scapular fractures. Orthopedic consultation is warranted for clavicle fractures that are open, have neurovascular compromise, or have persistent skin tenting. Presence of a scapula fracture mandates investigation for associated intrathoracic injuries. Displaced glenoid articular fractures, angulated glenoid neck fractures, and certain acromial and coracoid fractures may require surgical intervention.

Clinical Features

Acromioclavicular joint injuries range from mild sprain to complete disruption of all ligaments that attach the scapula and clavicle. The classification of these injuries and their physical findings are described in Table 172-1.

Diagnosis and Differential

Acromioclavicular radiographs can help determine the severity of the injury and identify any associated fractures.

Emergency Department Care and Disposition

Treatment for type I and type II injuries includes sling immobilization, rest, ice, and analgesics. Early range-of-motion exercises are recommended at 7 to 14 days post injury. Treatment for type III is controversial, but the trend favors conservative management with sling immobilization rather than operative management. Treatment for type IV through VI is operative.

Clinical Features

Table 172-2 describes the various mechanisms of injury, physical findings, and associated injuries with each type of glenohumeral joint dislocation.

Diagnosis and Differential

AP and scapular “Y” view radiographs confirm the type of dislocation and identify any associated fractures. The presence of minor fractures, such as a Hill-Sachs lesion or Bankart fracture, does not change ED management. Consider omitting prereduction radiographs in patients with a history of recurrent shoulder dislocation who present with signs and symptoms of a recurrence in the absence of trauma.

Emergency Department Care and Disposition

Reduction techniques include traction, leverage, and scapular manipulation.

1. Modified hippocratic technique. This method uses traction and countertraction. Place the patient supine with their arm abducted and the elbow flexed 90°. A sheet is placed across the thorax of the patient and tied around the waist of the assistant. Another sheet is placed around the patient's flexed elbow and the clinician's waist. Gradually apply traction while an assistant provides countertraction. Gentle internal and external rotation may aid reduction.

2. Milch technique. With the patient supine, slowly abduct and externally rotate the arm to the overhead position. Apply gentle traction with the elbow fully extended. If reduction is not achieved, attempt to manipulate the humeral head into the glenoid fossa with the free hand.

3. Scapular manipulation technique. Scapular manipulation accomplishes reduction by repositioning the glenoid fossa rather than the humeral head. The first step is to apply traction to the patient's arm held in 90° of forward flexion. This can be accomplished in the prone position or in a seated position with an assistant applying traction. Position the arm in slight external rotation. Push the scapular tip as far medially as possible while stabilizing the superior aspect of the scapula with the other hand. A small amount of dorsal displacement of the scapula tip is recommended.

4. External rotation technique. Place the patient supine with the arm adducted to the side. With the patient's elbow flexed to 90°, slowly and gently externally rotate the arm. No traction is applied. Reduction is subtle and usually occurs before reaching the coronal plane.

5. Aronen technique. This technique is most useful when reduction is simple to achieve, as in recurrent dislocations or immediately after injury before muscle spasm and swelling have occurred. This technique can be taught to patients with recurrent dislocations, as self-reduction may be the only method available to them in certain situations (eg, solo sailing, crosscountry skiing, etc). In this technique, the patient is seated on a gurney with the ipsilateral leg and knee in flexion. Patients are instructed to clasp their hands around the ipsilateral knee and then relax the shoulder muscles, thereby allowing the weight of the lower limb to provide gentle inline traction. Countertraction is applied by the patients' upper body weight and their own paraspinous muscles. Taping the clasped hands together can aid reduction.

Procedural sedation is recommended; however, an intraarticular injection of 10 to 20 mL of 1% lidocaine can facilitate reduction and may obviate the need for sedation. Once reduced, assess neurovascular status and provide sling immobilization. Postreduction radiographs are useful for confirmation and documentation of successful reduction. Urgent orthopedic follow-up is necessary. Some studies show that immobilization in adduction and external rotation reduces recurrent dislocation. Early operative repair may decrease incidence of recurrence as well.

Clinical Features

Patients with proximal humeral fractures have pain, swelling, tenderness, ecchymosis, and crepitus about the shoulder. Range of motion is severely limited; patients hold their arm closely against the chest wall. Patients with humeral shaft fractures present with pain, swelling, localized tenderness, limited mobility, and crepitus on palpation. Shortening of the arm can be seen in displaced fractures. A careful neurovascular exam is essential. Injuries to the axillary nerve and artery are common in proximal humerus fractures. The radial nerve is most frequently injured in humeral shaft fractures.

Diagnosis and Differential

Radiographs confirm the diagnosis. The Neer classification system divides the proximal humerus into four parts (articular surface of the humeral head, greater tubercle, lesser tubercle, and diaphysis of the humerus) and is used to guide treatment.

Emergency Department Care and Disposition

Proximal humerus fractures that are nondisplaced or one-part fractures (displaced <1 cm or angulated <45°) require sling immobilization, ice, analgesics, and orthopedic referral. Humeral shaft fractures that are nondisplaced require a coaptation splint (sugar tong), hanging cast, or functional bracing. Multipart proximal humeral fractures, significantly displaced or angulated shaft fractures, open fractures, or any fracture with neurovascular injuries require immediate orthopedic consultation.