The Shoulder

THE SHOULDER

The shoulder region is made of three bones

• Proximal humeral end. • Clavicle. • Scapula

• Clavicle is a S shaped bone, with double curves

• Functions of the clavicle: 1- Power and stability of the arm. 2- Motion of the shoulder girdle. 3- Muscle attachments. 4- Protection of the neurovascular structures.

Related important structures

THE SHOULDER • INJURIES • TUMOURS • DEGENERATIVE CHANGES

Injuries of the Shoulder Region

Fractures of the clavicle

Fracture of the clavicle • Middle third, Most common. • Lateral third. • Medial third

Latera l

Medial

Mechanism of injury • Direct trauma. • Indirect trauma: fall on outstretched hand(most common) fall on the point of the shoulder.

Clinical picture • Pain, swelling. • Deformity, tenderness &

crepitus at the site of fracture. • Drooping of the affected shoulder. • The patient supports the arm of the affected side to decrease the painful movements.

:PATIENT SHOULD BE EXAMINED FOR • Other skeletal

injuries. • Distal pulsations.?

Investigations Plain X-ray •

Complications • Neurovasular injury. • Nonunion. • Malunion.

Treatment • Conservative

treatment: (main line) 1- Figure of 8 bandage: NOT RECOMMENDED. (Why?)

2- Simple arm support

Open reduction and internal • :fixation 1- patients with neurovascular injuries, 2- Lateral end fractures. 3- Nonunited fractures

Fractures of the proximal end of the humerus

Anatomy

It is formed of 4 parts:

• Fractures of the proximal end may be:

1- Non displaced fracture. 2- Displaced fracture.

Mode of trauma • Fall on outstretched hand. • Minor trauma to old osteoporotic patients. • Major trauma to young patients.

Clinical picture • Pain, swelling & inability to move the

shoulder. • Ecchymosis & crepitus over the affected shoulder. • Deformity due to fracture or to associated dislocation. • Neurological and vascular examination: axillary nerve

Plain X ray

C.T scan

Complications Axillary nerve • injury Deltoid wasting

Malunion •

Treatment • Non operative

treatment: Non or minimally displaced fracrtures

• Open reduction and internal

fixation. Big fragments, mild comminution

• Arthroplasty. Comminuted fractures, fractures involving the head

Fractures of the glenoid ))Very rare

Extra-articular: not involving the articular • .surface Intra-articular: extends to the articular • .surface

Shoulder Dislocation

Shoulder dislocations are divided into:

• Acute dislocation. • Chronic (negelected) dislocation. • Recurrent dislocation.

Direction of dislocation Described according to the relation of the head to the glenoid

• Anterior: most common type. • Posterior. • Inferior.

Mechanism of injury • Indirect force: combined abduction, extension and external rotation.

• Direct force: blow directed to the proximal humerus.

Clinical picture

• Pain & inability to move the shoulder. • Deformity of the shoulder joint, the humeral head is • • •

palpable in the dislocated position. The arm is held in abduction and slight external rotation (anterior dislocation). Associated axillary nerve injury. Vascular injury.

X ray

Complications • Vascular injury: Axillary artery injury, at

the time of dislocation and at the time of relocation. • Neural injury: to the brachial plexus. Neural injury may be Neurapraxia, Axonotmesis, or Neurotmesis. Most common injury involves the axillary nerve. • Recurrence of dislocation.

Recurrence of dislocation • This is the most common complication. • Causes of recurrence: 1- Patient age: High incidence below the age of 40 years. 2- Inadequate immobilization: less than 3 weeks. 3- associated head fractures: )Hill-Sachs lesion) increase the incidence of recurrence. 4- Glenoid labral injury )Bankart lesion)

Mechanism of Hill Sachs lesion

Treatment

Acute dislocation • Closed reduction under general

anesthesia as urgent as possible. Neurovascular examination is mandatory after closed reduction.

• Open reduction is rarely needed in cases of locked dislocations

Closed reduction

Traction & counter traction

Recurrent dislocation • Operative treatment: for soft tissue balance, repair ,or blocking the dislocation mechanism.

• Physiotherapy program.

TUMOURS IN THE SHOULDER REGION

A- BENGIN OSTEOCHONDROMA

TUMOURS IN THE SHOULDER REGION A- BENGIN CHONDROBLASTOMA

TUMOURS IN THE SHOULDER REGION B-MALIGNANT CHONDROSARCOMA

TUMOURS IN THE SHOULDER REGION B-MALIGNANT CHONDROSARCOMA

TUMOURS IN THE SHOULDER REGION

B-MALIGNANT SECONDARIES

PATHOLOGICALFRACTURES IN THE SHOULDER REGION

DEGENERATIVE ARTHROSIS

EXAMINATION OF THE NECK

Examination Starts in the…. Trauma Bay E.R.

• Information • Mechanism – ↑energy, ↓energy

• Direction of Impact • Associated Injuries

Step1: Frontal Inspection flat/frontal view – Head: eyes – Neck: posture – Thorax: chest contusions, flail chest, asymmetric chest expansion

Remove all clothes

• Inspection--patient

Step1: Frontal Inspection • Inspection--patient – Abdomen: lap-belt ecchymosis – Peritoneum/Pelvis: priapism, scrotal swelling, bruising – Extremities: gross movement, tone, flaccid

Remove all clothes

flat/frontal view

Step 2: Neurological Examination • Detailed and Systematic – Sensory – Motor – Reflexes

DOUBLE LEVEL SPINAL INJURIES

NEUROLOGICAL PUZZLE 1. Test sensation to pinprick in all dermatomes, record the most caudal dermatome that feels pinprick 2. Check motor function 3. Test deep tendon reflexes 4. Rectal examination to assess sphincter tone and sensation 5. Insert Foley catheter; note sensation to insertion and to bladder distention with saline solution; bulbo-cavernosus reflex

D e r m a t o m e s

Motor Grade 0/5 1/5 2/5 movement 3/5 4/5 5/5

e.g.

+/-

Biceps

none trace some anti-gravity anti-resistance normal

Test in contracted/shortened position

Motor Cervical muscle to test each level/root 1

Deltoid e n o Biceps k c Pi s c le Triceps u m Finger Flexors Hand intrinsics (abduction)

C5 C6 C7 C8 T1

PRIMITIVE (spinal) REFLEXES

Anus

Glans

Babiniski test

Bulbo-cavernosus test

Pathologic Reflexes • Hyperreflexia • Clonus ≥ 4 beats • Babinski • Inverted Radial Reflex • Hoffmans

Rectal •Anal sensation •Rectal tone •Bear down/contraction

SCALENUS SYN

THORACIC OUTLET SYN