shoulder complexx

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Clavicle injuriesClavicle injuries

Most common mechanism is fall on outstretched hand, forceMost common mechanism is fall on outstretched hand, forcebeing transmitted up the arm to clavicle.being transmitted up the arm to clavicle.

By fall or blows on the point of shoulder and by directBy fall or blows on the point of shoulder and by direct

violence.violence.# is commonest at the junction of M/3# is commonest at the junction of M/3 rd

rdand L/3and L/3rd

rdand to aand to a

lesser extent at outer 3lesser extent at outer 3rdrd..

Subluxation and dislocations may involve AC joint and SCSubluxation and dislocations may involve AC joint and SCjoint.joint.


Greenstick # are common and so it is often helpful inGreenstick # are common and so it is often helpful inchildren to have both shoulders included for comparison.children to have both shoulders included for comparison.

Sometimes the only abnormality visible will be local kinking ofSometimes the only abnormality visible will be local kinking ofthe clavicle contour.the clavicle contour.

Healing of this type of # is rapid and reduction is notHealing of this type of # is rapid and reduction is not required.required.

In adults, un displaced # are common, comparatively stableIn adults, un displaced # are common, comparatively stableand late slipping is rare. Symptoms settle rapidly and minimaland late slipping is rare. Symptoms settle rapidly and minimaltreatment is required.treatment is required.


With greater violence there is separation of bone ends. TheWith greater violence there is separation of bone ends. Theproximal end under the pull of sternomastoid often becomesproximal end under the pull of sternomastoid often becomeselevated. Shoulder loses the prop like effect of clavicle so itelevated. Shoulder loses the prop like effect of clavicle so ittends to sag downwards and forwards.tends to sag downwards and forwards.

With greater displacement of distal fragment there isWith greater displacement of distal fragment there isoverlapping and shortening. In spite of off-ending union isoverlapping and shortening. In spite of off-ending union israpid and remodeling even in adults is so effective thatrapid and remodeling even in adults is so effective that

strenuous attempts at reduction are unnecessary.strenuous attempts at reduction are unnecessary.


Pathological # may result from radio necrosis (followingPathological # may result from radio necrosis (following

radiotherapy for Ca breast) and may be mistaken for localradiotherapy for Ca breast) and may be mistaken for localrecurrence.recurrence.

DiagnosisDiagnosis

Clinically tenderness at # site, sometimes obvious deformity,Clinically tenderness at # site, sometimes obvious deformity,

with local swelling, local bruising some days after the injurywith local swelling, local bruising some days after the injury

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After careAfter care

Inspection and possible tightening every 2-4 days. WhereInspection and possible tightening every 2-4 days. Wherebraces are used along with a sling, the sling may be discardedbraces are used along with a sling, the sling may be discardedafter 2 weeks. All supports removed as soon as tendernessafter 2 weeks. All supports removed as soon as tenderness

disappears from # site.disappears from # site.Physiotherapy is seldom required except in elderly patientsPhysiotherapy is seldom required except in elderly patientswho develop shoulder stiffness.who develop shoulder stiffness.

A childA childs mother should always be advised that thes mother should always be advised that theprominent callus round the # is normal and will disappear inprominent callus round the # is normal and will disappear infew months.few months.

AC joint injuriesAC joint injuries

Fall in which patient rolls on to the shoulder.Fall in which patient rolls on to the shoulder.

In subluxation and sprains, damage is confined to ACIn subluxation and sprains, damage is confined to AC

ligaments, clavicle preserves some contact with acromion.ligaments, clavicle preserves some contact with acromion.In dislocation the clavicle loses all contact with scapula, theIn dislocation the clavicle loses all contact with scapula, theconoid and trapezoid ligaments tearing away from inferiorconoid and trapezoid ligaments tearing away from inferiorborder of clavicle.border of clavicle.

Displacement may be severe, and ensuing haematoma mayDisplacement may be severe, and ensuing haematoma mayossify.ossify.


Diagnosis : Patient should be standing and both theDiagnosis : Patient should be standing and both theshoulders compared. The outer end of clavicle will beshoulders compared. The outer end of clavicle will beprominent. In case of damage to conoid and trapezoidprominent. In case of damage to conoid and trapezoidligament the prominence may be quite striking.ligament the prominence may be quite striking.

Local tenderness always present.Local tenderness always present.

Confirm any subluxation by supporting the elbow with oneConfirm any subluxation by supporting the elbow with onehand and gently pushing the clavicle down with other hand.hand and gently pushing the clavicle down with other hand.Improvement in the contour of outer end of clavicle willImprovement in the contour of outer end of clavicle will

confirm the diagnosis.confirm the diagnosis.


Now stand behind the patient and abduct the arm to 90Now stand behind the patient and abduct the arm to 90..

Flex and extend the shoulder while gently palpating the ACFlex and extend the shoulder while gently palpating the ACjoint. Failure of the outer end of clavicle to accompany thejoint. Failure of the outer end of clavicle to accompany theacromion indicates rupture of conoid and trapezoid ligaments.acromion indicates rupture of conoid and trapezoid ligaments.


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X-rays : They are often fallacious in indicating the severity ofX-rays : They are often fallacious in indicating the severity ofinjury and indeed may not show it. The reason is thatinjury and indeed may not show it. The reason is thatspontaneous reduction tends to occur in recumbency-thespontaneous reduction tends to occur in recumbency-theposition in which AP x-rays are normally taken. Displacementposition in which AP x-rays are normally taken. Displacement

of clavicle by a diameter or more relative to acromionof clavicle by a diameter or more relative to acromionsuggests rupture of conoid and trapezoid ligaments.suggests rupture of conoid and trapezoid ligaments.

Therefore x-rays should be taken in standing position only.Therefore x-rays should be taken in standing position only.The weight of the limb is sufficient to show up dislocation butThe weight of the limb is sufficient to show up dislocation butit is common to have patient hold weights in both hands andit is common to have patient hold weights in both hands andto include both shoulders for comparison.to include both shoulders for comparison.


Treatment : Broad arm sling under the clothes for 4-6Treatment : Broad arm sling under the clothes for 4-6weeks. Subluxation is easily reduced and held by adhesiveweeks. Subluxation is easily reduced and held by adhesivestrapping but this should not be employed as early skinstrapping but this should not be employed as early skinreaction will always force abandonment.reaction will always force abandonment.

In case of gross instability, good results are achieved withIn case of gross instability, good results are achieved with

conservative treatment.conservative treatment.

AC joint injuriesAC joint injuriesAlthough complications are common after surgery, thisAlthough complications are common after surgery, thisshould be considered in patients who are engaged in heavyshould be considered in patients who are engaged in heavymanual work.manual work.

Methods include coracoclavicular screw or use of threadedMethods include coracoclavicular screw or use of threadedpin across joint. Any tears in trapezius and deltoid should bepin across joint. Any tears in trapezius and deltoid should berepaired.repaired.

Less satisfactory is use of K-wires across the joint or figureLess satisfactory is use of K-wires across the joint or figureof eight acromioclavicular wiring. In all cases there is a strongof eight acromioclavicular wiring. In all cases there is a strong

tendency for devices to cut out. IF devices must be removedtendency for devices to cut out. IF devices must be removedat 6-8 weeks before full mobilization.at 6-8 weeks before full mobilization.


If a dislocation reduces with the arm in abduction, aIf a dislocation reduces with the arm in abduction, a

shoulder spica for 6-8 weeks may be used.shoulder spica for 6-8 weeks may be used.

Complications : AC OA may be relieved by acromionectomyComplications : AC OA may be relieved by acromionectomy

or excision of the outer 2 cm of clavicle. Fascial reconstructionor excision of the outer 2 cm of clavicle. Fascial reconstruction

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of coracoclavicular ligament can be used for persistentof coracoclavicular ligament can be used for persistentinstability.instability.

# L/3# L/3rdrd of clavicleof clavicle

Displacement is generally minimal as coracoclavicularDisplacement is generally minimal as coracoclavicularligaments are usually not torn. When these ligaments are tornligaments are usually not torn. When these ligaments are torndisplacement may be marked and rarely can lead to nondisplacement may be marked and rarely can lead to nonunion.union.

Treated as for AC joint injuries. Clavicle bracing is valuelessTreated as for AC joint injuries. Clavicle bracing is valuelessand a sling under the clothes for 4-5 weeks is adequate.and a sling under the clothes for 4-5 weeks is adequate.

Complications : Glenohumeral joint stiffness treated withComplications : Glenohumeral joint stiffness treated withphysiotherapy, persistent sharp clavicle spike even afterphysiotherapy, persistent sharp clavicle spike even afterremodeling cause discomfort against clothes and requireremodeling cause discomfort against clothes and require

excision and non union though extremely rare treated with IFexcision and non union though extremely rare treated with IFand BG.and BG.

Sternoclavicular dislocationsSternoclavicular dislocations

Commonest is mild subluxation caused by fall or blow onCommonest is mild subluxation caused by fall or blow onfront of shoulder or fall on out stretched hand.front of shoulder or fall on out stretched hand.

There is asymmetry of inner ends of clavicles due to affectedThere is asymmetry of inner ends of clavicles due to affectedside subluxing downwards and forwards. Local tenderness isside subluxing downwards and forwards. Local tenderness ispresent.present.

AP and oblique x-ray are difficult to interpret. May beAP and oblique x-ray are difficult to interpret. May beconfirmatory in major dislocation when inner end of clavicle isconfirmatory in major dislocation when inner end of clavicle isdisplaced on sternum or in rare case where clavicle passesdisplaced on sternum or in rare case where clavicle passesbehind sternum, endangering the great vessels.behind sternum, endangering the great vessels.

Sternoclavicular dislocationsSternoclavicular dislocations

Treatment : Minor subluxation should be accepted,Treatment : Minor subluxation should be accepted,

prominence of inner end may persist, with some asymmetryprominence of inner end may persist, with some asymmetry

of suprasternal notch but a pain free result is usual. Armof suprasternal notch but a pain free result is usual. Armshould be rested in sling for 2-3 weeks until acute pain hasshould be rested in sling for 2-3 weeks until acute pain hassettled.settled.

Gross displacement should be reduced under GA. A sand bagGross displacement should be reduced under GA. A sand bagplaced between shoulders, which are firmly pressedplaced between shoulders, which are firmly pressedbackwards. Clavicle braces are then applied along with abackwards. Clavicle braces are then applied along with abroad arm sling for 4-5 weeks. If reduction is unstable,broad arm sling for 4-5 weeks. If reduction is unstable,surgical repair with fascia lata done.surgical repair with fascia lata done.

Irreducible dislocation may require OR which is hazardous.Irreducible dislocation may require OR which is hazardous.

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Scapular #Scapular #

# of blade of scapula are usually caused by direct violence.# of blade of scapula are usually caused by direct violence.

Even when comminuted and angled, healing is usually rapidEven when comminuted and angled, healing is usually rapidand excellent outcome is the rule.and excellent outcome is the rule.

Treatment is by broad arm sling and analgesics. MobilizationTreatment is by broad arm sling and analgesics. Mobilization

is started as soon as acute symptoms subside, usually after 2is started as soon as acute symptoms subside, usually after 2weeks.weeks.

Scapular #Scapular #

# of scapular neck are associated with much bruising and# of scapular neck are associated with much bruising and

swelling. Comminution is common sometimes withswelling. Comminution is common sometimes with

involvement of GH joint. If so, position of humeral headinvolvement of GH joint. If so, position of humeral headchecked. A good outcome is the rule, provided mobilization ischecked. A good outcome is the rule, provided mobilization isstarted as early as possible.started as early as possible.

Dislocation of shoulderDislocation of shoulder

Head come to lie mainly in front of glenoid (Anterior), behindHead come to lie mainly in front of glenoid (Anterior), behind

glenoid (Posterior) or beneath the glenoid (luxatio erecta).glenoid (Posterior) or beneath the glenoid (luxatio erecta).Anterior dislocation is by far the commonest.Anterior dislocation is by far the commonest.

Anterior dislocationAnterior dislocation

From fall leading to external rotation of shoulder (or trunkFrom fall leading to external rotation of shoulder (or trunkinternally rotating over a fixed hand).internally rotating over a fixed hand).

Rare in children, common in 18-25 years age group fromRare in children, common in 18-25 years age group frommotorcycle and athletic injuries and comparatively common inmotorcycle and athletic injuries and comparatively common inelderly.elderly.

Head of Humerus externally rotates out of glenoid and liesHead of Humerus externally rotates out of glenoid and liesmedially in front of scapula.medially in front of scapula.

Anterior dislocationAnterior dislocation

Damage to anterior structures, capsule is torn away from itsDamage to anterior structures, capsule is torn away from itsattachment to glenoid. This is so called Bankart lesion,attachment to glenoid. This is so called Bankart lesion,although frequent simultaneous displacement of glenoidalthough frequent simultaneous displacement of glenoidlabrum attracts this term.labrum attracts this term.

In elderly patients there may be tearing or stretching ofIn elderly patients there may be tearing or stretching ofanterior capsule with associated damage to shoulder cuff,anterior capsule with associated damage to shoulder cuff,

especially subscapularis. The greater tuberosity may # andespecially subscapularis. The greater tuberosity may # and

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occasionally there is a damage to Axillary artery or brachialoccasionally there is a damage to Axillary artery or brachialplexus.plexus.

DiagnosisDiagnosisShoulder is very painful, patient resents movement and toShoulder is very painful, patient resents movement and toprevent this often holds the injured limb. Arm does notprevent this often holds the injured limb. Arm does notalways lie to the side, appearing to be in slight abduction.always lie to the side, appearing to be in slight abduction.Outer contour of shoulder may appear slightly kinked due toOuter contour of shoulder may appear slightly kinked due todisplaced humeral head.displaced humeral head.

Palpate under the edge of acromion, the usual resistancePalpate under the edge of acromion, the usual resistanceoffered by the humeral head is absent. If in doubt, compareoffered by the humeral head is absent. If in doubt, comparethe two sides. Displaced humeral head may be palpable lyingthe two sides. Displaced humeral head may be palpable lying

anteriorly.anteriorly.

DiagnosisDiagnosis

In doubtful case, assess the relative positions of humeralIn doubtful case, assess the relative positions of humeral

head and glenoid by palpation in axilla.head and glenoid by palpation in axilla.

Axillary (circumflex) N palsy is common. Assess sensation toAxillary (circumflex) N palsy is common. Assess sensation to

pin prick over regimental badge area.pin prick over regimental badge area.Look for radial portion of posterior cord and involvement ofLook for radial portion of posterior cord and involvement of

Axillary artery.Axillary artery.

X-RayX-Ray

Majority of anterior dislocation show quite clearly onMajority of anterior dislocation show quite clearly on

standard AP x-ray.standard AP x-ray.

Humeral head may lie preglenoid, subcoracoid orHumeral head may lie preglenoid, subcoracoid or

subclavicular. This classification is of little importance.subclavicular. This classification is of little importance.Important diagnostic feature is loss of congruity betweenImportant diagnostic feature is loss of congruity betweenhumeral head and glenoid.humeral head and glenoid.

X-RayX-Ray

Second x-ray projection is essential of diagnosis is in doubt.Second x-ray projection is essential of diagnosis is in doubt.If humeral head has minimal medial displacement, the APIf humeral head has minimal medial displacement, the APview may appear normal. This is peculiar in posteriorview may appear normal. This is peculiar in posterior

dislocations. Most useful is tangential lateral or axial view. Itdislocations. Most useful is tangential lateral or axial view. It

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is taken with patient lying on his back with arm abducted tois taken with patient lying on his back with arm abducted to9090. X-ray tube is parallel to the trunk, central ray passes. X-ray tube is parallel to the trunk, central ray passesthrough the axilla to the plate which is placed above shoulder.through the axilla to the plate which is placed above shoulder.

X-RayX-Ray

Shoulder may be too painful to allow axial lateral view,Shoulder may be too painful to allow axial lateral view,second best is the translateral which is often difficult tosecond best is the translateral which is often difficult tointerpret. In normal shoulder in this view, the posteriorinterpret. In normal shoulder in this view, the posteriorborder of Humerus and the Axillary border of scapula form aborder of Humerus and the Axillary border of scapula form ashallow parabolic curve, this is disturbed in any dislocation.shallow parabolic curve, this is disturbed in any dislocation.

Associated # of greater tuberosity is common. This does notAssociated # of greater tuberosity is common. This does not

influence initial treatment of dislocation by reduction, but mayinfluence initial treatment of dislocation by reduction, but mayrequire subsequent attention.require subsequent attention.

X-RayX-Ray

Subluxation of Glenohumeral joint : Most obvious if AP x-raySubluxation of Glenohumeral joint : Most obvious if AP x-ray

is taken in standing position. No active treatment is requiredis taken in standing position. No active treatment is requiredbut frank dislocation excluded by a lateral x-ray.but frank dislocation excluded by a lateral x-ray.

Reduction by KocherReduction by Kochers methods method

Most popular method. Done under IV diazepam or IMMost popular method. Done under IV diazepam or IMPethidine . In severe pain or muscular patients GA isPethidine . In severe pain or muscular patients GA ispreferable.preferable.

Apply traction, rotate the arm externally taking plenty ofApply traction, rotate the arm externally taking plenty oftime. In conscious patient if muscle resistance is felt, stop fortime. In conscious patient if muscle resistance is felt, stop for a moment and then continue. Reach up to 90a moment and then continue. Reach up to 90 of externalof externalrotation.rotation.

Shoulder frequently reduces with a clear clunking sensationShoulder frequently reduces with a clear clunking sensationduring external rotation.during external rotation.

Reduction by KocherReduction by Kochers methods method

If this does not happen, adduct the shoulder so that elbowIf this does not happen, adduct the shoulder so that elbow

starts to come across the chest. Now internally rotate thestarts to come across the chest. Now internally rotate theshoulder, bringing the patientshoulder, bringing the patients hand towards the opposites hand towards the opposite

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shoulder. If reduction has not occurred, repeat all stages,shoulder. If reduction has not occurred, repeat all stages,attempting to get more external rotation.attempting to get more external rotation.

If doubt remains, repeat x-rays taken. Complete failure isIf doubt remains, repeat x-rays taken. Complete failure is

rare under GA.rare under GA.

Hippocratic methodHippocratic method

Traction is applied to arm and the head of Humerus isTraction is applied to arm and the head of Humerus is

levered back in position. Heel of surgeon is placed against thelevered back in position. Heel of surgeon is placed against thechest (without being pressed hard into axilla) to act as achest (without being pressed hard into axilla) to act as afulcrum, while the arm is adducted.fulcrum, while the arm is adducted.

Gravitational tractionGravitational traction

Generous dose of powerful analgesic like Pethidine, aGenerous dose of powerful analgesic like Pethidine, asandbag is placed under clavicle and arm allowed to hangsandbag is placed under clavicle and arm allowed to hangover the side of the couch. With muscle relaxation due toover the side of the couch. With muscle relaxation due toanalgesia and gravitational traction, the shoulder may reduceanalgesia and gravitational traction, the shoulder may reducespontaneously within an hour. Failure is an indication of GA.spontaneously within an hour. Failure is an indication of GA.


Check x-rays taken before anesthesia is discontinued. ArmCheck x-rays taken before anesthesia is discontinued. Armshould be supported after reduction to lessen the risk ofshould be supported after reduction to lessen the risk of

immediate re dislocation. Begin by placing a gamgee or woolimmediate re dislocation. Begin by placing a gamgee or wool pad in axilla and apply a broad arm sling. External rotationpad in axilla and apply a broad arm sling. External rotationshould be prevented by a body bandage or outside cloths.should be prevented by a body bandage or outside cloths.After 3 weeks if there is residual pain, outside sling may beAfter 3 weeks if there is residual pain, outside sling may beworn for a further week. Mobilization is usually rapid .worn for a further week. Mobilization is usually rapid .


In younger patients there is high risk of recurrence (50%)In younger patients there is high risk of recurrence (50%)

within 2 years. So continue supporting the limb as describedwithin 2 years. So continue supporting the limb as describedfor 4 weeks.for 4 weeks.

In elderly patient risk of recurrence is minimal but risk ofIn elderly patient risk of recurrence is minimal but risk ofstiffness is more. Sling under clothes applied initially andstiffness is more. Sling under clothes applied initially anddiscarded as soon as pain will permit. Mobilization of bothdiscarded as soon as pain will permit. Mobilization of bothshoulder and elbow usually started after 1-2 weeks.shoulder and elbow usually started after 1-2 weeks.


If there is associated # of greater tuberosity, this generallyIf there is associated # of greater tuberosity, this generallyreduces adequately with the dislocation and mobilizationreduces adequately with the dislocation and mobilization

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commenced as soon as pain will permit usually after 3-4commenced as soon as pain will permit usually after 3-4weeks.weeks.

If tuberosity remains seriously displaced e.g. under acromionIf tuberosity remains seriously displaced e.g. under acromionand cannot be reduced by placing the arm in abduction, itand cannot be reduced by placing the arm in abduction, it

should be openly replaced and fixed with a screw.should be openly replaced and fixed with a screw.If Axillary N palsy with loss of deltoid function is there, theIf Axillary N palsy with loss of deltoid function is there, thelesion is usually in continuity and full recovery may occur. Maylesion is usually in continuity and full recovery may occur. Maytake several months and is not invariable.take several months and is not invariable.

Posterior dislocationPosterior dislocation

Fall on outstretched, internally rotated hand or from directFall on outstretched, internally rotated hand or from directblow on the front of shoulder. Head of Humerus is displacedblow on the front of shoulder. Head of Humerus is displaced

directly backwards and because of this a single AP may showdirectly backwards and because of this a single AP may showa little or no abnormality. Nevertheless clinically there is pain,a little or no abnormality. Nevertheless clinically there is pain,deformity and local tenderness.deformity and local tenderness.

Additional lateral view is taken which shows head lyingAdditional lateral view is taken which shows head lyingclearly behind the glenoid.clearly behind the glenoid.

Posterior dislocationPosterior dislocation

If pain does not permit axial view, translateral view has toIf pain does not permit axial view, translateral view has to

be taken which shows parabolic curve, shaped like path of abe taken which shows parabolic curve, shaped like path of a comet, formed by shaft of Humerus and the edge of scapulacomet, formed by shaft of Humerus and the edge of scapulawill be broken and show the humeral head to lie behind thewill be broken and show the humeral head to lie behind theglenoid shadow.glenoid shadow.

TreatmentTreatment

Reduction is usually easy by applying traction to the arm inReduction is usually easy by applying traction to the arm in9090 abduction and then externally rotating the limb. Ifabduction and then externally rotating the limb. If

reduction is stable, the arm should be rested in a sling.reduction is stable, the arm should be rested in a sling.If reduction is unstable, arm is kept in 60If reduction is unstable, arm is kept in 60 lateral rotation forlateral rotation for4 weeks to give the torn capsule and the labrum reasonable4 weeks to give the torn capsule and the labrum reasonablechance of healing. Achieved by application of shoulder spicachance of healing. Achieved by application of shoulder spicain 40in 40 shoulder abduction, 60shoulder abduction, 60 external rotation and fullexternal rotation and fullextension of shoulder.extension of shoulder.

Luxatio erectaLuxatio erecta

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Rare type of shoulder dislocation with obvious deformity, armRare type of shoulder dislocation with obvious deformity, armbeing held in abduction. X-ray confirms the diagnosis easily.being held in abduction. X-ray confirms the diagnosis easily.Patient should be carefully examined for evidence ofPatient should be carefully examined for evidence ofneurological or vascular deficit and reduction should be doneneurological or vascular deficit and reduction should be done

immediately.immediately.Reduction is easy by applying traction in abduction andReduction is easy by applying traction in abduction andswinging the arm into adduction.swinging the arm into adduction.

Shoulder is supported after reduction as for anteriorShoulder is supported after reduction as for anteriordislocation.dislocation.

Late diagnosed Ant dislocationLate diagnosed Ant dislocation

Up until 6 weeks or so, closed reduction which is oftenUp until 6 weeks or so, closed reduction which is oftensuccessful should be attempted. Forearm is suspended by asuccessful should be attempted. Forearm is suspended by acanvas sling or bandage from a ceiling hook, G/A is given withcanvas sling or bandage from a ceiling hook, G/A is given withmuscle relaxant.muscle relaxant.

Patient is turned opposite side and sling adjusted so that byPatient is turned opposite side and sling adjusted so that byusing arm as lever, assistant exerts considerable tractionusing arm as lever, assistant exerts considerable tractionthrough patientthrough patients body weight. Humeral head is thens body weight. Humeral head is thenmanipulated over the glenoid lip. Mobilization commenced atmanipulated over the glenoid lip. Mobilization commenced atan early stage around 1 week.an early stage around 1 week.

Late diagnosed Ant dislocationLate diagnosed Ant dislocation

If closed reduction fails, open reduction is consideredIf closed reduction fails, open reduction is consideredthrough anterior approach. If reduction is unstable,through anterior approach. If reduction is unstable,temporary pin fixation may be required.temporary pin fixation may be required.

If reduction is not achieved, resection of humeral head withIf reduction is not achieved, resection of humeral head withor without replacement (excision arthroplasty,or without replacement (excision arthroplasty,hemiarthroplasty) is done.hemiarthroplasty) is done.

In older patients if found after few months, it should be leftIn older patients if found after few months, it should be leftuntil the outcome of prolonged physiotherapy has beenuntil the outcome of prolonged physiotherapy has beenassessed.assessed.

In younger patients exploration and open reduction orIn younger patients exploration and open reduction orarthroplasty should be considered.arthroplasty should be considered.

Late diagnosed Post dislocationLate diagnosed Post dislocation

Manipulative reduction attempted as late as a year. PressureManipulative reduction attempted as late as a year. Pressure

being applied from behind the shoulder on a posteriorlybeing applied from behind the shoulder on a posteriorlydisplaced head.displaced head.

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Failure of reduction should be managed by open reductionFailure of reduction should be managed by open reduction

using a posterior approach.using a posterior approach.Recurrent dislocationRecurrent dislocation

Even after early adequate treatment, re dislocation mayEven after early adequate treatment, re dislocation may

occur. Progressively less trauma is required in each occasion,occur. Progressively less trauma is required in each occasion,eventually patient may be able to reduce dislocationeventually patient may be able to reduce dislocationvoluntarily.voluntarily.

Pathological # include Bankart lesion, attrition of anteriorPathological # include Bankart lesion, attrition of anterior

shoulder cuff, defect with flattening of posterolateral aspect ofshoulder cuff, defect with flattening of posterolateral aspect ofhead and rounding of glenoid margin.head and rounding of glenoid margin.

Recurrent dislocation-DiagnosisRecurrent dislocation-Diagnosis

History is usually clear, clinically external rotation of shoulderHistory is usually clear, clinically external rotation of shouldergive rise to considerable apprehension. Recurrent dislocationgive rise to considerable apprehension. Recurrent dislocationshould be distinguished from habitual dislocation in which theshould be distinguished from habitual dislocation in which thepatients are frequently psychotic or suffer from joint laxitypatients are frequently psychotic or suffer from joint laxitysyndromes. They repeatedly dislocate the shoulder, oftensyndromes. They repeatedly dislocate the shoulder, oftenvoluntarily and without pain, joint reduces easily andvoluntarily and without pain, joint reduces easily andspontaneously. Surgery is often unsuccessful, and should bespontaneously. Surgery is often unsuccessful, and should beavoided where possible.avoided where possible.

Recurrent dislocation-DiagnosisRecurrent dislocation-DiagnosisAn axial projection may clinch the diagnosis. PosterolateralAn axial projection may clinch the diagnosis. Posterolateraldefects in humeral head are often quite striking. If doubt stilldefects in humeral head are often quite striking. If doubt still remains, take axial stress films.remains, take axial stress films.

With shoulder in 90With shoulder in 90 abduction, two films are exposed whileabduction, two films are exposed whilehumeral head is alternately pulled forwards and pushed backhumeral head is alternately pulled forwards and pushed backas in draweras in drawers test of knee. Abnormal excursion of humerals test of knee. Abnormal excursion of humeralhead confirms the instability.head confirms the instability.

Recurrent dislocation-TreatmentRecurrent dislocation-TreatmentBankart repair : Shoulder joint is opened by dividing theBankart repair : Shoulder joint is opened by dividing thesubscapularis and the capsule. If glenoid labrum is loose andsubscapularis and the capsule. If glenoid labrum is loose anddisplaced into the joint, it is excised. If not it is ignored.displaced into the joint, it is excised. If not it is ignored.Humeral head is retracted laterally, the glenoid edge is rawedHumeral head is retracted laterally, the glenoid edge is rawedand drilled obliquely to take anchoring sutures. Now shoulderand drilled obliquely to take anchoring sutures. Now shoulderis internally rotated and sutures which have been passedis internally rotated and sutures which have been passedthrough bone are used to anchor the lateral part of capsule tothrough bone are used to anchor the lateral part of capsule tothe raw edge of glenoid. With shoulder in neutral rotation,the raw edge of glenoid. With shoulder in neutral rotation,

medial part of capsule is sewn over the lateral. Subscapularismedial part of capsule is sewn over the lateral. Subscapularis

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is repaired F/B layer closure. The arm is bandaged to the sideis repaired F/B layer closure. The arm is bandaged to the sidefor 4 weeks before mobilization is commenced.for 4 weeks before mobilization is commenced.

Recurrent dislocation-TreatmentRecurrent dislocation-TreatmentPutti-Platt repair : Strong mattress sutures are inserted intoPutti-Platt repair : Strong mattress sutures are inserted intoperiosteum, capsule or other intact tissue on scapular neckperiosteum, capsule or other intact tissue on scapular neckand used to anchor the lateral part of capsule andand used to anchor the lateral part of capsule andsubscapularis. The medial parts are sewn in front, deliberatelysubscapularis. The medial parts are sewn in front, deliberatelyrestricting external rotation and forming a four layer barrierrestricting external rotation and forming a four layer barrierof tissue in front of joint. The arm is kept in internal rotationof tissue in front of joint. The arm is kept in internal rotationfor 4-6 weeks before mobilization. Failure rate in thisfor 4-6 weeks before mobilization. Failure rate in thisprocedure is low (


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# of proximal Humerus# of proximal Humerus

Group 2 : All # of anatomical neck displaced > 1cm. TheseGroup 2 : All # of anatomical neck displaced > 1cm. These

rare injuries may be complicated by AVN of humeral head.rare injuries may be complicated by AVN of humeral head.

Group 3 : All appreciably displaced or severely angled # ofGroup 3 : All appreciably displaced or severely angled # of

surgical neck. No AVN. These may be impacted, displaced orsurgical neck. No AVN. These may be impacted, displaced orcomminuted. Angulation is often anterior and may give ancomminuted. Angulation is often anterior and may give anerroneous impression of abduction or adduction.erroneous impression of abduction or adduction.


Group 4 : All # of greater tuberosity displaced by the pull ofGroup 4 : All # of greater tuberosity displaced by the pull ofsupraspinatus. In 3 part #, a # of surgical neck allows thesupraspinatus. In 3 part #, a # of surgical neck allows thesubscapularis to rotate the head internally so that its articularsubscapularis to rotate the head internally so that its articularsurface faces mainly posteriorly.surface faces mainly posteriorly.

Group 5 : Involves lesser tuberosity. In 3 part #, humeralGroup 5 : Involves lesser tuberosity. In 3 part #, humeral head may be abducted and externally rotated so that itshead may be abducted and externally rotated so that itsarticular surface faces anteriorly. 4 part # identical with 4articular surface faces anteriorly. 4 part # identical with 4part injuries of group 4 may render head avascular.part injuries of group 4 may render head avascular.


Group 6 : Comprises of # dislocations. Dislocation ofGroup 6 : Comprises of # dislocations. Dislocation of

shoulder with associated greater tuberosity # is included inshoulder with associated greater tuberosity # is included in

group 4.group 4.More serious are dislocations where 2 part # is throughMore serious are dislocations where 2 part # is through

surgical neck of Humerus.surgical neck of Humerus.

Most difficult of all are 3 and 4 part injuries, especially whenMost difficult of all are 3 and 4 part injuries, especially when

humeral head is completely detached and displaced, or worsehumeral head is completely detached and displaced, or worsestill is split.still is split.


ChildrenChildrens injury : Commonest is greenstick # of surgicals injury : Commonest is greenstick # of surgical

neck. This is classified as Neer group 1, 2 part #.neck. This is classified as Neer group 1, 2 part #.

Also common is slight or moderately displaced proximalAlso common is slight or moderately displaced proximal

humeral epiphyseal injury with an juxta epiphyseal # (Salterhumeral epiphyseal injury with an juxta epiphyseal # (Salterand Harris type 2 injury). This would fit into group 1 or 2and Harris type 2 injury). This would fit into group 1 or 2depending in displacement and angulation.depending in displacement and angulation.

Mechanism of injuryMechanism of injury

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These # may be caused by a fall on the side often leading toThese # may be caused by a fall on the side often leading to

impacted, minimally displaced #. Also caused by directimpacted, minimally displaced #. Also caused by directviolence or fall on outstretched hand.violence or fall on outstretched hand.

DiagnosisDiagnosisPatient tends to support the arm with the other hand.Patient tends to support the arm with the other hand.

Tenderness over proximal Humerus and in severely angled orTenderness over proximal Humerus and in severely angled ordisplaced # there may be obvious deformity.displaced # there may be obvious deformity.

Gross bruising gravitating down the arm is an outstandingGross bruising gravitating down the arm is an outstanding

feature.feature.

RadiographsRadiographs

Diagnosis is established firmly by x-rays. Two features mayDiagnosis is established firmly by x-rays. Two features maybe clear, # involves the cancellous bone of head and neck andbe clear, # involves the cancellous bone of head and neck andthat there is impaction of fragments. Both these factorsthat there is impaction of fragments. Both these factorscontribute to rapid healing.contribute to rapid healing.

Good translateral or less helpfully a film taken at right anglesGood translateral or less helpfully a film taken at right anglesto the plane of scapula is desirable for true assessment ofto the plane of scapula is desirable for true assessment ofthese injuries as they will clarify relationship of majorthese injuries as they will clarify relationship of majorelements.elements.

RadiographsRadiographs

In children the epiphyseal line is frequently mistaken for a #.In children the epiphyseal line is frequently mistaken for a #.

This line lies obliquely so that instead of appearing as a line itThis line lies obliquely so that instead of appearing as a line it is seen as oval, as one part of this will be less distinct thanis seen as oval, as one part of this will be less distinct thanthe other.the other.

Treatment guidelines Group-1Treatment guidelines Group-1

Undisplaced # of greater tuberosity : May occur in isolationUndisplaced # of greater tuberosity : May occur in isolation

or accompany a spontaneously reduced dislocation ofor accompany a spontaneously reduced dislocation ofshoulder. Arm should be supported in cuff and collar slingshoulder. Arm should be supported in cuff and collar slinguntil acute symptoms have resolved (1-2 weeks), whenuntil acute symptoms have resolved (1-2 weeks), whenmobilization can be started.mobilization can be started.


Impacted # of surgical neck : If there is minimalImpacted # of surgical neck : If there is minimal

displacement and angulation, prolonged immobilization isdisplacement and angulation, prolonged immobilization isunnecessary.unnecessary.

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Un impacted # of surgical neck : In spite of not beingUn impacted # of surgical neck : In spite of not being

impacted, an appreciable area of cancellous bone is inimpacted, an appreciable area of cancellous bone is incontact, generally assuring rapid healing. Secondarycontact, generally assuring rapid healing. Secondarydisplacement is unlikely provided the limb is adequatelydisplacement is unlikely provided the limb is adequately

protected.protected.


Slightly displaced and moderately angled humeral neck #Slightly displaced and moderately angled humeral neck #

may be treated satisfactorily by external support alone.may be treated satisfactorily by external support alone.

Arm is supported in a sling.Arm is supported in a sling.

Where disimpaction is undesirable, a broad arm sling isWhere disimpaction is undesirable, a broad arm sling is

preferred.preferred.

Where # is disimpacted, then a cuff and collar sling hasWhere # is disimpacted, then a cuff and collar sling hassome potential for gravitational correction of any angulation.some potential for gravitational correction of any angulation.


In addition, arm should be protected from rotational stressesIn addition, arm should be protected from rotational stressesby a body bandage under the clothes. Pain is often severe,by a body bandage under the clothes. Pain is often severe, and analgesics required for 1-2 weeks.and analgesics required for 1-2 weeks.

After 2 weeks body bandage may be discarded unless pain isAfter 2 weeks body bandage may be discarded unless pain isthere. Sling should be worn under outer clothes.there. Sling should be worn under outer clothes.

Rocking movements (abduction and flexion) commenced andRocking movements (abduction and flexion) commenced andpatient asked to remove the arm from sling 3 or 4 times perpatient asked to remove the arm from sling 3 or 4 times per day to flex and extend the elbow.day to flex and extend the elbow.


At 4 weeks sling can be placed outside the clothes. GentleAt 4 weeks sling can be placed outside the clothes. Gentleactive movements practiced. Over next 2 weeks the patientactive movements practiced. Over next 2 weeks the patientshould be encouraged to discard sling in gradual stages.should be encouraged to discard sling in gradual stages.

At 6 weeks full physiotherapy started. Range of movementsAt 6 weeks full physiotherapy started. Range of movementsrecorded at fortnightly intervals, and physiotherapyrecorded at fortnightly intervals, and physiotherapydiscontinued when gains cease. Some permanent restrictiondiscontinued when gains cease. Some permanent restrictionof Glenohumeral movement is common, but seldomof Glenohumeral movement is common, but seldomincapacitating.incapacitating.


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Displaced # of anatomical neck : Often complicated by AVNDisplaced # of anatomical neck : Often complicated by AVN

of humeral head. Unless the displacement is very severe withof humeral head. Unless the displacement is very severe withoff-ending or there is some complication such as vascularoff-ending or there is some complication such as vascularobstruction in the arm, avoid manipulation or open reduction.obstruction in the arm, avoid manipulation or open reduction.

If AVN ensues, joint replacement has to be considered.If AVN ensues, joint replacement has to be considered.


Severely displaced or angled # of surgical neck : In elderlySeverely displaced or angled # of surgical neck : In elderlypatients, good results are expected in this type of injuriespatients, good results are expected in this type of injurieswhere deformity is accepted and conservative management iswhere deformity is accepted and conservative management ispursued.pursued.

Nevertheless some restriction of abduction will remain.Nevertheless some restriction of abduction will remain.

So where the deformity is particularly severe or patient isSo where the deformity is particularly severe or patient isvery active, manipulative reduction should be attempted.very active, manipulative reduction should be attempted.


Manipulative reduction : Assistant maintains traction inManipulative reduction : Assistant maintains traction inadduction. Now apply pressure on the humeral shaft, pushingadduction. Now apply pressure on the humeral shaft, pushingit laterally. At the same time attempt to control the proximalit laterally. At the same time attempt to control the proximal fragment with the other hand, applying firm pressure beneathfragment with the other hand, applying firm pressure beneaththe acromion. If medial edges of # can be opposed, reductionthe acromion. If medial edges of # can be opposed, reduction

may be completed by the assistant abducting the arm gentlymay be completed by the assistant abducting the arm gentlyand gradually releasing the traction. After reduction of #, theand gradually releasing the traction. After reduction of #, thelimb should be supported in a broad arm sling and bodylimb should be supported in a broad arm sling and bodybandage.bandage.


If closed methods fail, consider ORIF, either with a Rush pinIf closed methods fail, consider ORIF, either with a Rush pin

and screws for the separate fragment, an AO T-plate andand screws for the separate fragment, an AO T-plate andscrews or # is held with an external fixator. Such solutionscrews or # is held with an external fixator. Such solutionmay also be required for # which reduces by closed methodsmay also be required for # which reduces by closed methodsbut is unstable.but is unstable.


Displaced # of greater tuberosity : 2 part injuries reducedDisplaced # of greater tuberosity : 2 part injuries reduced

either by closed methods or by ORIF. In 3 part injurieseither by closed methods or by ORIF. In 3 part injuriesarticular surface of humeral head is directed posteriorly byarticular surface of humeral head is directed posteriorly by

subscapularis. Viability of head is usually preserved andsubscapularis. Viability of head is usually preserved and

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operative reduction should be reserved for the young andoperative reduction should be reserved for the young andactive.active.


Displaced # of lesser tuberosity : 2 part injuries are rare andDisplaced # of lesser tuberosity : 2 part injuries are rare andtreated conservatively.treated conservatively.

In 3 part injuries, supraspinatus is unopposed and humeralIn 3 part injuries, supraspinatus is unopposed and humeralhead points forwards, treat it as 3 part group 4 injuries.head points forwards, treat it as 3 part group 4 injuries.

4 part injuries are identical with 4 part injuries in group 4;4 part injuries are identical with 4 part injuries in group 4;there is high risk of AVN of the detached head. These injuriesthere is high risk of AVN of the detached head. These injuries may also be managed conservatively, and complication dealtmay also be managed conservatively, and complication dealtwith as they arise.with as they arise.


Fracture dislocations : 2 part injuries in which there isFracture dislocations : 2 part injuries in which there is

dislocation of shoulder and # of greater tuberosity are dealtdislocation of shoulder and # of greater tuberosity are dealt with as though they were uncomplicated dislocations i.e. bywith as though they were uncomplicated dislocations i.e. bymanipulative reduction. The greater tuberosity usually returnsmanipulative reduction. The greater tuberosity usually returnsto its normal location, but if it remains severely displacedto its normal location, but if it remains severely displacedreduction should be undertaken.reduction should be undertaken.


If 2 part injury involves # of surgical neck, degree ofIf 2 part injury involves # of surgical neck, degree ofseparation of fragments affects the chances of satisfactoryseparation of fragments affects the chances of satisfactoryclosed reduction. Where there is little separation an intactclosed reduction. Where there is little separation an intactperiosteal sleeve will generally permit manipulative reduction.periosteal sleeve will generally permit manipulative reduction.Where there is wide separation of elements closed reductionWhere there is wide separation of elements closed reductionis difficult. In severe separation, the risk of failure isis difficult. In severe separation, the risk of failure isparticularly high, so in every case cross matched blood andparticularly high, so in every case cross matched blood andfull theatre facilities should be available and kept ready infull theatre facilities should be available and kept ready in

case an open procedure becomes necessary.case an open procedure becomes necessary.


Closed reduction : Apply strong traction in neutral position orClosed reduction : Apply strong traction in neutral position orslight abduction and apply manual pressure to the head viaslight abduction and apply manual pressure to the head viaaxilla and front of shoulder. Avoid hyper abduction.axilla and front of shoulder. Avoid hyper abduction.

If this fails, pass a threaded pin into humeral head (3 cmIf this fails, pass a threaded pin into humeral head (3 cmbelow acromial arch). Apply lateral traction to the pin withbelow acromial arch). Apply lateral traction to the pin withslight traction to the arm and manual pressure over theslight traction to the arm and manual pressure over the

humeral head. After care is as for group 3 injuries.humeral head. After care is as for group 3 injuries.

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Where closed methods fail, consider for open reduction. In 3Where closed methods fail, consider for open reduction. In 3

& 4 part, where there is splitting of head fragment, risk of& 4 part, where there is splitting of head fragment, risk ofAVN with persistent pain and stiffness are high. Under theseAVN with persistent pain and stiffness are high. Under thesecircumstances excisional arthroplasty, hemi-arthroplasty orcircumstances excisional arthroplasty, hemi-arthroplasty ortotal joint replacement should be considered.total joint replacement should be considered.

Treatment in childrenTreatment in children

In children, un impacted # may be of adult pattern or groupIn children, un impacted # may be of adult pattern or group 2 epiphyseal injuries. Open reduction should be avoided.2 epiphyseal injuries. Open reduction should be avoided.Manipulate as described, but if deformity recurs on bringingManipulate as described, but if deformity recurs on bringing

the arm to side, apply a shoulder spica in abduction. Bonythe arm to side, apply a shoulder spica in abduction. Bonyapposition should be obtained, but persisting angulation inapposition should be obtained, but persisting angulation inexcess of 30excess of 30 should not induce pessimism as rapid recoveryshould not induce pessimism as rapid recoveryof function through remodeling is the rule.of function through remodeling is the rule.

ComplicationsComplications

Pathological # from simple bone cyst is common in proximalPathological # from simple bone cyst is common in proximal

humeral shaft in children. Treated as uncomplicated #.humeral shaft in children. Treated as uncomplicated #.

Healing usually proceeds normally, often with spontaneousHealing usually proceeds normally, often with spontaneous

disappearance of the cyst. Only rarely following repeated # ordisappearance of the cyst. Only rarely following repeated # orcyst expansion is curettage and packing with bone chipscyst expansion is curettage and packing with bone chipsindicated.indicated.

ComplicationsComplications

Radio necrosis may follow radiation therapy for Ca breast,Radio necrosis may follow radiation therapy for Ca breast,leading to pathological #. Active treatment is difficult due toleading to pathological #. Active treatment is difficult due tolocal fibrosis and vascular change, but joint replacementlocal fibrosis and vascular change, but joint replacement

might be considered in selected cases. Arterial obstructionmight be considered in selected cases. Arterial obstructiongenerally responds to reduction of #. If exploration isgenerally responds to reduction of #. If exploration isrequired, preliminary exposure and tapping of the subclavianrequired, preliminary exposure and tapping of the subclaviantrunk at the root of the neck must be anticipated.trunk at the root of the neck must be anticipated.

# of Humerus shaft# of Humerus shaft

Result from indirect violence like fall on outstretched hand orResult from indirect violence like fall on outstretched hand ordirect violence like fall on the side or blow on the arm.direct violence like fall on the side or blow on the arm.

In # involving U/3In # involving U/3rdrd, proximal fragment tends to be pulled, proximal fragment tends to be pulled

into adduction by the unopposed action of pectoralis major.into adduction by the unopposed action of pectoralis major.

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In # involving M/3In # involving M/3rdrd, proximal fragment tends to be abducted, proximal fragment tends to be abducted

due to deltoid pull. Radial N palsy, non union and compounddue to deltoid pull. Radial N palsy, non union and compoundinjuries are commonest in M/3injuries are commonest in M/3rdrd..

# of Humerus shaft-Diagnosis# of Humerus shaft-Diagnosis

The arm is flail and supported with other hand. ObviousThe arm is flail and supported with other hand. Obviousmobility at # site leaves little doubt regarding diagnosis.mobility at # site leaves little doubt regarding diagnosis.Confirmation is by radiographs.Confirmation is by radiographs.

Look for evidence of Radial N Palsy; drop wrist and sensoryLook for evidence of Radial N Palsy; drop wrist and sensoryimpairment dorsum of hand. This is an uncommonimpairment dorsum of hand. This is an uncommoncomplication as a slip of brachialis lies beneath the nerve; thiscomplication as a slip of brachialis lies beneath the nerve; this generally prevents it from coming in contact withgenerally prevents it from coming in contact with

musculoskeletal groove or the # bone ends.musculoskeletal groove or the # bone ends.If however radial N palsy accompanies a compound #,If however radial N palsy accompanies a compound #,exploration is mandatory.exploration is mandatory.

# of Humerus shaft-Treatment# of Humerus shaft-Treatment

U-slab method : Single # treated by U-plaster. If angulationU-slab method : Single # treated by U-plaster. If angulationis slight, no anesthetic is required. Patient should be seatedis slight, no anesthetic is required. Patient should be seatedand plaster slab prepared such as to allow it to stretch fromand plaster slab prepared such as to allow it to stretch frominside of the arm round the elbow and over shoulder.inside of the arm round the elbow and over shoulder.

Wool roll is applied over arm with particular attention toWool roll is applied over arm with particular attention toelbow. Padding should extend from shoulder to U/3elbow. Padding should extend from shoulder to U/3rd

rdofof

forearm.forearm.


Slab is now wetted and applied to the arm, starting in theSlab is now wetted and applied to the arm, starting in themedial side of the Axillary fold and then bringing it round themedial side of the Axillary fold and then bringing it round theelbow up to the shoulder. Slab should be carefully smoothedelbow up to the shoulder. Slab should be carefully smootheddown. Overlapping of edges of slab anteriorly or posteriorly isdown. Overlapping of edges of slab anteriorly or posteriorly isof little consequence. Plaster is secured with a wet openof little consequence. Plaster is secured with a wet openweave cotton bandage. Suring the setting, # may be gentlyweave cotton bandage. Suring the setting, # may be gentlymoulded and slight angulation corrected. Thereafter armmoulded and slight angulation corrected. Thereafter armshould be supported in a sling worn under the clothes.should be supported in a sling worn under the clothes.


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If # is badly displaced, heavy sedation or G/A is desirable.If # is badly displaced, heavy sedation or G/A is desirable.

Assistant should apply light traction to arm and U-slab appliedAssistant should apply light traction to arm and U-slab appliedwith careful molding of # as the plaster sets. A sling is wornwith careful molding of # as the plaster sets. A sling is wornunder the cloths for additional support.under the cloths for additional support.


Hanging cast method : Principle of this treatment is thatHanging cast method : Principle of this treatment is that

weight of limb plus plaster reduce the # and maintainweight of limb plus plaster reduce the # and maintainreduction. A long arm plaster is along with a cuff and collarreduction. A long arm plaster is along with a cuff and collarsling. The patient must be ambulant for this line of treatment.sling. The patient must be ambulant for this line of treatment. There may be higher rate of non union from occasionalThere may be higher rate of non union from occasional distraction.distraction.


After initial pain has settled say 2-3 weeks the hanging castAfter initial pain has settled say 2-3 weeks the hanging castis replaced by a polythene sleeve or other form of functionalis replaced by a polythene sleeve or other form of functionalbracing, but many prefer to continue cast until union. Checkbracing, but many prefer to continue cast until union. Checkfor this clinically and radio logically at 9 weeks. If judgedfor this clinically and radio logically at 9 weeks. If judgedsound, a sling may be worn as an additional precaution for 2sound, a sling may be worn as an additional precaution for 2weeks, but mobilization of shoulder and elbow commenced.weeks, but mobilization of shoulder and elbow commenced.Depending on progress of union, patient should be consideredDepending on progress of union, patient should be considered

for physiotherapy.for physiotherapy.


ORIF considered in bed ridden patients especially with # inORIF considered in bed ridden patients especially with # in

both arms, 2 or more # in one limb, radial N palsy in a cleanboth arms, 2 or more # in one limb, radial N palsy in a clean compound # or radial N palsy follows manipulation. Methodscompound # or radial N palsy follows manipulation. Methodsinclude Rush nailing, or Kuntscher nailing form above, Rushinclude Rush nailing, or Kuntscher nailing form above, Rushnailing form olecrenon fossa or plating.nailing form olecrenon fossa or plating.

Complication : Non unionComplication : Non unionMost frequent in M/3Most frequent in M/3rdrd #, especially in obese where support#, especially in obese where support

of # may be difficult or where gravitational distraction of #of # may be difficult or where gravitational distraction of #occurs. Rigid IF with well fitting Kuntscher nail, compressionoccurs. Rigid IF with well fitting Kuntscher nail, compressionplating, etc and often BG are advised with postoperativeplating, etc and often BG are advised with postoperativefixation in plaster shoulder spica. Visualization of radial N isfixation in plaster shoulder spica. Visualization of radial N isessential to avoid damage, and a posterior approach isessential to avoid damage, and a posterior approach isfrequently used.frequently used.

Complication : Radial N PalsyComplication : Radial N Palsy

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Generally the lesion in continuity, and recovery oftenGenerally the lesion in continuity, and recovery often

commences 6-8 weeks after the initial injury especially incommences 6-8 weeks after the initial injury especially inclosed #. Drop wrist splint preferably of lively type is appliedclosed #. Drop wrist splint preferably of lively type is appliedas soon as possible and active and passive movements ofas soon as possible and active and passive movements of

fingers, thumb and wrist started. If there is no evidence offingers, thumb and wrist started. If there is no evidence ofrecovery in 8 weeks an EMG is taken. If this shows no sign ofrecovery in 8 weeks an EMG is taken. If this shows no sign ofrecovery, exploration of radial N undertaken.recovery, exploration of radial N undertaken.

Lesions of rotator cuff-EtiologyLesions of rotator cuff-Etiology

Tendinous fibers of rotator cuff at or near their insertion intoTendinous fibers of rotator cuff at or near their insertion intotuberosity undergo degenerative changes with advancing age.tuberosity undergo degenerative changes with advancing age.Deterioration is pronounced after 5Deterioration is pronounced after 5th

thdecade and is observeddecade and is observed

in all shoulders after 60 years. The area where degenerativein all shoulders after 60 years. The area where degenerativechanges are most severe is known as critical area. At 6changes are most severe is known as critical area. At 6thth

decade defects on the cuff are seen almost universally. Thedecade defects on the cuff are seen almost universally. Thetendon is worn down by attrition between humeral head andtendon is worn down by attrition between humeral head andcoracoacromial arch.coracoacromial arch.

Lesions of rotator cuff-EtiologyLesions of rotator cuff-Etiology

As the tendon disintegrates and disappears, remainder ofAs the tendon disintegrates and disappears, remainder of

tendon becomes fixed in bicipital groove. As overlying softtendon becomes fixed in bicipital groove. As overlying softtissues are worn down, tuberosity is subjected to pressuretissues are worn down, tuberosity is subjected to pressure

and friction as it rides against the under surface of acromion,and friction as it rides against the under surface of acromion,and becomes eroded. Bone at this site becomes sclerotic andand becomes eroded. Bone at this site becomes sclerotic andcystic. As the cuff wears away, deltoid gradually takes overcystic. As the cuff wears away, deltoid gradually takes overmore function.more function.

Lesions of rotator cuff-Clinical pictureLesions of rotator cuff-Clinical picture

Recurring pains and stiffness, aggravated by activity,Recurring pains and stiffness, aggravated by activity,

occurring in shoulder and radiating down the anterior aspectoccurring in shoulder and radiating down the anterior aspectof arm.of arm.

In acute rupture, H/O fall on shoulder or lifting objectIn acute rupture, H/O fall on shoulder or lifting object

outwards. A severe acute pain and snap on shoulder is feltoutwards. A severe acute pain and snap on shoulder is feltimmediately and patient is unable to abduct the arm. Painimmediately and patient is unable to abduct the arm. Painbecomes progressively severe over next few hours.becomes progressively severe over next few hours.

Lesions of rotator cuff-ExaminationLesions of rotator cuff-Examination

Arm can be raised actively up to 45Arm can be raised actively up to 45 after which elevation ofafter which elevation ofarm is accomplished by shrugging. Pain is most severe in thearm is accomplished by shrugging. Pain is most severe in thearc from 45arc from 45 to 90to 90 when traumatized tendon is compressedwhen traumatized tendon is compressedbetween the tuberosity and coracoacromial arch. If the arm isbetween the tuberosity and coracoacromial arch. If the arm iselevated passively above 90elevated passively above 90 further abduction is possible. Iffurther abduction is possible. Iftear is in posterosuperior portion, pain is most severe whentear is in posterosuperior portion, pain is most severe when

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arm is rotated internally during abduction. If tear is inarm is rotated internally during abduction. If tear is inanterosuperior portion, pain is severe when arm is abductedanterosuperior portion, pain is severe when arm is abductedand externally rotated.and externally rotated.

Lesions of rotator cuff-ExaminationLesions of rotator cuff-Examination

Strength of abduction is proportionate to size of tear. If tearStrength of abduction is proportionate to size of tear. If tearis extensive, abduction is weak and performed through ais extensive, abduction is weak and performed through asmall range. If tear is small, range of motion is complete.small range. If tear is small, range of motion is complete.However when resistance is offered to abduction, weakness isHowever when resistance is offered to abduction, weakness ismanifest by arm dropping to the side. A stub of tendon ormanifest by arm dropping to the side. A stub of tendon oractual gap in deep soft tissues may be felt adjacent to greateractual gap in deep soft tissues may be felt adjacent to greatertuberosity. As arm is abducted, rough grating is palpable attuberosity. As arm is abducted, rough grating is palpable atthis point and crepts may be audible.this point and crepts may be audible.

Lesions of rotator cuff-Subsequent courseLesions of rotator cuff-Subsequent course

Pain gradually lessens over months and ability to abductPain gradually lessens over months and ability to abduct

improves. Eventually a full range of painless motion results.improves. Eventually a full range of painless motion results.Atrophy of suraspinatus and infraspinatus renders theAtrophy of suraspinatus and infraspinatus renders thescapular spine prominent. Despite the rupture of long head ofscapular spine prominent. Despite the rupture of long head ofbiceps, fairly good active elbow flexion is regained.biceps, fairly good active elbow flexion is regained.

Lesions of rotator cuff - X-rayLesions of rotator cuff - X-ray

In early acute case, negative. An arthrogram using air orIn early acute case, negative. An arthrogram using air orradiopaque fluid may demonstrate a communication betweenradiopaque fluid may demonstrate a communication between

joint and bursa but it is important to recognize that jointjoint and bursa but it is important to recognize that jointnormally communicates with subacromial bursa in few youngnormally communicates with subacromial bursa in few youngpeople, number increasing with advancing age. Procedure ispeople, number increasing with advancing age. Procedure ismore valuable if negative, because no communication rulesmore valuable if negative, because no communication rulesout a rupture of rotator cuff. In chronic case, tuberosityout a rupture of rotator cuff. In chronic case, tuberosityrecedes and becomes irregular, sclerotic and cystic.recedes and becomes irregular, sclerotic and cystic.

Lesions of rotator cuff-TreatmentLesions of rotator cuff-Treatment

When preservation of strength is desirable, tendon should beWhen preservation of strength is desirable, tendon should berepaired immediately. Edges of tear are approximated andrepaired immediately. Edges of tear are approximated and

sutured. Postoperatively arm is placed in cast in 90sutured. Postoperatively arm is placed in cast in 90abduction, 60abduction, 60 external rotation and 30external rotation and 30 forward flexion for 3forward flexion for 3weeks after which active exercises started. If repair isweeks after which active exercises started. If repair isdelayed, edges of tear retract and approximation is difficult.delayed, edges of tear retract and approximation is difficult.Contraindication to repair are old age and sedentaryContraindication to repair are old age and sedentaryoccupation.occupation.

Lesions of rotator cuff-TreatmentLesions of rotator cuff-Treatment

Contusion of cuff, a slight tear, or traumatic bursitis mayContusion of cuff, a slight tear, or traumatic bursitis maysimulate a complete tear clinically. In such doubtful case,simulate a complete tear clinically. In such doubtful case,

watchful waiting is acceptable in 90-60-30 position.watchful waiting is acceptable in 90-60-30 position.

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In neglected case, stiffness develops and physiotherapy,In neglected case, stiffness develops and physiotherapy,application of heat, active and passive exercises will mobilizeapplication of heat, active and passive exercises will mobilizethe joint sufficiently. When full passive abduction is possible,the joint sufficiently. When full passive abduction is possible,active abduction by shrugging mechanism defines a tear ofactive abduction by shrugging mechanism defines a tear of

cuff and repair is indicated.cuff and repair is indicated.Peri arthritis shoulderPeri arthritis shoulder

Peri arthritis shoulder or frozen shoulder is a condition ofPeri arthritis shoulder or frozen shoulder is a condition of

unknown etiology characterized by gradually progressive,unknown etiology characterized by gradually progressive,painful restriction of all joint motion, chronic behavior, andpainful restriction of all joint motion, chronic behavior, andslow spontaneous restoration of partial or complete motionslow spontaneous restoration of partial or complete motionover months to years.over months to years.

Peri arthritis shoulder- EtiologyPeri arthritis shoulder- Etiology

Actual cause is unknown.Actual cause is unknown.

Tendonitis of rotator cuff and other shoulder injuries.Tendonitis of rotator cuff and other shoulder injuries.

Bicipital Tenosynovitis.Bicipital Tenosynovitis.

Muscle imbalance developing from inactivity.Muscle imbalance developing from inactivity.

RSDRSDPeri arthritis shoulder- EtiologyPeri arthritis shoulder- Etiology

The condition exhibits some constant factors like :-The condition exhibits some constant factors like :-

Muscular inactivity, often precedes the onset.Muscular inactivity, often precedes the onset.

Tenosynovitis of long head of biceps found almost in everyTenosynovitis of long head of biceps found almost in every

case at operation.case at operation.

Frozen shoulder develops in joints with severe degenerativeFrozen shoulder develops in joints with severe degenerative

changes.changes.Peri arthritis shoulder- EtiologyPeri arthritis shoulder- Etiology

Frequent association of frozen shoulder with CV disease andFrequent association of frozen shoulder with CV disease andpainful restriction of hand motion strongly suggests anpainful restriction of hand motion strongly suggests anirritating focus that exerts its influence through sympatheticirritating focus that exerts its influence through sympatheticnervous system.nervous system.

In abduction, humeral head and tuberosity are closelyIn abduction, humeral head and tuberosity are closelyapproximated to the acromion and very sharp edgedapproximated to the acromion and very sharp edgedcoracoacromial ligament. For prominence of tuberosity tocoracoacromial ligament. For prominence of tuberosity toproceed beneath the arch, head is depressed inferiorly awayproceed beneath the arch, head is depressed inferiorly awayfrom arch by contraction of biceps, whose long tendon passesfrom arch by contraction of biceps, whose long tendon passesover the head.over the head.

Peri arthritis shoulder- EtiologyPeri arthritis shoulder- Etiology

Rotator cuff also depresses the head but also fixes it againstRotator cuff also depresses the head but also fixes it against

the glenoid while deltoid abducts the arm. When these forcesthe glenoid while deltoid abducts the arm. When these forces

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are ineffective, the upwards thrust of deltoid acts alone andare ineffective, the upwards thrust of deltoid acts alone andat about 45at about 45 of abduction the tuberosity impinge onof abduction the tuberosity impinge oncoracoacromial arch and further Glenohumeral movement iscoracoacromial arch and further Glenohumeral movement isimpossible. Scapular motions alone effect further raising ofimpossible. Scapular motions alone effect further raising of

arm by shrugging mechanism.arm by shrugging mechanism.Peri arthritis shoulder- EtiologyPeri arthritis shoulder- Etiology

After an injury to limb, severe, diffuse, poorly localized painAfter an injury to limb, severe, diffuse, poorly localized pain

at one or several points, such as shoulder, elbow and handat one or several points, such as shoulder, elbow and handassociated with soft tissue swelling, thinning of skin, slightassociated with soft tissue swelling, thinning of skin, slightcyanosis of part, coldness, hypersensitivity, limitation ofcyanosis of part, coldness, hypersensitivity, limitation ofmotion, and increased sweating of hand results. When themotion, and increased sweating of hand results. When thehand and shoulder are involved, it is known as shoulder handhand and shoulder are involved, it is known as shoulder handsyndrome.syndrome.

Peri arthritis shoulder- Clinical picturePeri arthritis shoulder- Clinical picture

55thth and 6and 6thth decades, particularly women with CV disease aredecades, particularly women with CV disease are

predisposed. Onset is insidious, develops during the period ofpredisposed. Onset is insidious, develops during the period ofrelative inactivity. Vague antecedent injury may be blamed.relative inactivity. Vague antecedent injury may be blamed.Pain is located over anterolateral aspect of joint and radiatesPain is located over anterolateral aspect of joint and radiatesto anterior aspect of upper arm and occasionally to flexorto anterior aspect of upper arm and occasionally to flexoraspect of forearm. Worse at night and interferes with sleep.aspect of forearm. Worse at night and interferes with sleep.


Tenderness is generalized about humeral head and overTenderness is generalized about humeral head and overbicipital groove. Active and passive motions are limited in allbicipital groove. Active and passive motions are limited in alldirections, pain accentuated at extremes of motion. Muscledirections, pain accentuated at extremes of motion. Musclespasm is seen. Arm is held protectively at the side in aspasm is seen. Arm is held protectively at the side in aposition of internal rotation. As condition progresses overposition of internal rotation. As condition progresses overmonths, motion gradually diminishes and pain lessens.months, motion gradually diminishes and pain lessens.Eventually, little or no motion remains, and pain is slight orEventually, little or no motion remains, and pain is slight orabsent.absent.


After subsidence of pain, begins slow restoration of motion.After subsidence of pain, begins slow restoration of motion.During period of fixation and non use, scapular musclesDuring period of fixation and non use, scapular musclesbecomes atrophic, scapular spine becomes prominent,becomes atrophic, scapular spine becomes prominent,humeral head is held high against the acromion as comparedhumeral head is held high against the acromion as comparedto opposite side, pectoralis major is contracted. Signs of RSDto opposite side, pectoralis major is contracted. Signs of RSDoften develops in hand with swelling of fingers, shiny atrophicoften develops in hand with swelling of fingers, shiny atrophicskin, mottled dusky discoloration, coldness, hyperhydrosis,skin, mottled dusky discoloration, coldness, hyperhydrosis,hypersensitivity and marked limitation of motions.hypersensitivity and marked limitation of motions.

Peri arthritis shoulder-TreatmentPeri arthritis shoulder-Treatment

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Conservative : In early stages, bed rest, application of heat,Conservative : In early stages, bed rest, application of heat,and sedatives. If pain is severe, ice bags are applied. Armand sedatives. If pain is severe, ice bags are applied. Armshould hang in dependant position, the weight of armshould hang in dependant position, the weight of armproviding traction. Pendulum exercises are practiced as soonproviding traction. Pendulum exercises are practiced as soon

as they are tolerated. Later overhead pulley exercises areas they are tolerated. Later overhead pulley exercises areadded. Range of painless motion gradually increases over aadded. Range of painless motion gradually increases over aperiod of months to as long as 2 years.period of months to as long as 2 years.

Forcible manipulations are not desirable.Forcible manipulations are not desirable.Peri arthritis shoulder-TreatmentPeri arthritis shoulder-Treatment

When urgency of relief is there careful manipulation mayWhen urgency of relief is there careful manipulation mayshorten the course and eliminate the need of surgery. Undershorten the course and eliminate the need of surgery. UnderGA the arm is moved slowly and passively in all directions.GA the arm is moved slowly and passively in all directions.Assistant fixes the scapula by grasping the trapezius ridgeAssistant fixes the scapula by grasping the trapezius ridgemedial to AC joint and surgeon flexes the elbow andmedial to AC joint and surgeon flexes the elbow andsupporting the forearm to maintain neutral rotation, abductssupporting the forearm to maintain neutral rotation, abductsthe patientthe patients arm slowly, at the same time assistant pressess arm slowly, at the same time assistant presseshumeral head medially and caudally.humeral head medially and caudally.


Sudden release of resistance accompanied by audibleSudden release of resistance accompanied by audiblesnapping sounds suggests freeing of adhesions. Next the armsnapping sounds suggests freeing of adhesions. Next the armis rotated externally and internally. If resistance to rotation isis rotated externally and internally. If resistance to rotation is

encountered, further attempts should be abandoned.encountered, further attempts should be abandoned.

Over next 24 to 48 hours pain is controlled by ice bag andOver next 24 to 48 hours pain is controlled by ice bag and analgesics. As soon as tolerance to pain permits, activeanalgesics. As soon as tolerance to pain permits, activeexercises are started and continued for weeks. Patient isexercises are started and continued for weeks. Patient isinformed about recurrence if exercises are neglected.informed about recurrence if exercises are neglected.


Surgery : Indicated when pain is severe and persistent, andSurgery : Indicated when pain is severe and persistent, andrecovery of motion must be hastened. Transacromialrecovery of motion must be hastened. Transacromialapproach, much of acromion is discarded, subacromial bursaapproach, much of acromion is discarded, subacromial bursa

is resected. Coracohumeral ligament is split longitudinally,is resected. Coracohumeral ligament is split longitudinally,intra articular biceps tendon is freed and its origin at glenoidintra articular biceps tendon is freed and its origin at glenoidis cut, tendon is removed to the point where it enters bicipitalis cut, tendon is removed to the point where it enters bicipitalgroove. Transverse humeral ligament is cut, the Fascial roof isgroove. Transverse humeral ligament is cut, the Fascial roof issplit. Postoperatively the arm is immobilized at the side forsplit. Postoperatively the arm is immobilized at the side forseveral weeks F/B gradual active and passive exercises. Thisseveral weeks F/B gradual active and passive exercises. Thisoffers dramatic recovery of motion and subsidence of pain.offers dramatic recovery of motion and subsidence of pain.

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shoulder complexx

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