USS University
Lectures of Orthopedics by Dr Abas
Hassan Ahmed
Topic: Injuries around Shoulder and
elbow.
Injuries around the shoulder
• Shoulder joint consists:
1- Glenohumeral joint
2- Acromioclavicular joint
3- Sternoclavicular joint
In this chapter we are going to discuss the
injuries concerning these three joints and the
fractures of Clavicular, Scapula and proximal part
of the humerus.
Clavicle
• Anatomically it has Anterior and Posterior
sides but when we are looking at the radio
graphic images the following is very import
tant to look at it.
1- Lateral end
2- Shaft(middle)
3- Medial end
Function of the clavicle
• It increases arm strength mechanism
It protects neurovascular bundle consisting of
subclavian vessels and brachial plexus.
• It gives attachment to important muscles
around the shoulder.
• It braces the shoulder back during the rest and
the motion.
Mechanism of the injuries of the clavicle
• Direct injuries
1-Fall on the point of the shoulder 91%
2-Traffic accidents 8%
• Indirect
1- Over stretched hands
Sites of the fracture
• 85% of the clavicle fracture occurs at the
junction of the middle
• 5% occurs at the medial end
• 10% occurs at the lateral end
Classification of fracture of the
clavicle(Allman’s)
• Group 1: Fracture involves one third of the fracture
of the shaft
• Group 2: Fracture involves lateral 3rd distal part to
the attachment of the cracoclavicular ligament, this
is farther is divided into two subgroups
1- Type A: Cracoclavicular ligament intact
2- Type B: Cracoclavicular ligament raptured
3- Type C: Intra-articular extention into
acromioclavicular joint.
Group 3: Medial 3rd fractures
Clinical features
• The patients presents with pain, swelling,
deformity and inability to raise the shoulder.
Rarely the patient may represent pseudo-
paralysis of the effected arm
Principles of treatment
• Before proceeding to the treatment proper one
needs to understand the two distracting forces
acting on the fracture fragments making the
treatment difficult.
• The sternocleidomuscle pulls up the medial end
of the clavicle and pectoralis major(major
pectoral) muscle pull down the clavicle at the
lateral end. To counter the above 2 determinal
forces the shoulder should be braced up and back
while treating fracture of the clavicle
Conservative methods
This is the treatment of choice and consist of the following
methods
• Cuff and collar sling for undisplaced fracture
• Strapping of the fracture site after reduction of the fracture
by elevating the arm and bracing the shoulder upwards and
back wards gives good result in both children and adults
• Billington Yoke method- Uses a plaster of Paris over a well-
padded figure of 8 dressing
• Figure of 8- is popularly used and it acts by retracting by
shoulder griddle minimizes overlap and allows more
anatomical healing
Surgical methods
• Intramedulary fixation with K-wires
• Rigid plate and screw fixation with AO semitubular plate
or with pelvic constrative plate(constractive plate)
• Indications:
- Injury to neurovascular bundle, nonunion, if the fracture
is threatening to penetrate the skin Fracture near
acromioclavicular joint, floating shoulder(when fracture of
clavicle is combined with fracture of different bone), Soft
tissue inter postion(The term interposition means that new
tissue is placed between the damaged surfaces )
Complication of the clavicle fracture
• Neurovascular injury may be immediate due
to direct force or delayed due to very large
callus the stracture commonly inujried are
subclavian vessels and medial cord of brachial
plexus through which the ulnar nerve is
derived.
• This occurs in fracture of middle one third of
the clavicle which is the most common.
Malunion after the fracture of the clavicle
• This is very common due to difficults in
holding fracture fragments together because
of distraction force we mentioned before.
• This causes only cosmetic problem and it
doesn’t usually impair functions and hence no
treatment is required.
Injuries of acromioclavicular joint
• Acromioclavicular joint is diarthrodial joint
with fibrocarteliginious disk between 2 bones
similar to the a meniscus.
• This joint permits gliding(wing movement)
rotation between the clavicle and the scapula.
The stractural integrity depends on intrisic
capsular element, supperior acromioclavicular
element.
Machanism of injuries
• Direct force: The most cause is road traffic
accidents, sports such as wrestling, Judo
• Indirect fore: due to outstretched hands
Clinical feature
• The patient complains pain, swelling, difficult,
in raising arms up.
• The patient supports the affected arm by
holding the elbow with unaffected hand.
• By examination there is tenderness and the
lateral part of the clavicle is permenently felt
Classification by Sage and Salvatore
• Based on injuries of acromioclavicular and coracoclavicular
ligament.
- Type I Minor sprain to acromio clavicular ligament
- Type II: Rapture of acromioclavicular ligament sprain in
coracoacromial ligament
- Type III Both acromioclavicular ligament and coracoacromial
ligaments are raptured and the clavicle is displaced upwards
- Type IV Similar to Type III but with upward and posterior
displaced clavicle
- Type V similar to Type III but sever displacement towards
base of the neck
Radiography
• The following views are required
- AP view with 15degrees cephalic tilt to prevent
overlap of the spine of the scapula
- Lateral views axillary views of the shoulder
- Stress radiographs: to differentiate type II and
type III suspending of weight of 10 to 15lbs( 4.5-
7kgs)
Treatment
• Type I: rest icebags and NSAIDs
• Type II sling for 10 to 15 days, strapping. Surgery is
required for persisting pain
• Type III conservative methods like reduction and
retention with sling. Surgical methods include: -
acromioclavicular repair -carcoclavicular repair-
Excission of distal end of clavicle for old
symptomatic case.
• Type IV, V, VI require open reduction and internal
fixation, repair and reconstraction.
Injuries of sterno clavicular joint
• Mechanism of Injuries occur either
- Direct : Rarely cause injuries for example
collision of an athlete with and other person,
or a post
- Indirect force of loading of one end of the
shoulder while someone lies at the othe end
- Sports such as practicing of Judo and Jiujutsu
when there is an arm
Causes
• Road traffic accident
• Sports
• Military training
Classification
• Anatomical Classification
- Anterior dislocation
- Posterior dislocation
• Etiological Classification
- Sprain
- Acute dislocation
- Recurent dislocation
-Unreduced disloction
• Atraumatic
- Voluntary
- Involantary
- congenital
- Degenerative
- Infective
Clinical features
• The patient complains of pain, swelling of the
medial end of the clavicle is prominent in
anterior dislocation.
• Affected shoulder is short.
Radiographs
• Anterior posterior veiw is difficult to interpret
• Spacial 90degrees of cephalocaudal views-,
this helps to see the medial end of both
clavicles
• Tomogram is usefull(Tomography recording)
• CT scan and MRI
Treatment
• Mild sprain. Treatment consist ice, sling and
pain killers
• Sublaxation-Treatment, ice(first 12hrs)
warmth(24-48 hours) clavicle stramp and
figure 8
• Disclocation- Treatment of choicel is closed
reduction.
• Thanks for your attention