Chapter 2 Shoulder and elbow emergencies
Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.
Glenohumeral dislocations
Key facts
Anterior shoulder dislocations are usually clinically obvious
Posterior shoulder dislocations can be difficult to identify
The shoulder is the most commonly dislocated joint in the body
95% of shoulder dislocations will be anterior
Patients < 30 years of age have a high risk of recurrence
Clinical presentation
The shoulder is the most commonly dislocated joint in the body
95% of shoulder dislocations will be anterior
Patients have a squared-off appearance to the shoulder
The arm is held in slight abduction
Posterior dislocations can be difficult to detect by appearance alone
Patients often hold the arm adducted to the side
Seizures are classically associated with posterior dislocations
A thorough neurovascular exam of the affected extremity is essential to exclude a neurovascular injury
Diagnostic testing
Plain films of the shoulder are the test of choice
Perform an AP (Figure 2.1A) and a lateral projection (axillary lateral or scapular Y-view) (Figure 2.1B)
PEARL: Failure to obtain a lateral projection can result in missing a posterior dislocation in up to 50% of cases.
Figure 2.1A and 2.1B Radiographs of a posterior shoulder dislocation.
A: An AP projection is shown with no obvious dislocation.
B: A lateral projection (scapular Y-view) for the same patient shows the humeral head to be dislocated posteriorly.
Treatment
Emergency Department management
Provide adequate analgesia
Procedural sedation has been the historical mainstay for joint reductions
Reduction performed with an intra-articular anesthetic injection is an acceptable alternative
There are a multitude of techniques
Be familiar with more than one – no technique has a 100% success rate
Perform pre- and post neurovascular exams
Perform confirmatory radiographs
Place the patient in a standard sling or shoulder immobilizer
External rotation slings may provide better anatomic alignment but are not often available in many EDs
External rotation slings have been shown to reduce the recurrence rate of first-time dislocators
Referral to an orthopedic surgeon in 7–10 days is appropriate
Prognosis
Most patients can return to a pre-injury level of function after several weeks
Patients < 30 years of age have a high risk of recurrence and may benefit from surgical stabilization
Patients > 40 years of age may have greater morbidity if the rotator cuff has been injured
Procedures
Intra-articular injection of lidocaine (Figure 2.2)
Supplies needed
1–3 cc syringe
1–20 cc syringe
2–18-gauge needles
1–27-gauge needle
1–20-gauge 3.5 inch spinal needle
Chlorhexidine/betadine scrub
4 × 4 gauze pads
Sterile gloves
30 cc vial of 1% lidocaine solution
Technique
Positioning
Place the patient in the seated position with the affected arm adducted to the side
Preparation
Prep the lateral aspect of the shoulder with betadine or chlorhexidine solution
Apply sterile gloves and perform procedure with standard aseptic technique
Draw 1 cc of 1% lidocaine into the 3 cc syringe and cap with the 27-gauge needle; set aside for use as local skin anesthesia
Draw 15 cc of 1% lidocaine into the 20 cc syringe and cap with the 20-gauge spinal needle
Identify the lateral aspect of the acromion (identified by the squared-off shoulder)
Make a sterile mark 1 cm below the inferior-most aspect of the acromion
Procedure
Make a small skin wheal at the marked site using the 3 cc syringe with lidocaine
Holding negative pressure, insert the 20 cc syringe with attached spinal needle into the lateral aspect of the shoulder perpendicular to the skin
Continue advancing until the glenohumeral joint is entered
Hemarthrosis may be apparent
Change in resistance from entering the joint space can be felt
Inject 15 cc of 1% lidocaine into the joint space
Remove the needle and place a sterile dressing
Allow 15 minutes for the anesthetic to take effect
Various different techniques exist with excellent success rates (Table 2.1)
External rotation method: can be performed safely by a single provider and does not require a lot of strength for success (Figure 2.3)
Place the patient in the supine position
Hold the affected extremity adducted to the side with the elbow flexed at 90°
Bring the shoulder into 20° of forward flexion
The physician should hold the patient’s wrist with one hand, stabilize the elbow with the other hand and gently externally rotate the forearm
The physician should stop and hold the position when resistance is felt until the muscles relax and then proceed further
Once reduction is achieved, the arm can be returned to an internally rotated position and placed in a sling
Figure 2.2 Intra-articular injection of lidocaine.
After sterile prep, the needle enters the shoulder perpendicular to the skin, just below the lateral edge of the acromion, until the glenohumeral joint is entered.
Figure 2.3 The external rotation method for glenohumeral reduction.
A: Place the patient in the supine position with the affected extremity adducted to the side and the elbow flexed at 90° and shoulder forward flexed at 20°. The physician should hold the patient’s wrist with one hand and stabilize the elbow with the other.
B: Gently externally rotate the forearm, stopping periodically when resistance or muscle spasm is felt, to allow for muscle relaxation.
C: Once reduction is felt, the arm should be checked through a range of motion and may be returned to an internally rotated position with a sling.
Scapular fractures
Key facts
The scapula links the axial skeleton to the upper extremity and serves as the stabilizing platform for arm motion
Scapular fractures result from a high-energy mechanism and require a thorough trauma assessment to exclude life-threatening injuries
Clinical presentation
Scapular fractures account for only 1% of all fractures and 5% of shoulder fractures
The majority of fractures occur in the body of the scapula
Scapular fractures often occur with a high-energy mechanism and may be associated with more serious injuries
In one series, patients with scapular fractures had an average of 3.9 additional major injuries
Mechanism of injury
High-energy direct blow/trauma to the shoulder area
Fall on to an outstretched arm
Physical examination findings
Injured patients often hold the arm adducted to the side
Significant pain with ipsilateral arm motion
Localized tenderness over the scapula
Swelling, crepitus, and ecchymosis may be present over the scapula
Perform a careful neurovascular examination to rule out arterial injury or brachial plexopathy
May occur in 13% of scapular fractures
PEARL: Evaluate closely for associated pulmonary contusions that may lead to significant morbidity and mortality.
Diagnostic testing
Plain radiography is the initial test of choice in the evaluation of suspected scapular fractures
Dedicated scapular series includes an AP/lateral/scapular views
Scapular fractures may be obscured by overlying structures
Os acromiale may be confused for a mid-acromion fracture
Normal variant in 15% of patients
Rounded edges and bilateral appearance are reassuring
CT scans of the chest or scapula may better identify fractures
Electromyogram (EMG) testing can be performed at a later date to evaluate suspected nerve injuries
Optimal results > 3 weeks after injury
May evaluate the extent of the injury and potential for recovery
Treatment
Emergency Department management
Pain control
Sling
Encourage early ROM
Referral to an orthopedic surgeon
Treat concurrent injuries
Long-term management
Majority of fractures are treated non-surgically
Scapular body fractures
Surgical intervention may be considered for
Prognosis
86% scapular body fractures heal with excellent or good results
82% glenoid fractures treated operatively heal with excellent or good results
Complications are uncommon
Glenoid fractures managed non-operatively may lead to shoulder instability
Most fractures heal in approximately 6 weeks
Full functional recovery may take up to a year
Healing with slight non-union does not result in significant disability
Clavicle fractures
Key facts
Clavicle fractures often result from high-mechanism trauma
Adequate pain control is a key aspect in the management of clavicle fractures
The majority of clavicle fractures can be managed conservatively with a simple sling
Displaced mid-shaft clavicle fractures have a higher risk of non-union and should be referred to an orthopedic surgeon for operative consideration (Figure 2.4)
Figure 2.4 Displaced mid-shaft clavicle fracture.
Clinical presentation
The majority of patients will present with pain over the clavicle or shoulder region
Males between the ages of 15–30 years are the most likely to suffer this injury
Mechanism of injury
Young patients generally require a high-impact direct trauma
Sporting injuries
Falls
Motor vehicle collisions
Elderly patients may have a more minor mechanism such as a simple fall from standing height
Physical examination findings are straightforward
Affected limb held adducted to the side
Tenderness over the clavicle
Limited shoulder abduction and forward flexion because of pain
Deformity is often apparent because of the subcutaneous location of the clavicle
A thorough neurovascular examination of the affected extremity is essential to exclude an associated neurovascular injury
Diagnostic testing
Plain radiographs are the preferred test for evaluation of suspected clavicle fractures
Standard clavicle plain films
Serendipity view: 40° cephalic tilt view
Better evaluates the medial clavicle
Zanca view: AP view where the x-ray beam is directed at the acromioclavicular joint with 10-degree cephalic tilt
Better evaluates the distal clavicle and AC joint
Classification
Middle-third fractures (Allman Type I)
Most common type (69–80%)
Lateral-third fractures (Allman Type II)
21–25% of clavicle fractures
More common in elderly
Medial-third fractures (Allman Type III)
Rare (2%)
More common in elderly
Treatment
Emergency Department management for all clavicle fractures
Adequate pain control
Sling for comfort
Figure-of-8 bandages are an alternative
Restrict from overhead activity
Long-term management
Majority of clavicle fractures can be managed non-operatively with recovery in 6–8 weeks
Referral to an orthopedic specialist in 1–2 weeks
Sternoclavicular injuries
Key facts
Sternoclavicular (SC) injuries are relatively rare
Anterior dislocations are unstable and often remain so after treatment
Posterior sternoclavicular dislocations may result in concurrent injuries to mediastinal structures in 30% of cases
Reduction of a posterior SC dislocation is best performed in the operating room with orthopedic and cardiothoracic surgery support
Clinical presentation
SC dislocations are uncommon
Injuries to patients < 25 years of age are often physeal injuries as opposed to true dislocations
Patients present complaining of shoulder and/or chest pain
Both anterior and posterior dislocations may occur
Mechanism of injury:
Anterior dislocations
Anterolateral force resulting in posterior pressure on the shoulder and medial directed pressure on the clavicle
Posterior dislocations
Posterolateral force resulting in an anterior directed pressure on the shoulder and a simultaneous medial directed force on the clavicle
Direct hit to the medial clavicle
Physical examination findings
Tenderness at the SC joint
Painful shoulder ROM
Prominent medial clavicle in anterior dislocations
Affected arm may be held adducted with elbow flexed
A thorough examination is warranted to exclude associated injuries
Venous congestion of the neck or ipsilateral arm, hoarseness, cough, shortness of breath may be concerning findings
Diagnostic testing
Plain radiography with a clavicle series or chest radiograph is often non-diagnostic
A serendipity view to better evaluate the medial clavicle and SC joint may be obtained
CT imaging is the test of choice for evaluation of the SC joint
For posterior dislocations, additional evaluation for concurrent injuries should be considered
CT angiography
Chest radiography
Bronchoscopy
Endoscopy
Treatment
Adequate pain control should be provided for all dislocations
Anterior dislocations are unstable and may remain so even after treatment
Closed reduction should be attempted in the ED
Procedural sedation is often required
Post reduction, the patient should be placed in a figure-of-8 brace or a clavicle harness for 4–6 weeks
Referral to an orthopedic surgeon for follow-up is advised
Posterior dislocations
Associated injuries should be thoroughly evaluated and treated as appropriate
An emergent orthopedic consultation should be obtained
Reduction is best performed in the operating room
Closed reduction may be successful in the first 48 hours, but open reduction is often required
Consultation with a cardiothoracic surgeon is advised to address any complications from the reduction
Post reduction, the patient should be placed in a figure-of-8 brace for 6–8 weeks
PEARL: Management of a posterior SC dislocation is best performed in consultation with an orthopedic and cardiothoracic surgeon.
Prognosis
Anterior dislocations often remain unstable post treatment but rarely cause any long-term functional impairment
Posterior dislocations are generally stable post reduction
Associated injuries with a posterior dislocation can result in poorer outcomes
Procedure
Closed reduction of anterior SC dislocation
Local anesthesia or procedural sedation may be used for analgesia at the provider’s discretion
Cardiopulmonary monitoring as indicated
Place the patient supine on the gurney with a towel roll or firm pad in between the shoulder blades
Technique
Bring the affected arm into 90° abduction and 10° extension
Apply traction to the affected arm
An assistant should provide a posterior force on to the medial aspect of the clavicle until the deformity has resolved
After reduction is complete, place the patient in a valpeau bandage or figure-of-8 brace
Acromioclavicular injuries
Key facts
Acromioclavicular (AC) injuries are the most common shoulder injuries in contact sports
Type I AC injuries are radiographically normal and may be missed without an adequate physical examination
Classification of injuries using the Rockwood classification can be helpful in determining management and prognosis (Table 2.2)
Emergency department treatment should be focused on adequate pain control and a sling for comfort
Early referral to an orthopedic surgeon is advised for Type III–VI injuries (Figure 2.5)
Table 2.2 Rockwood classification of AC injuries.
Abbreviations: AC, acromioclavicular; CC, coracoclavicular; CCD, coracoclavicular distance; D, deltoid attachment at clavicle; T, trapezius attachment at clavicle. *Management of Type III injuries is controversial. Non-operative management is most common but surgical management may be considered in some populations.
Figure 2.5 Grade III AC separation. Note the elevation of the distal clavicle relative to the acromion suggestive of injuries to both the acromioclavicular and coracoclavicular ligaments.
Clinical presentation
Acromioclavicular injuries involve injuries to the acromioclavicular and coracoclavicular ligaments
AC injuries are the most common shoulder injury in contact sports
Mechanism of injury
Fall directly on the adducted shoulder
Fall on outstretched hand (FOOSH)
Physical examination findings
Tenderness over the acromioclavicular joint
Pain with cross-arm abduction test
Deformity may be apparent in higher-grade AC injuries
A thorough neurovascular examination of the affected extremity is essential to exclude an associated neurovascular injury
Diagnostic testing
The diagnosis of AC injuries is often apparent on physical examination
Plain radiographs of the shoulder are the preferred test for further evaluation of suspected AC injuries and assist in identifying the severity of the injury
Type I AC sprains will be radiographically normal
Widening of the AC joint greater than 3 mm is suggestive of an acromioclavicular ligament injury
Widening of the coracoclavicular distance greater than 13 mm is suggestive of a coracoclavicular ligament injury
PEARL: A normal shoulder film does NOT exclude the diagnosis of an AC sprain.
Classification
Treatment
Emergency Department management for all AC injuries
Adequate pain control
Sling for comfort
Early range of motion
Restrict the patient from overhead activity
Referral to an orthopedic specialist in 1–2 weeks
Consider earlier referral for Type III–VI AC injuries as they may be candidates for operative repair
PEARL: Type III AC separations have controversial management and should be referred to an orthopedic surgeon for further evaluation.
Proximal humerus fractures
Key facts
More than 80% of proximal humerus fractures are non-displaced (Figure 2.6) or minimally displaced and do not require surgery
The rotator cuff tendons are at risk for concurrent injury given their insertion on to the greater and lesser tuberosities
Early range of motion exercises improve functional recovery
Figure 2.6 Non-displaced proximal humerus fracture.
Clinical presentation
Proximal humerus fractures are the third most common fractures in the elderly
Increased incidence with elderly age and female gender
Mechanism of injury
Fall on to an oblique angle on an outstretched hand
Fall on to the shoulder from a standing height
High-impact direct trauma to the shoulder in young patients
Physical examination findings
Distinct point of tenderness over the proximal humerus
Painful range of motion
Arm often held in slight abduction
Deformity not often apparent
A thorough neurovascular examination of the affected extremity is essential
Axillary nerve injuries are associated with displaced fractures or fracture–dislocations
Brachial plexus also at risk of injury
Diagnostic testing
Plain radiographs are the test of choice to evaluate the shoulder
AP view of the scapula and glenohumeral joint
Axillary view and lateral Y-view of the scapula
Findings
Pseudo-subluxation of the humeral head inferiorly suggests hemarthrosis
Greater tuberosity fractures are associated with anterior shoulder dislocations
Classification
Table 2.3 Neer classification of proximal humerus fractures.
The Neer classification separates the humerus into four anatomic parts based on old epiphyseal lines (anatomic neck, surgical neck, greater and lesser tuberosities). A fragment is defined as being displaced if separation is > 1 cm or angulation > 45°. *Note: Two-part anatomic neck fractures and four-part fractures are at highest risk for AVN.
Treatment
Emergency department management
Adequate pain control
Immobilize with sling for 1–3 weeks
Encourage early range of motion
Urgent orthopedic consultation is advised for:
Anatomic neck fractures
Four-part fractures
Fracture/dislocations
Long-term treatment
Definitive treatment based primarily on the number of segments involved and degree of displacement
Non-displaced fractures managed conservatively with immobilization in a sling, early motion and orthopedic follow-up
Recovery may be 2–3 months
Multiple part fractures may benefit from operative management
Elderly patients may have acceptable results with non-operative treatment
PEARL: Early range of motion exercises can decrease pain and result in improved functional outcomes.
Humeral shaft (diaphyseal) fractures
Key facts
Humeral shaft fractures typically occur by direct trauma to the arm or shoulder in the middle-age population
Humeral shaft fractures associated with an ipsilateral forearm fracture result in a floating elbow that requires urgent intervention
Associated radial nerve injuries can lead to wrist drop
Pain control and adequate immobilization are the key aspects to the emergent care of humeral shaft fractures
Clinical presentation
Humeral shaft fractures are much less common than proximal humerus fractures
Mechanism of injury
Benign fall with a direct strike to the elbow producing a bending force
Fall on to an outstretched hand with axial loading
Physical examination findings
Localized tenderness and swelling
Painful deformed arm
Arm shortening in the setting of displacement
Associated radial nerve palsy (wrist drop) occurs in 15–18%
Extension of the wrist and digits should be examined
Diagnostic testing
Plain radiographs are the preferred test for evaluation of suspected humeral shaft fractures (Figure 2.7A, B)
AP and lateral views of the humerus
Trans-thoracic and axillary views of the shoulder
Both the shoulder and elbow should be visualized radiographically
PEARL: Consider additional forearm views to exclude concurrent fractures.
