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Damage to the Shoulder Girdle

  • The shoulder girdle consists of the clavicle, scapula and humerus

Midshaft Clavicle Fracture

Epidemiology

  • Young, active males
  • >70% of clavicle fractures occur in the middle segment

Etiology

  • Mechanism of injury – fall on an outstretched arm or direct trauma to shoulder
  • Associated conditions – ipsilateral scapular fracture, rib fracture, pneumothorax, neurovascular injury

Pathophysiology

  • Middle third is the thinnest part of the clavicle and is the only area that is not reinforced with muscle and ligaments – makes it more vulnerable to fracture
  • Displaced fractures
    • Medial fragment – SCM muscle pulls the medial fragment postero-superiorly
    • Lateral fragment – pectoralis major muscle pulls the lateral fragment infero-medially
  • Open fracture – is as a result of the medial fragment ‘button-holing’ through the platysma

Classification

  • AO classification
    • Types – A (simple); B (wedge); C (complex)
  • Neer classification

Clinical features

  • Anterior shoulder pain
  • Skin tenting – indicates impending open fracture

Diagnosis

  • X-ray – to determine displacement
  • CT – to evaluate vascular injury

Treatment

  • Sling with gentle ROM exercises – for <1cm displacement and no neurovascular injury
  • ORIF – severe displacement; neurovascular injury

Distal Clavicle Fracture

Epidemiology

  • More common in older/osteoporotic patients
  • Less common than midshaft clavicle fractures

Etiology

  • Mechanism – direct compressive force to the shoulder (fall/trauma)
  • Associated conditions – floating shoulder, rib fracture, pneumothorax, neurovascular injury

Anatomy of  acromioclavicular joint

  • Acromioclavicular ligament – horizontal stability
  • Coracoclavicular ligament – vertical stability
    • 2 components – trapezoid ligament, conoid ligament

Pathophysiology

  • Displacement is based on
    • Fracture location – extra-articular vs intra-articular
    • Fracture pattern – simple vs Comminuted fracture
    • Integrity of coracoclavicular ligaments (CCL)

Classification

  • AO classification
    • Types – A (non displaced + intact CCL); B (displaced + intact CCL); C (displaced + torn CCL)
  • Neer classification

Clinical features

  • Anterior shoulder pain, swelling, tenderness to palpation
  • AC joint deformity
  • Tenting of skin indicates impending open fracture
  • Weakness of external rotation when arm is adducted – indicates suprascapular nerve injury

Diagnosis

  • X-ray – to determine displacement
  • CT

Treatment

  • Sling with gentle ROM exercises
  • Operative – ORIF

Scapular Fracture

Epidemiology

  • Uncommon fracture
  • 50% involve body and spine of scapula

Etiology

  • Due to high energy trauma, usually during chest trauma – e.g. in motor vehicle accidents
  • Associated injuries – rib fractures, clavicle fracture, pulmonary injury, pneumothorax, head injury

Classification – based on location of fracture

  • Coracoid fracture
  • Acromial fracture
  • Glenoid fracture
  • Scapular neck fracture
  • Scapular body fracture

Clinical features

  • Localised pain, tenderness, swelling
  • Reduced ROM

Diagnosis

  • X-ray
  • CT

Treatment

  • Sling and ROM exercises – most fractures heal without further problems
  • ORIF – for glenohumeral instability, displaced scapula neck, open fracture, loss of rotator cuff function

Sterno-clavicular Joint Dislocation

Epidemiology/etiology

  • Traumatic causes – motor vehicle accidents
  • Spontaneous – more common in young men
  • Associated injuries
    • Anterior dislocation – pneumothorax, hemothorax, rib fracture
    • Posterior dislocation – subclavian vasculature injury, pneumothorax, oesophageal injury

Pathology

  • Anterior dislocation – more common, less serious
  • Posterior dislocation – more serious due to potential damage to mediastinal structure

Clinical features

  • Anterior dislocation – palpable deformity
  • Posterior dislocation – more subtle
    • Dyspnea, stridor, dysphagia – if there is compression of thoracic structures

Diagnosis

  • X-ray – joint space widening, displacement of medial head of clavicle
  • CT – associated injuries to the mediastinum

Treatment

  • Conservative treatment – for anterior dislocation
  • Closed reduction
  • ORIF – for unreduced posterior dislocations

Acromio-clavicular Joint Dislocation

  • Rare injury
  • Due to fall on the outer prominence of the shoulder
  • Can result in partial or complete rupture of the acromio-clavicular or coracoclavicular ligaments
  • Clinical features – localised pain and swelling
  • Diagnosis – X-ray
  • Treatment – sling and analgesia; ORIF
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