Shoulder Trauma (Fractures and Dislocations)

Trauma to the shoulder is common. Injuries range from a separated shoulder resulting from a fall onto the shoulder to a high-speed car accident that fractures the shoulder blade (scapula) or collarbone (clavicle). One thing is certain:
everyone injures his or her shoulder at some point in life.
Anatomy

The shoulder is made up of three bones:

Scapula (shoulder blade)
Clavicle (collar bone)
Humerus (arm bone)

These bones are joined together by soft tissues (ligaments, tendons, muscles, and joint capsule) to form a platform for the arm to work.

The shoulder is made up of three joints:

Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
The shoulder also has one articulation, which is the relationship between the scapula (shoulder blade) and the chest wall.

The main joint of the shoulder is the glenohumeral joint. This joint comprises a ball (the humeral head) on a golf-tee-shaped joint (the glenoid of the scapula).

The bones of the shoulder are covered by several layers of soft tissues.

The top layer is the deltoid muscle, a muscle just beneath the skin, which gives the shoulder a rounded appearance. The deltoid muscle helps to bring the arm overhead.
Directly beneath the deltoid muscle is sub-deltoid bursa, a fluid-filled sac, analogous to a water balloon.

Types of Shoulder Injuries

There are many types of shoulder injuries:

Fractures are broken bones. Fractures commonly involve the clavicle (collar bone), proximal humerus (top of the upper arm bone), and scapula (shoulder blade).
Dislocations occur when the bones on opposite sides of a joint do not line up. Dislocations can involve any of three different joints.
A dislocation of the acromioclavicular joint (collar bone joint) is called a "separated shoulder."
A dislocation of the sternoclavicular joint interrupts the connection between the clavicle and the breastbone (sternum).
The glenohumeral joint (the ball and socket joint of the shoulder) can be dislocated toward the front (anteriorly) or toward the back (posteriorly).
Soft-tissue injuries are tears of the ligaments, tendons, muscles, and joint capsule of the shoulder, such as rotator cuff tears and labral tears.
The following discussion will focus on fractures and dislocations.

Related Articles
Diseases & Conditions

Clavicle Fracture (Broken Collarbone)
Diseases & Conditions

Dislocated Shoulder
Diseases & Conditions

Scapula (Shoulder Blade) Fractures
Diseases & Conditions

Shoulder Separation
Cause
Fractures

Fractures of the clavicle or the proximal humerus can be caused by a direct blow to the area from a fall, collision, or motor vehicle accident.

Because the scapula is protected by the chest and surrounding muscles, it is not easily fractured. Therefore, fractures of the scapula are usually caused by high-energy trauma, such as a high speed motor vehicle accident. Scapula fractures are often associated with injuries to the chest.
Shoulder Dislocations

Anterior dislocations of the shoulder are caused by the arm being forcefully twisted outward (external rotation) when the arm is above the level of the shoulder. These injuries can occur from many different causes, including a fall or a direct blow to the shoulder.
Posterior dislocations of the shoulder are much less common than anterior dislocations of the shoulder. Posterior dislocations often occur from seizures or electric shocks when the muscles of the front of the shoulder contract and forcefully tighten.

Shoulder Separations

Dislocations of the acromioclavicular joint can be caused by a fall onto the shoulder or from lifting heavy objects. The term "shoulder separation" is not really correct, because the joint injured is actually not the true shoulder joint.
Symptoms of Fractures

Symptoms of fractures about the shoulder are related to the specific type of fracture.
General Findings

Pain
Swelling and bruising
Inability to move the shoulder
A grinding sensation when the shoulder is moved
Deformity -- "It does not look right"

Specific Findings: Clavicle Fracture

Swelling about the middle of the collarbone area
An area that may have a "bump," which is actually the prominent ends of the fracture under the skin Shoulder range of motion is limited, although not as much as with fractures of the proximal humerus

Specific Findings: Proximal Humerus Fracture

A severely swollen shoulder
Very limited movement of the shoulder
Severe pain

Specific Findings: Scapular Fracture

Pain
Swelling
Severe bruising about the shoulder blade

Specific Findings: Shoulder Separation (Acromioclavicular Joint Separation)

Pain over the top of the shoulder
A prominence or bump about the top of the shoulder
The sensation of something sticking up on the shoulder

Specific Findings: Shoulder Dislocation (Glenohumeral Joint Dislocation)

A prominence about the front of the shoulder
Inability to move the arm
An arm rotated outward
The sensation of a "dead arm"

Diagnosis

Most fractures are diagnosed with X-rays of the area and by physical examination. Sometimes, additional imaging techniques, such as computed tomography, are necessary.
Treatment Options
Clavicle Fractures

Most clavicle fractures can be treated without surgery. Surgery is necessary when there is a compound fracture that has broken through the skin or the bone is severely out of place. Surgery typically involves fixing of the fracture with plates and screws or rods inside the bone.
Proximal Humerus Fractures

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is usually required. Surgery usually involves fixation of the fracture fragments with plates, screws, or pins or it involves shoulder replacement.
Scapula Fractures

Most fractures of the scapula can be treated without surgery. Treatment involves immobilization with a sling or shoulder immobilizer, icing, and pain medications. The patient will be examined for additional injuries.

About 10% to 20% of scapula fractures need surgery. Fractures that need surgery usually have fracture fragments involving the shoulder joint or there is an additional fracture of the clavicle. Surgery involves fixation of the fracture fragments with plates and screws.
Shoulder Separations (Acromioclavicular Joint)

Treatment of shoulder separations is based on the severity of the injury as well as the direction of the separation and the physical requirements of the patient.

Less severe shoulder separations) are usually treated without surgery.

Severe separations in an upward direction or dislocations in the backward or downward directions often require surgery.
Surgery involves repair of the ligaments.

Professional athletes and manual laborers are often treated with surgery, but the results are often unpredictable.
Shoulder Dislocations (Glenohumeral Joint)

The initial treatment of a shoulder dislocation involves reducing the dislocation ("putting it back in the socket").
This usually involves treatment in the emergency room.

The patient is given some mild sedation and pain medicine, usually through an intravenous line. Often, the physician will pull on the shoulder until the joint is realigned. Reduction is confirmed on an X-ray and the shoulder is then placed in a sling or special brace.

Additional treatment at a later date is based on the patient's age, evidence of persistent problems with the shoulder going out of place, and the underlying associated soft-tissue injury (either to the rotator cuff or the capsulolabral complex).

Patients who are 25 years of age or younger generally require surgery. Persistent instability (repeat dislocations) of the shoulder usually requires surgery. Surgery involves repair of the torn soft tissues.
Life After a Shoulder Injury

Life after a shoulder fracture, separation, or dislocation can be greatly affected for several weeks or even months. Most shoulder injuries whether treated surgically or nonsurgically require a period of immobilization followed by rehabilitation.

If the injury was not severe, there is fairly rapid improvement and return of function after the first 4 to 6 weeks. Shoulder exercises, usually as part of a supervised physical therapy program, are usually necessary. Exercises decrease stiffness, improve range of motion, and help the patient regain muscle strength.
What Should You Discuss With Your Orthopaedic Surgeon?

Some of the information you should discuss with your orthopaedic surgeon includes the following:

The exact type of your injury
The severity of the injury
The treatment plan
The possible complications
Whether surgery will be necessary
When it is expected that you will be maximally improved
What is the expected outcome will be both in the short term and in the long term

Read More

Shoulder Pain and Common Shoulder Problems

What most people call the shoulder is really several joints that combine with tendons and muscles to allow a wide range of motion in the arm — from scratching your back to throwing the perfect pitch.

Mobility has its price, however. It may lead to increasing problems with instability or impingement of the soft tissue or bony structures in your shoulder, resulting in pain. You may feel pain only when you move your shoulder, or all of the time. The pain may be temporary or it may continue and require medical diagnosis and treatment.

This article explains some of the common causes of shoulder pain, as well as some general treatment options. Your doctor can give you more detailed information about your shoulder pain.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Cause

Most shoulder problems fall into four major categories:

Tendon inflammation (bursitis or tendinitis) or tendon tear
Instability
Arthritis
Fracture (broken bone)
Other much less common causes of shoulder pain are tumors, infection, and nerve-related problems. Bursitis

Bursae are small, fluid-filled sacs that are located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, and help reduce friction between the gliding muscles and the bone.

Sometimes, excessive use of the shoulder leads to inflammation and swelling of the bursa between the rotator cuff and part of the shoulder blade known as the acromion. The result is a condition known as subacromial bursitis.

Bursitis often occurs in association with rotator cuff tendinitis. The many tissues in the shoulder can become inflamed and painful. Many daily activities, such as combing your hair or getting dressed, may become difficult. Tendinitis

A tendon is a cord that connects muscle to bone. Most tendinitis is a result of inflammation in the tendon.

Generally, tendinitis is one of two types:

Acute. Excessive ball throwing or other overhead activities during work or sport can lead to acute tendinitis. Chronic. Degenerative diseases like arthritis or repetitive wear and tear due to age, can lead to chronic tendinitis.

The most commonly affected tendons in the shoulder are the four rotator cuff tendons and one of the biceps tendons. The rotator cuff is made up of four small muscles and their tendons that cover the head of your upper arm bone and keep it in the shoulder socket. Your rotator cuff helps provide shoulder motion and stability.

Tendon Tears

Splitting and tearing of tendons may result from acute injury or degenerative changes in the tendons due to advancing age, long-term overuse and wear and tear, or a sudden injury. These tears may be partial or may completely separate the tendon from its attachment to bone. In most cases of complete tears, the tendon is pulled away from its attachment to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Impingement

Shoulder impingement occurs when the top of the shoulder blade (acromion) puts pressure on the underlying soft tissues when the arm is lifted away from the body. As the arm is lifted, the acromion rubs, or "impinges" on, the rotator cuff tendons and bursa. This can lead to bursitis and tendinitis, causing pain and limiting movement.

Instability

Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.

Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.

Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Recurring dislocations, which may be partial or complete, cause pain and unsteadiness when you raise your arm or move it away from your body. Repeated episodes of subluxations or dislocations lead to an increased risk of developing arthritis in the joint.

Arthritis

Shoulder pain can also result from arthritis. There are many types of arthritis. The most common type of arthritis in the shoulder is osteoarthritis, also known as "wear and tear" arthritis. Symptoms such as swelling, pain, and stiffness, typically begin during middle age. Osteoarthritis develops slowly and the pain it causes worsens over time.

Osteoarthritis, may be related to sports or work injuries or chronic wear and tear. Other types of arthritis can be related to rotator cuff tears, infection, or an inflammation of the joint lining.

Often people will avoid shoulder movements in an attempt to lessen arthritis pain. This sometimes leads to a tightening or stiffening of the soft tissue parts of the joint, resulting in a painful restriction of motion.

Fracture

Fractures are broken bones. Shoulder fractures commonly involve the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade).

Shoulder fractures in older patients are often the result of a fall from standing height. In younger patients, shoulder fractures are often caused by a high energy injury, such as a motor vehicle accident or contact sports injury.

Fractures often cause severe pain, swelling, and bruising about the shoulder.

Doctor's Examination

In the case of an acute injury causing intense pain, seek medical care as soon as possible. If the pain is less severe, it may be safe to rest a few days to see if time will resolve the problem. If symptoms persist, see a doctor.

Your doctor will conduct a thorough evaluation in order to determine the cause of your shoulder pain and provide you with treatment options.
Medical History

The first step in the evaluation is a thorough medical history. Your doctor may ask how and when the pain started, whether it has occurred before and how it was treated, and other questions to help determine both your general health and the possible causes of your shoulder problem. Because most shoulder conditions are aggravated by specific activities, and relieved by specific activities, a medical history can be a valuable tool in finding the source of your pain.
Physical Examination

A comprehensive examination will be required to find the causes of your shoulder pain. Your doctor will look for physical abnormalities, swelling, deformity or muscle weakness, and check for tender areas. He or she will observe your shoulder range of motion and strength.
Tests

Your doctor may order specific tests to help identify the cause of your pain and any other problems.
X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.
Magnetic resonance imaging (MRI) and ultrasound. These imaging studies create better pictures of soft tissues. MRI may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
Computed tomography (CT) scan. This tool combines x-rays with computer technology to produce a very detailed view of the bones in the shoulder area.
Electrical studies. Your doctor may order a test, such as an EMG (electromyogram), to evaluate nerve function.
Arthrogram. During this x-ray study, dye is injected into the shoulder to better show the joint and its surrounding muscles and tendons. It may be combined with an MRI.
Arthroscopy. In this surgical procedure, your doctor looks inside the joint with a fiber-optic camera. Arthroscopy may show soft tissue injuries that are not apparent from the physical examination, x-rays, and other tests. In addition to helping find the cause of pain, arthroscopy may be used to correct the problem.

Treatment
Activity Changes

Treatment generally involves rest, altering your activities, and physical therapy to help you improve shoulder strength and flexibility. Common sense solutions such as avoiding overexertion or overdoing activities in which you normally do not participate can help to prevent shoulder pain.
Medications

Your doctor may prescribe medication to reduce inflammation and pain. If medication is prescribed to relieve pain, it should be taken only as directed. Your doctor may also recommend injections of numbing medicines or steroids to relieve pain.
Surgery

Surgery may be required to resolve some shoulder problems. However, the large majority of patients with shoulder pain will respond to simple treatment methods such as altering activities, rest, exercise, and medication.

Certain types of shoulder problems, such as recurring dislocations and some rotator cuff tears, may not benefit from exercise. In these cases, surgery may be recommended fairly early.

Surgery can involve arthroscopy to remove scar tissue or repair torn tissues, or traditional open procedures for larger reconstructions or shoulder replacement.

Read More