THE SHOULDER

The shoulder region is

made of three bones

• Proximal humeral end.

• Clavicle.
• Scapula
• Clavicle is a S shaped bone, with double
curves

• Functions of the clavicle:

1- Power and stability of the arm.
2- Motion of the shoulder girdle.
3- Muscle attachments.
4- Protection of the neurovascular structures.
Related important
structures
THE SHOULDER
• INJURIES
• TUMOURS
• DEGENERATIVE CHANGES
 Injuries of the
Shoulder Region
Fractures of the
clavicle
Fracture of the clavicle
• Middle third, Most common.
• Lateral third.
• Medial third

Latera Medial
l
 Mechanism of injury

• Direct trauma.

• Indirect trauma:
fall on outstretched hand(most
common)
fall on the point of the shoulder.
Clinical picture
• Pain, swelling.
• Deformity, tenderness &
crepitus at the site of
fracture.
• Drooping of the affected
shoulder.
• The patient supports the
arm of the affected side to
decrease the painful
movements.
:PATIENT SHOULD BE EXAMINED FOR

• Other skeletal
injuries.
• Distal pulsations.?
Investigations
Plain X-ray •
 Complications
• Neurovasular
injury.
• Nonunion.
• Malunion.
 Treatment
• Conservative
treatment: (main line)
1- Figure of 8 bandage:
NOT RECOMMENDED.

(Why?)

2- Simple arm support

 Open reduction and internal •
:fixation

1- patients with neurovascular injuries,

2- Lateral end fractures.
3- Nonunited fractures
Fractures of the proximal
end of the humerus
Anatomy
It is formed of 4 parts:
• Fractures of the proximal end may
be:

1- Non displaced fracture.

2- Displaced fracture.
Mode of trauma

• Fall on outstretched hand.

• Minor trauma to old osteoporotic
patients.
• Major trauma to young patients.
 Clinical picture
• Pain, swelling & inability to move the
shoulder.
• Ecchymosis & crepitus over the affected
shoulder.
• Deformity due to fracture or to associated
dislocation.
• Neurological and vascular examination:
axillary nerve
Plain X
ray
C.T scan
 Complications
Axillary nerve •
injury

Deltoid wasting
Malunion •
Treatment

• Non operative
treatment:
Non or minimally
displaced fracrtures
• Open reduction and internal
fixation.
Big fragments, mild comminution
• Arthroplasty. Comminuted fractures,
fractures involving the head
Fractures of the
glenoid
))Very rare
Extra-articular: not involving the articular •
.surface
Intra-articular: extends to the articular •
.surface
Shoulder Dislocation
Shoulder dislocations are divided
into:

• Acute dislocation.

• Chronic (negelected) dislocation.

• Recurrent dislocation.
 Direction of dislocation
Described according to the relation of
the head to the glenoid

• Anterior: most common type.

• Posterior.

• Inferior.
 Mechanism of injury

• Indirect force: combined abduction,

extension and external rotation.

• Direct force: blow directed to the

proximal humerus.
 Clinical
picture
• Pain & inability to move the shoulder.
• Deformity of the shoulder joint, the humeral head is
palpable in the dislocated position.
• The arm is held in abduction and slight external
rotation (anterior dislocation).
• Associated axillary nerve injury.
• Vascular injury.
X ray
 Complications
• Vascular injury: Axillary artery injury, at
the time of dislocation and at the time of
relocation.
• Neural injury: to the brachial plexus.
Neural injury may be Neurapraxia,
Axonotmesis, or Neurotmesis. Most
common injury involves the axillary
nerve.
• Recurrence of dislocation.
 Recurrence of dislocation
• This is the most common complication.
• Causes of recurrence:
1- Patient age: High incidence below the
age of 40 years.
2- Inadequate immobilization: less than 3
weeks.
3- associated head fractures: )Hill-Sachs
lesion)
increase the incidence of recurrence.
4- Glenoid labral injury )Bankart lesion)
Mechanism of Hill Sachs lesion
Treatment
Acute dislocation

• Closed reduction under general

anesthesia as urgent as possible.
Neurovascular examination is mandatory
after closed reduction.

• Open reduction is rarely needed in

cases of locked dislocations
Closed reduction

Traction & counter traction

 Recurrent dislocation

• Operative treatment: for soft tissue

balance, repair ,or blocking the
dislocation mechanism.

• Physiotherapy program.
 TUMOURS
IN THE SHOULDER REGION
A- BENGIN
OSTEOCHONDROMA
TUMOURS
IN THE SHOULDER REGION

A- BENGIN
CHONDROBLASTOMA
TUMOURS
IN THE SHOULDER REGION
B-MALIGNANT
CHONDROSARCOMA
TUMOURS
IN THE SHOULDER REGION
B-MALIGNANT
CHONDROSARCOMA
 TUMOURS
IN THE SHOULDER REGION
B-MALIGNANT
SECONDARIES
PATHOLOGICALFRACTURES
IN THE SHOULDER REGION
DEGENERATIVE ARTHROSIS
EXAMINATION OF THE NECK
Examination
Starts in • Information
the…. • Mechanism
Trauma – ↑energy, ↓energy
Bay • Direction of
E.R. Impact
• Associated
Injuries
Step1: Frontal Inspection
• Inspection--patient

Remove all
flat/frontal view

clothes
– Head: eyes

– Neck: posture

– Thorax: chest contusions, flail

chest, asymmetric chest
expansion
Step1: Frontal Inspection
• Inspection--patient
flat/frontal view

Remove all
– Abdomen: lap-belt ecchymosis

clothes
– Peritoneum/Pelvis: priapism,
scrotal swelling, bruising

– Extremities: gross movement,

tone, flaccid
Step 2: Neurological
Examination

• Detailed and Systematic

– Sensory
– Motor
– Reflexes
 DOUBLE LEVEL SPINAL INJURIES

NEUROLOGICAL PUZZLE
1. Test sensation to pinprick in all
dermatomes, record the most
caudal dermatome that feels
pinprick
2. Check motor function
3. Test deep tendon reflexes
4. Rectal examination to assess
sphincter tone and sensation
5. Insert Foley catheter; note
sensation to insertion and to
bladder distention with saline
solution; bulbo-cavernosus
reflex
D
e
r
m
a
t
o
m
e
s
 Motor Grade e.g.
Biceps
+/-
0/5 none
1/5 trace
2/5 some
movement
3/5 anti-gravity
4/5 anti-resistance
5/5 normal

Test in contracted/shortened position

Motor
Cervical
muscle to test each level/root 1

o n e Deltoid C5
c k C6
Pi s c le
Biceps
C7
m u Triceps
C8
Finger Flexors T1
Hand intrinsics (abduction)
PRIMITIVE
(spinal) REFLEXES

Anus

Glans

Babiniski test

Bulbo-cavernosus test
Pathologic Reflexes

• Hyperreflexia
• Clonus ≥ 4 beats
• Babinski
• Inverted Radial Reflex
• Hoffmans
Rectal
•Anal sensation
•Rectal tone
•Bear down/contraction
SCALENUS SYN
THORACIC OUTLET SYN