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Shoulder and Humerus Fractures and Dislocations PowerPoint Presentation

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Published on : Aug 07, 2014
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Slide 1 - Shoulder and Humerus Fractures and Dislocations Steve Lan Aug 28, 03
Slide 2 - Overview Common shoulder and humerus injuries seen in the ED For each injury Mechanism Physical exam Diagnostic imaging Classification Management Watch out!
Slide 3 - Mechanism of Injury
Slide 4 - Injuries to be Covered AC separation Clavicle fracture Scapula fracture Shoulder dislocation Humeral Fractures proximal mid shaft
Slide 5 - Shoulder Anatomy
Slide 6 - How bad is it doc??
Slide 7 - AC Separation Mechanism Downward force on tip of shoulder AC and CC ligaments disrupted Watch for associated # of clavicle, coracoid process
Slide 8 - Normal AC joint
Slide 9 - AC classification – Clinically Grade I Mild tenderness over AC joint, mild swelling Full ROM Grade II Mod/severe pain, clavicle slightly displaced up Grade III Arm kept in adduction, obvious deformity
Slide 10 - AC Classification Grade I Mechanism Grade II Grade III
Slide 11 - AC Imaging AP shoulder (cephalic tilt) Normal CC distance 1.1-1.3cm (injury if > 5mm on comparison) Axillary lat view ?Stress views - 10-15lbs tied to wrists Watch for os acromiale Secondary ossification centre on distal acromion
Slide 12 - AC Separation
Slide 13 - Management I and II Conservative (sling, ice, analgesia, physio) 6/52 before lifting III Conservative with late distal clavicle excision Refer to Ortho <72h
Slide 14 - Ouch!
Slide 15 - Clavicle Fractures Function “strut”, only bony connection to axial skeleton Mechanism direct blow > FOOSH
Slide 16 - Clavicle - Physical Exam Gross deformity Palpation potential injury to medial cord (Ulnar N dysfunction)
Slide 17 - Clavicle fracture
Slide 18 - Clavicle Imaging AP 30 degree cephalad view
Slide 19 - Is it Broke?
Slide 20 - Classification Proximal/middle/distal third
Slide 21 - Clavicle # - Middle third 80% of fractures medial portion - displaced up by sternocleidomastoid lateral portion - displaced down by weight
Slide 22 - Clavicle # - Middle third Management Management figure of eight vs sling (J Acta Ortho Scand 58 (1):71-4, 1987) 2-4 wks kids, 4-8 wks adults Kids: possible greenstick – immobilize and recheck in 7-10d Indication for OR (increases risk of non union) - cosmesis, tenting, open, vascular injury
Slide 23 - Clavicle Fracture Sling and Swathe
Slide 24 - Clavicle Fracture Velpeau
Slide 25 - Clavicle # - Distal Third 10-15% Classification I: minimal displacement II: torn CC ligament, prone to non-union III: articular surface (may mistake for 1st AC) Management conservative (J. Acta. Ortho. Scand. 64 (1):87-91, 1993 ?OR for II (BJAS 23(1): 44-6, 1992.
Slide 26 - Distal third #
Slide 27 - Clavicle # - complications Injury to brachial plexus, great vessels, lungs watch out for floating shoulder if associated with scapular surgical neck #
Slide 28 - Scapular Fractures Rare, high energy Males ~30 y.o. Associated with other injuries (lung, rib, clavicle)
Slide 29 - Scapular # Clinically If awake, arm adducted Tender, crepitus, hematoma
Slide 30 - Scapular # Classification Type I Body and spine Type II Acromion or coracoid process Type III Scapular neck or glenoid fossa Type I Type III Type II
Slide 31 - Scapular Fracture
Slide 32 - Scapular # - Management Conservative OR Displaced acromial # impinging on joint Associated coracoid # if CC ligament disrupted Scapular neck/glenoid fossa #
Slide 33 - Shoulder Dislocation Men 20-30, women 60-80 yo kids more prone to # through growth plate (joint capsule and ligaments 2-5x stronger than epiphyseal plate)
Slide 34 - Shoulder Dislocation - Classification Anterior (95-97%) Subcoracoid (most common) subglenoid (1/3 associated with # greater tuberosity, or # glenoid rim) subclavicular Posterior Inferior and superior
Slide 35 - Shoulder Dislocation Anterior dislocations Traumatic/nontraumatic Primary/recurrent
Slide 36 - Shoulder Dislocation Anterior
Slide 37 - Shoulder Dislocation Anterior Clinically Slight abduction, ext rotation Squared off, loss of coracoid process Mechanism abduction+extension+posterior force shoulder capsule torn
Slide 38 - Shoulder Dislocation Anterior: Exam Check brachial plexus, Axillary N
Slide 39 - Shoulder Dislocation - Imaging Do you want films? Recurrent dislocation vs primary, ?nontraumatic Avulsion # of greater tuberosity in 10-15% True AP Axillary view trans-scapular view Stryker Notch: West point Axillary Apical oblique view
Slide 40 - Anterior dislocation
Slide 41 - Shoulder dislocation - Management Anesthesia - conscious sedation vs intra-articular lidocaine Reduction (“know three methods well”) External rotation Scapular rotation Stimson’s Milch
Slide 42 - Shoulder Dislocation Reductions
Slide 43 - Shoulder Dislocation Reductions
Slide 44 - Shoulder dislocation - Management Check NV post reduction ? Repeat films (advised by Rosen) Sling and swathe, Velpeau Uncomplicated: sling x 3-4/52 if < 20 y.o., 1-2/52 if > 40 y.o. (early mobilization!) Complications: NV injury, rotator cuff tear, etc. f/u with ortho
Slide 45 - Shoulder Dislocation - Complications Bankart lesion primary lesion in recurrent ant instability Hill Sach lesion 35-40% of ant dislocations, predisposes to recurrent injury recurrent dislocation young adults redislocation in 55-95% skeletally mature, < 30yo: ? Early arthroscopic reconstruction (Arthroscopy 15(5) 1999: 507-12)
Slide 46 - Shoulder Dislocation Posterior 2-4% of shoulder dislocations Secondary to seizure, direct blow to shoulder Need to dx early to prevent long term complications
Slide 47 - Shoulder Dislocation Posterior: clinical features Arm held across chest Adducted Internally rotated Flat and squared off
Slide 48 - Shoulder Dislocation Posterior: Imaging AP may appear normal! Loss of half moon elliptical overlap of humeral head and glenoid fossa “Rim sign” – increased distance between ant glenoid rim and articular surface of humeral head “light bulb” – int rotation of humeral head “trough sign” Reverse Hill Sachs (anteromedial impaction)
Slide 49 - Shoulder Dislocation Posterior: Imaging
Slide 50 - Shoulder Dislocation Posterior: Management Conscious sedation and closed reduction Axial traction, pressure on humeral head, external rotation Complications: Missed Dx: “locked” – ORIF # glenoid rim, tuberosities, humeral head
Slide 51 - Shoulder Dislocation Inferior (Luxatio Erecta) Rare Arm locked overhead 110-160 deg abduction, hand resting on head AP radiograph: spine parallel to humerus Reduce with traction
Slide 52 - Shoulder Dislocation Inferior (Luxatio Erecta)
Slide 53 - Humerus Fractures Proximal Mid shaft Supra condylar
Slide 54 - Proximal Humerus Fractures Primarily older population FOOSH, arm pronated limits abduction Older pts #, while younger pts dislocate Both if middle aged Arm held close to body, mov’t limited by pain Tender, hematoma, bruising
Slide 55 - Proximal Humerus Fractures 85% minimally displaced – conservative rx Separation along old epiphyseal lines Articular surface (anatomic neck) Greater and lesser tuberosity Humeral shaft (surgical neck) Considered displaced if: > 1cm away > 45 degrees
Slide 56 - Proximal Humeral Fractures Neer’s Classification
Slide 57 - Proximal Humeral Fractures Minimal displaced 3 part #
Slide 58 - Proximal Humerus Fractures Management Minimally displaced # held together by capsule, periosteum, muscles Analgesia, sling and swathe x 3-4/52 2,3,4 part – consult ortho Fracture/dislocation – caution with force, don’t want to displace segments Complications: adhesive capsulitis
Slide 59 - Proximal Humeral Epiphysis Rare Usually Males 11-17 FOOSH # through zone of hypertrophy of epiphyseal plate Arm held close to body, swelling Classification: Salter Harris
Slide 60 - Proximal Humeral Epiphysis
Slide 61 - Proximal Humeral Epiphysis Management Potential for growth disturbance <6 yo : usually Salter I, analgesia, sling and swathe > 6 yo: usually Salter II If > 20 deg need to reduce
Slide 62 - Midshaft Humerus Fractures Mechanism Direct blow, severe twisting, FOOSH Obvious deformity, crepitus Shortened limb, rotated Assess radial nerve Exam shoulder and elbow
Slide 63 - Midshaft Humerus Fractures
Slide 64 - Midshaft Humerus Fractures Management Hanging arm cast (displaced) / Sugar tong (nondisplaced) F/U with ortho in 24-48h overriding #: accept up to 1 inch shortening ORIF unacceptable alignment, radial nerve involvement, segmental #, other upper extremity injuries, pathological #, limited to bedrest
Slide 65 - Midshaft Humerus Fractures 1 in prox to #
Slide 66 - Midshaft Humerus Fractures
Slide 67 - Midshaft Humerus Fractures Children Radial nerve injury is rare accept 1-1.5cm shortening, 15-20 deg angulation 4-6 wks in modified Velpeau or sling and swathe (compliance difficult for hanging cast)
Slide 68 - Supracondylar Fracture Usually < 8yo Extension (95%) vs flexion
Slide 69 - Supracondylar Fracture- Mechanism
Slide 70 - Supracondylar Fracture- clinically Mild swelling to gross deformity arm held to side, immobile, extension S-shaped configuration
Slide 71 - Supracondylar Fracture- Classification Gartland I - nondisplaced II - displaced with intact posterior cortex III - displaced fracture, no intact cortex A: postermedial rotation of distal fragment B: posterolateral rotation
Slide 72 - Supracondylar Fracture- Management If NV compromise - urgent ortho consult if no response in 60 min may attempt 1 reduction watch brachial artery and median nerve Gartland I - splint and ortho f/u 24h Gartland II - controversy but most get pinned Gartland III - closed reduction and pin
Slide 73 - Supracondylar Fracture- Reduction
Slide 74 - Spot the #
Slide 75 - Spot the #