Shoulder And Elbow Injuries
The extreme mobility of the shoulder joint, which relies on soft tissues – muscles, ligaments and cartilage – for stability, comes at a price. The shoulder is relatively unstable, and prone to stiffness if not used. There is a wide range of injury patterns, which change according to the age of the patient.
In any injury affecting the upper limb, dominance (handedness) and occupation and hobbies must be recorded. Shoulder pain can also be referred, e.g. cardiac, diaphragmatic, respiratory. Injury is usually caused by either a fall onto outstretched hand (FOOSH) or direct trauma.
Look Compare with the other side.
Feel Start at the medial end of the clavicle and work laterally, feeling for tenderness of clavicle, coracoid process, acromioclavicular (AC) joint, humeral head and greater tuberosity. Feel the olecranon, epicondyles and radial head. An elbow effusion may be felt below the radial head.
Move Limited or painful shoulder movement warrants an X-ray; very little movement will be possible with a dislocated shoulder or fracture. A full range of elbow extension makes fracture unlikely.
Specific injuries and their corresponding neurovascular deficits are:
• Shoulder dislocation and fracture neck of humerus: test the axillary nerve – loss of sensation over lower deltoid area.
• Humeral shaft fractures – radial nerve.
• Medial epicondyle fracture – ulna nerve injury.
• Elbow dislocations – brachial artery and median nerve.
Plain X-rays are indicated in most patients presenting with shoulder pain and reduced range of movement after trauma. Elbow fractures are very unlikely if there is full elbow extension. Fractures are difficult to see and radiographs should be examined carefully for evidence of an effusion: the dark shadows caused by the anterior and posterior fat pads.
Analgesia is achieved by immobilisation (e.g. sling), and oral analgesics before imaging. Patients with severe pain and deformity require intravenous opiates and early assessment. Early active move- ment of the shoulder is important to avoid stiffness in the elderly.
Ensure urgent orthopaedic referral for:
• Any fracture with neurovascular compromise.
• Open fractures, which require urgent antibiotics.
This injury most commonly occurs at the junction between the middle and outer third. Most heal with good function by providing rest in a sling and analgesia.
Acromio-clavicular joint injuries
Acromio-clavicular joint (ACJ) injuries are caused by fall onto tip of shoulder, causing disruption to the ACJ and ligaments. With complete disruption, the clavicle will ‘float’ above the acromion. ACJ injuries are treated with analgesia, rest in a sling and physiotherapy in the first instance, but the more severe grades of disruption may need fixation later.
The shoulder usually dislocates anteriorly (95%) from a fall with the arm in the ‘hailing a taxi’ position – the humerus is externally rotated and abducted. The humeral head may be palpable and the patient will support the arm, holding it by their side.
There are many different reduction techniques, each with their own proponents. It is generally best to start with a passive technique that requires only nitrous oxide/oxygen analgesia and can be conducted by nursing staff. The active techniques require intravenous analgesia ± sedation (Chapter 6).
• Passive: hanging weight technique. The patient lies prone on a couch with the arm hanging down with a 2–5 kg weight suspended from their wrist.
• Active: Hippocratic technique. Traction of the patient’s arm, together with mild rotation. The traditional method of counter-traction involved the doctor’s ‘stockinged foot’ in the patient’s axilla. The modern version uses a sheet under the axilla so an assistant at the head of the bed can provide counter-traction.
• Active: modified Kocher’s technique. This technique must not be rushed and requires good analgesia and sedation.
1. Flex elbow, continuous gentle traction.
2. Using the forearm as a lever, the humerus is externally rotated to almost 90° very slowly to overcome pectoral spasm.
3. The arm is brought across the body and the humerus internally rotated to achieve reduction.
Reduction should be confirmed on X-ray, which may show any damage to the humeral head. Patients with a first dislocated shoulder should have the shoulder immobilised for 6 weeks to allow the capsule to heal. Patients with multiple dislocations need surgery to stabilise the shoulder.
Fractured neck of humerus
This injury is common in the elderly, due to FOOSH; underlying causes for falls should be sought (Chapter 30). Early mobilisation with appropriate analgesia is necessary to avoid long-term stiffness (‘frozen shoulder’) that may be far more disabling than the original injury. Displaced fractures may require reduction ± fixation.
Hyperextension of the elbow forces the humerus anteriorly over the coronoid process of the ulna. Neurovascular status should be checked, and this should be reduced by traction under sedation.
Fractured head of radius
This is the most common elbow fracture, which can be difficult to see on plain X-ray, although the elbow effusion ‘fat pad sign’ will be visible. Diagnosis can be confirmed by tenderness over the radial head, and reduced pronation/supination. Most fractures make a good recovery with analgesia and early mobilisation.
Fractured shaft of humerus
Twisting injuries produce spiral fractures, bending injuries transverse fractures. Radial nerve injury can occur in fractures of the middle third of the humerus.
Diagnoses not to miss
Posterior dislocation of shoulder
This injury is most common after epileptic fits or electrical injury forcing contraction of the strong latissimus dorsi muscles. Posterior dislocation is difficult to spot on X-ray: there is reduced glenohumeral overlap and the greater tuberosity is not visible, creating the ‘lightbulb sign’: the humeral head appears symmetrical. If in doubt, ask for an axillary view X-ray.
Scapular fractures can be difficult to see on X-ray, but are usually very painful due to distension of the tight capsule and may need admission for analgesia. Significant energy is necessary to fracture a scapula, and other injuries should be sought.