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CHAPTER 271: Shoulder and Humerus Injuries 1821 radiocapitellar line may aid in the diagnosis. Additionally, the apex of the ulna fracture points in the direction of the radial head dislocation to provide another radiographic clue. Obtain consultation with an orthopedic surgeon. Monteggia’s fracturedislocations are generally treated with open reduction and internal fixation of the ulna fracture and closed reduction of the radial head dislocation. Complications include nonunion, recurrent dislocation, chronic pain, infection, and paralysis of the posterior interosseous nerve, the deep branch of the radial nerve that controls finger extension. RADIUS FRACTURES  FRACTURES OF THE PROXIMAL TWO THIRDS OF THE RADIUS Radius fractures can be divided into those in the proximal two thirds and those in the distal one third of the bone. Excluding radial head fractures, isolated fractures of the proximal two thirds of the radius are uncom mon because the radius is relatively well protected from direct blows by the ulna and surrounding forearm musculature. Fractures of the proximal two thirds of the radius are often displaced by both the force of the injury and the action of the forearm supinators and pronators on the radius. Typically, supination of the proximal segment and pronation of the distal segment are seen, although a fracture located beyond these muscle groups may have minimal deformity. Displaced fractures require emergent orthopedic consultation. Nondisplaced fractures are treated with cast immobilization. Compartment syndrome is rare with these fractures. Most complications involve malunion or nonunion because of inadequate or lost reduction.  GALEAZZI’S FRACTURE-DISLOCATION Fracture of the distal third of the radial shaft accompanied by a dislocation of the distal radioulnar joint is known as Galeazzi’s fracture-dislocation (Figure 270-16). This injury results from falls on the outstretched hand in forced pronation or from a direct blow. Galeazzi’s fracture-dislocation is also referred to as Piedmont fracture, reverse Monteggia’s fracture, or fracture of necessity, reflecting the need for surgical intervention.57 There is localized tenderness and swelling over the distal radius and wrist. The radius fracture usually results in dorsal lateral angulation. The distal radioulnar joint injury can be subtle. Radiographs may show only a slightly increased distal radioulnar joint space on the anteroposterior view. On the lateral view, the ulna is displaced dorsally. Obtain immediate orthopedic consultation in the ED. Complications include infection, nonunion, and malunion. If the radius heals with a rotational deformity, there may be pain at the distal radioulnar joint with extreme pronation and supination. Acknowledgments: The authors wish to recognize the contributions of Harold Chin, MD; Arthur F . Proust, MD; Jason H. Bredenkamp, MD; Brian P . Jokhy, MD; and Dennis T. Uehara, MD, MS, in previous edi tions of this chapter, and of Sue Lahey, MLS, for her research assistance. REFERENCES The complete reference list is available online at www.TintinalliEM.com. FIGURE 270-16. Galeazzi’s fracture-dislocation.

rthur F . Proust, MD; Jason H. Bredenkamp, MD; Brian P . Jokhy, MD; and Dennis T. Uehara, MD, MS, in previous edi tions of this chapter, and of Sue Lahey, MLS, for her research assistance. REFERENCES The complete reference list is available online at www.TintinalliEM.com. FIGURE 270-16. Galeazzi’s fracture-dislocation. A B Shoulder and Humerus Injuries Lars Bjoernsen Alexander Ebinger  STERNOCLAVICULAR SPRAINS AND DISLOCATIONS ANATOMY The sternoclavicular joint contains an intra-articular fibrocartilaginous disc and has the least amount of bony stability of any major joint because less than half of the medial end of the clavicle articulates with the upper sternum. However, the joint is remarkably stable, due to the strong surrounding ligaments. As a result, most injuries are simple sprains, while dislocations and fractures are uncommon. 1-4 The medial clavicular epiphysis is the last epiphysis of the body to appear radiographically (age 18 years old) and the last to close (age 22 to 25 years old). Because of this, an apparent sternoclavicular joint dislocation in children and young adults is typically a Salter-Harris type I or II fracture, with either anterior or posterior displacement of the clavicular metaphysis that requires orthopedic consultation and follow-up for optimal healing and remodeling. 1,5 CLINICAL FEATURES AND DIAGNOSIS The major symptom of dislocation is severe pain, exacerbated by arm motion and lying supine. A posterior dislocation results from a direct blow or from an indirect force to the shoulder, causing the shoulder to roll forward at the time of impact. The shoulder may appear shortened and rolled forward. In posterior dislocations, the medial clavicle end is less visible and often not palpable, and the patient may have signs and symptoms of impingement of the superior mediastinal contents, such as stridor, dysphagia, and shortness of breath ( Figure 271-1). 3,4 An anterior dislocation may result from a similar indirect force if the shoulder is rolled backward at the moment of impact. On examination, anterior dislocations have a prominent medial clavicle end that is visible and palpable anterior to the sternum, although swelling and tenderness may impede diagnosis. Minor trauma may result in a sprain to the sternoclavicular joint with only pain and swelling localized to the joint. Sprains of the sternocla vicular joint are treated with ice, sling, and analgesics. In a nontrauma CHAPTER Tintinalli_Sec22_p1767-1880.indd 1821 8/2/19 6:16 PM

lling and tenderness may impede diagnosis. Minor trauma may result in a sprain to the sternoclavicular joint with only pain and swelling localized to the joint. Sprains of the sternocla vicular joint are treated with ice, sling, and analgesics. In a nontrauma CHAPTER Tintinalli_Sec22_p1767-1880.indd 1821 8/2/19 6:16 PM 1822 SECTION 22: Orthopedics FIGURE 271-1. Posterior sternoclavicular joint dislocation impinging on the medias tinal structures. Sternoclavicular joints Trachea Esophagus Sternum Left subclavian artery Left lung Right lung Left common carotid artery Right subclavian vein Right innominate artery Left subclavian vein FIGURE 271-2. CT scan of right posterior sternoclavicular dislocation. Arrow indicates disrupted sternoclavicular joint with posterior displacement of clavicle and compression of adjacent lung. patient, pain at the sternoclavicular joint should raise suspicion for septic arthritis, especially in injection drug users. US can detect effusion and aid in joint aspiration. Routine radiographs have a low sensitivity for the detection of dis location, but an immediate chest radiograph is needed to exclude a pneumothorax, pneumomediastinum, and hemopneumothorax. Special views and comparison with the other clavicle may be helpful. 1 CT is the imaging procedure of choice ( Figure 271-2) and is recommended in any posterior dislocation with concern for injury to the mediastinal structures. IV contrast may be administered to further delineate injury. Point-of-care US can identify sternoclavicular joint effusions and may been used to rapidly diagnose posterior sternoclavicular dislocation in the ED. 6,7 TREATMENT OF ANTERIOR STERNOCLAVICULAR DISLOCATIONS Patients with uncomplicated anterior dislocations may be discharged without an attempted reduction, because this injury has little or no impact on function. Clavicular splinting, ice, analgesics, sling, and orthopedic referral are required. For closed reduction, which can be performed within 10 days of the injury, the patient is placed supine with a towel roll or similar between the scapulae. The arm is abducted to 90 degrees, longitudinal traction is applied with slight extension by moving the arm toward the ground, and pressure is placed over the medial end of the clavicle. 8 Even with reduction, the joint is usually unstable and redislocates (50%) when pressure is released. Refer to an orthopedist. TREATMENT OF POSTERIOR STERNOCLAVICULAR DISLOCATIONS Posterior dislocations may be associated with life-threatening injuries to adjacent structures, including pneumothorax or compression or laceration of surrounding great vessels, trachea, or esophagus. 1,2 Orthopedic consultation is necessary for closed or open reduction. Open reduction should be performed in the operating room with trauma or vascular surgery available. 1,3,8,10  CLAVICLE FRACTURES ANATOMY The clavicle provides support and mobility for upper extremity tasks by functioning as a strut that connects the shoulder girdle to the trunk. It articulates with the sternum proximally and the acromion distally. In addition, the clavicle protects the adjacent lung, brachial plexus, and subclavian and brachial blood vessels. The clavicle is S-shaped, and the midportion of the clavicle is the thinnest, having no accompanying ligamentous or muscular attachments. Fracture results from a direct blow to the shoulder, buckling the clavicle. CLINICAL FEATURES AND DIAGNOSIS Clinical signs are swelling, deformity, and tenderness overlying the clavicle. The arm is slumped inward and downward, and range of motion is limited. The fracture can often be palpated, and crepitus may be present. Most clavicle fractures can be diagnosed on standard shoulder and clavicle radiographs.

ES AND DIAGNOSIS Clinical signs are swelling, deformity, and tenderness overlying the clavicle. The arm is slumped inward and downward, and range of motion is limited. The fracture can often be palpated, and crepitus may be present. Most clavicle fractures can be diagnosed on standard shoulder and clavicle radiographs. Occasionally, routine clavicle radiographs may miss some fractures, particularly at either end of the bone, due to overlap of surrounding structures. If a fracture is clinically suspected but not initially diagnosed with standard radiographs, a 45-degree cephalad tilt view may be used for further assessment. Definitive diagnosis may require CT. Obtain emergent orthopedic consultation for open fractures, fractures with neurovascular injuries, and fractures with persistent skin tenting. TREATMENT OF MIDDLE THIRD CLAVICLE FRACTURES Fractures of the middle third of the clavicle are most common. Although midclavicular fractures are often managed nonoperatively, operative fixation may result in improved functional outcome and a lower rate Tintinalli_Sec22_p1767-1880.indd 1822 8/2/19 6:16 PM

skin tenting. TREATMENT OF MIDDLE THIRD CLAVICLE FRACTURES Fractures of the middle third of the clavicle are most common. Although midclavicular fractures are often managed nonoperatively, operative fixation may result in improved functional outcome and a lower rate Tintinalli_Sec22_p1767-1880.indd 1822 8/2/19 6:16 PM CHAPTER 271: Shoulder and Humerus Injuries 1823 Type IIa Type IIb Type III FIGURE 271-3. Classification of distal clavicular fractures. TABLE 271-1 Middle Clavicle Fracture Nonunion Risk Factors •  Initial  shortening >2 cm •  Comminuted  fracture •  Displaced  fracture >100% •  Significant  trauma •  Female •  Elderly of malunion and nonunion. 11-13 Some fractures (Table 271-1), including severely comminuted or displaced fractures, benefit from referral and possible operative intervention. 14,15 Additional considerations for orthopedic referral include athletes, professional impact, and cosmetic concerns. Referral to an orthopedist within a few days of injury should be considered in the above instances. In cases where the patient does not want surgery or is a poor surgical candidate, conservative treatment is an appropriate strategy. Initial treatment of midclavicle fractures includes immobilization with either a sling or figure-of-eight brace. The length of immobilization is typically 4 to 8 weeks, until the fracture is no longer painful. Initial primary care or orthopedic follow-up should be in 1 to 2 weeks after injury in conservative treatment. The patient may use the arm as pain permits, but should avoid repeat injury from direct contact. Encourage daily range of motion of the elbow immediately and of the shoulder as soon as pain allows (3 to 5 days). TREATMENT OF DISTAL CLAVICLE FRACTURES Distal clavicle fractures are divided into three subtypes. 16 In type I fractures, the fracture is distal to the coracoclavicular ligaments, with the ligaments remaining intact. Type II fractures are broken into two categories. In type IIa, the fracture is medial to the coracoclavicular ligaments, although the ligaments remain intact. This results in an upward displacement of the proximal aspect of the clavicle. In a type IIb distal clavicle fracture, the fracture is between the coracoacromial ligaments with the conoid ligament torn and the trapezoid ligament intact, or lateral to the coracoacromial ligaments with both ligaments disrupted (Figure 271-3). Type II distal clavicle fractures may require operative intervention to avoid nonunion. 17 Type III fractures are intra-articular fractures through the acromioclavicular (AC) joint. Type I and III fractures can be managed conservatively with sling immobilization and primary care follow-up in 1 to 2 weeks.  TREATMENT OF PROXIMAL THIRD CLAVICLE FRACTURES Proximal third clavicle fractures are often high-mechanism injuries and can be associated with intrathoracic trauma. CT can diagnose the fracture and identify additional injuries. Emergent referral is required when posteriorly displaced fragments compromise mediastinal structures. Refer all other proximal third fractures to orthopedics within 1 to 2 weeks. Initial management includes sling immobilization.  SCAPULA FRACTURES ANATOMY The scapula is a triangularly shaped, flat bone that links the axial skel eton to the upper extremity and stabilizes motion of the arm. It serves as the site of origin of the rotator cuff and muscles about the shoulder. The mechanism of injury usually is from high-energy trauma to the shoulder area or from a fall on an outstretched hand. Scapular fractures are classified by their anatomic location (Figure 271-4), 19,20 with fractures of the body (Figure 271-5) and glenoid neck being most common.

or cuff and muscles about the shoulder. The mechanism of injury usually is from high-energy trauma to the shoulder area or from a fall on an outstretched hand. Scapular fractures are classified by their anatomic location (Figure 271-4), 19,20 with fractures of the body (Figure 271-5) and glenoid neck being most common. CLINICAL FEATURES AND DIAGNOSIS Patients with isolated scapular fractures typically present with local ized tenderness over the scapula and the arm held in adduction. Arm movement exacerbates pain. Due to the high energy typically required to fracture this protected bone, there is a high association of injuries to the ipsilateral lung, thoracic cage, and shoulder girdle, with fractures of the ribs being most common. Carefully determine the mechanism of injury to assist in diagnosis and raise suspicion for concurrent injuries. Assess the spine and pelvis because scapular injuries often occur with high-impact trauma. 19-21 The indirect axial load transmitted by a fall on an outstretched arm may result in a scapular neck fracture or glenoid fracture through shoulder impac tion or dislocation. Overlying structures may obscure a scapular fracture on a single trauma anteroposterior chest radiograph. A dedicated scapular series, including anteroposterior, lateral, and axillary scapular views, will identify most fractures and will guide the need for a CT scan. 20 Scapular fractures are often associated with other significant injuries, and hence, diagnosis may be delayed or initially missed entirely. CT scan of the chest can identify both scapular and associated pathology, and a dedi cated CT of the scapula can also be obtained. Tintinalli_Sec22_p1767-1880.indd 1823 8/2/19 6:16 PM

apular fractures are often associated with other significant injuries, and hence, diagnosis may be delayed or initially missed entirely. CT scan of the chest can identify both scapular and associated pathology, and a dedi cated CT of the scapula can also be obtained. Tintinalli_Sec22_p1767-1880.indd 1823 8/2/19 6:16 PM 1824 SECTION 22: Orthopedics FIGURE 271-4. Sites of scapular fractures. A. Body. B. Glenoid rim. C. Intra-articular glenoid. D. Neck. E. Acromion. F. Spine. G. Coracoid. FIGURE 271-5. Scapular Y view demonstrating scapular body fracture. [Photo used with permission of Alexander Ebinger, MD.] Acromion process Coracoid process Coracoacromial ligament Coracoclavicular ligament: Trapezoid Conoid Clavicle Acromioclavicular joint FIGURE 271-6. Anatomy of the acromioclavicular joint. TREATMENT OF SCAPULAR FRACTURES Most scapular fractures are treated nonsurgically, with sling, ice, anal gesics, and early range-of-motion exercises. Surgery may be necessary for significant or displaced articular fractures of the glenoid, angulated glenoid neck fractures, acromial fractures associated with a rotator cuff tear, and some coracoid fractures. 19,22 Disability is more likely to be associated with fractures of the glenoid, acromion, or coracoid. Isolated scapular fractures should be referred to an orthopedic surgeon. TREATMENT OF SCAPULOTHORACIC DISSOCIATION Traumatic dislocation of the scapula from the thoracic wall results from severe massive traction force applied to the ipsilateral upper extremity and shoulder girdle. Associated disruption of the subclavian or axillary arteries and brachial plexus makes proper identification and treatment critical. 23,24 Chest radiograph demonstrates significant lateral displacement of the scapula.23,24 Associated radiographic abnormalities include distracted clavicle fracture, AC separation, and sternoclavicular dislocation. Per form a CT scan to identify intrathoracic injuries.  ACROMIOCLAVICULAR JOINT INJURIES ANATOMY The AC joint is a diarthrodial joint that, together with the sterno clavicular joint, connects the upper extremity to the axial skeleton (Figure 271-6). Support of the AC joint is through the AC and coracoclavicular ligaments and the attachment of the trapezius and deltoid muscles. Surrounding the AC joint is a thin capsule, which is reinforced by the AC ligaments. The AC ligaments provide horizontal stability to the joint. The strong coracoclavicular ligaments consist of two parts, the more lateral trapezoid and the medial conoid, and attach the distal inferior clavicle to the coracoid process of the scapula. The coracoclavicular ligament is the major suspensory ligament of the upper extremity and provides vertical stability to the AC joint. AC joint injuries range from mild sprain to complete disruption of the ligaments that link the scapula and clavicle. The mechanism of injury is usually direct trauma to the joint from a fall with the arm adducted. The result is that the scapula and shoulder girdle are driven inferiorly while the clavicle remains in its normal position. An indirect mechanism is a fall on the outstretched hand with transmission of force to the AC joint. CLINICAL FEATURES AND DIAGNOSIS The diagnosis of an AC joint injury is clinical. The mechanism of injury, along with tenderness and deformity at the AC joint, especially when compared with the contralateral AC joint, is confirmatory. Range of Tintinalli_Sec22_p1767-1880.indd 1824 8/2/19 6:16 PM

f force to the AC joint. CLINICAL FEATURES AND DIAGNOSIS The diagnosis of an AC joint injury is clinical. The mechanism of injury, along with tenderness and deformity at the AC joint, especially when compared with the contralateral AC joint, is confirmatory. Range of Tintinalli_Sec22_p1767-1880.indd 1824 8/2/19 6:16 PM CHAPTER 271: Shoulder and Humerus Injuries 1825 motion may be limited, depending on the severity of injury. Cross-arm abduction testing is often painful. Radiographs are useful for identifying other fractures and determin ing the severity of injury. Specifically order AC radiographs because they require only one third to one half of the penetration of standard shoulder films. Shoulder radiographs may overpenetrate the AC joint, and small fractures can be missed. Although standard AC radiographs are generally sufficient, an axillary view is required to identify posterior clavicular dislocation (type IV). Stress radiographs may be ordered but are no longer routinely obtained. 25,26 TREATMENT OF ACROMIOCLAVICULAR JOINT INJURIES Obtain emergency orthopedic consultation for open fractures, fractures with neurovascular injuries, and fractures with persistent skin tenting. Table 271-2 describes specific AC joint injuries. Treatment of type I and II injuries consists of rest, ice, analgesics, and immobilization, followed by early range-of-motion exercises (7 to 14 days). 27 A simple sling is the most convenient and effective initial treatment. Prognosis for type I and II injuries is excellent, with only a small percentage of patients developing late symptoms requiring excision of the distal clavicle. Treatment of type III injuries varies, with most orthopedists recommending a trial of conservative treatment with sling immobi lization. 28-30 Surgical strategies have yielded good results in selected patients, with the specific management being operator dependent. Treatment decisions are based on such factors as age, occupation, and activity level. Types IV , V , and VI are severe injuries , and most experts recommend surgical repair. Because other injuries are asso ciated with these more severe forms of AC joint injuries (especially type VI), a careful clinical and radiographic examination must be performed. 28,29  GLENOHUMERAL JOINT DISLOCATION ANATOMY The glenohumeral joint is a ball-and-socket joint, with the articulation between the glenoid fossa of the scapula and the articular surface of the humeral head. The socket of the shoulder is shallow. The glenoid labrum deepens the socket and helps provide joint stability. The capsule and tendinous attachments about the joint also provide stability. Anterior dislocations of the glenohumeral joint are the most common; posterior dislocations account for <1%. Other dislocations include inferior (luxatio erecta) and superior (very rare). CLINICAL FEATURES AND DIAGNOSIS The combination of abduction, extension, and external rotation with sufficient force will cause an anterior dislocation. There are mul tiple types of anterior glenohumeral dislocations (Figure 271-7). These include subcoracoid, which is the most common; subglenoid; subcla vicular; and the very rare intrathoracic dislocation. In an anterior dislocation, the associated arm is usually in slight abduction and external rotation. The shoulder is “squared off, ” lacking the normal rounded contour. The patient resists adduction and internal rotation and often cannot touch the contralateral shoulder with the hand of the affected extremity. The humeral head can often be palpated anteriorly. Perform a careful neurovascular examination. The axillary nerve is most commonly injured. This nerve may be tested by pinprick sensation over the skin of the deltoid muscle.

tion and often cannot touch the contralateral shoulder with the hand of the affected extremity. The humeral head can often be palpated anteriorly. Perform a careful neurovascular examination. The axillary nerve is most commonly injured. This nerve may be tested by pinprick sensation over the skin of the deltoid muscle. Prereduction radiographs are advisable when there has been significant trauma, unless time is crucial because circulation is threatened. Radiographs are needed because dislocations and fracture-dislocations may have a similar appearance on physical examination, but the tech niques used to treat them may be very different. TABLE 271-2 Classification and Physical Findings in Acromioclavicular Joint Injuries ( Continued) Type Injury Mechanism Radiograph/Exam I Sprained acromioclavicular ligaments Radiograph: Normal Exam: Tenderness over acromioclavicular joint II Acromioclavicular ligaments ruptured; coracoclavicular ligaments sprained Radiograph: Slight widening of acromioclavicular joint; clavicle elevated 25%–50% above acromion; may be slight widening of the coracoclavicular interspace Exam: Tenderness and mild step-off deformity of acromiocla vicular joint (Continued) Tintinalli_Sec22_p1767-1880.indd 1825 8/2/19 6:16 PM

vicular ligaments sprained Radiograph: Slight widening of acromioclavicular joint; clavicle elevated 25%–50% above acromion; may be slight widening of the coracoclavicular interspace Exam: Tenderness and mild step-off deformity of acromiocla vicular joint (Continued) Tintinalli_Sec22_p1767-1880.indd 1825 8/2/19 6:16 PM 1826 SECTION 22: Orthopedics TABLE 271-2 Classification and Physical Findings in Acromioclavicular Joint Injuries ( Continued) Type Injury Mechanism Radiograph/Exam III Acromioclavicular ligaments ruptured; coracoclavicular ligaments ruptured; deltoid and trapezius muscles detached Clavicle elevated 100% above acromion; coracoclavicular interspace widened 25%–100% Exam: Distal end of clavicle prominent; shoulder droops IV Rupture of all supporting structures; clavicle displaced posteriorly in or through the trapezius Radiograph: May appear similar to type II and III; axillary radiograph required to visualize posterior dislocation Exam: Possible posterior displacement of clavicle V Rupture of all supporting structures (more severe form of type III injury) Radiograph: Acromioclavicular joint dislocated; generally 200%–300% disparity of coracoclavicular interspace compared to normal shoulder Exam: More pain; gross deformity of clavicle VI Acromioclavicular ligaments disrupted; coracoclavicular ligaments may be disrupted; deltoid and trapezius muscles disrupted Radiograph: Acromioclavicular joint dislocated; clavicle displaced inferiorly Exam: Severe swelling; multiple associated injuries Tintinalli_Sec22_p1767-1880.indd 1826 8/2/19 6:16 PM

f clavicle VI Acromioclavicular ligaments disrupted; coracoclavicular ligaments may be disrupted; deltoid and trapezius muscles disrupted Radiograph: Acromioclavicular joint dislocated; clavicle displaced inferiorly Exam: Severe swelling; multiple associated injuries Tintinalli_Sec22_p1767-1880.indd 1826 8/2/19 6:16 PM CHAPTER 271: Shoulder and Humerus Injuries 1827 Subcoracoid Subglenoid Subclavicular Intrathoracic Subglenoid Subgleno Subcoracoid FIGURE 271-7. Types of anterior shoulder dislocations. Obtain anteroposterior and either axillary or scapular lateral or (“Y”) radiographs before attempting reduction in patients with firsttime dislocation or if a fracture is suspected to confirm the anatomic type of dislocation and identify any associated fractures. Although the anteroposterior radiograph will reveal the dislocation, the axillary or scapular Y radiograph will indicate whether the dislocation is anterior or posterior. 31,32 Postreduction radiographs are valuable for confirming the success of joint reduction, as well as for providing documentation, in the event the joint redislocates after the patient is discharged from the ED. There is an expenditure of time, money, and radiation associated with pre- and postreduction films; however, there is currently no validated clinician decision rule that allows safe elimination of prereduction films after injury. 33 In clinical practice, films are sometimes omitted in patients with a history of multiple recurrent dislocations of the shoulder who present with history, signs, and symptoms typical of another recurrence in the absence of significant trauma. 32,33 GENERAL TREATMENT OF ANTERIOR GLENOHUMERAL DISLOCATIONS Shoulder dislocations or subluxations combined with proximal humerus fractures generally require orthopedic consultation and may need operative repair. Through the third decade, fracture-dislocations occurred less than 1% of the time. The incidence of shoulder dislocation with associ ated proximal humerus fracture increases with age and rises with each decade of life. In most patients, shoulder dislocation produces a significant amount of pain and muscle spasm. It is essential to provide appropriate analge sia. The use of procedural sedation is common, but any reduction tech nique may be attempted without medication when performed slowly and atraumatically. 35,36 Muscle relaxation and pain management should be tailored to the individual patient and may include NSAIDs, opiates, or benzodiazepines, intra-articular lidocaine injection, or procedural sedation. Although one can significantly reduce pain with IV medica tions, the most effective way to relieve pain is to rapidly reduce the dislocation. Intra-articular injection of 10 to 20 mL of 1% lidocaine reduces the pain associated with reduction and can complement procedural sedation.31,37,38 After sterile skin preparation, introduce the needle at the hollow created by the displaced humeral head, just inferior to the acromion. US can facilitate intra-articular injection. Perform neurovascular examination before and after reduction.  COMPLICATIONS OF GLENOHUMERAL DISLOCATION Complications associated with anterior glenohumeral dislocations include recurrence, rotator cuff tears, humeral head bony defects (Hill- Sachs deformity), glenoid labral defects (Bankart lesions), and rarely, neurovascular injuries. 39 The most common complication is recurrent dislocation, and children and young adults may have a recurrence rate of more than 90%. 39,40 Early surgical repair may decrease the recurrence rate, so patients with first-time shoulder dislocations should be referred for orthopedic evaluation. 41-43 The rotator cuff weakens with advancing age, and in older patients, anterior dislocation is usually associated with rotator cuff tears.

te of more than 90%. 39,40 Early surgical repair may decrease the recurrence rate, so patients with first-time shoulder dislocations should be referred for orthopedic evaluation. 41-43 The rotator cuff weakens with advancing age, and in older patients, anterior dislocation is usually associated with rotator cuff tears. Rotator cuff tears can be difficult to identify on ED examination after reduction but can be suspected with weakness upon external rotation. 39 Any patient with pain persisting for greater than 2 weeks should follow up with orthopedics. For further discussion, see Chapter 280, “Shoulder Pain. ” Bony injuries are common and include fractures of the humeral head (Hill-Sachs lesions) and glenoid (bony Bankart lesion) (Figures 271-8 and 271-9) and tears of the anterior glenoid labrum (soft Bankart lesion) and greater tuberosity. Such fractures are often evident only on postre duction films, 32 and there is no specific ED treatment other than followup with orthopedics. Vascular injuries are rare, but when they occur, they tend to involve the axillary artery in elderly patients. Clinical findings of vascular injury include absent radial pulse, axillary hematoma, bruising of the lateral chest wall, and an axillary bruit. Nerve injuries, which occur in 10% to 25% of acute dislocations, are the result of traction neurapraxia. Most involve the axillary nerve, resulting in loss of sensation over the skin of the upper arm. This injury FIGURE 271-8. Bankart lesion. CT of right shoulder showing a frontal view with fracture tear of the anterior-inferior glenoid bony cavity (Bankart lesion). [Photo used with permission of Erik Magnus Berntsen, MD, PhD, Department of Radiology, St. Olavs University Hospital, Trondheim, Norway.] Tintinalli_Sec22_p1767-1880.indd 1827 8/2/19 6:17 PM

on. CT of right shoulder showing a frontal view with fracture tear of the anterior-inferior glenoid bony cavity (Bankart lesion). [Photo used with permission of Erik Magnus Berntsen, MD, PhD, Department of Radiology, St. Olavs University Hospital, Trondheim, Norway.] Tintinalli_Sec22_p1767-1880.indd 1827 8/2/19 6:17 PM 1828 SECTION 22: Orthopedics is temporary and resolves spontaneously. The motor portion of the axillary nerve supplies the teres minor and the deltoid, and injury can result in weakness of shoulder abduction and external rotation. Other nerves that may be injured are the radial, ulnar, median, musculocutaneous, and brachial plexus.  DISPOSITION After reduction, place the arm in a shoulder immobilizer or sling that maintains the shoulder in adduction and internal rotation (Figure 271-10). Provide instructions for orthopedic follow-up in 1 week for uncomplicated dislocations and within 1 to 2 days for dislocations complicated by bony or soft tissue injury. REDUCTION TECHNIQUES The three main categories of reduction techniques are traction, lever age, and scapular manipulation 31,45-50 (See Video: Anterior Shoulder Dislocation Reduction: Traction Techniques). Success rates are between FIGURE 271-9. Bankart lesion and Hill-Sachs fracture. CT of right shoulder, oblique coronal view, demonstrating both the bony Bankart lesion and the Hill-Sachs fracture of the humeral head. [Photo used with permission of Erik Magnus Berntsen, MD, PhD, Department of Radiology, St. Olavs University Hospital, Trondheim, Norway.] FIGURE 271-10. Arm sling. FIGURE 271-11. Modified Hippocratic technique. 70% and 96% regardless of technique. It is best to be comfortable with two or three techniques in case of a failed first attempt. Considerations in selection of a technique include ease of performance, effectiveness, requirement for sedation, number of assistants, and duration. The most common techniques are described below.  TRACTION-COUNTERTRACTION TECHNIQUE (MODIFIED HIPPOCRATIC) A modification of the Hippocratic method uses traction-countertraction (Figure 271-11). The patient is supine with the arm abducted and elbow flexed at 90 degrees. A sheet is tied and placed across the thorax of the patient and then around the waist of the assistant. Another sheet is tied and placed around the forearm of the patient at the elbow and the waist of the physician. Gradually apply traction to the proximal forearm as the assistant provides countertraction. Gentle internal and external rotation or outward pressure on the proximal humerus may aid reduction.  STIMSON TECHNIQUE Place the patient prone with the dislocated extremity hanging over the side of the stretcher and a 10-lb weight attached to the wrist. Inject intraarticular lidocaine. Complete muscle relaxation is required. Reduction Tintinalli_Sec22_p1767-1880.indd 1828 8/2/19 6:17 PM

al humerus may aid reduction.  STIMSON TECHNIQUE Place the patient prone with the dislocated extremity hanging over the side of the stretcher and a 10-lb weight attached to the wrist. Inject intraarticular lidocaine. Complete muscle relaxation is required. Reduction Tintinalli_Sec22_p1767-1880.indd 1828 8/2/19 6:17 PM CHAPTER 271: Shoulder and Humerus Injuries 1829 FIGURE 271-12. Scapular manipulation technique. 90° FIGURE 271-13. A and B. External rotation (Kocher’s) technique. [Reproduced with permission from Simon RR, Sherman SC, Koenigsknecht SJ: Emergency Orthopedics, The Extremities, 5th ed. © 2007, McGraw-Hill Inc., New York.] occurs in 20 to 30 minutes. Although the time to reduction can be a drawback, this technique is safe, effective, and easy to learn.  SCAPULAR MANIPULATION TECHNIQUE The patient is positioned with weights in the same manner as the Stim son technique (Figure 271-12). After adequate sedation, the physician pushes the tip of the scapula medially using the thumbs, while stabiliz ing the superior aspect with the cephalad hand. This technique reports a 96% success rate.  EXTERNAL ROTATION TECHNIQUE (KOCHER’S TECHNIQUE) Place the patient supine with the affected arm adducted to the patient’s side. With the elbow at 90 degrees of flexion, slowly externally rotate the arm (Figure 271-13). No longitudinal traction is applied. Perform the movement slowly to allow time for spasm and pain to resolve. Reduction is usually complete before reaching the coronal plane and is often not noted either by the patient or physician. If needed, the elbow may be brought anteriorly and internally rotated to the opposite shoulder.  MILCH TECHNIQUE The maneuvers for the Milch technique are external rotation, arm abduction to 180 degrees with simultaneous pressure on the humeral head, and in-line longitudinal traction with continued pressure on the humeral head (Figure 271-14).  CUNNINGHAM TECHNIQUE The Cunningham technique is based on the combination of humerus and scapular positioning and specific massage of a spasming biceps muscle (Figure 271-15) (See Video: Anterior Shoulder Reduction: Cunningham Technique). Seat the patient comfortably, as upright as pos sible, with shoulders relaxed. Supporting the affected arm, slowly and gently move the humerus into full adduction with the elbow in flexion. Have the hand of the affected extremity resting against the physician’s shoulder. Gently massage the trapezius and deltoids, which helps to relax the patient. Then, gently massage the biceps at the mid-humeral level. Ask the patient to elevate and shrug or retract the shoulders (attempting to touch the scapulae together) and continue the biceps massage. The goal is to wait for the patient to relax fully and have the humeral head slip back into place.  FARES TECHNIQUE The FARES (FAst, REliable, and Safe) method, which was first described in 2009, is a modified Milch technique 50 (Figure 271-16) (See Video: Anterior Shoulder Dislocation: Fares Technique). The FARES method may be the alternative of choice, with a success rate of almost 90% without the use of any sedation, anesthesia, or analgesia. 45 Place the patient in a supine position and hold the patient’s wrist with gentle traction in a neutral position. Gently move the limb anteriorly and posteriorly in small oscillating movements on the outstretched arm and start abduct ing the limb slowly while continuing to apply traction. Once the limb is abducted 90 degrees, the limb is externally rotated. Continue to slowly abduct the limb past this position. Reduction is usually achieved once the limb is abducted to 120 degrees. Successful reduction of acute posterior shoulder dislocations without general anesthesia has been achieved using the FARES method.

e limb is abducted 90 degrees, the limb is externally rotated. Continue to slowly abduct the limb past this position. Reduction is usually achieved once the limb is abducted to 120 degrees. Successful reduction of acute posterior shoulder dislocations without general anesthesia has been achieved using the FARES method. POSTERIOR GLENOHUMERAL DISLOCATIONS Posterior dislocation may occur with the humeral head in the subacromial, subglenoid, or subspinous position, but most often, it occurs with the humeral head posterior to the glenoid and inferior to the acromion (Figure 271-17). The subglenoid and subspinous positions are rare. The usual mechanism is an indirect force that produces forceful internal rotation and adduction or a direct blow to the anterior shoulder. On examination, there is a prominence of the posterior shoulder and anterior flattening of the normal shoulder contour on the affected side, especially when compared to the nonaffected side. The patient will be unable to externally rotate or abduct the affected arm. (See Video: Posterior Shoulder Dislocation Reduction.) Tintinalli_Sec22_p1767-1880.indd 1829 8/2/19 6:17 PM

shoulder and anterior flattening of the normal shoulder contour on the affected side, especially when compared to the nonaffected side. The patient will be unable to externally rotate or abduct the affected arm. (See Video: Posterior Shoulder Dislocation Reduction.) Tintinalli_Sec22_p1767-1880.indd 1829 8/2/19 6:17 PM 1830 SECTION 22: Orthopedics FIGURE 271-14. Milch technique. [Reproduced with permission from Reichman EF: Emergency Medicine Procedures , 2nd ed. Chapter 81. Shoulder Joint Dislocation Reduction. McGraw-Hill, Inc., 2013. Figure 81-7A-C.] into the glenoid fossa.52 Fractures of the posterior glenoid rim, humeral head (reversed Hill-Sachs deformity), humeral shaft, or lesser tuberosity are common complications. Neurovascular and rotator cuff tears are less common than in anterior dislocations. Obtain postreduction radiographs to confirm successful reduction. Immobilize the shoulder with an arm sling, with follow-up with an orthopedist.  INFERIOR DISLOCATIONS (LUXATIO ERECTA) Inferior dislocation is associated with significant soft tissue trauma or fracture. The mechanism of injury is a hyperabduction force, which levers the neck of the humerus against the acromion. As the force con tinues, the inferior capsule tears, and the humeral head is forced out inferiorly. The patient presents with the humerus fully abducted, the elbow flexed, and the patient’s hand on or behind the head. The humeral head can be palpated on the lateral chest wall. Reduction consists of traction in an upward and outward direction in line with the humerus ( Figure 271-20 ). Have the assistant apply countertraction. Reduction is signaled by a “clunk. ” The arm is then brought to the patient’s side and immobilized in a shoulder immobilizer. Complications include severe soft tissue injuries and fractures of the proximal humerus. The rotator cuff, which usually becomes detached, requires orthopedic follow-up. Neurovascular compression injuries are usually found but almost always resolve after reduction. When the humeral head is buttonholed through the inferior capsule, the disloca tion is irreducible, and operative reduction is required. (See Video: Luxatio Erecta Dislocation Reduction.)  PROXIMAL HUMERUS FRACTURES ANATOMY The proximal humerus is composed of the articular segment and ana tomic neck, the greater and lesser tuberosities, and the proximal shaft (Figure 271-21). The supraspinatus, infraspinatus, and teres minor insert on the greater tuberosity, whereas the subscapularis inserts on the lesser tuberosity. The biceps tendon passes through the bicipital groove. The anterior and posterior humeral circumflex arteries branch off the axillary artery and course around the surgical neck. CLINICAL FEATURES AND DIAGNOSIS Patients with fractures typically present with pain, swelling, and tenderness about the shoulder. Range of motion is often significantly limited, and the arm is held in adduction. Crepitus and ecchymosis may be present. Carefully perform the neurovascular examination. The most commonly injured nerve is the axillary nerve, and sensation overlying the deltoid muscle should be tested. The second most commonly injured nerve is the suprascapular nerve, which innervates the supraspinatus and infraspinatus. 53 Range of motion may be limited, but assessment of shoulder abduction should be performed. Vascular injuries may occur with even trivial trauma in atherosclerotic elderly patients. The most common vascular injury is to the axillary artery and may be suggested by weak distal pulses compared to the uninjured side, paresthesias, pallor, pulselessness, or an expanding hematoma. Neurovascular injuries can occur in nondisplaced and displaced fractures but are much higher (>50%) in displaced fractures.

The most common vascular injury is to the axillary artery and may be suggested by weak distal pulses compared to the uninjured side, paresthesias, pallor, pulselessness, or an expanding hematoma. Neurovascular injuries can occur in nondisplaced and displaced fractures but are much higher (>50%) in displaced fractures. Radiographs consisting of anteroposterior, lateral shoulder, and axil lary views will diagnose most proximal humerus fractures and evaluate for accompanying glenohumeral dislocation.  SPECIFIC PROXIMAL HUMERUS INJURIES The most common fractures of the proximal humerus include the surgical neck and greater tuberosity. To guide treatment, the Neer system classifies fracture displacement into “parts. ” The proximal humerus is divided into four segments based on epiphyseal lines where fractures primarily occur: the articular surface of the humeral head; the greater tuberosity; the lesser tuberosity; and the shaft of the humerus (Figure 271-22). The The scapular Y radiograph is diagnostic (Figure 271-18). An axillary view can also demonstrate a posterior dislocation (Figure 271-19). Reduction of a posterior dislocation is performed with the patient supine. Apply traction to the adducted arm in the long axis of the humerus. Have an assistant gently push the humeral head anteriorly Tintinalli_Sec22_p1767-1880.indd 1830 8/2/19 6:17 PM CHAPTER 271: Shoulder and Humerus Injuries 1831 FIGURE 271-15. Cunningham technique. FIGURE 271-16. FARES (FAst, REliable, and Safe) technique. Tintinalli_Sec22_p1767-1880.indd 1831 8/2/19 6:17 PM 1832 SECTION 22: Orthopedics

Radiographs consisting of anteroposterior, lateral shoulder, and axil lary views will diagnose most proximal humerus fractures and evaluate for accompanying glenohumeral dislocation.  SPECIFIC PROXIMAL HUMERUS INJURIES The most common fractures of the proximal humerus include the surgical neck and greater tuberosity. To guide treatment, the Neer system classifies fracture displacement into “parts. ” The proximal humerus is divided into four segments based on epiphyseal lines where fractures primarily occur: the articular surface of the humeral head; the greater tuberosity; the lesser tuberosity; and the shaft of the humerus (Figure 271-22). The The scapular Y radiograph is diagnostic (Figure 271-18). An axillary view can also demonstrate a posterior dislocation (Figure 271-19). Reduction of a posterior dislocation is performed with the patient supine. Apply traction to the adducted arm in the long axis of the humerus. Have an assistant gently push the humeral head anteriorly Tintinalli_Sec22_p1767-1880.indd 1830 8/2/19 6:17 PM CHAPTER 271: Shoulder and Humerus Injuries 1831 FIGURE 271-15. Cunningham technique. FIGURE 271-16. FARES (FAst, REliable, and Safe) technique. Tintinalli_Sec22_p1767-1880.indd 1831 8/2/19 6:17 PM 1832 SECTION 22: Orthopedics Subglenoid dislocation Subcoracoid dislocation Subclavicular dislocation FIGURE 271-17. Posterior shoulder dislocations. FIGURE 271-18. Scapular Y view of posterior dislocation, with the humeral head posterior. [Photo used with permission of Alexander Ebinger, MD.] FIGURE 271-19. Axillary view of posterior dislocation. [Photo used with permission of Alexander Ebinger, MD.] displacement of a fracture fragment from the proximal humerus is called a “part. ” Parts are therefore not based on the number of fracture lines or segments. Rather, a “one-part” fracture is one in which the fragment is not displaced at all, is displaced <1 cm, or is not angulated >45 degrees. There can be multiple fragments, but if none of the fragments is displaced >1 cm or is angulated >45 degrees, the proximal humerus fracture is termed a “one-part” fracture. Approximately 50% of all proximal humerus fractures are one-part fractures. 54,55 Treatment of a one-part proximal humerus fracture generally consists of immobilization (such as sling and swathe), Tintinalli_Sec22_p1767-1880.indd 1832 8/2/19 6:17 PM

egrees, the proximal humerus fracture is termed a “one-part” fracture. Approximately 50% of all proximal humerus fractures are one-part fractures. 54,55 Treatment of a one-part proximal humerus fracture generally consists of immobilization (such as sling and swathe), Tintinalli_Sec22_p1767-1880.indd 1832 8/2/19 6:17 PM CHAPTER 271: Shoulder and Humerus Injuries 1833 ice, analgesics, and orthopedic referral. Early mobilization is important to avoid subsequent adhesive capsulitis and can be started when pain allows. The prognosis is generally good. All other proximal humerus fractures and fracture-dislocations require orthopedic consultation in the ED because they are more frequently associated with complications and are often difficult to manage. Closed reduction, operative treatment, or a combination of the two may be necessary. 56-58 Any fracture involving the anatomic neck or the articular surface may result in compromise of the blood supply to the articular segment of the humeral head. If ischemic necrosis of the articular segment occurs, insertion of a humeral head prosthesis may be required. Significantly angulated surgical neck fractures are a risk for neurovascular damage (axillary neurovascular structures as well as the brachial plexus) and should be immobilized and radiographed in the position of presentation. Significant displacement of a greater tuberosity fracture implies a concomitant rotator cuff tear, with surgical repair often necessary for the active patient. Fracture of the lesser tuberosity should alert the examiner to a potential posterior shoulder dislocation. Pediatric humerus fractures are discussed in Chapter 141, “Pediatric Orthopedic Emergencies. ” FIGURE 271-20. Reduction of luxatio erecta. Greater tubercle Intertubercular sulcus (groove) Crest of greater tubercle Head Anatomic neck Surgical neck Crest of lesser tubercle Lesser tubercle FIGURE 271-21. Proximal humerus. [Reproduced with permission from Pansky B: Review of Gross Anatomy, 6th ed. New York: McGraw Hill, 1995.] FIGURE 271-22. The four segments of the humerus according to the Neer classification: 1, articular surface of the humeral head; 2, greater tubercle; 3, lesser tubercle; 4, diaphysis or shaft of humerus. A one-part fracture is defined as a fracture fragment displaced by <1 cm or <45 degrees; two-, three-, and four-part fractures have more displacement and angulation.  HUMERAL SHAFT FRACTURES ANATOMY The humerus serves as the attachment site for the rotator cuff muscles, deltoid, pectoralis major, and coracobrachialis. Additionally, it is the site of origin of the biceps, triceps, and brachioradialis. The radial nerve courses along the spiral groove on the posterior aspect of the humerus. Fractures of the humeral shaft occur in a bimodal age distribution, with peaks in the third and seventh decades of life, representing active young men and osteoporotic elderly women, respectively. Humeral shaft fractures may be caused by a direct blow that produces a bend ing force resulting in a transverse fracture. They may also be caused by an indirect mechanism, such as a fall on an outstretched hand that produces a torsion force, resulting in a spiral fracture. A combination of bending and torsion forces results in an oblique fracture, sometimes with comminution, producing the “butterfly” fragment. The humerus is also a common site of pathologic fractures, especially from metastatic breast cancer. Fractures in young children should raise suspicion of abuse. CLINICAL FEATURES AND DIAGNOSIS Clinical examination reveals localized tenderness, swelling, pain, and abnormal mobility or crepitus on palpation. Displaced fractures are associated with shortening of the upper extremity. Attention must be given to the initial neurovascular status.

dren should raise suspicion of abuse. CLINICAL FEATURES AND DIAGNOSIS Clinical examination reveals localized tenderness, swelling, pain, and abnormal mobility or crepitus on palpation. Displaced fractures are associated with shortening of the upper extremity. Attention must be given to the initial neurovascular status. Complications may include injury to the brachial artery and vein, or the radial, ulnar, or median nerves. A radial nerve injury, which is the most common, may be manifested by weak wrist extension, wrist drop, or altered sensation at the dorsal thumb index web space. Fractures of the distal third are par ticularly prone to entrapment of the radial nerve, either as a result of the initial injury or after closed reduction. Neurovascular injuries require emergency orthopedic consultation. Tintinalli_Sec22_p1767-1880.indd 1833 8/2/19 6:17 PM

nsation at the dorsal thumb index web space. Fractures of the distal third are par ticularly prone to entrapment of the radial nerve, either as a result of the initial injury or after closed reduction. Neurovascular injuries require emergency orthopedic consultation. Tintinalli_Sec22_p1767-1880.indd 1833 8/2/19 6:17 PM 1834 SECTION 22: Orthopedics Radiographs should include two views of the humerus. Images of the shoulder and elbow should be obtained if additional injuries cannot be excluded.  FRACTURES OF THE MIDDLE THIRD OF THE HUMERUS The most common site of fracture is the middle third of the humerus. Displacement of fracture fragments is the result of the insertions and actions of the various muscles (deltoid, biceps, triceps, supraspinatus, and pectoralis major) that act on the upper arm ( Figure 271-23). Most closed fractures of the shaft of the humerus are managed nonopera tively, although treatment options vary and there has been an increase in operative fixation. 61,62 A 2012 Cochrane Review did not find any evi dence to suggest outcome differences from surgical versus nonsurgical management. 63 Fractures with less than 20 degrees of angulation in the sagittal plane and less than 30 degrees of varus or valgus angulation and that are shortened less than 2 to 3 cm often can be managed nonopera tively. 64 The treatment of uncomplicated fractures includes immobilization, ice, analgesia, and referral. Closed treatment options include the coaptation splint (sugar-tong), hanging cast, and functional bracing. A simple sling and swathe are adequate for the emergency management of most such patients.  DISTAL HUMERUS FRACTURES Distal humerus fractures require emergency orthopedic consultation. These fractures are complex given the anatomical relationship of the bony and neurovascular structures. Clinical examination should include evaluation of the radial, median, ulnar, and anterior and posterior interosseous nerves. See Chapter 270, “Elbow and Forearm Injuries, ” for a discussion of supracondylar fractures.  BRACHIAL PLEXUS INJURIES  ANATOMY The brachial plexus ( Figure 271-24) and its peripheral nerve branches are infraclavicular and lay anteromedial to the glenohumeral joint. Anatomically, the brachial plexus stems from the C4-T1 cervical roots and ultimately from the lateral, posterior, and medial cords. At the lateral border of the pectoralis minor, these cords ultimately form the five major peripheral nerves of the arm (musculocutaneous nerve, axillary nerve, radial nerve, median nerve, and ulnar nerve). 65 Traumatic brachial plexus lesions are the most common form of plexus injuries and can occur from penetrating, compression, or closed trac tion injuries. Injuries can be divided into supraclavicular (roots and trunks) or infraclavicular (cords and terminal nerves) injuries.  CLINICAL FEATURES AND DIAGNOSIS High-speed motor vehicle or motorcycle crashes result in traction injuries as nerves are stretched longitudinally, with simultaneous traction of the arm and opposite distraction of the head. 65,66 Penetrating trauma and surgical interventions can also lead to a disruption of the nerves. The initial identification of brachial plexus injuries is often overshadowed by the presence of other severe injuries to, for example, the head, chest, and vasculature. In addition to neurologic impairment, neuropathic pain in the arm is frequently present. Significant swelling and soft tissue injury to the neck and shoulder girdle suggest traumatic forces sufficient to injure the brachial plexus. The accumulation of cerebrospinal fluid from avulsed spinal roots may cause swelling in the posterior triangle. Horner’s syndrome (ipsilateral ptosis, miosis, and anhidrosis of the face) may be present due to adjacent ganglion damage.

nd shoulder girdle suggest traumatic forces sufficient to injure the brachial plexus. The accumulation of cerebrospinal fluid from avulsed spinal roots may cause swelling in the posterior triangle. Horner’s syndrome (ipsilateral ptosis, miosis, and anhidrosis of the face) may be present due to adjacent ganglion damage. However, brachial plexus injury may not be clinically apparent until a responsive patient can indicate the extent of motor and sensory deficits, days to weeks after initial stabilization and treatment. Arm pain that is constant and burning in character is common. The pain is usually worst in the distal parts of the arm and hand, typically in a nondermatomal distribution. Upper limb and shoulder girdle motor and sensory deficits define the extent of damage to the brachial plexus. Adduction and internal rotation of the shoulder indicate weakness of the deltoid and infraspinatus muscles (C5), whereas elbow extension is due to weakness of the biceps (C6), and flexion of the digits and wrists is due to weakness of the extensors (C7). The sensory distributions of the cervical roots and the peripheral nerves are shown in Figure 271-25. MRI and CT myelography are common radiographic imaging procedures. Electromyographic and nerve conduction velocity studies may aid in diagnosis, and surgical exploration of the area may be necessary. The delineation of pre- and postganglionic injury may not be possible until Wallerian degeneration is completed 2 weeks after injury. Treat ment and prognosis will depend on the location and extent of nerve damage. FIGURE 271-23. Humeral fractures anterior view. The actions of the muscles inserting on the humeral shaft determine fracture angulation and displacement. A. Angulation of fragments with fracture line distal to rotator cuff insertion. B. Angulation of fragments with fracture line distal to pectoralis major insertion. C. Angulation of fragments with fracture line distal to deltoid insertion. Tintinalli_Sec22_p1767-1880.indd 1834 8/2/19 6:17 PM

angulation and displacement. A. Angulation of fragments with fracture line distal to rotator cuff insertion. B. Angulation of fragments with fracture line distal to pectoralis major insertion. C. Angulation of fragments with fracture line distal to deltoid insertion. Tintinalli_Sec22_p1767-1880.indd 1834 8/2/19 6:17 PM CHAPTER 271: Shoulder and Humerus Injuries 1835 C4 C5 C6 C7 T1 Terminal nerves Cords Divisions Trunks Roots Dorsal scapular nerve Suprascapular nerve Long thoracic nerve Upper Middle Lower Lateral Posterior Medial Musculocutaneous nerve Median nerve Axillary nerve Radial nerveUlnar nerve FIGURE 271-24. Brachial plexus.  COMPLICATIONS OF TOTAL SHOULDER ARTHROPLASTY Total shoulder arthroplasty is an increasingly common method of surgical management of glenohumeral arthritis and degenerative shoulder conditions. Overall, surgical outcomes are excellent. Similar to many surgical conditions, complications may arise after this procedure. Pros thetic loosening, infection, periprosthetic fracture, glenohumeral insta bility, and soft tissue dysfunction are the most commonly encountered postoperative complications. Perform a thorough neurovascular exam of the affected extremity. Neurologic injuries occur in 1% to 4.3% of shoulder arthroplasty cases, with the axillary nerve most commonly affected. 67 There are also reports of injury to the brachial plexus and radial nerve. Obtain radiographs in patients with shoulder pain in the setting of shoulder arthroplasty. Radiographs can be useful for detecting peri prosthetic fractures as well as prosthetic dislocation. Infection is the most concerning of the possible complications, although the incidence of infection is only between 0% and 4%. 67 The diagnosis of infection can be challenging. Most infections develop in patients with underlying immunocompromise, including diabetes, rheumatoid arthritis, Anterior (volar) Posterior (dorsal) Anterior (volar) Posterior (dorsal) C6 C7 C7 C8 T1 C6 Upper lateral cutaneous nerve of arm Medial cutaneous nerve of arm and intercostal brachial nerve Cutaneous branches of radial nerve Medial cutaneous nerve of forearm Lateral cutaneous nerve of forearm Ulnar nerve Radial nerve Median nerve FIGURE 271-25. Sensory distribution of the brachial plexus. Tintinalli_Sec22_p1767-1880.indd 1835 8/2/19 6:17 PM