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I. Pathology of the shoulder complex

A. sternoclavicular joint

1. sternoclavicular joint sprains usually due to compression from direct blow

a. indirect trauma from fall on outstretched arm, abnormal repetitive motions can also damage joint

b. most commonly have anterior displacement with disruption of costoclavicular and sternoclavicular ligaments

1. first degree sprain will have point tenderness, mild pain over SC joint with no visible deformity, little disability

2. second degree sprain has bruising, swelling, significant pain over joint line

a. will not be able to horizontally adduct arm without significant pain

3. third degree sprains involve total disruption of joint and may have fracture of sternal clavicle

c. posterior dislocation of SC joint is rare but extremely serious

1. is great potential for damage to trachea, esophagus, subclavian artery

2. may have depression between sternal end of clavicle and manubrium

3. may have pain with shoulder protraction

4. may have hoarseness, difficulty breathing, diminished radial pulse

B. acromioclavicular joint sprains also called a shoulder pointer, or a shoulder separation

1. can occur from direct blow, fall on AC joint or from fall on outstretched arm that transmits force through humerus

2. first degree injury has minimal swelling with mild tearing of acromioclavicular ligament

a. is no visible deformity and mild tenderness over joint line

b. is pain with abduction over 90 degrees

3. second degree sprain involves damage to the superior and inferior acromioclavicular ligaments

a. will have some subluxation of joint surfaces but coracoclavicular ligament still intact

b. clavicle rides above level of acromion, swelling present over joint line

c. pain increases with pressure on clavicle inferior or anteroposterior

d. may have palpable gap or step-off over joint line

e. point tenderness along posterior border of clavicle may indicate tearing of trapezius and deltoid fibers

f. horizontal adduction will be painful and may elicit snapping or clicking at the AC joint

4. third degree sprains completely disrupt acromioclavicular and coracoclavicular ligaments

a. will have obvious swelling, bruising, step deformity

b. greatly increased excursion of the clavicle and increased pain may indicate tearing of trapezius, deltoid attachments

c. must strongly consider possibility of fracture

5. type IV, V, VI injuries usually require surgical intervention

C. glenohumeral joint sprain is a subluxation

1. may involve glenohumeral ligaments, particularly the inferior glenohumeral

2. may result in tearing of glenoid labrum

3. could cause swelling in structures passing through coracoacromial arch, worsening an impingement syndrome

D. glenohumeral joint dislocations

1. most are anteriorly displaced

a. since glenoid fossa is facing somewhat anteriorly

2. usually occur through mechanism of abduction, external rotation, extension

3. capsule and capsular ligaments significantly damaged as humeral head slides anterior, inferior out of glenoid fossa to locate adjacent to coracoid process

4. may have tingling, numbness down arm into hand

5. usually painful though recurrent dislocations may be less so

6. will have sharp contour on affected shoulder with prominent acromion process on affected shoulder

7. humeral head may be palpated in axilla anterior to acromion

8. must assess integrity of axillary nerve and artery

a. pulse can be taken at medial proximal humerus over brachial artery or at radial artery in wrist

b. axillary nerve supplies teres minor and deltoid, provides sensory function to upper lateral arm

1. stroke skin on affected side and compare to skin overlying other deltoid

9. first time dislocation may be associated with fracture

Bilateral shoulder dislocation after trying to lift weight overhead. NEJM Vol 367, No. 8,p. E12. Aug 23, 2012

E. rotator cuff dysfunction

1. rotator cuff functions to centralize the humeral head in the glenoid fossa

a. can experience great forces during deceleration phase of overhead sports; tennis, baseball, volleyball

b. could sustain rotator cuff strain or rupture

c. most commonly is an overuse injury

1. as develop pain, swelling, weakness, will lose control of humeral head

2. will place increasing stress on rotator cuff, capsule and labrum

F. bicipito-labral complex degeneration

1. long head of biceps attaches at superior labrum

a. is involved eccentric deceleration of upper extremity, (particularly the forearm) and to resist glenohumeral joint distraction

b. forces can pull on labral attachment or cause a proximal bicipital tendinitis

G. labral tears

1. as humeral head fails to stay centralized in glenoid fossa, varying degrees of subluxation may occur

2. if humeral head contacts edge of rim and labrum, can get wear and tear

a. can result in tears and degenerative changes in the labrum

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H. impingement syndrome

1. occurs due to superior migration of humeral head

2. is limited room in the coracoacromial arch (supraspinatus outlet)

a. unwanted humeral migration will contact greater tuberosity, rotator cuff musculature or biceps against inferior surface of acromion or coracoacromial ligament

I. scapular dysfunction

1. scapula provides stable base for shoulder function

a. periscapular musculature works in tandem pairs to stabilize and to elevate acromion

b. serratus anterior and lower portions of trapezius are most likely problem areas

J. clavicular fractures are common

1. often at lateral third junction where clavicle changes shape – is weaker with transition in direction and shape

2. treatment often is figure of eight sling

3. may need plating if displaced fracture with shortening > 20mm

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Displaced and comminuted right sided midshaft clavicle fracture.

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Open reduction internal fixation of a right sided clavicle fracture with a precontoured clavicular plate.

II. frequently injury to one structure is secondary to breakdown of another

A. in athletes, instability with resultant shoulder dysfunction is the initial consideration

1. could be traumatic

a. a specific traumatic event will often result in a unidirectional pattern of instability

2. could be overuse

B. athletes with increased baseline laxity of shoulder are often the better overhead athletes

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