CHAPTER 71. The shoulder and upper arm Introduction EXAMINING THE SHOULDER AND UPPER ARM

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1 CHAPTER 71 The shoulder and upper arm 71.1 Introduction Most shoulder injuries are caused by a patient falling on the point of his shoulder, or on his outstretched hand. If he does this, he can dislocate the joints at either end of his clavicle, or break it anywhere. He can injure his brachial plexus. He can also break his scapula, dislocate his shoulder, or break the neck of his humerus. Occasionally, he breaks the neck of his humerus and dislocates its head. We have already discussed the general principles of examining an injured limb (69.1), so here are some more detailed methods, which will be particularly useful, if you don t have X rays. Do them gently, because they can be painful, particularly examining for crepitus. EXAMINING THE SHOULDER AND UPPER ARM THE CLAVICLE EXAMINATION Look carefully at either end of the patient s clavicle. Are they same on both sides? (abnormal prominence suggests a dislocation). Stand behind him, feel the entire subcutaneous surface of his clavicle, and the joints at either end. Where exactly is it swollen and tender? (fractures). Is there any abnormal movement between his clavicle and his acromion? (acromio clavicular dislocation). If so, can you reduce the dislocation by raising his humerus with your hand under his elbow, and depressing his clavicle? THE SCAPULA EXAMINATION Palpate the spine of the patient s scapula and his acromion. Tenderness and swelling probably indicate a fracture. Flex his arm to 90 and rest it on your forearm. Gently move his whole arm up and down. Provided his clavicle is intact, abnormal mobility or crepitus in his shoulder suggests that he has fractured the neck of his scapula. THE SHOULDER JOINT EXAMINATION INSPECTION is the outline of the patient s shoulder flattened, and the normal roundness of his deltoid muscle lost as in Fig. 71-4? (dislocation, or a circumflex nerve injury causing wasting of his deltoid). Is his anterior axillary fold lowered, his deltopectoral groove swollen, or his elbow displaced away from his body? Does the axis of his humerus point towards the middle of his clavicle as in Fig. 71-4? (these are all signs of an anterior dislocation of the shoulder). Is his shoulder grossly swollen? (the neck of his humerus is probably fractured, perhaps with dislocation of its head. In a fracture dislocation swelling of the shoulder joint hides the flattening caused by the dislocation, so this injury is often missed). PALPATION Can you feel the head of the patient s humerus dislocated into an abnormal position? Feel high up into his axilla. You may be able to feel a thickened capsule, or an effusion. Are the tip of his acromion, the tip of his coracoid, and the greater tuberosity of his humerus in their normal places? MOVEMENTS OF THE SHOULDER Stand behind him. Put one hand round in front of him and hold the outer end of his clavicle firmly. With your other hand hold the tip of his scapula still. With his scapula held, you can now be sure that any movements he makes are those of his shoulder, not those of his scapula moving over his chest. If pain begins as soon as he starts to move his arm in any direction, there is something seriously wrong with his shoulder. Abduction How far can the patient abduct his shoulder? He should be able to abduct it to 90 before his scapula starts to move. If his scapula starts to move earner, abduction of his shoulder is limited. Adduction With his forearm flexed, and his scapula held, can he bring his elbow across to the midline in front? Rotation Can he externally rotate his flexed forearm, so that it reaches the coronal plane? Can he rotate it internally enough to scratch the small of his back? If any of the above active movements are limited, repeat them passively. Finally, ask him to lift his arm from his side, at first to 90 and then above his head. If he can do this, he has no serious shoulder injury. OTHER SIGNS IN THE SHOULDER Stand behind the patient and rest your hands on the point of each of his shoulders. Try to insert the tips of your fingers under the edge of each acromion, between it and the head of his humerus. You may be able to feel that the head of his humerus is dislocated on the injured side. 1

2 71 The shoulder and upper arm SUPPORTING AN INJURED ARM A This is the standard sling for an injured arm B shaft. On both sides, measure the distance from the tip of his acromion to his lateral epicondyle. Shortening indicates a fracture. This test is particularly useful if you suspect it is impacted. NERVES AND VESSELS in any injury of a patient s shoulder and upper arm, test his median, ulnar, radial and, axillary nerves (Fig. 55-6). If his clavicle is injured, check his subclavian vessels and listen to the breath sounds in his lungs. X RAYS Ask for the following views. Clavicle An X ray is usually unnecessary for the clavicle. (St. John s sling) Acromio clavicular joint Ask for an AP view of the injured shoulder. Dislocation may be difficult to see, so if you suspect it, ask for a distraction view in which the patient holds a weight. if a hand is injured, this sling will make it more comfortable C D for fractures of the humerus only E No! Shoulder Ask for an AP and a lateral view- if you suspect a posterior dislocation ask for an axillary view. This is difficult, because he may be holding his arm to his side, so you may have to take it yourself. Shaft of humerus Ask for an AP and a lateral view Casts, slings, and exercises for injuries of the upper limb Fig. 71.1: SLINGS FOR AN INJURED ARM. Most injured arms are best in sling A. If a hand is injured, the St John sling B, will raise it. Fractures of the humerus need sling C, in which the patient s elbow hangs free. Supracondylar fractures need the collar and cuff D. The narrow bandage sling E, is commonly used but is much less satisfactory. Put one hand on his shoulder, and grasp his elbow with your other one. Bring your hands together so as to compress his humerus. If this is painful it may be fractured. Grasp the top of his shoulder, so that your thumb lies over the head of his humerus, and your fingers over the spine of his scapula. Flex his forearm and use it to rotate his humerus. If you cannot feel the head moving under your thumb, or if there is crepitus, the neck of his humerus has fractured. If the fracture is impacted, this sign is absent. If, at the same time, the head is displaced, he has a fracture dislocation. The shoulder joint is hidden under muscles, so you cannot see if it is swollen, but you can see swelling of the subacromial bursa, especially if you look from behind and above, and compare both sides. Later chapters start with a description of the appropriate casts. These are seldom needed for injuries of the elbow and almost never for injuries of the shoulder and upper arm. The slings in Fig are important for ambulant patients with injured arms. An injured or infected arm which hangs down is painful a sling makes it much more comfortable and alows it to be exercised when necessary. Many hospitals supply plaster casts and sell or hire out crutches. They should do the same for slings. A loop of bandage (E, in Fig. 71-1) is not good enough. An important principle in all shoulder injuries is for the patient to start exercising his elbow and fingers as soon as he can. Even in a sling he can do some of the exercises in Fig FRACTURE OF THE CLAVICLE UPPER ARM EXAMINATION Palpate the lower half of the patient s humerus for the signs of a fracture. This is more difficult in its upper half, which is hidden by muscles. Support his forearm and gently abduct his arm. Pain, tenderness, angulation, or crepitus, indicate a fracture of the 2 Fig. 71.2: FRACTURE OF THE MIDDLE THIRD OF THE CLAVICLE. If an adult breaks the middle third of his clavicle, his sternomastoid muscle pulls the medial fragment up, while the weight of his arm pulls the lateral one down.

3 71.5 Dislocations of the sterno clavicular joint ACTIVE MOVEMENTS FOR INJURIES OF THE SHOULDER GIRDLE INDICATIONS (1) All fractures of the clavicle. (2) Most dislocations of the sterno clavicular and acromio clavicular joints. METHOD A sling will relieve the patient s pain. Make it with a triangular bandage, and rest his arm in it for 2 or 3 weeks, or until the fracture site is no longer tender. Start elbow and finger exercises immediately. Begin shoulder exercises in 2 or 3 days. If his clavicle is fractured, bracing his shoulders back will help him to hold it to length. Encourage him to move his arm as soon as he can. Don t leave a sling on too long. Remove it at a set time, some patients develop a sling neurosis and are unwilling to part with it. ELBOW AND FINGER EXERCISES MUST START IMMEDIATELY 71.3 Injuries of the brachial plexus If an injured patient has a totally paralysed insensitive arm, he has a brachial plexus injury in which he has injured all three cords of his brachial plexus. He can also injure them separately. These injuries can be the result of falling from a tree, or from a motor cycle, as in Fig If a patient is lucky, he merely stretches his nerve roots, if he is unlucky he pulls them away from his cord. In both types of injury he loses the power and feeling in his arm, but in a stretch injury, he can usually still move his rhomboid muscles, because the nerve which supplies them leaves the brachial plexus close to the cord. In an avulsion injury, this nerve is torn from his cord with the rest of his brachial plexus, so that his rhomboid muscles no longer function on the injured side. BRACHIAL PLEXUS INJURY Ask the patient to pull his shoulder blades together. If he can do this, the function of his rhomboids is intact. If his rhomboids are intact, support his arm in a sling, protect it from injuries, such as cuts, bruises, and burns, until its sensation returns. Make sure that one of his relatives exercises his shoulder, elbow, and hand for 6 months or longer, because his arm may continue to recover for at least a year. If his rhomboids are paralysed, he has probably torn the roots of his brachial plexus away from his cord, so that his injury is permanent. If he shows no signs of recovery at 6 months, consider amputating his upper arm through skin which has sensation. coraco clavicular ligament, the medial end of his clavicle is little displaced, because these ligaments hold it. If it breaks medially to the ligaments, its outer end may appear to be displaced backwards and upwards, so that it forms a lump under his skin. Without an X ray these fractures are difficult to distinguish from subluxation of the acromio clavicular joint. Treat all fractures of the clavicle with a sling and active movements, as in Section The clavicle almost always unites with no loss of function, and although the patient has a lump, this will disappear in a child and usually does so in an adult. If it is unslightly, it can be removed Dislocations of the sterno clavicular joint The clavicle can dislocate anteriorly or posteriorly. An anterior dislocation makes a patient s sterno clavicular joint swollen and tender. This distinguishes it from a fracture of the medial end of his clavicle, where tenderness is immediately lateral to the joint. Reduction is usually unnecessary, so encourage him to use his arm (71.1). It will be weak for some months, but movement will in time become full and painless. A posterior dislocation is rare and is usually combined with a chest injury, in which several of the patient s ribs may be broken at the same time. The dislocated end of his clavicle obstructs his superior mediastinum and causes severe pain, a tight feeling in his throat, difficult swallowing, and fullness of the veins of his neck. Try closed reduction first. Place a sandbag between his scapulae, and press his shoulders back. If this fails, refer him Dislocation of the acromio clavicular joint If only the ligaments between a patient s clavicle and his acromion are torn, those joining his clavicle to his coracoid can prevent severe displacement. His clavicle is stable and you cannot move it backwards or forwards. If you want to see whether the gap between his acromion and his clavicle is greater than normal, compare it with an X ray of the other side. DISLOCATION OF THE ACROMIOCLAVICULAR JOINT 71.4 Fractures of the clavicle A B The clavicle often breaks, especially in a child. He crys when he moves his arm, but there may be little to suggest that he has broken his clavicle. Feel carefully, and you will find an area of tenderness but no swelling. The fracture may be greenstick and difficult to see on an X ray. Sometimes there is a swelling without any history of injury. If an adult breaks the middle third of his clavicle, his sternomastoid muscle pulls the medial fragment up, while the weight of his arm pulls the lateral one down. Often there is a third middle fragment. If the fracture is lateral to his lateral end of his acromion rides free Fig. 71.3: DISLOCATION OF THE ACROMIO CLAVICULAR JOINT. A, shows the characteristic deformity of the shoulder. B, shows the method of strapping it. 3

4 71 The shoulder and upper arm If all the ligaments joining his clavicle to his scapula are torn, the weight of his arm pulls his shoulder downwards, while his sternomastoid muscle pulls his clavicle upwards, as in A, Fig The joint is so wildly unstable that the lateral end of his clavicle rides free, high above his acromion, and you can easily move it backwards and forwards. X ray him standing, and holding a 2 kg weight to distract his acromio clavicular joint, because the dislocation may reduce itself spontaneously when he is lying down. Treat a mild dislocation with a sling and active movements (71.2) until pain subsides. If a patient has a major dislocation, stick pads to his acromion and his elbow, and reduce his dislocation by binding them together with adhesive strapping; then put his arm in a sling, as in B, Fig Don t refer these injuries for surgical repair Fractures of the scapula The scapula can break in several ways. Direct blows occasionally break it into several pieces. Its coracoid process can fracture, either with no displacement, or with downward displacement. Its neck can fracture, so that its glenoid articulation breaks off and is displaced. This is the most common scapula injury, and provided it does not involve the joint surface, it needs only symptomatic treatment. The acromion may fracture with only a crack, or with severe communition and displacement. These fractures cause much pain and bleeding and are difficult to diagnose without sophisticated X rays. A patient s clavicle, his ribs, or his spine may be broken at the same time. The scapula is splinted on both sides by muscle, so treatment is easy. Give him a sling and encourage him to move his shoulder, elbow, and fingers actively and early Anterior dislocation of the shoulder Dislocation is the most common shoulder injury. It is usually anterior and only occasionally posterior. In an anterior ANTERIOR DISLOCATION OF THE SHOULDER two angles over the shoulder line of the upper arm straight line of the upper arm interrupted ANTERIOR DISLOCATION OF THE SHOULDER Fig. 71.5: THE X RAY APPEARANCES of an anterior dislocation of the shoulder. Always take an AP and an oblique view before you try to reduce what might seem to be an ordinary dislocation. If you take an oblique view routinely, you will not miss a rare posterior dislocation. A quarter of all acute dislocations are associated with a fracture, most commonly a fracture of the greater tuberosity. dislocation the head of a patient s humerus passes forwards and downwards to lie in front of his scapula. In the common subcoracoid variety, the normal outline of his shoulder is broken by the two sharp angles shown in Fig He is in great pain. This dislocation is often missed because nobody examines the patient for loss of movement, which is the critical sign. Typically, he holds his elbow fixed away from his side, and he cannot make it touch his chest. His injured arm looks longer than his normal one, his shoulder joint is fixed, his elbow is flexed, and his forearm is internally rotated. Although you can make his scapula move over his chest, you cannot make his humerus move on his scapula. If his shoulder is not too swollen, you may be able to feel the displaced head of his humerus below his coracoid process. The main differential diagnoses of an anterior dislocation are: (1) a fracture of the neck of the humerus, and (2) a fracture dislocation. Both are much less common than a simple dislocation. The treatment for these injuries differs. If you treat either of the latter two injuries as if it were a simple dislocation, the results can be disastrous, so always take an AP and an oblique view before you try to reduce what might seem to be an ordinary dislocation. If you take an oblique view routinely, you will not miss a rare posterior dislocation (71.9). An oblique view is more difficult to take than a true lateral view but is easier to interpret. Three signs will help you in the differential diagnosis: (1) Can you make the patient s elbow touch his side? (2) Will his humerus move on his scapula? If one or both these signs are present, he may have fractured the neck of his humerus, or he may have a fracture dislocation. (3) Much swelling also makes a simple dislocation unlikely. LACK OF SHOULDER MOVEMENT AND AN ABNORMAL CONTOUR ARE THE CRITICAL SIGNS OF A DISLOCATED SHOULDER Fig. 71.4: AN ANTERIOR DISLOCATION OF THE SHOULDER. Note the characteristic profile of the patient s shoulder. 4

5 71.8 Anterior dislocation of the shoulder for a while. When you return you may find the dislocation reduced. If it is not reduced, bend his elbow and move his arm in all directions. At the same time pull on his arm. His shoulder will usually go back into its socket with a sudden spontaneous click. TWO METHODS FOR A DISLOCATED SHOULDER A B THE HIPPOCRATIC METHOD FOR A RECENT ANTERIOR DISLOCATION Fig. 71.6: TWO METHODS FOR REDUCING A DISLOCATED SHOULDER. A, the arm swinging method, and B, the Hippocratic method. The editor is on the floor; the sock belongs to Peter Bewes! A, kindly contributed by Gerald Hankins. We have not described Kocher s method for reducing a dislocated shoulder. If you use it and are inexperienced, you may fracture the neck of a patient s humerus. ANTERIOR SHOULDER DISLOCATION Reduce the patient s dislocation immediately. If his injury is recent, reduction is usually easy. INDICATIONS Anterior dislocations less than 3 weeks old. If the dislocation is older than this, see below. Have you X rayed him to make sure your diagnosis is correct? Check his axillary nerve (Fig. 55-6), and his radial pulse. ANAESTHESIA If the patient s injury is recent, he may not need an anaesthetic. Good relaxation is required if it is more than a few hours oid, or if he is very muscular. (1) General anaesthesia with a muscle relaxant. (2) Ketamine and diazepam (A 8.2).(3) intravenous pethidine with diazepam (A 8.8). THE ARM SWINGING METHOD FOR A RECENT ANTERIOR DISLOCATION Try this first, especially if the patient s dislocation is very recent, using pethidine, preferably with diazepam. Lie him on a table, face downwards, with his arm over its edge. Ask him to relax his arm as much as he can. If the table is high enough, tie a 2 kg weight to his wrist. Dead weight traction of this kind is often more successful than manual traction, because it is easier for him to relax. Leave him alone METHOD Lie the patient on the floor. If he has dislocated his right shoulder, remove your shoe and put your right foot in his axilla, lean backwards, and pull on his abducted arm. If you are agile, you can also use this method while he is on a table, by raising your foot and placing it in his axilla. Pull gently and steadily for 5 minutes. CAUTION! Don t exert excessive force. You may injure his brachial plexus. If this does not reduce the dislocation, ask an assistant to exert traction as above. While he does so, press the head of the patient s humerus backwards with both your thumbs in the direction of its socket. Or, grasp his arm with both hands and pull laterally. If you fail and are not using general anaesthesia, try again using it and a relaxant. POSTOPERATIVE CARE (both methods) As soon as the patient is awake ask him to abduct his arm gently. Check that you have not injured his axillary or musculocutaneous nerves during reduction. Examine him to make sure that you have reduced his dislocation, and check with an X ray. Put his arm in a sling for 3 weeks, and start pendulum exercises in the sling immediately. Then start most of the other early exercises in Fig Avoid abduction and external rotation exercises, because they are dangerous and may redislocate his shoulder. DIFFICULTIES WITH DISLOCATED SHOULDERS If you suspect that a patient has a dislocation but you have NO X RAYS, anaesthetize him and move his shoulder gently. A dislocation may reduce spontaneously, and you are unlikely to harm him. If PART OF HIS GREATER TUBEROSITY HAS BROKEN OFF, it will probably return to its bed as you reduce his dislocation. If it does so, well and good. But if it fails to do so, and prevents him abducting his arm, try the methods in Section A quarter of all acute dislocations are associated with a fracture, most commonly a fracture of the greater tuberosity. You can easily see this in routine X ray views of a patient s shoulder. The external rotator muscles of his shoulder pull a piece of bone away from the head of his humerus as his shoulder dislocates. If you FAIL TO REDUCE HIS DISLOCATION under diazepam or ketamine, try general anaesthesia with a relaxant. This usually succeeds. If it fails don t try again using more force. Instead, refer him for open reduction. If his DISLOCATION RECURS after 6 weeks, it will probably continue to do so, so refer him for an operative reoair. A dislocated shoulder is usually stable after you have reduced it. But, if it dislocated after only a very minor injury, it probably did so because the labrum separated from the glenoid ring. Adult cartilage does not usually unite with bone, so his 5

6 71 The shoulder and upper arm SHOULDER EXERCISES 2 Wall crawling Swinging 3 arms to the side 1 Arm dangling 6 Swinging one arm also called pendulum exercise Backs of 5 hands to the wall 4 Swinging arms in front 8 7 Flat on the back and touch the floor Swinging both arms CLAP! 9 Touching the back of your neck and the small of the back Fig. 71.7: SHOULDER EXERCISES are in two groups. EARLY EXERCISES should be done smoothly and rhythmically with gradually increasing amplitude. Here are the instructions to a patient. (1) Stoop forwards and circle your arm ( arm dangling ). (2) Put your arm against a wall. With your arm straight, move steadily closer to it ( wall crawling ). (3) Stand astride with your arms crossed and swing them sideways and upwards. (4) Stand astride and swing your arms forwards and upwards. (5) Lean against a wall with your arms bent, turn your arms to touch the backs of your hands against the wall. LATE EXERCISES should be done more vigorously. (6) Put one leg in front of the other, put your hand on your knee, and swing your arm. (7) Stand astride with your arms crossed, swing your arms sideways and upwards, and clap them above your head. (8) Lie on your back with your arm stretched and press downwards to touch the floor. (9) Stand astride; alternately touch the back of your neck and fold your hands behind your back. Kindly contributed by Michael Wood. shoulder may continue to dislocate with increasing ease. Finally, it may dislocate even when he sneezes or turns over in bed. If the HEAD OF HIS HUMERUS DROPS OUT OF HIS GLENOID because his axillary nerve has been paralysed, support his arm in a sling for several months until his nerve recovers. Tighten the sling regularly so as to keep the contour of his shoulder normal, and show his spouse how to do the same. This is not the same condition as recurrent dislocation of the shoulder. Suspect it when a patient is anaesthesic over his deltoid, and is totally unable to abduct his arm. If his SHOULDER REMAINS STIFF after a dislocation, explain that movements will eventually return. Active exer6 cises are safer and more effective than passive ones. Avoid excessive force, because this will only make the stiffness worse. His shoulder is more likely to become stiff if he fails to move it early. If a patient s BRACHIAL PLEXUS IS INJURED, it will probably recover in a year. Meanwhile, put his shoulder through a safe range of movements to prevent contractures. Some nerve injury is common after a dislocation, and may involve any of the three cords of his brachial plexus. His axillary and musculocutaneous nerves are commonly involved. Sometimes his whole brachial plexus is torn from his spinal cord, paralysis is permanent, and his useless aneasthetic arm has to be amputated (71.3). If his AXILLA RAPIDLY SWELLS after a shoulder injury, his axillary artery has been torn- This is a very rare disaster in an old patient with hard arteries, and may follow a fracture dislocation. It is more likely to occur if you are trying to reduce a fracture dislocation, particularly an oid one, or if you use greater force than the original injury. The patient s torn artery bleeds and forms a large arterial haematoma (55.5) round his shoulder. Suspect this disaster if a rapidly increasing swelling in a patient s axilla follows a shoulder injury. If you don t diagnose a torn axillary artery, and it is not repaired (55.6), he may bleed to death. Tying it is a desperate operation, but you will not have time to refer him. Firm axillary pressure may stop the bleeding, so try it. If this fails, you may have to clamp or tie his subclavian artery (3.4). If the CIRCULATION IN HIS ARM IS POOR before his dislocation is reduced, reduce it gently. If this does not restore his circulation, his axillary vessels should be explored and his axillary artery repaired, if necessary. So, refer this rare complication quickly. If a patient with a DISLOCATED SHOULDER PRESENTS LATE (more than 3 weeks after the dislocation), refer him. A difficult open operation may be justified, especially if pressure on the structures in his axilla causes symptoms, but the results may be poor. If you cannot refer him, movement between his scapula and his chest may give him a useful range of painless movement. Ask him to do active exercises, so that he can preserve as much movement as possible in his other joints. Reduction becomes increasingly difficult and dangerous as time passes. Initially, every hour is important, and after 6 weeks reduction may be impossible. Using force may break the neck of a patient s humerus, or tear his axillary vessels or nerves. A PATIENT WHO CANNOT MOVE HIS SHOULDER AFTER AN INJURY HAS A DISLOCATION UNTIL PROVED OTHERWISE REDUCE ALL DISLOCATIONS IMMEDIATELY 71.9 Posterior dislocation of the shoulder (rare) If a patient has pain, swelling, and reduced movement after a shoulder injury, together with an apparently normal AP X ray, suspect that he has a posterior dislocation. Typically, he cannot move his arm, which is locked in adduction and internal rotation. The outline of his shoulder is abnormal,

7 71.10 Fracture of the greater tuberosity AN ALTERNATIVE METHOD FOR A POSTERIOR DISLOCATION POSTERIOR DISLOCATION 2 A B 1 abnormally flask shaped humerus AP view 3 Axillary view Fig. 71.8: POSTERIOR DISLOCATIONS OF THE SHOULDER are often missed because the AP view looks almost normal. The closeness of the head to the film does however make it look abnormally small. The head also looks flask shaped. You will not miss a posterior dislocation if you always take an oblique or a lateral view whenever you X ray an injured shoulder. An axillary view (ifyou can move the patient s arm far enough from his side to get the tube into his axilla) shows the dislocation best. but not as abnormal as in an anterior dislocation. His corticoid process is prominent, and in late cases he has a characteristic dimple on the front of his shoulder. Looked at from above, his shoulder bulges posteriorl. Also, you may be able to feel the head of his humerus posteriorly under the spine of his scapula. His shoulder movements are poor and his humerus feels as if it is fixed to his scapula. You will probably be able to reduce his dislocation without too much difficulty. POSTERIOR DISLOCATION OF THE SHOULDER Give the patient a general anaesthetic. Try to put his shoulder through a normal range of movements, while pulling upwards on his humerus, with his arm above his head, and his elbow flexed to relax his biceps tendon. The dislocation will usually reduce promptly. If this fails, try the alternative method in Fig If this also fails, refer him. If reduction is successful, put his arm in a sling for 3 weeks and encourage him to move it as soon as he can. DIFFICULTIES WITH A POSTERIOR DISLOCATION OF THE SHOULDER If the patient s DISLOCATION is OLD, reduction may be possible, so refer him. If this is impractical, ignore the dislocation, and concentrate on active movements and exercises. Occasionally, an arthrodesis is necessary for severe and persistent pain. Posterior dislocations are often overlooked in early stages, so they are often diagnosed too late. POSTERIOR DISLOCATIONS OF THE SHOULDER ARE OFTEN MISSED C D 4 5 Fig. 71.9: AN ALTERNATIVE METHOD FOR REDUCING A POSTERIOR DISLOCATION. Flex the patient s elbow, and exert traction in the long axis of his arm (1). Ask an assistant to press downwards on the head of his humerus with his thumb (2). Adduct his arm while still maintaining traction (3). When the head reaches the glenoid cavity, rotate his arm externally (4), then gently rotate it internally (5). His axillary nerve may be injured, so support his arm in a sling to prevent his humerus dropping out of his glenoid. After de Palma, with kind permission Fracture of the greater tuberosity The greater tuberosity of a patient s humerus can be fractured by a direct blow, or it can be torn off when he dislocates it. Treatment depends on how far displaced the fragment is. FRACTURES OF THE GREATER TUBEROSITY MINIMAL DISPLACEMENT Begin active shoulder, elbow, and finger movements immediately. If necessary give the patient a sling for a few days. MORE THAN MINIMAL DISPLACEMENT Try the following methods in this order, until you find one which works. First try abducting the patient s arm. This will cause the fragment to press against the under side of his acromion and may push it into place. If this fails try the method in Fig If reduction is successful, put his arm in a sling and encourage active movements. If reduction fails, repeat it again 2 weeks later, when the fragment will have become sticky if this too fails, and ab7

8 71 The shoulder and upper arm FRACTURE OF THE GREATER TUBEROSITY FRACTURES OF THE NECK OF THE HUMERUS tuberosity detached 1 2 tuberosity replaced 3 Child, with no displacement Adult with severe displacement Fig : FRACTURES OF THE NECK OF THE HUMERUS. A, is an incomplete fracture in a child. B, shows considerable displacement of the shaft. There is such a wide range of movement in the shoulder joint that the exact position of the fragments is unimportant. swollen, tender shoulder, so the diagnosis is often missed. Soon, she has severe bruising extending to her elbow. If the head of her humerus is impacted on the shaft, the fracture is more likely to heal with reasonable function. These fractures are less common in young adults, but when they do occur, they usually heal well. Fig : FRACTURE OF THE GREATER TUBEROSITY. Infiltrate the fracture site with local anaesthetic. Abduct the patient s arm (1), and press firmly on the fragment with your thumb (2), continue to press on the fragment while you lower his arm (3), so that it stays in place while you do so. After de Palma, with kind permission. duction is severely limited, refer him for operative treatment. Meanwhile encourage active movements, as above Fractures of the neck of the humerus The surgical neck of the humerus is the region between the tuberosities, and the insertions of the pectoralis and teres major. When it breaks the soft tissues hold the fragments together very satisfactorily, and provided there is some contact between them, they always unite. There is such a wide range of movement in the shoulder joint that the exact position of the fragments is unimportant. Even if the joint surfaces do not fit together perfectly, good function is still possible, but only if the patient starts to move his shoulder early. Most of these fractures need not be reduced. The only ones which you should reduce are those in which there is no contact between the broken surface of the neck and the shaft. Fractures of the surgical neck are common in children, and are not common again until middle age. FRACTURES OF THE NECK OF HUMERUS IN AN ADULT Check the patient s axillary nerve (55.8) and his radial pulse. X RAYS Take two X rays at right angles. The fragments may be widely separated, but overlie one another in a single view. Is the fracture impacted? If you can move the patient s arm through a reasonable range without causing severe pain, it is impacted. REDUCING A FRACTURE OF THE NECK OF THE HUMERUS Fractures of the neck of the humerus in adults The patient, who is typically an older woman, falls on her outstretched arm and injures her shoulder. Her osteoporotic humerus breaks across its neck. Sometimes, its head is comminuted. In spite of her pain, she may be able to use her 8 Fig : REDUCING A FRACTURE OF THE NECK OF THE HUMERUS with wide separation or severe angulation. After de Palma, with kind permission.

9 71.13 Fractures of the neck of the humerus in children IMPACTED FRACTURES OF THE HUMERAL NECK IN AN ADULT Fractures of the neck of the humerus in children Begin active and assisted shoulder movements immediately. Between these exercises, put the patient s arm in a sling for 4 to 6 weeks. Make sure that it supports his elbow, and so prevents disimpaction. He must not lift heavy objects for 3 months. Some children with a fracture of the neck of the humerus are in great pain and are quite unable to move their arms; others have little pain and a surprising range of shoulder movement. If a child is in pain, don t try to examine his shoulder X ray it. Take two views to determine the position of the fragments. In young children the fracture is transverse and is about 2 cm below the epiphyseal line. When the fracture is complete, the shaft rides up in front of the upper fragment, and overlaps it. In an older child the fracture line passes through the epiphyseal line, so that the epiphysis separates. Sometimes, the fragments bow outwards, but do not separate, or they may separate so that the end of the shaft lies under the skin. UNIMPACTED FRACTURES OF THE HUMERAL NECK IN AN ADULT Treatment depends on how widely separated the fragments are. THERE IS NO SEPARATION AND ONLY MILD ANGULATION (1) The broken surfaces of the fragments are in contact. And, (2) angulation between the head and the neck is less than 90. Shoulder exercises are too painful to begin immediately. So put the patient s arm in a sling and give him an analgesic. If pain is unbearable, bandage it to his chest. Begin elbow, wrist, and finger movements. Wait for 3 weeks before starting active shoulder exercises. THERE IS WIDE SEPARATION OR SEVERE ANGULATION (1) There is no contact between the broken surfaces of the fragments. Or, (2) there is angular deformity of more than 90. Get good muscle relaxation with a general anaesthetic. Flex the patient s elbow and pull on the humerus as in Fig (1). While still pulling, adduct his elbow across his chest and flex it in the frontal plane of his body. (2) The combination of these movements will restore the length of his humerus. Place your other hand in his axilla. Press on the head with your thumb (3), and pull the shaft outwards (4). After the fragments are aligned, release traction gradually, so that the fragments engage (5). If the fracture is stable after reduction, put his arm in a collar and cuff. Keep it to his side for 3 weeks, then gradually begin progressive movements as pain lessens, starting with pendulum exercises and continuing with wall crawling exercises (Fig. 71-7). If the fracture is unstable after reduction, put him in forearm traction as in Fig for 2 weeks, then give him a sling and arm dangling excercises. IF THERE is SO MUCH SEPARATION THAT THE SHAFT OF THE PATIENT S HUMERUS IS IN HIS AXILLA, laceration of his axillary artery is the danger, so check his pulse at his wrist before you try to reduce his fracture. If his pulse is obliterated, bind his arm to his side and refer him. If you cannot refer him, take him to the theatre, and be prepared to tie his subclavian artery above his clavicle (3.4). As you do the reduction, you may pull a spicule of bone out of his axillary artery and cause massive bleeding. CONSCIENTIOUS EXERCISES WILL OFTEN RESTORE MOVEMENTS TO A STIFF SHOULDER FRACTURES OF THE NECK OF THE HUMERUS IN CHILDREN Check the child s radial pulse and his axillary nerve (55.8). Treat incomplete and complete fractures in the same way. If the fragments are not widely separated, put his arm in a sling and encourage him to move it. If the fragments are widely separated, try to get them to hitch, as described above for widely separated unimpacted fractures in adults (71.12). If you fail to get the fragments to hitch, put him in traction for 2 weeks, as in Fig DIFFICULTIES WITH FRACTURES OF THE NECK OF THE HUMERUS IN CHILDREN If the SHARP END OF THE DISTAL FRAGMENT HAS POKED THROUGH THE CHILD S SHOULDER MUSCLES, and you can feel it under his skin, anaesthetize him and manipulate the broken end of his humerus back through his muscles. Use a combination of pulling and twisting movements, and get it to hitch with the proximal fragment. Sometimes the distal fragment goes right through the skin. If you CANNOT MAINTAIN REDUCTION with his arm in a sling, apply skin traction, using overhead suspension (Fig ), a pulley, and enough weight to keep his arm raised 2 kg will probably be about right. Don t tie his arm REDUCING A FRACTURE DISLOCATION A B Fig : REDUCING A FRACTURE DISLOCATION OF THE NECK OF THE HUMERUS. A, before reduction. B, during reduction. The arrows show where to push with your thumbs to return the head of the patient s humerus back into his glenoid. 9

10 71 The shoulder and upper arm to a pole, because if he sits up, reduction is lost. Continue traction for 2 weeks until the fragments are sticky. Then put his arm in a sling and start pendulum exercises (Fig. 7-7). FRACTURES OF THE SHAFT OF THE HUMERUS Dislocation of the shoulder with fracture of the neck of the humerus This is a serious injury, usually of older people. The neck of the patient s humerus breaks, either at the time of the accident, or while a simple dislocation is being reduced with excessive force. The head of his humerus lies in front of his glenoid, or it may be displaced into his axilla. His axillary vessels and his brachial plexus are sometimes injured at the same time. FRACTURE DISLOCATION OF THE HEAD OE THE HUMERUS If possible refer the patient, particularly if he is a child, because the results of operating are better in children. If this is not possible, give the patient a general anaesthetic and proceed as follows. Good relaxation is essential. REDUCTION Try the following methods in turn, until you find one which works. (1) Try the arm swinging method for a dislocated shoulder (71.8). Combine this with gently trying to push the head back into place with your thumbs. (2) Try the Hippocratic method with a foot in the patient s axilla (71.8). (3) Ask an assistant to pull the patient s arm into abduction, as in Fig As he does so, use both your thumbs to press the head of his humerus towards its socket. If possible, X ray his shoulder to check reduction while he is still anaesthetized. If you can reduce the head, treat him as if he had an uncomplicated fracture of the neck of his humerus (71.12). If you cannot reduce the head the first time, try only once more. If you fail again, and cannot refer him, accept the position and start pendulum exercises immediately (Fig ). Later, attempt wall crawling exercises (Fig. 71-7). Function will not be perfect, and he will not be able to raise his arm above his head, but he will be able to use it at waist level without pain Displacement of the upper humeral epiphysis In children between 5 and 15 years the head of the humerus sometimes becomes detached from the shaft, and may take a piece of the shaft with it. The head of the humerus is very mobile, so reduction can be difficult. Perfect reduction is not necessary because the head readily remodels. Anaesthetize the child, reduce the displacement by abducting his arm. Maintain traction in bed for 2 weeks as in Fig Then protect it in a sling for another week. IF AN ADULT INJURES HIS SHOULDER, EXERCISE HIS ELBOW AND FINGERS FROM THE BEGINNING 10 transverse oblique segmented comminuted Fig : FRACTURES OF THE SHAFT OF THE HUMERUS. Put the patient s arm into a narrow sling, so that half the weight of his forearm acts on the lower fragment to reduce the overlap and the angulation. All these fractures can be treated in the same way Fractures of the shaft of the humerus Babies A baby s humerus is often fractured during a difficult delivery, or in a non accidental injury. It heals rapidly with massive callus formation and needs no treatment. Bind his arm loosely to his chest wall for a week to prevent further injury. At the end of a year there will be no trace of the fracture. Adults Fractures of the shaft of the humerus are not common again until adult life. They are of many kinds, but you can treat them all in the same way. If you do this properly, they cause no problems. Union is the first priority, then elbow movement. Moderate angulation is no disability. Put the patient s arm in a narrow sling, as in C, and E, Fig , so that half the weight of his forearm acts on the lower fragment to reduce overlap and angulation. Put his arm across his chest to correct rotation. The muscles attached to his humerus will hold the fragments in place. Overlap and shortening are unimportant. In young children they are even desirable. There are no indications for internal fixation unless the patient also has other injuries, or must be back at work quickly. Some surgeons (including ourselves) treat these fractures without a splint, and argue that a little movement is a good thing in fractures of the shaft of the humerus because it promotes union; others splint them to reduce pain, and protect the patient s arm in case he should fall. The ideal splint is a stiff, light cuff with Velcro fastenings, which will allow active shoulder and elbow movement. Failing this, you can apply a light U slab, or you can use strips of bamboo as described below. If you use a plaster splint, it must be a light one, or its weight will distract the fragments and cause non

11 71.16 Fractures of the shaft of the humerus union. The traditional splint in Fig is admirable. FRACTURES OF THE SHAFT OF THE HUMERUS INDICATIONS if the patient is ambulant, use this method for all fractures of the mid shaft of the humerus, whether they are spiral, oblique, transverse, or comminuted. CONTRAINDICATIONS if the patient is unable to sit or stand because of other injuries, treat him in traction as described later. X RAYS are not essential, unless there are signs which suggest that the patient s shoulder may be dislocated also, or unless the fracture is so low in the shaft as to be supracondylar (72-11). FRACTURES OF THE SHAFT OF THE HUMERUS B E No! He is exercising his shoulder D late non union As it should be This heavy cast pressing on his forearm cause non union F C He is exercising his elbow No! A non union! sore No! Fig : TREATING A FRACTURE OF THE SHAFT OF THE HUMERUS. A, how it should not be done. This heavy cast will press on the patient s forearm and distract the bone ends. B, a properly treated patient exercising his shoulder. C, the same patient exercising his elbow. D, non union after a fracture 30 years before. This patient had suprisingly little disability. E, success. F, failure. Kindly contributed by Peter Bewes. TREATMENT FOR FRACTURES OF THE SHAFT OF THE HUMERUS Before starting, check the patient s peripheral pulses, and test the function of his radial nerve and record it (Fig. 75-3). Can he dorsiflex his wrist or extend his fingers? If his radial nerve is injured and fails to recover, he will not be able to blame your treatment. If the fracture is grossly angulated, reduce it under anaesthesia. Manipulate him carefully. His radial nerve is close to the fracture site. You can use local anaesthesia of the fracture haematoma, provided you do it in a sterile manner (A 5.6). Alternatively, wait for the bone ends to become sticky in about 10 to 20 days and then manipulate them. Make the patient a sling 10 cm wide which supports only the distal part of his forearm. It must not include his elbow which must be at 90. Make it by folding a triangular bandage several times, as in Fig CAUTION! The width of the sling is critical. Use a narrow wrist sling which supports only the distal half of the patient s forearm. Don t use: (1) an elbow sling which raises and supports his elbow, or (2) a collar and cuff, or (3) a bootlace or piece of bandage. If his elbow is supported in a full sling, the weight of his forearm cannot reduce the overlap. A collar and cuff will draw the lower fragment forwards and angulate the fracture. A bootlace or a single turn of bandage will be acutely uncomfortable. If you decide to splint the patient s arm: (1) ideally use a plastic splint with Velcro fastenings. Or, (2) pad his arm well with cotton wool, place some strips of bamboo (ideally sewn between two pieces of cloth) along it, and cover these with a crepe bandage. Or, (3) apply a light U slab. CAUTION! If you decide to put a U slab on his arm (and you will usually be wise not to), it must be as thin and light as possible. Apply it during the first few days only. It is unnecessary later, and may distract fragments undesirably. Tell the patient that he may hear and feel crepitus for the first week or two, but that this is a good sign. He may think he needs a splint. Reassure him that he does not. If he is to avoid a stiff shoulder, he MUST exercise it. If he has a transverse fracture, the only safe exercises are the rhythmical pendulum exercises shown in A, Fig and B, Fig Show him how to bend forwards, and to move his arm in all directions from his shoulder. Tell him to use his hand actively, and to flex and extend the muscles of his elbow a little inside the sling, as in C, Fig He must not take off his sling until there is clinical union, or the bone may angulate at the fracture site, and break again. Passive movements are unnecessary and potentially dangerous. Supervise these exercises carefully, or the fracture may not unite. If he is 100% on your side and smiling (patient E), you have won. If he looks like patient F, expect failure. CAUTION! (1) Exercises must start within a day or two of the injury, or the fracture will be slow to unite. (2) If he has a transverse fracture, warn him that he must not abduct his arm at the shoulder or let his forearm hang by his side until his fracture is solidly united. He should wait for you to tell him that it is safe for him to do this. Extending his arm when his elbow is stiff will cause forward bowing and may fracture the callus, or cause delayed union or malunion. If you wish to correct the position, do it at about 15 days when the bone ends are sticky. This is seldom necessary, because almost any position is acceptable. 11

12 71 The shoulder and upper arm Good callus usually forms in 4 weeks. Wait for signs of consolidation (Fig. 69-4). These are: (1) No tenderness over the fracture site. (2) Attempts to angulate the bone at the fracture site fail, and do not cause pain. When, and only when, there are definite signs of clinical union, cautiously remove the sling for longer periods each day, until the patient has good elbow movements. Consolidation usually takes 2 months in spiral fractures and 3 months in transverse ones; it normally takes twice as long as clinical union. So, if consolidation takes 6 weeks, the patient should continue to wear his sling for 12 weeks. If there is any danger of his humerus refracturing, as in a crowded bus, he must wear his sling, but he can take it off at other times. CAUTION! (1) A hanging cast, as in A, Fig is the most common cause of non union. (2) Forced movements of his elbow may refracture his humerus. So, be careful! DIFFICULTIES WITH FRACTURES OF THE SHAFT OF THE HUMERUS If the patient s ARM IS PULSELESS AND COLD, reduce it and apply gentle traction. If this does not restore his circulation immediate exploration of his artery is indicated (55.3). Meanwhile keep his arm cold. If its circulation is not restored, his arm may need amputating. If his SHOULDER OR ELBOW IS STIFF, he may complain about it long after his arm has healed. But, provided it has not been injured, his shoulder should not become stiff, if he does his dangling exercises properly. A stiff shoulder is a serious disability. Loss of movement is less serious in the elbow, because people commonly use only a limited range of elbow movements. If UNION IS DELAYED, or fails, assist it by encouraging him to contract his arm muscles vigorously, so that he can hear the bone ends grating! Unless there is vigorous muscular action, little callus will be formed, and union will be poor. Be patient if it is slow. Keep his arm in a sling and make him use the flexors and extensors of his elbow. These cross the fracture site and their action will encourage union. Delayed union or non union can be the result of: (1) Removing the sling too early, so causing posterior angulation of the fracture. (2) Using a sling which supports the elbow. (3) Other injures which confine the patient to bed, (4) Applying a heavy cast which distracts the fragments. (The more plaster you apply to these fractures, the less likely they are to unite.) (5) Unskilled internal fixation, as in Fig (6) Traction. (7) Soft tissue between the bone ends. When non union has occurred, if the patient is painfree, encourage him to accept the disability, as in D, Fig and continue his daily activities- if he cannot accept his pain and disability, consider referring him for internal fixation and a bone graft. This may fail, even in the best hands. If he CANNOT DORSIFLEX HIS WRIST after a fracture of his humerus, he has injured his radial nerve. He can do this in various ways: (1) it can be bruised or stretched at the time of the injury and slowly recover. (2) it can be torn at the time of the injury and not recover. Or, (3) a radial nerve paralysis can develop during treatment, as the result of fibrosis and constriction of the radial nerve tunnel. Whatever the cause, he will probably recover. Refer him for exploration of his radial nerve if: (1) it shows no signs of recovery in 6 months, or (2) the paralysis develops some weeks after the injury. Meanwhile, use a cock up splint to support his wrist in dorsiflexion and prevent a contracture, as in Fig Sometimes passive exercises are enough. Ask him to extend his fingers several times a day with his other hand. If he has FRACTURED THE SHAFT OF HIS HUMERUS AND DISLOCATED ITS HEAD, the dislocation will be almost impossible to reduce, because traction on his arm will not move the head of his humerus. So refer him rapidly for open reduction and internal fixation. If he has fractured the shaft of his humerus and has OTHER injuries WHICH PREVENT HIM SITTING OR STANDING, you can treat his fracture in a sling as usual, if he can sit. If his other injuries prevent this, you will have to use traction instead. Either apply skin traction, as in Fig , or drill a Kirschner wire through the thick part of his olecranon, and hold it in a Gissane stirrup, as in Fig Pass a cord from the stirrup over the foot of his bed. Use skin traction to suspend his forearm with his elbow flexed at 90 and his humerus slightly abducted. CAUTION! Start with 2 kg in an adult, and check reduction with X rays once or twice during the first week. Adjust the weight so as not to distract the fragments. As soon as he can sit up, change to the sling method of treatment. Alternatively, make a light plaster gaiter (Fig. 81-6) round TRACTION FOR FRACTURES OF THE SHAFT OF THE HUMERUS 90 the adhesive strapping must start below the fracture Fig : TRACTION FOR FRACTURES OF THE SHAFT OF THE HUMERUS when a patient is confined to bed. Use skin traction to suspend his forearm with his elbow flexed to 90 and his humerus slightly abducted. Kindly contributed by John Stewart. 12

13 71.17 Fractures of the humerus, radius, and ulna the shaft of his humerus, and encourage early active movements. DON T LET THE PATIENT TAKE HIS ARM OUT OF HIS SLING TOO SOON! HEAVY CASTS ENCOURAGE NON UNION Fractures of the humerus, radius, and ulna If a patient has broken his humerus, his radius, and his ulna, concentrate on his radius and ulna; his humerus will probably heal itself. Management depends on the type of humerus fracture he has. If his humerus fracture is transverse, a long arm cast will probably cause serious distraction. So refer him for open reduction and internal fixation. If referral is impossible, there are four things you can do: (1) You can risk applying a forearm cast, and support it well in the hope that it will not distract his humerus. (2) You can put a thin (not more than 4 mm) Steinmann pin through his olecranon (Fig ), and a Kirschner wire through his metacarpals (70.11). When you have done this, you can suspend his arm vertically with his forearm horizontal, supported by a stirrup. (3) You can apply traction, as in Fig , but using metacarpal traction instead of skin traction. (4) You can splint his forearm fracture in a light cast in a position of function. Splint his humerus fracture with a light slab on its lateral side, held in place with a crepe bandage. Finally, support his arm in a sling as in A, Fig MULTIPLE ARM FRACTURES If a patient s humerus fracture is spiral, distraction is less of a problem and it will probably unite, so reduce his forearm fracture and apply a thin long arm cast with his elbow at 90 and his forearm in mid pronation, so that if rotation is reduced subsequently, his hand will be in the best position. Support the cast in a sling so that its weight does not distract his humerus fracture. 13