Shoulder Trauma

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Shoulder Trauma
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Normal anatomy

• Standard AP shoulder series demonstrates most of
  the essential anatomy
• Internal rotation, external rotation, abduction
  (baby arm)
• Specialized views
• may be required
• to reduce overlap
• of certain
• structures
• http//eorif.com/Shoulderarm/XrayShoulder.html

http//www.ski-injury.com/specific-injuries/should
er
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Clavicle Fractures

• 15 of all fractures most common fracture during
  birth
• Usually direct trauma
• Males 2/3 of all clavicle fractures
• More common in children and adolescents
  incidence decreases with age

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Clavicle fractures by location

• Medial 1/3- least common (5)
• Middle 1/3- most common (75)
• If fracture is complete, medial fragment will be
  elevated by action of SCM and lateral fragment
  will be depressed
• by the weight of the upper
• extremity
• Distal 1/3- (20)
• Fracture may extend and
• become intra-articular

http//eorif.com/Shoulderarm/Clavicle20medial.htm
l
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Clavicle fracture complications

• Child and adolescent heal without complication
  95 of the time
• Increased chance of complications in adults
• Complications include
• Neurovascular damage
• Non-union
• Mal-union
• Degenerative arthritis
• Post-traumatic osteolysis

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Neurovascular damage

• Most commonly subclavian artery less commonly
  subclavian vein occasionally brachial plexus and
  sympathetic chain

http//bestpractice.bmj.com/best-practice/monograp
h/592/basics/aetiology.html
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Non-union

• 5 of cases
• Lack of callous formation by 6 weeks post-injury
  signifies non-union
• Radiographic signs
• Fracture margins become sclerotic and rounded
  with smooth
• contours over time
• May require surgery

http//www.gentili.net/fracture.asp?ID16
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Malunion

• If bones overlap and massive callus develops,
  cosmetic deformity and functional impairment
  results
• May require surgery

http//www.sciencedirect.com/science/article/pii/S
1058274604002678
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Degenerative Arthritis

• Painful arthritis follows untreated
  intra-articular fractures
• Radiographic signs are the usual findings in OA

http//www.drmaffet.com/shoulder-surgery-houston/a
c-joint-arthosis-2/
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Post-traumatic Osteolysis

• Bone resorption of distal clavicle
• First becomes radiographically visible 2- 3
  months after the injury
• Distal cortex becomes
• hard to define and may
• become tapered over time
• Injury may be trivial, not
• necessarily fracture or
• dislocation
• Common in weightlifters

http//radiopaedia.org/images/631648
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Scapular fractures

• 80 have other fractures due to severity of
  trauma required to fracture scapula
• May be seen on other shoulder views, but special
  projections may be required
• 80 involve body and neck
• Coracoid or acromion
• less often
• Glenoid fractures occur
• with humeral dislocations
• (Bankhart and reverse
• Bankhart lesions)

http//www.feinberg.northwestern.edu/emergencymed/
residency/ortho-teaching/shoulder/case42/case42an
swer.html
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Humerus Fractures

• Classified by anatomic location
• Anatomic neck, greater tuberosity, lesser
  tuberosity, surgical neck, proximal shaft
• Complications
• Non-union, malunion, DJD,
• AVN of humeral head, myositis
• ossificans, neurovascular
• damage

http//www.shoulderdoc.co.uk/article.asp?article7
35
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Anatomic Neck Fractures

• Isolated neck fractures are
• rare
• Usually associated fractures
• High incidence of AVN
• Hill-Sachs and reverse
• Hill-Sachs lesions
• Impaction fractures of
• humeral head when it
• bangs against glenoid
• during dislocation

http//web.me.com/radrep/Radiographers_Reporting/T
he_Shoulder..html
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Greater Tuberosity Fracture

• AKA Flap fracture
• May occur by direct trauma or avulsion
• Frequently fractured
• during anterior humeral
• dislocation
• Best seen on external
• rotation view

http//en.wikipedia.org/wiki/FileGreatertrochaner
AP.png
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Lesser Tuberosity Fracture

• Can't be directly impacted, but may be associated
  with other fractures

http//www.internationalshoulderjournal.org/viewim
age. asp?imgIntJShoulderSurg_2011_5_2_50_83198_u3
.jpg
http//www.medscape.com/viewarticle/420763
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Surgical Neck Fracture

• Immediately distal to tuberosities
• Most common of proximal humeral fractures
• Axial artery and nerve prone to injury at this
  location

http//www.wheelessonline.com/ortho/proximal_humer
al_fracture
http//www2.aofoundation.org
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Proximal Shaft Fracture

• Mechanism is usually direct trauma
• Fracture location in relation to muscular
  attachments determines deformity that is produced
• Proximal to pec M, head abducts and rotates
• Between pec M and delt,
• head will adduct
• - Distal to deltoid, head
• will abduct

http//radiopaedia.org/cases/proximal-humeral-frac
ture-in-child?fullscreentrue
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Shoulder girdle dislocations

• Most common joint in body to dislocate
• Greater than 50 of all this locations
• Four joints of the shoulder girdle
• Glenohumeral joint 85, acromioclavicular joint
  12, sternoclavicular joint 2 and scapula
  thoracic joint 1

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Glenohumeral Joint Dislocation

• Classified by direction of displacement of
  humeral head
• Anterior (most common), posterior, inferior or
  superior

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Anterior GH Joint Dislocation

• M.C. shoulder dislocation (95)
• Mechanism is forceful abduction and external
  rotation
• Associated fractures during dislocation are
  common
• Radiographic signs- interior
• medial head displacement,
• altered head shape and
• presence of Hill-Sachs or
• Bankart lesions
• Humerus usually settles
• subcoracoid

http//www.feinberg.northwestern.edu/emergencymed/
residency/ortho-teaching/shoulder/case49/
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Anterior GH Joint Dislocation

• Hill-Sachs lesion (hatchet deformity)
• Impaction fracture of posterior-superior aspect
  of head where it
• bangs into inferior glenoid
• Bankart lesion
• Fracture of inferior
• glenoid by humeral head
• impact complications
• recurrence

http//www.orthopaedia.com/display/Main/Hill-Sachs
Sign
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Posterior GH Dislocation

• Uncommon (2-4)
• Fixes humeral head in internal rotation
• Caused by epileptic convulsions, electric shock
  or extreme trauma, thus
• triple e syndrome
• Reverse Hill-Sachs and
• reverse Bankart lesions
• Impaction of anteromedial
• humeral head and posterior
• glenoid

http//www.radsource.us/clinic/0506
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Posterior GH Dislocation

• Radiographic signs
• Rim sign- widening of glenohumeral joint space gt
  6 mm
• Trough line sign- appearance of double articular
  surface line
• Lack of humeral head/glenoid fossa overlap
• Vacant glenoid sign- lack of close contact at
  anterior joint
• margin
• Tennis racquet appearance-
• cystic appearance of humeral
• head in its malposition
• Superior displacement of
• humeral head
• - Rare, but could have reverse Hill-
• Sachs (impaction fx. of anteromedial
• aspect of head) or reverse Bankart
• (posterior glenoid fx.)

http//imageinterpretation.co.uk/images/shoulder/P
OSTERIOR20DISLOCATION220AP.jpg
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Inferior GH Dislocation

• AKA luxatio erecta
• Mechanism is severe hyperabduction
• In that motion, acromion acts as fulcrum on
  humeral neck, which levers humeral head
  inferiorly
• Humerus gets stuck in abduction

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Superior dislocation

• Rare
• Requires great force with elbow flexed and
  adducted
• More likely to have superior displacement of head
  due to torn rotator cuff

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Rotator cuff tears

• Incidence increases with age
• May be traumatic or degenerative
• Radiographic sign is superior subluxation of
  humeral head (not dislocation)
• Tear produces reduces holding power of
  infraspinatus tendon allowing unopposed elevation
  of humeral head by deltoid
• Acromiohumeral measurement lt7mm signifies tear
• Head may form pseudo-joint superiorly with
  clavicle and acromion

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Rotator Cuff Tears

• Arthrography- 85 sensitive shows extravasation
  of contrast
• Ultrasound- 60 to 85 sensitive
• MRI up to 100 sensitive if tear is gt2cm

http//stemcelldoc.wordpress.com/tag/alternatives-
to-rotator-cuff-surgery/
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Glenoid Labral Tears

• AKA SLAP lesion (Superior Labrum Anterior to
  Posterior
• Occurs during dislocation
• Associated with instability
• MRI is modality of choice
• Demonstrates labral
• avulsion, absence or a
• cleft

http//www.ericcressey.com/tag/slap-lesion
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AC Joint Separation

• Demonstrated with AP projection at 15cephalic
  tube tilt (like clavicle view), but taken with
  and without weights
• Needs to be bilateral for comparison
  measurements
• Coracoclavicular
• ligament is actually
• 2 ligaments
• - Conoid and
• trapezoid ligaments

Trapezoid
Conoid
http//www.conquestchronicles.com/pages/The_Should
er_Sprain
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AC Joint Separation

• Radiographic features
• AC joint space normally 2-4 mm
• AC joint alignment- should be in good horizontal
  alignment
• Coracoclavicular distance- normally 11-13 mm
  should be no more than 5 mm difference from side
  to side

http//www.emedx.com/emedx/diagnosis_information/s
houlder_disorders/shoulder_separation_images.htm
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Classification of AC Joint Injuries

• Based on degree of injury
• Type I- No tear no radiographic signs
• Type II- AC ligaments torn coracoclavicular
  ligaments stretched, but intact
• Radiograph shows increased AC joint space, but
  normal coracoclavicular distance
• Type III- Next slide

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Classification of AC Joint Injuries

• Type III- AC ligaments AND coracoclavicular
  ligaments torn
• Radiographic signs include widened AC joint
  space, elevation of distal clavicle above
  acromion and coracoclavicular distance gt5 mm
  wider than the opposite side

http//velonews.competitor.com/2010/11/news/should
er-separations-explained_150447
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Sternoclavicular Joint Dislocation

• Rare
• Requires severe trauma
• Posterior displacement of clavicle at SC joint is
  potentially life-threatening
• CT is modality of choice

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Scapulothoracic Joint Dislocation

• AKA locked scapula
• Rare
• Severe trauma or post-thoracoplasty

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References

• Yochum, T.R. (2005) Yochum and Rowes Essentials
  of Skeletal Radiology, Third Edition. Lippincott,
  Williams and Wilkins Baltimore.