TRAUMATIC SHOULDER CONDITIONS John W. Gibbs, DO Orthopaedic Surgeon Rochester Regional Health Orthopaedics at Red Creek

Traumatic Shoulder Conditions Fractures Dislocations Separations Tendon Tears Labral Tears

Fractures

Fractures Proximal Humerus Clavicle Scapular

Proximal Humerus Fractures Anatomy Head Greater Tuberosity Lesser Tuberosity Shaft

Proximal Humerus Fractures Comprise 4-5% of all fractures Comprise 45% of all humerus fractures High energy vs. Low Energy More common in Females (2:1 over males) Osteoporosis

Proximal Humerus Fractures Mechanism Low Energy (most common) Fall from a standing height Outstretched arm Elderly, osteoporotic High Energy MVC More severe fractures

Proximal Humerus Fractures Treatment Non-operative 85% of all proximal humerus fxs Immobilizer / sling Early mobilization 7-10 days Operative Considerations Displacement / Angulation Age Activity level Bone quality Associated injury

Clavicle Fractures Mechanism Fall onto the shoulder Most common (87%) Direct clavicle impact (7%) Fall onto outstretched hand (8%)

Clavicle Fractures Classification Middle third (80%) Most common Distal third (15%) Proximal third (5%)

Clavicle Fractures Treatment Majority non-operative Distal third Sling Beware “Z” configuration Risk nonunion Distal third Medial to CC ligaments

Scapula Fractures Relatively uncommon Associated injuries (<1% of all fractures) Associated injuries

Scapula Fractures Glenoid Associated with dislocation Body High energy

Scapula Fractures Treatment Body Glenoid Most non-operative Consider operative

Dislocations / Separations

Dislocations / Separations Glenohumeral Dislocation Acromioclavicular Separation

Dislocations Glenohumeral Dislocation Most commonly dislocated major joint 45% of all dislocations Anterior Most common 8-9 times greater than posterior Posterior 2nd most common Superior / Inferior rare Inferior Dislocation: Luxatio Erecta

Glenohumeral Dislocations Treatment Reduction Immobilizer Considerations Non-operative vs operative management Age Activity level Associated injuries

Separations Acromioclavicular Separation Males 10:1 over females Fall onto point of the shoulder

Separations Acromioclavicular Separation Treatment Non-operative Type I & II Most Type III Operative Some Type III Type IV, V, VI

Acromioclavicular Separations Classification considerations: AC & CC ligaments

Acromioclavicular Separations

Tendon Tears

Traumatic Tendon Tears Rotator Cuff Long head Bicep Pectoralis major

Traumatic Tendon Tears Rotator Cuff Supraspinatus Infraspinatus Teres Minor Subscapularis

Traumatic Tendon Tears Rotator Cuff Functional Loss High suspicion for tear with shoulder dislocation in older patient

Traumatic Tendon Tears Long head Bicep Distal migration of bicep muscle belly vs. proximal migration Functional deficit Supination 21% loss Elbow Flexion 8% loss

Traumatic Tendon Tears Long head Bicep Treatment options Non-operative Operative Bicep Tenodesis

Traumatic Tendon Tears Pectoralis major

Labral Tears

Labral Tears Many ways to tear your labrum

Labral Tears Overlapping signs / symptoms with other shoulder conditions Achy, dull pain Possible traumatic history Hanging by arms (Crossfit, Tough Mudder) Swinging arms (kettlebell) Ballistic shoulder activity Mechanical symptoms Clicking, popping, catching Associated neurologic symptoms Numbness, tingling

Labral Tears Treatment Wide spectrum of clinical presentation Analogous to varied meniscal tear presentation Non-operative Older, sedentary patients Degenerative tears Tend to get stiff from operative repair Operative Younger, active patients

Traumatic Shoulder Conditions Younger patients Older patients Tend to regain mobility Potential laxity / instability issues Tend to stay stiff Risk for Adhesive Capsulitis Consider associated / missed injuries

Case Presentation - 1 35 y/o male, chiropractor, body builder bench press, pain anterior shoulder region, divot in his infraclavicular region Able to continue bench press and weight lifting Weakness with incline bench press Presents to office 6 weeks s/p injury Diagnostic / Treatment options:

Case Presentation - 1 Diagnostic / Treatment options: Clinical diagnosis Clavicular head pectoralis major tear MRI Clavicular head pectoralis major origin avulsion Treatment Non-operative vs. operative Functional Cosmetic concerns

Case Presentation - 2 62 y/o female, retired nurse, active grandmother Slipped on the ice @ grocery store, pain in shoulder region, unable to elevate arm Seen at urgent care: no fracture, anterior dislocation Urgent care unable to reduce shoulder Shoulder reduced at Unity ED Presents to office 1 week s/p injury Diagnostic / Treatment options:

Case Presentation - 2 Diagnostic / Treatment options: Xrays repeated at office: maintained reduction Active elevation to 45 degrees / Abduction to 20 degrees Significant weakness with external rotation MRI: Supraspinatus & Infraspinatus complete tendon tear with retraction Operative intervention

Case Presentation - 3 60 y/o male, orthopaedic surgeon, active, cyclist, golfer Struck from behind by motor vehicle while riding bicycle Landed on point of shoulder, dominant arm Seen at urgent care: AC separation, Type III Self-diagnosed Presented to office with literature and requested surgery Active elevation to 45 degrees / Abduction to 20 degrees Distal clavicle prominent Primary form of cardiovascular exercise: cycling Diagnostic / Treatment options:

Case Presentation - 3 Diagnostic / Treatment options: MRI confirms Type III AC separation Coraco-clavicular ligaments disrupted Supraspinatus: low-grade partial thickness tearing Non-operative vs. operative considerations Shoulder fatigueability and scapular dysfunction AC arthritis Continued deterioration of rotator cuff Elected for AC repair Returned to all activities and operating

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