Fractures

of the Shoulder
dr. Muh. Sak3, SpOT

Anatomy; Musculature
There are 3 groups of
muscles;
Scapulohumeral rotator
cu, deltoid, teres major.
Axiohumeral trapezius,
rhomboids, serratus
anterior, levator scapulae
Axioscapular pectoralis
major, pectoralis minor,
la3smus dorsi.

Anatomy; Rotator Cu
Reinforces joint capsule
Annulus formed from
musculotendinous
inser3ons
A Supraspinatus
B Joint Capsule
C Labrum
D Subscapularis
E Long head of biceps
F Infraspinatus
G Teres Minor

BONE ANATOMY OF THE

SHOULDER

Basic Examina3on; Inspec3on

"

General; Swelling

Erythema

Joint Deformity

Muscle was3ng
Front;
Sternoclavicular Joint prominence

Clavicle deformity

Acromioclavicular joint prominence

Deltoid was3ng
Side; Swelling
Behind; Scapula shape and situa3on

Webbing of the skin

Winging
Above; Clavicle

Supraclavicular fossae

Swelling

Basic Examina3on; Palpa3on

Heat
Crepita3ons
Bony tenderness
Humoral head and
shaW

Basic Examina3on; Movement

Ac3ve before passive

Abduc3on 0 - 170
Adduc3on 50
Flexion 0 - 165
Extension 0 - 60
Internal rota3on in abduc3on - 70
External rota3on in abduc3on - 100
Internal rota3on in extension touch the opposite scapula
External rota3on in extension - 70
External rota3on in abduc3on hand behind the head

Prac3cal assessment
LiW your arm right up (demonstrates full
abduc3on)
Now let your arm down (painful arc oWen
more evident on downstroke)
Put your hand behind your head (tests
external rota3on)
Put your hands behind your waist (tests
internal rota3on)

X-Rays
Anterior Posterior view
The standard view in all
hospitals.
Ar3cular surfaces of
humerus and glenoid are
parallel.
Inferior aspects of
acromium and clavicle
should be at the same
level.
Humeral head looks like
a walking s3ck.

X-Rays
The Y view
The Y sits under
the humeral head.
The stem of the Y is
the blade of the
scapula.
The limbs of the Y
are the coracoid and
the acromium
process.

Scapula fracture
Uncommon injury,0.5
% all fracture
High energy injury
Usually direct blow
Look for associated
injuries
X-ray a trauma series:
A-P view,Axillary
view,Scapular Y view

Scapula fracture
Most scapula fracture are able to nonopera3f
treatment
Surgical indica3on :
1. Displaced intraar3cular involve > 25 %
of the ar3cular surface
2. Scapular neck with > 40-degree or > 1 cm
medial transla3on
3. Scapular fracture with clavicle fracture

Scapula fracture
4. Fracture of the coracoid process that
result fung3onal acromioclavicular
separa3on
5. Comminuted fracture of the scapular spine

Proximal Humerus Fractures

Proximal Humerus Fractures

Epidemiology
Most common fracture of the humerus
Higher incidence in the elderly, thought to be related to
osteoporosis
Females 2:1 greater incidence than males

Mechanism of Injury
Most commonly a fall onto an outstretched arm from
standing height
Younger pa3ent typically present aWer high energy trauma
such as MVA

Proximal Humerus Fractures

Clinical Evalua3on
Pa3ents typically present with arm
held close to chest by contralateral
hand. Pain and crepitus detected on
palpa3on
Careful NV exam is essen3al,
par3cularly with regards to the axillary
nerve. Test sensa3on over the deltoid.
Deltoid atony does not necessarily
conrm an axillary nerve injury

Proximal Humerus Fractures

Treatment
Minimally displaced fractures- Sling immobiliza3on, early mo3on
Two-part fractures-
Anatomic neck fractures likely require ORIF. High incidence of
osteonecrosis
Surgical neck fractures that are minimally displaced can be treated
conserva3vely. Displacement usually requires ORIF

Three-part fractures
Due to disrup3on of opposing muscle forces, these are unstable so closed
treatment is dicult. Displacement requires ORIF.

Four-part fractures
In general for displacement or unstable injuries ORIF in the young and
hemiarthroplasty in the elderly and those with severe comminu3on. High
rate of AVN (13-34%)

Fracture Clavicle
Check skin for
compromise
May cause neurovascular
damage
Rx broad arm sling occ.
Requires internal xa3on

Fracture Clavicle
Surgical indica3on including :
1. Open fracture
2. Floa3ng shoulder
3. with poten3al for skin breakdown
4. with neurovascular injury