276 Orthopaedic Emergencies
INJURIES TO THE SHOULDER AND UPPER ARM
Fractures of the clavicle
DIAGNOSIS
1 These fractures are usually due to direct violence or to transmitted force
from a fa ll on to t he outstretched hand.
2 A fracture between the middle and outer thirds is common in adults. A
greenstick fracture occurs in children.
3 The patient experiences pain on movement of the shoulder and examination
reveals tenderness over the clavicle associated with local deformity.
4 An anteroposterior X-ray of the shoulder usually shows the fracture clearly.MANAGEMENT
1 Support the weight of the arm in a triangular sling, and give an analgesic
such as paracetamol 500 mg and codeine phosphate 8 mg two tablets q.d.s.
(i) The traditional figure-of-eight bandage has been abandoned, as it
is uncomfortable and ineffective.
2 Rarely, comminuted fractures or fractures causing compression of underly-
ing nerves or vessels are treated operatively.
(i) Refer these immediately to the orthopaedic team.
3 Otherwise, refer the patient to the next fracture clinic.Acromioclavicular dislocation
DIAGNOSIS
1 Acromioclavicular injuries usually occur following a fall on to the apex of
the shoulder with the arm held in adduction.
2 A fall on to the shoulder that tears the acromioclavicular ligament results in
subluxation.
(i) Dislocation occurs if the strong coracoclavicular ligaments are
torn as well, with the clavicle losing all connection with the
scapula.
3 Subluxation causes local tenderness to palpation with minimal deformity.
(i) Full dislocation causes a prominent outer end of the clavicle and
drooping of the shoulder, with pain on movement.
4 Assess the clavicle and scapula for associated fractures.
5 X-ray the acromioclavicular joint with the patient standing to show the
displacement of the clavicle. This can be highlighted by comparing the
shoulders, with the patient holding a weight in each hand.