278 Orthopaedic Emergencies
INJURIES TO THE SHOULDER AND UPPER ARMFractures of the scapula
DIAGNOSIS
1 These can be divided into fractures of the neck, body, spine, acromion and
coracoid. They are usually due to direct trauma.
2 Their importance is that they ‘f lag’ that considerable force has been applied
to the area. Check for an associated rib, chest, vertebral column and shoulder
injury.
3 Request an anteroposterior shoulder view and lateral scapula view to
adequately visualize the majority of scapula injuries.
(i) A CT scan is indicated to delineate associated glenoid and or
coracoid fractures.MANAGEMENT
1 Treat the associated injuries as a priority.
2 Manage the majority of isolated undisplaced scapula fractures that do not
involve the glenohumeral articular surface with ice, sling immobilization, oral
analgesics, and early range of motion exercises. Refer to the next fracture clinic.
3 Displaced fractures of the glenoid and scapula neck are associated with
significant shoulder soft-tissue trauma and may require surgical reduction.
Refer these to the orthopaedic team.Anterior dislocation of the shoulder
DIAGNOSIS
1 This dislocation is caused by forced abduction, elevation and external
rotation of the shoulder relative to the trunk. It is commonest in young
adults from sports or traffic crashes, or in the elderly from a fall.
2 It tends to become recurrent, when dislocation may occur with a trivial
injury, movement or even spontaneously in bed.
3 Patients have severe shoulder pain and a limited range of movement.
4 The arm is held slightly abducted and the shoulder appears ‘square’, due to
loss of the deltoid contour and a prominent acromion.
5 Look for the following complications before any attempt is made at
manipulation:
(i) Axillary (circumflex) nerve damage
Assess for pinprick sensory loss over the ‘regimental badge’ area on
the upper lateral aspect of the deltoid (testing for shoulder movement
by the deltoid is too painful to be meaningful).
(ii) Posterior cord of the brachial plexus
Test wrist extension by the radial nerve. Rarely other parts of the bra-
chial plexus are damaged.