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Home / Trauma / Shoulder and acromioclavicular joint injury
Trauma

Shoulder and acromioclavicular joint injury

Anterior and posterior shoulder dislocation, fracture dislocation, AC joint dislocation.

36 questions 5 source pages 2 images

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36 questions
Q1Which classifications are used for ACJ and clavicle injuries?▸
  • ACJ: Rockwood
  • Clavicle: Allman & Neer
Q2Which classifications are used for the proximal humerus?▸
  • Neer
  • Hertel
Q3Which classifications are used for humeral shaft and distal humerus fractures?▸
  • Humeral shaft: by morphology
  • Distal humerus: AO, Holstein Lewis
Q4Which classifications are used around the elbow?▸
  • Elbow dislocation: terrible triad, Cori cycle
  • Olecranon: Mayo
  • Coronoid process: Regand & Morray
  • Radial head & neck: Mason
  • Capitellum: Regand & Morray
Q5Describe the radiographic signs of a posterior shoulder dislocation.📷▸
AP radiograph of the left shoulder showing posterior dislocation of right should
AP radiograph of the left shoulder showing posterior dislocation of right should
  • Light bulb sign
  • Trough line
  • Positive rim sign (widening of GHJ)
  • Absence of half-moon overlap
  • Proximal humerus internally rotated and adducted
  • No associated fracture in LT or surgical neck
Q6What history and examination findings suggest a posterior shoulder dislocation?▸
  • MOI: direct - axial load on arm in flexion, adduction, IR; indirect - electric shock/convulsion
  • Loss of shoulder contour, asymmetrical axillary fold, prominent coracoid (not obvious)
  • Arm held in IR and adduction; painful reduced ROM particularly ER and FF
  • Check NV status esp axillary nerve, brachial plexus, axillary artery; associated trauma (high energy), SSSC
Q7How do you confirm the diagnosis of posterior shoulder dislocation?▸
  • Clinical examination
  • Axillary view - most useful to assess direction of injury
  • Velpeau view - most useful if patient is in pain
  • CT - confirm direction of injury and associated fractures
Q8How is an acute traumatic posterior shoulder dislocation reduced?▸
  • Closed reduction under GA with an assistant
  • Delpalma method: caudal traction in line of the adducted IR deformity (elbow flexed) with lateral lifting
  • Recheck NV status post CR; immobilise in ER for 4-6 weeks
  • Arrange CT to assess associated occult fracture/bone defect
Q9What are the primary stabilisers against posterior shoulder dislocation?▸
  • Posterior band of IGHL - static restraint in IR
  • Subscapularis - dynamic restraint in ER
  • CH ligament
Q10How is a chronic missed posterior dislocation (>6 weeks) managed?▸
  • Reverse HS lesion = loss of normal convexity in the anteromedial part, depression/defect of humeral head
  • CR unlikely successful; complete workup with XR/CT to assess degree of reverse HS defect
  • Open reduction with subscapularis transfer (McLaughlin) or LT transfer (modified McLaughlin)
  • Castagna: modified McLaughlin - significant functional improvement, no intra/postop complications at mean FU 62.8 months
Q11What history points are important in a suspected posterior shoulder dislocation?▸
  • Mechanism of injury
  • Patient's age and hand dominance
Q12How are the axillary and Velpeau views taken?▸
  • Axillary: arm in 90 degrees abduction, plate above the shoulder, beam into the axilla
  • Velpeau: patient leans 45deg backward, plate on the floor, beam directed caudally
Q13What is the difference between the classic and modified McLaughlin procedure?▸
  • Classic: subscapularis transfer
  • Modified: adds transfer of the lesser tuberosity for better bone filling of the defect and more secure subscapularis insertion
Q14What is the terrible triad of shoulder dislocation?▸
  • Dislocation
  • Cuff injury
  • Brachial plexus injury
Q15When should a greater tuberosity fracture be fixed after reduction?▸
  • If GT displaced >5mm post reduction
  • May be fixed open or arthroscopically
Q16What is the evidence for arthroscopic fixation of the greater tuberosity?▸
  • Fixation with a double row of anchors shown to have superior postoperative ROM
  • CORR 2016
Q17How does the Rockwood classification guide management of ACJ dislocation?📷▸
AP Xray showing ACJ dislocation with marked superior displacement of the distal
AP Xray showing ACJ dislocation with marked superior displacement of the distal
  • 1-3: static stabilisers disrupted (AC sprain, AC torn, CC torn) - conservative
  • 4-6: dynamic (posterior through trapezius, D+T torn, inferior below coracoid) - surgical
  • Type 3: +/- operation
  • If untreated the shoulder becomes protracted
Q18What imaging views are used for ACJ dislocation?▸
  • Contralateral side for comparison
  • Axillary view - AP translation
  • Zanca view - 10 degree cephalic tilt, vertical translation
  • +/- stress view
Q19What is the Cochrane 2019 evidence for ACJ dislocation?▸
  • Low evidence for surgery
  • At 10 yr FU, minimal degenerative changes
  • Conservative actually has better functional outcomes at 6 weeks
Q20When is distal clavicle resection indicated in ACJ disease and how much bone is removed?▸
  • Indicated for ACJ arthritis without instability
  • Resect 7-8mm, <1.5cm of distal clavicle - too much jeopardises the ACJ capsule
  • Can be performed arthroscopically
Q21What is the role of tendon reconstruction in chronic ACJ dislocation?▸
  • Tauber 2009 AJSM: semitendinosus tendon graft for coracoclavicular ligament reconstruction
  • Gave superior clinical and radiologic outcomes compared with the modified Weaver-Dunn procedure
Q22Describe the X-ray findings in this ACJ dislocation.▸
  • AP: ACJ dislocation with marked superior displacement of the distal end of the clavicle
  • No associated fractures; will need further Xray to classify
  • Axillary view: posterior dislocation of the distal clavicle
  • Summary: Rockwood 3 posterior dislocation of the ACJ
Q23What history and examination points are important in ACJ dislocation?▸
  • Mechanism of injury; acute vs chronic
  • Associated injury around the shoulder girdle - SSSC, floating shoulder
  • Neurovascular status
  • Compare with the contralateral side
Q24What are the options for CC fixation in acute ACJ dislocation?▸
  • Bosworth screw, CC sling, fibre tape
  • Tightrope loop suspensory fixation (A-assisted)
Q25What is the direct ACJ fixation option and its drawback?▸
  • Hook plate
  • Provides anatomical reduction
  • Needs a second operation for implant removal
Q26How is chronic ACJ dislocation managed?▸
  • Modified Weaver-Dunn procedure (classic without additional fixation)
  • If just ACJ arthritis with no instability: resection of the distal clavicle
  • Tendon reconstruction with semitendinosus graft (Tauber 2009 AJSM)
Q27What are the ACJ stabilisers?▸
  • Static: AC lig, CC lig, ACJ capsule
  • Dynamic: Trapezius, deltoid muscle
Q28How do you assess a patient with a suspected ACJ dislocation?▸
  • Hx: mechanism of injury, acute vs chronic
  • P/E: associated injury around the shoulder girdle - floating shoulder / SSSC
  • Neurovascular status and contralateral side for comparison
Q29What is the evidence from the Cochrane 2019 review?▸
  • Low evidence for surgery; most studies used hook plate
  • At 10 yr FU, minimal degenerative change; conservative better functional outcomes at 6 weeks
  • Late reconstruction results comparable to early surgery; main problem is deformity
  • One report quotes 15% reduced bench press strength
Q30What are the options for CC fixation in acute ACJ dislocation?▸
  • Loop suspensory fixation (tightrope, A-assisted)
  • LARS ligament, Bosworth screw, CC sling, fibre tape
Q31What does the Arirachakaran 2016 meta-analysis show?▸
  • Suspensory device fixation gives higher shoulder function scores than metallic fixation (hook plate)
  • Suspensory fixation also had lower postop pain
Q32Describe the modified Weaver-Dunn procedure.▸
  • Excision of distal clavicle
  • Transfer acromial end of CA ligament to distal clavicle
  • CC fixation
  • Indicated for chronic ACJ dislocation with +ve arthritis
Q33What are the static and dynamic stabilisers of the ACJ?▸
  • Static: AC lig, CC lig, ACJ capsule
  • Dynamic: trapezius, deltoid muscle
Q34Describe the X-ray findings in this ACJ dislocation.▸
  • ACJ dislocation with marked superior displacement of the distal end of the clavicle
  • Look for associated fracture, especially floating shoulder or SSSC injury
  • Further X-ray needed to classify
Q35What is the direct fixation option for ACJ dislocation?▸
  • Hook plate
  • Provides anatomical reduction but needs a second operation for removal of the implant
Q36When is resection of the distal clavicle performed and how much bone is removed?▸
  • For chronic ACJ arthrosis without instability
  • Remove 7-8mm, less than 1.5cm of distal clavicle
  • Too much resection jeopardises the capsule
  • Can be performed arthroscopically
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