Acute Shoulder Injury and Pain

Overview

• Clavicle

  • Acromioclavicular injury

  • Clavicle fracture

• Glenohumeral dislocation (most common dislocation)

• Proximal humerus fracture

Acromioclavicular Joint Injury

Young adult presents with shoulder pain after falling onto shoulder while being tackled during a football game. Patient was carrying the football and suffered medial/inferior joint stress at the time of the injury. No swelling, deformity of clavicle with a negative cross body adduction test. Active and passive shoulder range of motion intact. Full strength with shoulder abduction, adduction, extension and flexion. Radial pulses 2+, capillary refill < 2 seconds, and no skin discoloration bilaterally. Sensation normal in shoulders, arms, and hands bilaterally.

• Obtain anteroposterior view, Zanca view, axillary x-rays of clavicle

• Treatment

  • Pain management: Acetaminophen, ibuprofen (age/weight based dosing)

  • Management per clavicle elevation (see below)

• Clavicle elevation and injury classification (Rockwood system)

  • < 25%

    • Discontinue shoulder sling once symptoms are tolerable with pain management alone

    • Encourage range of motion exercises

    • Refer to physical therapy

    • Patient counseled that pain may last up to 6 weeks

  • ≥ 25%

    • Refer to orthopedics

    • Patient counseled that pain may last for 3 months

• Patient counseled that he is at increased risk for future AC joint arthritis and/or degenerative changes

Clavicle Fracture

A football player for a Charlotte-based professional football team sustains a shoulder injury while performing a “superman” dive into the endzone. Player reports he landed on the anterior aspect of his shoulder during the descent. Denies shortness of breath. Radial pulses 2+ and capillary refill < 2 seconds. Patient able to touch thumb to each finger and spread fingers against resistance. Sensation intact in shoulders/arms/hands bilaterally.

• Obtain x-ray of affected clavicle

• Treatment

  • Refer to orthopedics if any of the following are present: Open injury, skin tenting, displaced group 1, any group 2 injury

  • Orthopedic referral not required

    • Place arm in sling during day for 2 to six weeks

    • Refer to physical therapy

    • Patient instructed to present to the emergency department immediately if he develops dyspnea or severe unilateral paresthesias

    • Follow-up for re-evaluation in 4 weeks

• Notes

  • Grouping system determines risk for brachial plexus injuries

    • Group 1 = proximal 3rd of clavicle

    • Group 2 = distal 3rd of clavicle

    • Group 3 = middle third of clavicle

  • Ask about shortness of breath to rule out pneumothorax

Glenohumeral Dislocation

Young adult patient with h/o glenohumeral instability, shoulder dislocation/subluxation, and participation in overhead sports present with acute onset shoulder pain s/p fall from bicycle. Reports lateral arm numbness. Patient noted to be holding affected arm in contralateral hand. Palpable humeral head in axilla, dimpling inferior to acromion, reduced range of motion, and lateral arm numbness on exam.

• Imaging

  • Obtain AP, scapular Y, and axillary x-ray to r/o fracture and to confirm successful reduction (see treatment)

  • Concern for axillary nerve injury due to lateral arm numbness, neurovascular deficits: Obtain baseline EMG

• Treatment

  • Injection and reduction

    • Prepare 20 mL intra-articular lidocaine 1% without epinephrine

    • Inject 1.5 cm distal and 2 cm medial to posterolateral corner of acromion

    • Reduce shoulder and repeat radiographs to confirm success

  • Instruct patient to wear sling x 4 weeks

• Follow-up 2 weeks s/p injury

  • No pathology on initial plain films: Repeat AP, scapular Y, and axillary views

  • repeat EMG if no significant improvement has occured

  • Encourage early mobilization to prevent frozen shoulder

• Consults

  • Recurrent dislocation: Refer to orthopedics for evaluation

  • Elite athlete: Consider orthopedics referral due to high risk for repeat dislocation

• Patient counseled that repeat dislocation risk increases with age and each repeat injury

Proximal humerus fracture

Elderly patient with h/o osteoporosis presents with acute shoulder/upper arm pain following a fall from standing position. Radial pulses and 2+ capillary refill bilaterally. Sensation present over lateral deltoid and in the medial, ulnar, and radial nerve distributions of the hand on the affected arm.

• Imaging

  • Obtain anteroposterior view of glenoid, scapular Y view, axillary view

  • If imaging is normal, repeat radiographs at 3 weeks to rule out occult fracture

• Treatment

  • Non-displaced fracture

    • Non-operative management recommended as it provides better outcomes

    • Apply sling x 6 weeks and then start range of motion exercises

  • Displaced fracture and/or cool, pulseless extremity: Refer to orthopedics for evaluation

Glenohumeral Instability

Pt with h/o shoulder dislocation/subluxation presents with shoulder pain s/p collision sustained while playing an overhead sport. Reports numbness over lateral deltoid. Generalized ligamentous laxity, positive apprehension test and joint relocation on exam.

• Consider shoulder x-ray; evaluate for Hill-Sachs lesion, dislocation, and inferior glenoid avulsion fracture

• Refer to PT for strength training

• Consider surgery if recurrent dislocation/subluxation occurs