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Acute Injuries: Shoulder Fractures and Acromioclavicular and Sternoclavicular Joint Injuries

Key Points

  • The most common cause of a proximal humerus fracture is a fall on outstretched hands from a standing position. Another mechanism of injury is excessive rotation while the arm is abducted.
  • Although fracture of the proximal humerus significantly limits function of the upper extremity, careful neurovas cular examination of the entire upper extremity should always be performed. There are three important nerves— axillary, suprascapular and musculocutanneous—in close proximity of the proximal humerus and nerve injury accompanies the majority of humerus fractures.
  • The trauma series, consisting of anteroposterior (AP) view of the scapula, a lateral, Y-view of the scapula, and axillary view, is the standard initial method of evaluation for proximal humerus fracture.
  • More than 80% of the proximal humerus fractures are nondisplaced and can be treated nonoperatively. The shoulder is initially immobilized in a sling at the side or in Velpaeu position. After pain has diminished and the fracture is stable (usually after 7 to 10 days), gentle pendulum exercises can be started.
  • Some dislocated two-part surgical neck fractures can also be treated conservatively. They may require closed reduction in conscious sedation or general anesthesia.
  • Multipart proximal humerus fractures or isolated fractures of the greater or lesser tuberosities that are displaced more than 5 mm should be treated with open reduction and internal fixation. Surgical modalities include plates, screws, intramedullary devices and their combinations.
  • Clavicle fractures account for 35% of fractures about the shoulder.
  • Most patients with clavicle fracture report a direct fall onto the shoulder with subsequent pain and deformity in a clavicular region.
  • Most middle third clavicle fractures are treated conservatively with a sling or figure-eight dressing for 3 to 6 weeks.
  • Similarly to other shoulder injuries, patients with the acromioclavicular joint injuries often report a fall or direct trauma to the shoulder. Physical exam reveals swelling and tenderness over distal clavicle associated with a deformity caused by a horizontal and/or vertical displacement of the clavicle.
  • Initial radiographic confirmation and evaluation of the clavicle fracture and acromioclavicular joint injury should include AP and 45 degree cephalic tilt (apical oblique) views with patient upright which brings the clavicular image away from the thoracic cage.

The shoulder joint mobility plays a vital role in upper extremity function. It is therefore not surprising that optimal management of acute shoulder injuries remains an important issue that confronts the orthopedic profession. Modern management of shoulder injuries has become technically sophisticated.

The purpose of this chapter is to provide a succinct review of current opinions and advancements in the management of proximal humerus and clavicle fractures as well as acromio- and sternoclavicular joint injuries.

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