CHAPTER

50 Shoulder
Mohamud Daya

clavicular, glenohumeral, and sternoclavicular), and

PERSPECTIVE one articulation (scapulothoracic). The clavicle is an
S-shaped bone that acts as a strut to support the upper
The shoulder joint is a unique and complex articula-
extremity and keep it away from the chest wall. The
tion unit. It has the largest range of motion of any
clavicle articulates medially with the sternum and lat-
appendicular joint in the body and can be moved
erally with the acromion process. The sternoclavicular
PART TWO TRAUMA • Section III Orthopedic Lesions

through a space that exceeds a hemisphere. The wide

joint (SCJ) represents the only true articulation between
range of motion also predisposes the joint to instabil-
the upper extremity and the axial skeleton. The large
ity and injury; this was depicted in 3000 B.C. in wall
articular surface of the sternal end of the clavicle fits
paintings of Egyptian tombs, which show accurate
poorly with the sloping narrow clavicular notch on the
drawings of manipulations (similar to the Kocher tech-
manubrium sterni. A circular flat fibrocartilaginous
nique) used to reduce shoulder dislocations.1 Hip-
disk helps reduce the discrepancy between the two
pocrates may have been the first to outline extensively
articular surfaces (Figure 50-2). The stability of the joint
the diagnosis and treatment of shoulder dislocations.2
largely depends on associated ligaments. A loose
Shoulder injuries are commonly encountered in
fibrous capsule whose expansions form the anterior
emergency medicine. Statistical studies show that 8% to
and posterior sternoclavicular ligaments envelops the
13% of all athletic injuries involve the shoulder and that
joint.5 The interclavicular and costoclavicular liga-
shoulder dislocations account for more than 50% of all
ments are two additional structures that stabilize the
major joint dislocations seen in the emergency depart-
joint. The costoclavicular ligament opposes the pull of
ment. Almost every major sport or athletic activity
the sternocleidomastoid and is the most important
involves use of the shoulder joint in one way or another.
stabilizing ligament.5 The SCJ participates in all move-
The shoulder can be injured by trauma (indirect or
ments of the upper extremity and is the most moved
direct) or by overuse. Traumatic injuries tend to occur
joint in the body.6 The superior mediastinum with its
in football and ice hockey, whereas overuse injuries
great vessels, trachea, esophagus, and other important
(impingement syndromes) are more common in swim-
structures are immediately posterior to the joint.
ming and baseball. Shoulder injuries also are common
The tubular clavicle flattens laterally to provide
in wrestling, tennis, volleyball, and javelin throwing.3
attachment sites for the coracoclavicular and acromio-
In general, children are vulnerable to the same injuries
clavicular ligaments (Figure 50-3). The clavicle also
as adults; however, the presence of the epiphysis and its
protects the subclavian neurovascular bundle and pro-
growth plate changes the pattern of injuries.4 The
vides the neck with an acceptable cosmetic appearance.
strength of the joint capsule and its ligaments is two to
The middle third of the clavicle, which is the most
five times greater than that of the epiphyseal plate. An
commonly fractured segment, is thin and untethered by
injury that produces a sprain or dislocation in an adult
any ligamentous structures.7 Rotation around the long
often causes a fracture through the hypertrophic zone
axis of the clavicle increases the range of motion of the
of the growth plate in a child. The shoulder girdle has
glenohumeral joint and improves the strength of the
epiphyseal plates at the acromion process, proximal
arm-trunk mechanism.7
humeral head, coracoid process, glenoid cavity, and
The acromioclavicular joint (ACJ) connects the
medial end of the clavicle. Complete or greenstick frac-
lateral end of the clavicle with the medial aspect of the
tures of the clavicle and fractures of the proximal
acromion process (see Figure 50-3). The bony configu-
humeral epiphysis are encountered more commonly
ration of the joint varies considerably and provides
in the pediatric population. Most shoulder injuries in
little or no stability.8 Stability is a function of associ-
children can be treated conservatively with a good pro-
ated ligaments and muscles. The joint capsule is
gnosis for full return of function.4
strengthened on all sides to form the relatively weak
anterior, posterior, superior, and inferior acromioclav-
icular ligaments. The clavicular and acromial attach-
PRINCIPLES OF DISEASE
ments of the deltoid and trapezius muscles provide
additional static and dynamic support for the superior
Anatomy
aspect of the joint. The powerful coracoclavicular liga-
The shoulder girdle connects the upper extremity to the ment, which is the primary suspensory ligament of the
axial skeleton (Figure 50-1). It consists of three bones upper extremity, also stabilizes the joint. The coraco-
670 (clavicle, humerus, and scapula), three joints (acromio- clavicular ligament is composed of two parts—the
 Acromioclavicular joint Coracoid process Figure 50-1. Anatomy of the shoulder
girdle. (From Roy S, Irwin R: Sports
Acromial process Medicine: Prevention, Evaluation, Man-
Clavicle agement and Rehabilitation. Engle-
Greater tubercle wood, NJ, Prentice Hall, 1983.)
Sternoclavicular joint
Lesser tubercle
Bicipital groove

Scapula
Glenohumeral joint
Body of sternum

Costal cartilage

Costochondral junction

CHAPTER 50 Shoulder
Anterior Figure 50-2. Ligaments and the interarticu-
Disk sternoclavicular lar disk of the sternoclavicular joint. (Redrawn
Interclavicular ligament from DePalma AF: Surgery of the Shoulder,
ligament 3rd ed. Philadelphia, JB Lippincott, 1983.)

Subclavius Tendon of
muscle subclavius
muscle
Posterior Coracoclavicular
fasciculus ligament

Anterior
fasciculus

Superior Figure 50-3. Ligaments of the acromioclavicular joint.

acromioclavicular (Redrawn from DePalma AF: Surgery of the Shoulder,
ligament 3rd ed. Philadelphia, JB Lippincott, 1983.)
Trapezoid ligament Coracoclavicular
Conoid ligament ligament

Coracoacromial
ligament

trapezoid and conoid ligaments.8 The trapezoid liga-
ment arises from the shaft of the coracoid process and
runs superiorly to insert onto the inferior surface of the
lateral clavicle. The conoid ligament arises from the
base of the coracoid process and inserts more medially
on the inferior surface of the distal clavicle. The dis-
tance from the clavicle to the coracoid process varies
from 1.1 to 1.3 cm in the standing adult. Although the
ACJ itself has only 5 to 8 degrees of movement, it allows
for 40 to 50 degrees of clavicular rotation. The latter is
required to achieve a full range of motion at the gleno-
humeral joint. 671

PART TWO TRAUMA • Section III Orthopedic Lesions
672
The scapula is a flat triangular bone that forms the
posterior aspect of the shoulder girdle. The thin body of
the scapula lies flat against the posterior thorax and
widens laterally to form the glenoid fossa. A stable base
from which glenohumeral motion can occur is provided
by 18 muscular origins and insertions on the scapula.9
The flat anterior surface of the scapula gives rise to
the subscapularis muscle, whereas the serratus anterior
muscle inserts onto its thickened medial border. Poste-
riorly the surface is divided into two parts by the scapu-
lar spine. The areas superior and inferior to the spine
give rise to the supraspinatus and infraspinatus
muscles. The teres minor and major muscles originate
from the posterior aspect of the lateral border of the
scapula. The thickened posteromedial border serves as
the attachment site for the rhomboid and levator scapu-
lae muscles.
The superior border of the scapula gives rise to an
anterior projection, the coracoid process (see Figure
50-1). As discussed, the coracoid provides attachment
for numerous important ligaments and muscles that
help stabilize the glenohumeral joint. The acromion, in
conjunction with the strong coracoacromial ligament,
forms the coracoacromial arch (see Figure 50-3).
Muscles attached to the coracoid process include the
short head of the biceps, coracobrachialis, and pec-
toralis minor. The neurovascular bundle is located
beneath the coracoacromial arch, immediately poste-
rior to the coracoid process.
The glenohumeral articulation is a ball-and-
socket–type joint (Figure 50-4). The glenoid fossa is
deepened by a rim of fibrocartilage (glenoid labrum)
and provides a bearing surface for only half of the
humeral head at any one time. The absence of congru-
ent surfaces makes the bony joint mechanically unsta-
ble. The stability of the joint primarily depends on
associated muscles and ligaments. A negative intra-
capsular pressure completes the stabilization mecha-
nism.10,11 The absence of bony stability permits a range
of motion, however, that is greater than that of any
other joint in the body.
A synovial membrane extends from the glenoid fossa
to the humeral head. The membrane is large and redun-
dant inferiorly to accommodate the extensive range of
movement. The synovial membrane extends medially
to form the subscapularis bursa and laterally to envelop
the long head of the biceps. Overlying the synovial
membrane is a loose and redundant fibrous capsule (see
Figure 50-4). Anteriorly the capsule is thickened to
form the superior, middle, and inferior glenohumeral
ligaments. The inferior glenohumeral ligament is sub-
divided further into an anterior band, a posterior band,
and an interposing pouch. The anterior band of the
inferior glenohumeral ligament is the most important
restraint to anterior glenohumeral dislocations.10,11
Superiorly the acromial process and the coracohumeral
ligament (see Figure 50-4) protect the capsule.
The proximal humerus articulates with the glenoid
fossa and provides for the attachment of many impor-
tant muscles. The supraspinatus, infraspinatus, and
teres minor insert onto facets of the greater tuberosity,
whereas the subscapularis inserts onto the lesser
tuberosity. Together, this group of muscles forms the
rotator cuff, which helps stabilize the humeral head
within the glenohumeral joint (Figure 50-5). The long
head of the biceps tendon originates from the supra-
glenoid tubercle and ascends over the humeral head to
enter the arm via the bicipital groove. The long head
acts as an additional stabilizer for the superior and
anterior aspect of the glenohumeral joint (see Figure
50-5). Long muscles that cross the articulation are
involved primarily in movements of the glenohumeral
joint. The pectoralis major, latissimus dorsi, and teres
major muscles all insert into the humeral intertubercu-
lar groove. Displacements encountered with fractures
of the humerus usually reflect the pull of these attached
muscle groups. The proximal humerus is composed
primarily of trabecular bone with a thin cortical shell.
Changes in bone density with age (osteoporosis) greatly
increase the risk of fractures in this area.7
The blood supply of the articular surface of the
humerus is derived from vessels contained in the
rotator cuff tendons and from the anastomosis of
the anterior and posterior circumflex humeral arteries.
The neurovascular bundle runs anteriorly, and the axil-
lary nerve is in close proximity to the inferior aspect of
the joint. Movements of the glenohumeral joint include
flexion, extension, abduction, adduction, internal rota-
tion, external rotation, and circumduction.
Four nerves supply most of the shoulder muscles.
The axillary nerve supplies the deltoid and teres minor
muscles; the suprascapular nerve, the supraspinatus
and infraspinatus muscles; the subscapular nerve, the
teres major and subscapularis muscles; and the mus-
culocutaneous nerve, the proximal arm muscles. These
nerves represent the final branches of the upper bracial
plexus (nerve roots C5-8), and injuries to the brachial
plexus invariably result in significant shoulder
dysfunction.
CLINICAL FEATURES
History
Most complaints usually involve some combination of
pain, stiffness, instability, and weakness. Pain can
result from many different conditions extrinsic and
intrinsic to the shoulder. Extrinsic sources of shoulder
pain include disorders of the cervical spine, thoracic
outlet syndromes, and Pancoast’s tumors. In addition,
pain can be referred to the shoulder from myocardial
processes, diaphragmatic irritation (e.g., subphrenic
abscess, lower lobe pneumonia, splenic hematoma,
ruptured ectopic pregnancy, gallbladder disease), and
gastric or pancreatic diseases.
Acute intrinsic pain usually is associated with a trau-
matic event. The most important factors to determine
are the time and mechanism of injury, its precise loca-
tion, and the intensity of the pain. Occasionally the
patient may have acute pain in the absence of associated
trauma (e.g., calcific tendinitis). Shoulder pain also can
present in an insidious manner, unrelated to any pre-
cipitating factor. In these instances, the duration,
 LATERAL INTERIOR

Clavicle
Coracoacromial ligament
Acromion
Tendon (subscapularis)
Long head
Coracoid process
of biceps
Superior
Middle Glenohumeral
Glenoid cavity ligaments
Glenoid labrum Inferior
Articular capsule
ANTERIOR
Acromioclavicular Clavicle
ligament
Acromion Conoid Coracoclavicular
Trapezoid ligaments
Coracoacromial ligament

CHAPTER 50 Shoulder
Articular capsule

Humerus

POSTERIOR

Coracoid process Coracohumeral ligament

Articular capsule
Acromion
Inferior transverse
scapular ligament

Humerus

Figure 50-4. Anatomy of the glenohumeral joint.

Supraspinatus muscle
and external rotators
Anatomic neck

Rotator interval

1 3
2 Biceps tendon
Biceps
Surgical neck
tendon
Subscapularis
muscle 4

Figure 50-5. The rotator cuff.

673
 location, character, and aggravating and alleviating
factors of the pain should be noted. Intrinsic shoulder
pain in general does not radiate past the elbow.
Stiffness usually signifies a restricted range of motion
resulting from an underlying painful condition of the
shoulder. Instability can be seen in the form of an
obvious subluxation or dislocation. Alternatively the
patient may relate the sensation of the shoulder almost
going out. A rotator cuff tear or an underlying nerve
lesion usually causes significant shoulder weakness.
Physical Examination
The shoulder should be inspected from the anterior,
posterior, and lateral positions. Any obvious deformity,
ecchymosis, laceration, swelling, or hematoma should
be noted. The masses of the trapezius, deltoid, infra-
PART TWO TRAUMA • Section III Orthopedic Lesions
carefully in all cases. After 45 degrees of abduction, the
scapula moves approximately 1 degree for every 2
degrees of glenohumeral motion.
A thorough neurovascular examination should be
performed in all cases before and after all manipula-
tions. The vascular status is checked by determining
the brachial, radial, and ulnar pulses with the arms in
various positions. A complete sensory (light touch and
pinprick) and full motor examination also should be
performed. The brachial plexus can be tested by eval-
uating the myotomes and dermatomes pertinent to each
nerve root (Table 50-1). In addition, the deep tendon
reflexes should be evaluated in both upper extremities.
DIAGNOSTIC STRATEGIES

spinatus, and supraspinatus muscles should be com- Radiology

pared to detect any atrophy.
Palpation of the shoulder should be performed sys- The initial assessment of traumatic injuries includes
tematically, beginning at the SCJ and moving laterally a three-view series of radiographs consisting of true
along the clavicle to the ACJ. Next the scapula, gleno- anteroposterior (45-degree lateral), transscapular
humeral joint, and humerus are palpated. Any point lateral, and axillary lateral views (Figures 50-6 and
tenderness, crepitus, swelling, or deformity should be
noted.
Active and passive ranges of motion should be tested. Table 50-1. Sensory and Motor Components of the
Active range of motion is best determined with the Brachial Plexus
patient in the sitting position, which eliminates the
contributions of the lumbar spine and lower extremity Level Sensory Area Muscle
joints. Passive range of motion is best evaluated with C2-4 — Trapezius
the patient in the supine position. The degrees of C5 Lateral arm Deltoid
abduction, forward flexion, extension, and internal and C6 Lateral forearm Biceps
external rotation should be recorded and compared C7 Index fingertip Thumb extensors
C8 Little fingertip Finger flexors
with the unaffected extremity. In addition, the motion T1 Medial forearm Interossei
of the scapulothoracic articulation should be observed

35 degrees

C
Figure 50-6. Positions for the trauma series of shoulder radiographs. A, Axillary view. B, True anteroposterior (35-degree oblique) view.
674 C, Transscapular lateral view.

A
B of the shoulder.
50-7). The true anteroposterior view (see Figure 50-7B)
is preferred over standard anteroposterior views
because it projects the glenohumeral joint without any
bony overlap. Standard anteroposterior views taken in
internal and external rotation profile the lesser and
greater tuberosity and are more useful in the evaluation
of soft tissue conditions.
Acceptable orthogonal views include the axillary
lateral, transscapular lateral, and apical oblique.12 The
preferred view is the axillary lateral (see Figure 50-7A),
which projects the glenohumeral joint in a cephalo-
caudal plane. This view is particularly useful for defin-
CHAPTER 50 Shoulder
Figure 50-7. Normal axillary (A), true anteroposterior
(B), and transscapular lateral (C) views (trauma series)
ing the relationship of the humeral head with the
glenoid fossa and in identifying lesions of the coracoid
process, humeral head, and glenoid rim.13 Some degree
of abduction is required to obtain the axillary view.
Because this may not be possible with some injuries, a
reverse projection or a modified axillary view (Figure
50-8) may be considered. The difficulty in obtaining the
axillary view has led to the popularity of the trans-
scapular view (see Figure 50-7C). Advantages of this
projection include its simplicity and reproducibility
and the clear delineation of anatomic structures. In this
view, the scapula is projected as a Y, with the body 675

PART TWO TRAUMA • Section III Orthopedic Lesions
676
25 degrees
Figure 50-8. Modified axillary view of the shoulder.
Figure 50-9. Displaced midclavicular fracture.
forming the lower limb and the coracoid and acromion
processes forming the upper limbs. The humeral head
is normally superimposed over the glenoid, which is
located at the junction of the three limbs. This view is
particularly useful in identifying anterior and posterior
glenohumeral dislocations. The apical oblique film
(obtained by placing the injured shoulder in a 45-
degree oblique position and angling the central ray 45
degrees caudally) provides a unique coronal view of the
glenohumeral joint. The view can be obtained easily
and painlessly and has been found to be more sensitive
than the transscapular view for detecting bone and joint
abnormalities in the injured shoulder.14 Plain radio-
graphs are the mainstay of the radiologic examination
in the emergency department, but in selected circum-
stances, additional bone and soft tissue details may be
obtained using computed tomography (CT) or magnetic
resonance imaging (MRI).15
25 degrees
SPECIFIC INJURIES
Fractures
Clavicle
Pathophysiology
The clavicle accounts for 5% of all fractures and is the
most commonly fractured bone in children. Epidemio-
logic studies in adults have documented an annual
incidence rate of 30 to 50 per 100,000 population, with
a 2 : 1 male-to-female ratio.16,17 Clavicular fractures are
classified anatomically and mechanistically into three
types. Fractures of the medial third are uncommon
(5%) and occur as a result of a direct blow to the ante-
rior chest. Fractures of the middle third are the most
frequent (Figure 50-9), accounting for 80% of all
injuries. The usual mechanism of injury involves a

direct force applied to the lateral aspect of the shoul-
der as a result of a fall, sporting injury, or motor vehicle
accident. Fractures of the lateral third (15%) result
from a direct blow to the top of the shoulder and are
classified further into three subtypes.18 Type I fractures
are stable and occur lateral to the coracoclavicular lig-
aments. Type II fractures are medial to the coracocla-
vicular ligaments and have a tendency to displace
because the proximal fragment lacks any stabilizing lig-
aments. Type III injuries involve the articular surface
(Figure 50-10).18
Clinical Features
The patient has pain over the fracture site, and the
affected extremity is held close to the body. With frac-
tures of the middle third, the shoulder typically is
slumped downward, forward, and inward. This is a
result of the effect of gravity and the pull of the pec-
toralis major and latissimus dorsi on the distal frag-
ment. The proximal fragment is often displaced
upward by the action of the sternocleidomastoid. The
head is often tilted toward the injured side in an
attempt to relax the effects of these displacing muscu-
lar forces. Ecchymosis, crepitus, and a palpable or
visible deformity may be present over the fracture site.
Although associated neurovascular injury is rare, the
close proximity of the subclavian vessels and brachial
plexus demands a thorough assessment. Rarely, injury
to the dome of the pleura may result in an associated
pneumothorax.
Management
Principles of initial management include pain
control, immobilization, and proper follow-up. Frac-
tures of the clavicle can be immobilized with support-
ive devices, such as a simple sling or sling and swathe
(Figure 50-11). Another immobilization technique
for midclavicular fractures still recommended in the
orthopedic literature is the clavicular (figure-of-eight)
Figure 50-10. Type III lateral clavicular fracture (intra-artic-
ular). (Courtesy of David Nelson, MD.)
CHAPTER 50 Shoulder
splint (Figure 50-12). This splint is applied after closed
reduction of the fracture, which is accomplished by
pulling the shoulders up and back. Such reductions
are difficult to maintain and may be associated
with increased discomfort at the fracture site. Cla-
vicular splints can lead to skin irritation and com-
pression of the neurovascular bundle in the axilla.
Because malunion and shortening are associated with
an acceptable functional and cosmetic outcome, treat-
ment with a simple sling is a valid and appropriate
alternative to the clavicular splint in the emergency
department.19,20
Disposition
Immediate orthopedic consultation should be sought
for open fractures or fractures associated with neu-
rovascular injuries, skin tenting, or interposition of soft
tissues. More urgent orthopedic consultation (before 72
hours) is recommended for type II lateral clavicle frac-
tures because these fractures have a 30% incidence of
nonunion and may require surgical repair.18 Severely
comminuted or displaced fractures of the middle third
(defined as >20 mm of initial shortening) also may
benefit from early orthopedic referral because these
have been associated with a higher incidence of
nonunion.21 Greenstick fractures of the midclavicle are
common in children (Figure 50-13). Most of these frac-
tures are nondisplaced and heal uneventfully. Initial
radiographs may appear normal despite suggestive
clinical findings. In these instances, the arm should be
immobilized in a simple sling and the radiographs
repeated in 7 to 10 days if symptoms persist.
Most fractures of the clavicle heal uneventfully and
can be followed by a primary care physician. A sling
should be worn until repeat radiographs show callus
formation and healing across the fracture site. Passive
shoulder range-of-motion exercises (Figure 50-14) are
encouraged to reduce the risk of adhesive capsulitis.
Younger children generally require shorter periods of 677
 Figure 50-11. Shoulder immobilization. A, Sling over
swathe. B, Velpeau sling immobilization.
PART TWO TRAUMA • Section III Orthopedic Lesions

A B

Figure 50-12. Clavicular or figure-of-eight

splint.

Figure 50-13. Greenstick fracture of the

clavicle (arrow).

678

Figure 50-14. Pendular shoulder exercises.
immobilization (2 to 4 weeks) than adolescents and
adults (4 to 8 weeks). Vigorous competitive play should
be avoided until the bone healing is solid.
Complications
Complications are unusual, with the most common
ones being delayed union or nonunion.16-18 Complica-
tions after fractures of the medial third resemble com-
plications associated with posterior sternoclavicular
dislocations. Fractures of the middle third have been
associated with injuries to the neurovascular bundle
and the pleural dome. Articular surface injuries (type
III lateral clavicle fractures) can lead to subsequent
osteoarthritis of the ACJ.
Scapula
Pathophysiology
Fractures of the scapula are rare injuries, with an
annual incidence of 10 to 12 per 100,000 popula-
tion.22,23 They account for 1% of all fractures and occur
primarily in men 30 to 40 years old.9 A thick muscle
coat and the ability to recoil along the chest wall
protect the scapula from direct and indirect trauma. In
general, considerable force and energy are required to
CHAPTER 50 Shoulder
fracture the scapula. Most fractures result from high-
speed vehicular accidents, falls from heights, or crush
injuries.24 Coracoid process fractures are usually avul-
sive, and glenoid rim fractures are commonly associ-
ated with anterior glenohumeral dislocations. An
acromial process fracture usually results from a direct
blow applied to the top of the shoulder.
The most important aspect of scapular fractures is the
high incidence (75% to 98%) of associated injuries to
the ipsilateral lung, chest wall, and shoulder girdle
complex.9,25,26 The most common associated orthopedic
injuries are fractures of the ribs, proximal humerus, and
clavicle. Associated lung injuries include pneumotho-
rax, hemothorax, and pulmonary contusion; these may
be seen in a delayed fashion, 2 to 3 days after the initial
injury. Associated injuries of the head, spinal cord,
brachial plexus, and subclavian or axillary vessels are
more significant but less common.9,25,26
Fractures of the scapula can be classified according
to their anatomic location. In the system proposed by
Ada and Miller,25 type I fractures involve the acromion
process, scapular spine, or coracoid process. Type II
fractures involve the scapular neck, and type III injuries
are intra-articular fractures of the glenoid fossa (Figure 679

PART TWO TRAUMA • Section III Orthopedic Lesions
680
Figure 50-15. Comminuted type III fracture of the scapular.
(Courtesy of David Nelson, MD.)
50-15). The most common are type IV fractures, which
involve the body of the scapula.25
Clinical Features
In a conscious patient, the shoulder is adducted, and
the arm is held close to the body. Any attempts at move-
ment result in significant pain. There may be associ-
ated tenderness, crepitus, or hematoma over the
fracture site. The clinical findings occasionally mimic
those seen with a rotator cuff tear. Hemorrhage into the
rotator cuff associated with the scapula fracture can
result in spasm and a temporary reflex inhibition of
function (pseudorupture).25 The presence of a scapula
fracture mandates a thorough search for associated tho-
racic, intracranial, orthopedic, and neurovascular
injuries.
Diagnostic Strategies
The trauma series of shoulder radiographs identifies
most fractures, as does careful examination of the
scapula on the trauma chest radiograph. The axillary
lateral view is especially useful in evaluating fractures
of the glenoid fossa and the acromion or coracoid
processes.9 The os acromiale (unfused acromial process
epiphysis) is present in 3% of the population and
should not be confused with a fracture of the
acromion.7 A comparison film can be useful because
the abnormality is present bilaterally in 60% of cases.
In many patients, fractures of the scapula initially are
overlooked because of the life-threatening nature of the
associated injuries.9
Management
Most fractures, including fractures with severe com-
minution and displacement, heal rapidly with conser-
vative therapy.9,24,25 Initial therapy consists of analgesia
and immobilization in a sling to support the ipsilateral
upper extremity. Passive shoulder exercises (see Figure
50-14) are initiated as soon as discomfort subsides to
reduce the risk of adhesive capsulitis. In general,
patients require a sling for 2 to 4 weeks.24
Fractures of the body and spine usually require no
further therapy. Nondisplaced fractures of the
acromion process also respond well to conservative
therapy. Displaced acromial fractures that impinge on
the glenohumeral joint require surgical management.
Rarely the acromion is fractured as part of a superior
dislocation of the humeral head. In these instances, an
accompanying tear of the rotator cuff is invariably
present and requires surgical repair. If the coracocla-
vicular ligaments remain intact, fractures of the cora-
coid process respond well to conservative therapy.
Severely displaced coracoid fractures with ruptured
coracoclavicular ligaments usually require open reduc-
tion and internal fixation.6 Scapular neck and glenoid
fossa fractures present the most difficult management
issues. Although most of these injuries do well with
conservative therapy, open reduction and internal fix-
ation are recommended for severely displaced or angu-
lated fractures.24,25
Complications
Associated injuries of the ipsilateral lung, chest wall,
and shoulder girdle account for most complications
after fractures of the scapula. A shear-type brachial
plexus injury has been associated with fractures of the
acromion process. Neurovascular (brachial plexus,
axillary artery) injuries also have been reported with
fractures of the coracoid process.6 Scapular neck, body,
or spine fractures that extend into the suprascapular
notch can injure the suprascapular nerve.6 Delayed
complications include adhesive capsulitis and rotator
cuff dysfunction.24
Proximal Humerus
Pathophysiology
Fractures of the proximal humerus are common and
account for 4% of all fractures.27 A prospective
Swedish study reported an incidence of 114 per
100,000 with a mean age of 67 years and a female-to-
male ratio of 3 : 1.28 These fractures occur primarily in
the older population, in whom structural changes asso-
ciated with aging (osteoporosis) weaken the proximal
humerus, predisposing it to injury. Although most of
these injuries are minimally displaced and do well
with conservative therapy, significantly displaced frac-
tures may require operative intervention.
Fractures of the proximal humerus separate along old
epiphyseal lines, producing four distinct segments con-
sisting of the articular surface (anatomic neck), greater
tuberosity, lesser tuberosity, and humeral shaft (surgi-
cal neck). The Neer classification system (Figure 50-16)
is based on the relationship of these fracture frag-
ments.29,30 In this system, a segment is considered
displaced if it is angled greater than 45 degrees or
separated more than 1 cm from the neighboring
segment. Because this classification system considers
 Figure 50-16. Neer’s classification of proximal
2 3 4
humeral fractures. (From Neer CS: Displaced prox-
part part part
imal humeral fractures: Part 1. Classification and
evaluation. J Bone Joint Surg Am 52:1077, 1979.)

Anatomic
neck

Surgical
neck
B C
A

Greater
tuberosity

CHAPTER 50 Shoulder
Lesser
tuberosity

Articular
surface

Fracture-
dislocation

Anterior
Posterior

only displacement, the number of fracture lines is irrel-

evant. There are four major categories of fracture:
minimal displacement (Figure 50-17), two-part dis-
placement (Figure 50-18), three-part displacement, and
four-part displacement. When present, anterior and
posterior dislocations are included as part of the clas-
sification. Impaction and head-splitting fractures are
classified separately.
The classic mechanism of injury involves a fall on an
outstretched abducted arm. Concurrent pronation
limits further abduction and levers the humerus against
the acromial process; this produces a fracture or dislo-
cation, depending on the tensile strengths of the bone
and surrounding ligaments. Older patients are prone to
Figure 50-17. Three-part minimally displaced fracture of the proxi-
fracture, whereas younger individuals are apt to dislo-
mal humerus.
cate. The combined injury (fracture and dislocation)
may be seen in middle-aged individuals. Proximal
humerus fractures also may result from a direct hematoma, ecchymosis, deformity, or crepitus may be
blow to the lateral side of the arm or from an axial load present over the fracture site. Although usually normal,
transmitted through the elbow. High-energy mecha- a thorough neurovascular examination helps identify
nisms and polytrauma are more common in younger associated injuries of the axillary nerve, brachial
individuals. plexus, or axillary artery.

Clinical Features Management

The affected arm is held close to the body, and all Minimally displaced fractures (see Figure 50-17)
movements are restricted by pain. Tenderness, constitute 80% to 85% of all cases. No displacement 681

PART TWO TRAUMA • Section III Orthopedic Lesions
682
Figure 50-18. Anteroposterior (A) and axillary (B) views of a two-
part displaced fracture of the proximal humerus. The degree of
displacement often is visualized better on the axillary view. (Cour-
tesy of David Nelson, MD.)
or angulation is present, and the fracture segments
are held together by the capsule, periosteum, and
surrounding muscles. Initial treatment consists of
adequate analgesia and immobilization with a sling
and swathe device. As soon as clinical union is
achieved (head and shaft move together), functional
exercises are initiated. Initial passive exercises (see
Figure 50-14) are slowly replaced by more active and
resistive exercises. Most nondisplaced fractures heal
over 4 to 6 weeks.
The treatment of two-part, three-part, and four-part
displaced fractures is beyond the scope of this discus-
sion. An orthopedic surgeon should be consulted
because many of these injuries require operative
repair.30 Fracture-dislocation injuries also may require
an orthopedic surgeon. Care must be used because
reductions of these injuries in the emergency depart-
ment are often unsuccessful and can cause separation
of previously undisplaced segments. Closed reduction
under x-ray control and general anesthesia may be
preferable.31
Posterior glenohumeral dislocations usually are asso-
ciated with anteromedial impression fractures of the
articular surface. A similar fracture of the posterolat-
eral aspect of the humeral head is present with anterior
dislocations (Hill-Sachs deformity). Impression frac-
tures involving less than 20% of the articular surface
are usually stable. With more than 20% involvement,
the reduction is usually unstable and requires surgical
repair.
Complications
The most common complication of proximal humeral
fractures is adhesive capsulitis (“frozen or stiff shoul-
der”). This complication can be prevented by the
early initiation of a thorough rehabilitation program.
Two-part fractures of the articular surface and four-part
fractures have a high incidence of avascular necrosis
of the humeral head. Repeated forceful attempts at
reduction of fracture-dislocations may be associated
with subsequent heterotopic bone formation (myositis
ossificans). Neurovascular injuries (axillary nerve,
brachial plexus, and axillary artery) may be encoun-
tered with displaced surgical neck fractures and
fracture-dislocations.
Proximal Humeral Epiphysis
Pathophysiology
Fractures of the proximal humeral epiphysis are
uncommon and account for 10% of all shoulder frac-
tures in children.32 The injury can occur at any age

A B
while the epiphysis remains open but is most common
in boys 11 to 17 years old.33 The most common mech-
anism of injury involves a fall onto the outstretched
hand, and the fracture typically occurs through the
zone of hypertrophy in the epiphyseal plate. Injuries
can be classified according to their location (Salter
system), stability, and degree of displacement.6
Clinical Features
The patient has the injured arm held tightly against the
body by the opposite hand. The area over the proximal
humerus is swollen and extremely tender to palpation.
Radiographs obtained at 90 degrees to each other
confirm the diagnosis. Comparison views may be
helpful with minimally displaced fractures.33
Management
Fractures of the proximal humeral epiphysis should
not be taken lightly because the potential for growth
disturbance exists even under the most ideal condi-
tions. The active healing process at the site of an epi-
physeal injury makes delayed reduction extremely
difficult. Early orthopedic consultation should be
obtained for all such injuries. Children younger than 6
years old usually have Salter I epiphyseal injuries
(Figure 50-19) and can be treated conservatively with
sling and swathe immobilization and analgesic agents.
Children older than age 6 usually have a Salter II epi-
physeal injury. Salter II injuries with greater than 20
degrees of angulation should be reduced.34 Closed
reduction is accomplished by reversing the mechanism
Figure 50-19. A, Salter I injury of the right proximal humeral
epiphysis. B, Normal left side is included for comparison.
CHAPTER 50 Shoulder
of injury. Imperfect reductions are often acceptable
because growth and remodeling correct the deformity
with time. After reduction, unstable injuries should be
immobilized in a shoulder spica cast, whereas stable
lesions can be immobilized with a sling and swathe.
Fractures of the proximal humeral epiphyses generally
heal in 3 to 5 weeks.34
Complications
Complications are rare and include malunion, growth
plate disturbances, and injuries to the neurovascular
bundle. Markedly displaced or angulated fractures are
more likely to result in a residual loss of mobility.32
Dislocations
Sternoclavicular
Pathophysiology
The SCJ is the least commonly dislocated major joint
in the body. Significant forces are required to disrupt
the strong ligamentous stabilizers of this joint. The
most common causes are motor vehicle accidents and
injuries sustained in contact sports, such as rugby or
football. The SCJ can dislocate in an anterior or poste-
rior direction. Anterior dislocations, which result from
indirect forces, are more common (9 : 1 ratio).5 The
usual mechanism of injury (Figure 50-20) involves an
anterolateral force to the shoulder, followed by back-
ward rolling, which levers the medial clavicle out of its
articulation. Posterior dislocations (Figure 50-21) can 683
 A B
Figure 50-20. Mechanisms that produce anterior and posterior displacements of the sternoclavicular joint. A, When the patient is lying on the
ground and a compression force is applied to the posterolateral aspect of the shoulder, the medial end of the clavicle is displaced posteriorly.
B, When the lateral compression force is directed from the anterior position, the medial end of the clavicle is dislocated anteriorly. The same
mechanism could apply with any type of lateral compression injury of the shoulder. (From Neer CS, Rockwood CA: Fracture and dislocations
of the shoulder. In Rockwood CA, Green DP [eds]: Fractures in Adults, 4th ed. Philadelphia, JB Lippincott, 1984.)
PART TWO TRAUMA • Section III Orthopedic Lesions

have the injured extremity foreshortened and sup-

Figure 50-21. CT scan shows posterior dislocation of the right ster-
noclavicular (arrow) joint with compression of the superior medi-
astinum. (Courtesy of Donald Sauser, MD.)
result from a direct blow to the medial clavicle (30%)
or from a posterolateral force to the shoulder followed
by inward rolling (70%). Posterior dislocations can be
associated with life-threatening injuries within the
superior mediastinum. Injuries to the SCJ can be graded
into three types.5 A grade I injury is a mild sprain sec-
ondary to stretching of the sternoclavicular and costo-
clavicular ligaments. A grade II injury is associated
with subluxation of the joint (anterior or posterior) sec-
ondary to rupture of the sternoclavicular ligament. The
costoclavicular ligament remains intact. Complete
rupture of the sternoclavicular and costoclavicular lig-
aments results in a grade III injury (dislocation). In
patients younger than age 25, these actually represent
Salter Type I injuries because the medial epiphysis of
the clavicle has not yet fused.35
Clinical Features
Clinical suspicion is the most important factor in diag-
nosing these injuries, and prompt diagnosis is vital
684 because it is associated with a better prognosis. Patients
ported across the trunk by the opposite arm. There is
pain with any movement of the upper extremity or
lateral compression of the shoulders. The SCJ is mildly
swollen and tender to palpation. With an anterior dis-
location, the displaced medial end of the clavicle may
be palpable. Posterior dislocations are associated with
more severe pain, and the neck is often flexed toward
the injured side.5 The clavicular notch of the sternum
may be palpable, and there may be complaints of
hoarseness, dysphagia, dyspnea, and weakness or
paresthesias in the upper extremities. Rarely, airway
complications can occur. These patients should be
examined thoroughly to identify any injuries to supe-
rior mediastinal or intrathoracic structures. When nec-
essary, appropriate consultation should be obtained
immediately.
Diagnostic Strategies: Radiology
Although the diagnosis of sternoclavicular dislocations
can be made clinically, it should be confirmed radio-
logically. Standard anteroposterior, oblique, and spe-
cialized (40-degree cephalic tilt) views are often
difficult to interpret because of overlapping rib,
sternum, and vertebral shadows. CT is best to visualize
these dislocations and associated injuries (see Figure
50-21) or MRI.15 Ultrasound also may be a useful
adjunct in some circumstances.5
Management
Treatment of grade I injuries includes immobilization
(simple sling), adequate analgesia, and primary care
follow-up. Immobilization generally is maintained (1 to
2 weeks) until full painless motion is restored. Grade
II injuries should be immobilized with a sling or soft
clavicular (figure-of-eight) splint and referred for ortho-
pedic follow-up. The figure-of-eight splint is preferred
because it maintains the clavicle in a more anatomic
position. Grade II injuries require a longer course of
immobilization (3 to 6 weeks) and are more likely to be
associated with persistent pain.5,6 All grade III injuries
should be managed by closed reduction. Anterior dis-
locations may be reduced in the emergency department

Figure 50-22. Reduction of dislocated sternoclavicular joints. (From
Simon RR, Koenigsknecht SJ: Emergency Orthopedics: The Extrem-
ities, 2nd ed. Norwalk, Conn, Appleton & Lange, 1987.)
after orthopedic consultation and intravenous analge-
sia (Figure 50-22). A rolled sheet is placed posteriorly
between the shoulder blades to elevate both shoulders
approximately 5 cm above the table. Traction is applied
to the arm in an extended (10- to 15-degree) and
abducted (90-degree) position. If reduction does not
occur, an assistant can add inward pressure on the
medial end of the clavicle. Stable reductions should
be maintained in a clavicular splint and referred for
orthopedic follow-up.5,6 Most reductions are unstable.
Because the deformity is primarily cosmetic and not
functional, the current treatment of choice for recurrent
anterior dislocations is benign neglect.
Posterior dislocations are true orthopedic emergen-
cies and should be reduced expeditiously.5 Ideally,
reduction of posterior dislocations should be attempted
in the operating room under general anesthesia,
although it can be attempted in the emergency depart-
ment under conscious sedation. Emergency reduction
may be required for patients with airway obstruction or
vascular compromise. The patient is positioned as
described previously, and traction is applied in an
extended and abducted position. If traction alone does
not reduce the dislocation, concurrent clavicular
manipulation may be helpful. The skin is sterilely pre-
pared, and the clavicle shaft is grasped with a sterile
towel clip and pulled out anterolaterally. When
reduced, these injuries are generally stable and can be
immobilized with a clavicular splint. Buckerfield and
Castle36 described an alternate method of reduction for
posterior dislocations. In this technique, traction is
applied to the adducted arm while both shoulders
simultaneously are forced posteriorly using direct pres-
sure. This technique levers the clavicle into place and
requires much less force than the traditional abduction-
extension method.
Complications
Complications of anterior injuries are primarily cos-
metic. Twenty-five percent of posterior dislocations
may be complicated by life-threatening injuries to
intrathoracic and superior mediastinal structures. A
potential long-term complication of both is degenera-
CHAPTER 50 Shoulder
tive osteoarthritis.
Acromioclavicular Joint
Pathophysiology
Injuries of the ACJ occur primarily in men and account
for 25% of all dislocations about the shoulder girdle.28
The annual incidence is 15 per 100,000, and most
injuries result from participation in contact sports,
such as football, rugby, ice hockey, and wrestling.28 A
small percentage of injuries are caused by motor
vehicle accidents and falls.
The most common mechanism of injury involves a
fall or direct blow to the point of the shoulder with the
arm adducted. The resultant force drives the scapula
downward and medially to produce the injury. The
weak acromioclavicular ligaments rupture first. With
increasing force, the coracoclavicular ligament rup-
tures, and the attachments of the deltoid and trapezius
muscles are torn from the distal clavicle. The ACJ also
can be injured after a fall onto the outstretched hand.
In this instance, the force is transmitted to the acromio-
clavicular ligaments only, and the coracoclavicular lig-
ament, which is relaxed, remains uninjured.37
The three-part Tossy and Allman classification
system is based on the degree of damage sustained by
the acromioclavicular and coracoclavicular ligaments
(Figure 50-23).8 Type I injuries are sprains of the
acromioclavicular ligaments. Type II injuries are asso-
ciated with disruption of the acromioclavicular liga-
ments. The joint space is widened, and the clavicle
displaces slightly upward. There are minor tears in the
attachments of the deltoid and trapezius muscles, but
the coracoclavicular ligament remains intact, and the
coracoclavicular distance is maintained. A type III
injury is characterized by complete disruption of
the acromioclavicular ligaments, coracoclavicular liga-
ment, and muscle attachments. The joint space is
widened, and the coracoclavicular distance is in-
creased. The clavicle is displaced upward by the pull
of the trapezius, and the shoulder is displaced down-
ward by the effect of gravity. Rockwood modified this
three-part classification system by describing three
additional types (IV, V, and VI) of ACJ injuries.35 In type
IV and V injuries, the ligamentous and muscle disrup-
tions are similar to the disruptions encountered in type 685

PART TWO TRAUMA • Section III Orthopedic Lesions
686
Figure 50-23. Mechanism of injury and classi-
fication of acromioclavicular joint injuries.
A, The direct force is applied to the point of the
shoulder (1); the scapula and attached clavicle
are forced downward and medially; the clavicle 1 3
approaches the first rib (2). If the force contin-
ues, the first rib abuts the clavicle, producing a
counterforce (3). Depending on the magnitude
of the force, a grade I, II, or III sprain may occur.
B, Grade I sprain. A few fibers of the acromio-
clavicular ligament stretch, and a few tear (1);
the acromioclavicular joint is stable (2); the
coracoclavicular ligament is intact (3). C, Grade
II sprain (subluxation). The capsule and the
acromioclavicular ligament rupture (1); the joint
is lax and unstable (2); the end of the clavicle
rides upward, usually less than half of the width A B
of the end of the clavicle (3); the coracoclavic-
ular ligament remains intact (4); the attachments
to the trapezius and deltoid remain intact.
D, Grade III sprain (dislocation). The capsule
and acromioclavicular ligaments rupture (1); the
coracoclavicular ligament ruptures (2); the
insertions of the trapezius and deltoid tear away
(3); the clavicle rides upward (4); the interval
between the clavicle and the coracoid process
is greatly increased (5). (From DePalma AF:
Surgery of the Shoulder, 3rd ed. Philadelphia,
JB Lippincott, 1983.)
C D
III injuries, but the clavicle displaces either posteriorly
into the trapezius (type IV) or superiorly in an exag-
gerated fashion (type V). In the rare type VI injury, the
clavicle displaces inferiorly.
Clinical Features
Patients should be examined while they are in the
sitting or standing position because the supine position
can mask ACJ instability. Type I injuries are associated
with mild tenderness and swelling over the ACJ
margin. No deformity occurs, and a full range of motion
is usually possible, although painful. Type II injuries
produce moderate pain, and the distal end of the clav-
icle may lie slightly superior or posterior to the
acromion. Patients with type III, IV, V, and VI injuries
usually have severe pain and hold the arm tightly
adducted to reduce traction stress across the joint. In
type III injuries, the shoulder hangs downward, and the
clavicle rides high, producing a visible clinical defor-
mity. In type IV injuries, the clavicle may be palpable
posteriorly, and in type V injuries, the clavicle may be
palpable subcutaneously above the acromion. In type
VI injuries, the shoulder assumes a flattened clinical
appearance.
Diagnostic Strategies: Radiology
The energy settings used for the radiographic trauma
series overpenetrate the ACJ. Specific ACJ views that
1
2
3
2
3
4
1
1
2 3
4
5 2
use one third to two thirds less intensity should be
ordered. The recommended projections include an
anteroposterior view of both joints on a single wide
film, an axillary lateral view, and a 15-degree cephalic
tilt view.8,35 The axillary lateral view is useful for iden-
tifying associated fractures and posterior dislocation of
the clavicle. The normal coracoclavicular distance
varies between 11 and 13 mm. A difference of more
than 5 mm between the injured and uninjured sides is
diagnostic of a complete coracoclavicular disruption.
Type I injuries have essentially normal radiographs.
Type II injuries show widening of the joint and a slight
upward or posterior displacement of the clavicle but a
normal coracoclavicular distance. Type III, IV, and V
injuries have a widened joint, an increased coraco-
clavicular distance, and either superior or posterior dis-
placement of the clavicle (Figure 50-24). Historically,
stress views of the ACJ have been recommended to dif-
ferentiate between type II and III injuries. Such views
lack efficacy for this purpose, and their routine use is
unnecessary.38
Management
Type I and II injuries should be immobilized in a sling
for comfort and to protect against further injury. These
patients should be referred for follow-up with their
primary care physician. When pain has subsided (1 to
3 weeks), the patient can begin range-of-motion and

Figure 50-24. Third-degree sprain of the acromioclavicular joint. The
coracoclavicular distance measures 18 mm (arrow). (Courtesy of
David Nelson, MD.)
strengthening exercises with a return to sports when
pain-free function has been achieved.8 Type IV, V, and
VI injuries require early surgical treatment. The man-
agement of type III injuries has changed dramatically
since the 1980s. Most studies have concluded that con-
servative treatment provides equal or, in some cases,
better functional results than surgical intervention. In
addition, surgical patients have longer recovery times
and higher complication rates.8 The main complica-
tions of conservative therapy are the persistence of nui-
sance symptoms (clicking or pain) and a cosmetic
deformity. Selected patients who are young, have
severe displacement (>2 cm), and perform repetitive
overhead activities may be candidates for surgical
intervention.8 Treatment of type III injuries in the emer-
gency department should consist of sling immobiliza-
tion and early (<72 hours) orthopedic referral. The
initial therapy in all cases should include adequate
analgesia.
Complications
The most common concurrent injuries are associated
fractures of the clavicle and coracoid process.
Osteoarthritis of the ACJ is a potential long-term com-
plication of an acute injury.8 Acromioclavicular arthri-
tis typically presents as an impingement syndrome
with shoulder pain between 120 and 180 degrees of
abduction.
Glenohumeral Dislocations
Perspective
The glenohumeral joint is the most commonly dislo-
cated major joint in the body. The lack of intrinsic
bony stability in conjunction with its wide range of
motion predisposes the joint to dislocations. The
annual incidence is 17 per 100,000, and there are
two distinct age peaks. The first is in men age 20 to 30
years, and the second is in women age 61 to 80 years.39
The glenohumeral joint can dislocate anteriorly, poste-
riorly, inferiorly, or superiorly. Anterior dislocations
account for 95% to 97% of all glenohumeral disloca-
tions. Posterior dislocations account for most of the
remainder, whereas inferior and superior dislocations
are rare.
Anterior Dislocations
Pathophysiology. Anterior dislocations can result from
indirect or direct forces. The most common mechanism
of injury consists of an indirect force transferred to the
anterior capsule from a combination of abduction,
extension, and external rotation. In younger indi-
CHAPTER 50 Shoulder
viduals, the injury usually is sustained during athletic
activities. In older patients, a fall onto the outstretched
arm is more common.28 Rarely a direct force applied to
the posterolateral aspect of the shoulder can force the
humeral head out of the glenoid fossa anteriorly.
Anterior dislocations can be classified according to
their etiology (traumatic or nontraumatic), frequency
(primary or recurrent), and the anatomic position of
the dislocated humeral head.39 After dislocation, the
humeral head can assume a subcoracoid, subglenoid,
subclavicular, or intrathoracic position (Figure 50-25).
The subcoracoid is the most common type of anterior
dislocation. The head is displaced anteriorly and rests
on the scapular neck inferior to the coracoid process.
The next most common type is the subglenoid disloca-
tion, in which the head is anterior and inferior to the
glenoid fossa. Together the subcoracoid and subglenoid
types account for 99% of all anterior dislocations. Sub-
clavicular and intrathoracic dislocations are extremely
rare and involve the addition of strong lateral to medial
forces that push the humeral head medially.
Clinical Features. The patient is in severe pain with
the dislocated arm held in slight abduction and exter-
nal rotation by the opposite extremity. The lateral edge
of the acromion process is prominent, and the normally
rounded shoulder assumes a “squared-off” appearance.
The coracoid process is indistinct, and the anterior
shoulder appears full. The patient leans away from the
injured side and cannot adduct or internally rotate the
shoulder even slightly without severe pain. A neu-
rovascular examination is performed to identify asso-
ciated injuries of the brachial plexus, axillary nerve,
radial nerve, or axillary artery. The reported incidence
of axillary nerve injuries after anterior glenohumeral
dislocation ranges from 5% to 54%.40,41 Axillary nerve
function can be assessed by testing for sensation over
the lateral aspect of the shoulder and by testing motor
function of the teres minor and deltoid muscles.
Deltoid function is tested by having the patient attempt
shoulder abduction while the examiner feels for muscle
contraction. Motor testing is more accurate because
sensory testing can be misleading owing to the pres-
ence of overlapping cutaneous nerve root dermatomes.
Axillary nerve injuries occur more frequently in
patients older than age 50 years.41 687
 Figure 50-25. Types of anterior disloca-
tion. A, Subcoracoid. B, Subglenoid.
C, Subclavicular. D, Intrathoracic. (From
DePalma AF: Surgery of the Shoulder, 3rd
ed. Philadelphia, JB Lippincott, 1983.)

A B
PART TWO TRAUMA • Section III Orthopedic Lesions

C D

Diagnostic Strategies: Radiology. The trauma series of

radiographs confirms the clinical diagnosis and identi-
fies the position of the humeral head (Figure 50-26).
Associated fractures may be present in 50% of cases.
The most common of these is a compression fracture of
the posterolateral aspect of the humeral head caused by
forceful impingement against the anterior rim of the
glenoid fossa. This defect in the humeral head, or Hill-
Sachs deformity (see Figure 50-26), is reported to be
present in 11% to 50% of all anterior dislocations. The
actual incidence is probably much higher because
minor compression fractures are difficult to visualize
on plain radiographs. The defect is best visualized on
an internal rotation anteroposterior view of the gleno-
humeral joint. A corresponding fracture of the anterior
glenoid rim (Bankart’s fracture) is present in approxi-
mately 5% of cases.10 Avulsion fractures of the greater
tuberosity are present in 10% to 15% of cases.10,40
Management. Closed reduction of the dislocation
should be accomplished expeditiously because the
incidence of neurovascular complications increases
with time.41 Radiographic documentation of the type of Figure 50-26. Recurrent anterior subcoracoid dislocation with
dislocation and any associated fractures should be Hill-Sachs deformity of the humeral head (arrow).
obtained before attempting reduction. Reduction can be
accomplished using various techniques, most of which
involve traction, leverage, or scapular manipulation shoulder. It is wise to be familiar with several tech-
principles.42 There are no good comparative studies of niques of reduction because none is uniformly
one reduction technique over another.42 The ideal successful.
method should be simple, quick, and effective; require Good muscle relaxation is the key to a successful
688 little assistance; and cause no additional injury to the reduction in most settings. Muscle relaxation can be

Figure 50-27. Stimson or hanging weight method of reduction for
anterior dislocations.
achieved using conscious sedation or interscalene,
supraclavicular, or suprascapular nerve blocks.43 Occa-
sionally, reductions can be accomplished without the
use of any analgesia, especially if the time from injury
to reduction is short or if the dislocation is a recurrent
one. Muscle relaxation and analgesia also can be pro-
vided through intra-articular injection of a local anes-
thetic agent.43,44 This technique is especially useful
when conscious sedation is contraindicated and is
associated with a shorter length of stay in the emer-
gency department after reduction.44 The joint is entered
under sterile technique 2 cm inferior to the lateral edge
of the acromion using an 18-gauge or 20-gauge needle.
Any associated hemarthrosis is aspirated, then 20 mL
of 1% lidocaine is injected over 30 seconds. The patient
is allowed to relax for 15 minutes before reduction is
attempted.
Gentle traction in various directions (forward flexion,
abduction, overhead, lateral) is used to overcome the
muscle spasm that holds the humeral head in its dis-
located position.42 In the Stimson or hanging weight
technique (Figure 50-27), the patient is placed prone
with the dislocated arm hanging over the edge of the
examining table. A 10- or 15-lb weight attached to the
wrist or lower forearm provides traction in forward
flexion. Reduction usually occurs over 20 to 30
minutes. In the traction-countertraction method (Figure
50-28), traction is applied along the abducted arm
while an assistant using a folded sheet wrapped across
the chest applies countertraction. The forward eleva-
tion maneuver of Cooper and Milch is also simple and
safe. The arm is initially elevated 10 to 20 degrees in
forward flexion and slight abduction. Forward flexion
is continued until the arm is directly overhead. Abduc-
tion is increased, and outward traction is applied to
complete the reduction.45
Another simple and effective traction technique is
the Snowbird technique.46 In this method, the patient
CHAPTER 50 Shoulder
Figure 50-28. Traction-countertraction method for reducing anterior
shoulder dislocations.
Figure 50-29. External rotation technique. The involved arm is slowly
adducted to the patient’s side, and the elbow is flexed 90 degrees.
Gentle external rotation is applied to the forearm to achieve
reduction. (From Simon RR, Koenigsknecht SJ: Emergency Ortho-
pedics: The Extremities, 2nd ed. Norwalk, Conn, Appleton & Lange,
1987.)
is seated in a chair, and the affected arm is supported
by the patient’s unaffected extremity. A 3-foot loop of
4-inch cast stockinet is placed along the proximal
forearm of the involved extremity with the elbow at 90
degrees. The patient is assisted or instructed to sit up,
and the physician’s foot is placed in the stockinet loop
to provide firm downward traction. The physician’s
hands remain free to apply any gentle external pressure
or rotation as needed until reduction is accomplished.
The most commonly recommended leverage tech-
nique is the external rotation method of Liedelmeyer.47
With the patient in the supine position, the involved
arm is slowly and gently adducted to the side. The
elbow is flexed to 90 degrees, and slow, gentle external
rotation is applied to achieve reduction (Figure 50-29).
Scapular manipulation accomplishes reduction by
repositioning the glenoid fossa rather than the humeral
head. The patient is placed in the prone position with
the affected arm hanging off the table as for the Stimson 689

PART TWO TRAUMA • Section III Orthopedic Lesions
690
Figure 50-30. Proper hand position and direction of rotation during
shoulder relocation using the scapular manipulation technique. (From
Kothari RU, Dronen SC: The scapular manipulation technique for the
reduction of acute anterior shoulder dislocations. J Emerg Med 8:625,
1990.)
technique. After the application of downward traction
(manual or hanging weights), the scapula is manipu-
lated by rotating the inferior tip medially (Figure 50-
30), while stabilizing the superior and medial edges
with the opposite hand.48 McNamara49 also described a
seated modification of the scapular method in which
traction is applied in the forward horizontal position
while an assistant manipulates the scapula. Scapular
manipulation can be difficult in heavyset individuals,
in whom it is difficult to palpate and grasp the inferior
tip of the scapula. More traditional techniques, such as
the Hippocratic method (traction with the foot in the
axilla) and the Kocher maneuver (leverage, adduction,
and internal rotation), are no longer recommended
because of a high incidence of associated complications
(axillary nerve injury, humeral shaft and neck fractures,
capsular damage).
The neurovascular examination must be repeated
after any attempt at reduction. It also is generally rec-
ommended that radiographs be repeated to confirm
reduction and to identify any associated fractures not
apparent on prereduction films. More recent studies
have questioned the need and cost-effectiveness of
routine postreduction radiographs.50-52 The authors of
these studies did not find any new clinically significant
fractures on postreduction radiographs and argued that
in most instances a successful reduction can be deter-
mined clinically by the presence of a palpable clunk,
decrease in pain, and improvement in the range of
motion. These findings must be confirmed in larger
prospective studies before they are adopted as a stan-
dard of care.
After reduction, the affected extremity is immobi-
lized using a sling and swathe bandage or a Velpeau
sling (see Figure 50-11). Patients should be discharged
with adequate analgesia and appropriate follow-up.
Primary dislocations and complicated cases (associated
fracture, rotator cuff tear, axillary nerve injury) should
receive orthopedic follow-up. In uncomplicated cases,
the shoulder is immobilized for 3 to 6 weeks in younger
patients and 1 to 2 weeks in older (>40 years old) indi-
viduals.10 The traditional position of immobilization is
with the shoulder in internal rotation. Studies suggest
that this positioning may delay healing and is associ-
ated with a higher recurrence rate.53 In a randomized
clinical trial, Itoi and coworkers54 found that 3 weeks
of immobilization in 10 degrees of external rotation was
associated with a zero recurrence rate at 13 to 15
months compared with a 30% recurrence rate with
sling immobilization in internal rotation. If these pre-
liminary findings are confirmed by additional trials,
sling immobilization may be replaced by external rota-
tion splints. Regardless of the immobilization tech-
nique, early initiation of shoulder exercises (see Figure
50-14) helps reduce the risk of adhesive capsulitis. A
meticulous rehabilitation program aimed at restoring
the static and dynamic stabilizers of the glenohumeral
joint follows the period of immobilization.10
Complications. Complications include the aforemen-
tioned fractures and neurovascular injuries. Most
axillary nerve injuries are neurapraxic, and the prog-
nosis for recovery of function is good.41 Rotator cuff
tears may be present in 10% to 15% of cases.55 Rotator
cuff tears are especially common in primary disloca-
tions in patients older than age 40. In this setting,
failure to abduct the arm often is misdiagnosed initially
as an axillary nerve injury. Most of these individuals
require tendon and capsular repair to restore shoulder
stability.55 Recurrence also is a common complication
after anterior dislocation, and patients younger than
age 30 have a reported recurrence rate of 79% to
100%.39 A Hill-Sachs deformity or glenoid rim fracture
is associated with increased risk of recurrence.10
Studies suggest that the traditional method of treatment
(immobilization followed by physical therapy) is inef-
fective in preventing redislocation in young, highly
athletic individuals. Arthroscopic studies of primary
anterior dislocations in young, highly athletic indivi-
duals have detected a high incidence of anterior-
inferior capsulolabral avulsions (Perthes-Bankart
lesion) from the glenoid rim. This avulsion is believed
to be the primary predisposing factor for recurrence,
and these individuals seem to benefit from early arthro-
scopic repair of the lesion.56 Recurrence rates decline
with increasing age and in the presence of a greater
tuberosity fracture.10

Figure 50-31. Technique for performing the shoulder apprehension
test. (From Simon RR, Koenigsknecht SJ: Emergency Orthopedics:
The Extremities, 2nd ed. Norwalk, Conn, Appleton & Lange, 1987.)
Anterior Subluxation
Transient anterior subluxation of the shoulder is
encountered often in young athletic adults. The patient
complains of sudden sharp shoulder pain and weak-
ness (dead arm syndrome) while performing an abduc-
tion and external rotation maneuver. The patient also
may relate a sensation of the shoulder slipping in and
out. Radiographs are usually normal, and a positive
apprehension sign confirms the diagnosis. The latter is
performed by gently reproducing the injury motion,
abduction, and external rotation of the arm while
applying an anterior force to the posterior shoulder
(Figure 50-31). This maneuver increases the pain and
may cause anterior displacement of the humeral head.
A lax or redundant anterior capsule is thought to be
responsible for this syndrome, and recurrent episodes
are common. These patients should be referred for
orthopedic follow-up because definitive therapy (cap-
sulorrhaphy) is surgical.57
Posterior Dislocation
Pathophysiology. Posterior dislocations are rare and
account for 2% of all glenohumeral dislocations.58 This
rarity is explained partly by anatomy of the shoulder
girdle. The 45-degree angulation of the scapula on the
thoracic cage positions the glenoid fossa posterior to
the humeral head and serves as a partial buttress
against posterior dislocation. Greater than 50% of pos-
terior dislocations are missed on initial evaluation, and
many remain unrecognized (“locked posterior disloca-
tions”) for weeks and months.59,60
A posterior dislocation can result from several dis-
tinct mechanisms of injury. Convulsive seizures
(epileptic or after electrical shock) often are associated
with unilateral or bilateral posterior dislocations. In
this instance, the larger and stronger internal rotator
muscles (latissimus dorsi, pectoralis major, teres major,
subscapularis) overpower the weaker external rotators
(teres minor, infraspinatus) to produce the injury.59 A
posterior dislocation also can occur after a fall onto the
outstretched hand with the arm held in flexion, adduc-
tion, and internal rotation or after a direct blow to the
anterior aspect of the shoulder. Acute posterior dislo-
cations are classified into three types (subacromial,
subglenoid, subspinous) based on the final resting posi-
Figure 50-32. Overlap of the glenoid rim associated with posterior
dislocation.
tion of the humeral head. The subacromial variety
accounts for 98% of all posterior dislocations.58
Clinical Features. Early diagnosis is essential to
CHAPTER 50 Shoulder
prevent long-term functional and therapeutic compli-
cations. As mentioned, the initial examining physician
misses the diagnosis with some regularity, in part
because of an overreliance on radiologic findings and
an underreliance on the clinical examination. The most
common misdiagnosis is adhesive capsulitis.58,60 The
patient holds the affected arm across the chest in
adduction and internal rotation. Although usually
painful, the injury can be relatively painless.59 The
normal shoulder contour is replaced by a flat, squared-
off appearance, and the coracoid process is prominent
and easily palpated. The humeral head may be palpa-
ble posteriorly beneath the acromion process. Abduc-
tion is severely limited, and external rotation is
completely blocked.
Diagnostic Strategies: Radiology. Standard anteropos-
terior radiographs can appear deceptively normal with
posterior dislocations. The common inability to diag-
nose posterior dislocation in the frontal plane has led
to the description of several characteristic radiographic
findings. Standard anteroposterior films show loss of
the half-moon elliptical overlap of the humeral head
and glenoid fossa. In addition, the distance between the
anterior glenoid rim and the articular surface of the
humeral head is increased (“rim sign”). The humeral
head is profiled in internal rotation and takes on a
“light bulb” or “drumstick” appearance. A true antero-
posterior film shows abnormal overlap of the glenoid
fossa with the humeral head (Figure 50-32). Finally, an
impaction fracture of the anteromedial humeral head
(reverse Hill-Sachs deformity) is invariably present
(Figure 50-33). This fracture may produce a curvilinear
density on the frontal projection parallel to the articu-
lar cortex of the humeral head (“trough sign”). An
orthogonal view, such as an axillary lateral, trans-
scapular, or apical oblique, confirms the diagnosis. The
axillary lateral view or apical oblique view also identi-
fies associated fractures of the humeral head and pos-
terior glenoid rim. CT may be helpful in some
instances.61
Management. Orthopedic consultation should be
obtained for all patients with posterior dislocations.
Closed reduction may be attempted in the emergency
department under conscious sedation. The technique
of reduction incorporates axial traction in line with the 691
PART TWO TRAUMA • Section III Orthopedic Lesions

Figure 50-33. Anteroposterior and axillary views of a posterior glenohumeral dislocation. Note the widened joint space (rim sign), anterome-
dial impaction fracture of the humeral head, and curvilinear density parallel (arrow) to the articular surface (trough sign). (Courtesy of Donald
Sauser, MD.)

Figure 50-34. Luxatio erecta. A, The mechanism by which

this injury occurs in hyperabduction. B, This is always
accompanied by disruption of the rotator cuff and tear
through the inferior capsule. (From Simon RR, Koenigsknecht
SJ: Emergency Orthopedics: The Extremities, 2nd ed.
Norwalk, Conn, Appleton & Lange, 1987.)

A B

humerus, gentle pressure on the posteriorly displaced Inferior Glenohumeral Dislocation

head, and slow external rotation. If this technique fails,
reduction with the patient under general anesthesia is
indicated. After reduction, the shoulder should be
immobilized in external rotation with slight abduc-
tion.60 Cases that were missed initially and present as
a chronic or locked posterior dislocation should be
referred to the orthopedist for follow-up. Locked pos-
terior dislocations usually require open reduction and
internal fixation or arthroplasty.60,61
Complications. Fractures of the glenoid rim, greater
tuberosity, lesser tuberosity, and humeral head account
for most associated injuries. Rarely the subscapularis
muscle may be avulsed from its insertion site on the
lesser tuberosity. Neurovascular injuries are uncom-
mon because the anterior location of the neurovascular
bundle protects it from injury. Recurrent posterior dis-
locations occur in 30% of patients and predispose the
692 joint to degenerative changes.
(Luxatio Erecta)
Pathophysiology. Luxatio erecta is a rare type of gleno-
humeral dislocation in which the superior aspect of the
humeral head is forced below the inferior rim of the
glenoid fossa. It is estimated that 0.5% of all shoulder
dislocations are of this variety. The mechanism of
injury involves either direct or indirect forces.62,63
Application of a direct axial load to an abducted shoul-
der can disrupt the weak inferior glenohumeral liga-
ment and drive the humeral head downward. Most
inferior dislocations result from indirect forces,
however, that hyperabduct the affected extremity62; this
causes impingement of the humeral head against the
acromion process. Further levering of the humeral shaft
against the acromion ruptures the capsule and dislo-
cates the head inferiorly (Figure 50-34).
Clinical Features. Clinically the patient has the arm
locked overhead in 110 to 160 degrees of abduction.

The elbow is usually flexed, and the forearm typically
rests on top of the head. The shoulder is fixed in this
position, and any attempts at movement result in sig-
nificant pain. The inferiorly displaced humeral head
may be palpable along the lateral chest wall. A thor-
ough neurovascular examination is essential.
Diagnostic Strategies: Radiology. Many cases of
luxatio erecta are mistakenly diagnosed and treated as
subglenoid anterior dislocations because the radio-
graphic features of these two clinical entities are
remarkably similar. Standard anteroposterior radio-
graphs show the superior articular surface inferior
to the glenoid fossa (Figure 50-35). In addition, the
humeral shaft characteristically lies parallel to the
spine of the scapula on the anteroposterior view.63 This
radiographic feature is useful in distinguishing luxatio
erecta from a subglenoid anterior dislocation because
in the latter, the humeral shaft lies parallel to the chest
wall. Associated fractures of the acromion, coracoid,
clavicle, greater tuberosity, humeral head, and glenoid
rim are common.
Management. If possible, orthopedic consultation
should be obtained before attempting closed reduction
under conscious sedation in the emergency depart-
ment. Reduction usually can be accomplished using
traction-countertraction maneuvers. Traction is applied
in line with the humeral shaft, while an assistant
applies countertraction across the shoulder (Figure
50-36). Gentle abduction usually reduces the disloca-
tion, and the arm is brought down into an adducted
position. In rare instances, buttonholing of the cap-
sule prevents closed reduction, necessitating open
reduction.
Complications. Neurapraxic lesions of the brachial
plexus are common, and thrombosis of the axillary
Figure 50-35. Anteroposterior view of
an inferior glenohumeral dislocation.
The humeral shaft lies parallel to the
spine of the scapula.
CHAPTER 50 Shoulder
artery has been associated with luxatio erecta.62 Tears
of the rotator cuff almost always accompany luxatio
erecta and may require surgical repair. Adhesive cap-
sulitis is a common long-term complication of luxatio
erecta.
Scapulothoracic Dislocation
Scapulothoracic dissociation is a rare and severe injury
characterized by complete disruption of the scapu-
lothoracic articulation. The mechanism of injury
involves a strong traction force applied to the upper
extremity (e.g., motorcyclist hangs onto the handlebars
while body is forced away). Massive local soft tissue
swelling associated with lateral displacement of the
scapula is seen on the chest radiograph. Additional
osseous injuries include acromioclavicular separation,
displaced fractures of the clavicle, and dislocations of
the SCJ. Associated neurovascular (subclavian or axil-
lary vessels, brachial plexus) injuries are common and
account for the poor functional outcomes associated
with this injury.64
Soft Tissue Conditions
Subacromial Syndromes and
Impingement (Rotator Cuff Tendinitis,
Subdeltoid/Subacromial Bursitis)
Pathophysiology
Rotator cuff tendinitis and subacromial bursitis can be
considered part of a pathophysiologic continuum
whose endpoint is represented by complete rupture of
the rotator cuff. These two conditions are common
causes of shoulder pain and have similar clinical pre-
sentations.65 A key feature of their clinical presentation 693
 is the presence of an impingement or painful arc syn-
drome (Figure 50-37).
The subacromial space is the area between the cora-
coacromial arch and the greater tuberosity of the
humerus. This space, which is only a few millimeters
wide, contains the long head of the biceps, the rotator
cuff, and the subacromial bursa. The last-mentioned
acts as the gliding mechanism between the musculo-
tendinous cuff and the coracoacromial arch. The func-
tional arc of shoulder elevation is forward, which
normally leads to impingement of the cuff and bursa
under the anterior third of the coracoacromial arch.
Similar impingement also occurs between 60 and 120
degrees of abduction and with the extremes of adduc-
tion. The critical wear from impingement is centered
on the supraspinatus tendon, near its insertion on the
greater tuberosity.66 Micro-opaque injection studies
PART TWO TRAUMA • Section III Orthopedic Lesions
also have shown a relative avascularity within this
“critical” area. The hypovascularity in conjunction
with repeated wear and age-related degenerative
changes ultimately results in rotator cuff tendinitis.
Narrowing of the subacromial space (anatomic variants
of anterior acromion) and occupations that require
1 characteristic.
2 crepitus within the glenohumeral joint.
Figure 50-36. Traction-countertraction method for reduction of
luxatio erecta humeri. The initial maneuver (1) includes steady axial
traction in line with the humeral shaft position followed by gentle
abduction. This reduces the glenohumeral dislocation. At this point
(2), the arm is brought down to a position of adduction and internal
rotation. (From Davids JR, Talbott RD: Luxatio erecta humeri. Clin
Orthop 252:144, 1990.)
Table 50-2. Three Progressive Stages of Impingement Lesions
Stage Pathology Age (yr)
I Edema, hemorrhage <25
II Fibrosis, tendinitis 25-40
III Bone spurs, tendon rupture >40
694
excessive overhead activity accelerate the entire
process. With time, the inflammatory reaction spreads
to involve the adjacent bursa. This inflammation leads
to edema, thickening, and fibrosis, further narrowing
the subacromial space (secondary impingement); this is
eventually followed by attritional changes within the
rotator cuff. Because the rotator cuff is a primary
humeral head depressor, loss of function adds to the
secondary impingement process.65
The impingement process also may involve the long
head of the biceps. If so, bicipital tenosynovitis, degen-
eration, or rupture may be present. In some cases,
osteoarthritis of the ACJ can narrow the subacromial
space and accelerate the pathologic process. Impinge-
ment in this context occurs between 120 and 180
degrees of abduction (see Figure 50-37).
Clinical Features
Neer66 classified the progressive pathologic processes
underlying subacromial syndromes into three stages
(Table 50-2). The impingement sign (Figure 50-38) is
positive in all three stages. Patients in stage 1 complain
of a dull ache around the deltoid area after strenuous
activity. On examination, tenderness is present over
the supraspinatus and anterior acromion. A painful
arc of abduction between 60 and 120 degrees is
Stage 2 is characterized by more persistent pain that
is particularly severe at night. The inflammatory
process within the bursa and tendons leads to the for-
mation of minor adhesions. Disruption of these adhe-
sions is thought to account for the nighttime pain.
Physical findings are similar to those of stage 1. In addi-
tion, bursal thickening leads to increased soft tissue
The hallmark of stage 3 is significant tendon degen-
eration after a prolonged history of tendinitis and
bursitis. Findings in this stage are discussed in the
section on tears of the rotator cuff. Radiographs are
usually normal in stages 1 and 2. Findings in stage 3
are similar to those seen with complete tears of the
rotator cuff.
The differential diagnosis of subacromial syndromes
is extensive and includes intrinsic and extrinsic causes
of shoulder pain. Extrinsic sources include the cervical
spine, lung, heart, and diaphragm. Intrinsic conditions
include acromioclavicular arthritis, adhesive capsuli-
tis, calcific tendinitis, and traumatic anterior subluxa-
tion. A positive impingement sign may be present in
many of these conditions. Relief of pain after the sub-
acromial injection of 10 mL of 1% lidocaine (impinge-
ment test [see Figure 50-38]) helps localize the
condition to the subacromial space.
Course Treatment
Reversible Conservative
Recurrent pain with activity Conservative, surgical
Progressive disability Surgical
 180° Figure 50-37. Arcs of painful abduction: sub-
acromial painful arc, 60 to 120 degrees;
acromioclavicular painful arc, 120 to 180
degrees. (From DePalma AF: Surgery of the
Shoulder, 3rd ed. Philadelphia, JB Lippincott,
1983.)
Acromioclavicular painful arc
120°

CHAPTER 50 Shoulder
90° Subacromial
painful arc

60°

0°

Figure 50-38. Impingement injection test. The impingement sign is elicited with the patient seated and the examiner standing. Scapular rota-
tion is prevented with one hand, while the other hand raises the arm in forced forward elevation, causing the greater tuberosity to impinge
against the acromion. This maneuver produces pain in patients with impingement lesions of all stages. It also causes pain in many other shoul-
der conditions. In the case of impingement lesions, the pain caused by this maneuver is relieved by the injection of 10 mL of 1% lidocaine
beneath the anterior acromion. This test is useful in separating impingement lesions of all stages from other causes of shoulder pain. (Redrawn
from Neer CS: Impingement lesions. Clin Orthop 173:70, 1983.)

695

PART TWO TRAUMA • Section III Orthopedic Lesions
696
Management
Initial treatment in stage 1 is conservative and consists
of rest, nonsteroidal anti-inflammatory drugs (NSAIDs),
and modification of activities that produce impinge-
ment. In stage 2, emphasis is on maintaining flexibility
and range of motion through physiotherapy and rotator
cuff strengthening exercises. Patients with stage 1 and
2 disease who present to the emergency department
reporting treatment failure with NSAIDs may benefit
from a subacromial injection of corticosteroids. Refrac-
tory stage 2 and some stage 3 patients may require
decompression surgery to control pain. Patients with
stage 2 and 3 disease may benefit from referral to an
orthopedist for more detailed evaluation and treatment.
Rotator Cuff Tears
Pathophysiology
The rotator cuff acts as a dynamic stabilizer of the
glenohumeral joint.67 Its primary function is to hold the
humeral head in place throughout the full range of
motion (see Figure 50-5). In addition, it contributes
power in all directions and is responsible for specific
movements. The infraspinatus and teres minor act as
external rotators, whereas the subscapularis is an inter-
nal rotator. The supraspinatus is essential for the first
30 degrees of shoulder abduction.
The tenuous blood supply of the rotator cuff, abusive
tensile overload, and chronic wear under the cora-
coacromial arch predispose it to age-related degenera-
tive changes. The advanced stage of this process is
characterized by complete rupture of the rotator cuff.
The role of impingement in the development of rotator
cuff tears is controversial. Primary impingement (e.g.,
acromial variance) is uncommon, but when present
accelerates the degenerative process. More often, weak-
ening or rupture of the cuff with age allows for superior
migration of the humeral head, which results in
secondary impingement. This impingement produces
secondary changes within the subacromial space and
symptoms characteristic of the painful arc syndrome.68
Most tears involve the dominant arm and occur in
men older than age 40 years. The occupational history
is significant for strenuous work requiring overhead
activity. Most tears occur near the attachment of the
supraspinatus and can extend anteriorly into the sub-
scapularis or posteriorly into the infraspinatus. Tears
can be classified according to their size, completeness,
pattern location, or duration. A clinically useful system
is to divide tears into acute or chronic types. Acute tears
(10%) usually are associated with a specific traumatic
event. Often no history of previous shoulder problems
exists. The most common mechanism of injury is forced
abduction associated with significant resistance; this
usually occurs when the patient attempts to break a fall
with an outstretched hand. Alternatively the tendon
rupture may occur while lifting a heavy object or after
falling directly onto an immovable object.69
Clinical Features
The patient complains of a sudden tearing sensation in
the shoulder followed by severe pain that radiates into
the arm. Pain and secondary muscle spasm limit shoul-
der motion. Physical findings depend on the com-
pleteness, size, and location of the tear. Point
tenderness is usually present over the site of rupture
(greater tuberosity). A palpable defect also may be
present. Subacromial injection of 10 mL of 1% lido-
caine eliminates pain and allows for proper evaluation
of motor function. The patient with a large tear cannot
initiate shoulder abduction. A discrepancy between
active and passive range of motion is highly suggestive
of a rotator cuff tear.69 The drop-arm test, performed by
passively abducting the arm to 90 degrees and asking
the patient to hold the arm in this position, is positive
with significant tears. Slight pressure on the distal
forearm or wrist causes the patient to drop the arm sud-
denly. The acute pain resulting from hemorrhage and
spasm subsides over a few days. Repeat examination at
this point confirms the loss of function in significant
tears.
Chronic tears account for approximately 90% of all
lesions. Chronic tears are attritional and more insidi-
ous in their presentation. Early findings include a
painful arc syndrome as a result of secondary impinge-
ment. The pain is worse at night and interferes with
sleep. Worsening pain is followed by the gradual onset
of weakness in the arm. Flexion and abduction are
affected first. The patient attempts to initiate abduction
using scapulothoracic movement. Internal rotation is
weakened by anterior extension of the tear. Posterior
extension compromises external rotation. The drop-
arm test is positive with large tears, and there may be
atrophy of the supraspinatus and infraspinatus
muscles.
Diagnostic Strategies: Radiology
Radiographs may be normal in acute and chronic tears,
but more often they show evidence of nonspecific
degenerative changes within the glenohumeral joint
and subacromial space. The greater tuberosity can have
a sclerotic or cystic appearance. Osteophytic spurs and
sclerosis of the undersurface of the acromion may
narrow the subacromial space. The hallmark of a com-
plete tear is superior displacement of the humeral head.
This displacement is best seen on an external rotation
view. The normal distance from the superior aspect of
the humerus to the undersurface of the acromion varies
from 7 to 14 mm. A distance of less than 6 mm is highly
suggestive of a complete tear. Outpatient MRI, ultra-
sound, or an arthrogram can confirm the diagnosis.
Management
Acute tears should be immobilized in a sling and
referred promptly for orthopedic follow-up. Early sur-
gical repair (<3 weeks) is preferred in these instances,
especially for a young or active individual. The man-
agement of chronic tears includes pain control and a
shoulder rehabilitation program. Painful arc symptoms
may respond to the subacromial injection of a corti-
costeroid preparation. Orthopedic follow-up is essen-
tial because patients with persistent pain and weakness
may require surgical repair.
Lesions of the Biceps Muscle
The biceps is composed of two heads. The long head
originates from the supraglenoid tubercle and glenoid
labrum and ascends over the humeral head to enter the
arm via the bicipital groove. The long head is covered
by a synovial sheath and is held in place within the
groove by the coracohumeral and transverse humeral
ligaments. The short head of the biceps originates from
the coracoid process and inserts with the long head
onto the tuberosity of the radius. The biceps is respon-
sible for flexion and supination at the elbow.
Bicipital Tenosynovitis
Pathophysiology. Anatomically the long head of the
biceps is subject to the same stresses as the rotator cuff
within the subacromial space. Irritation and micro-
trauma as a result of repetitive elevation or abduction
of the shoulder produce an inflammatory reaction
within the synovial sheath. Bicipital tenosynovitis
usually is associated with other acromial arch impinge-
ment conditions (e.g., subacromial bursitis and rotator
cuff tendinitis).70
The typical patient is middle-aged and involved in
an occupation or recreational activity that requires
overhead movement. The patient complains of pain in
the anterior part of the shoulder that radiates into the
upper arm. The pain usually is initiated by some minor
traumatic event involving forceful contraction of the
biceps. Pain increases with activity and decreases with
rest. Abduction and external rotation in particular are
painful. Pain increases at night and interferes with
sleep.
Clinical Features. On examination, tenderness is pre-
sent over the biceps tendon as it passes through the
bicipital groove. This is best shown with the arm in
abduction and external rotation. Active range of motion
is limited by pain, but the passive range remains intact.
Supination against resistance (Yergason’s test) with the
arm adducted and the elbow flexed to 90 degrees repro-
duces the pain (Figure 50-39). The biceps resistance
test in which forward flexion of the shoulder (elbow
extended and forearm supinated) is carried out against
resistance also produces pain in the bicipital groove.
Diagnostic Strategies: Radiology. Radiographs may
show evidence of subacromial space impingement by
associated acromioclavicular arthritis, inferior subluxa-
tion of the clavicle, and inferior acromial osteophytes.
Management. Emergency treatment consists of im-
mobilization in a sling and anti-inflammatory medica-
tion. Gentle stretching exercises are encouraged, and
refractory or progressive cases should be referred to
an orthopedic surgeon. Although the bicipital sheath
can be injected with a corticosteroid preparation,
the procedure is technically difficult. Subacromial
decompressive surgery and biceps tenodesis may be
necessary in patients who fail to respond to conserva-
tive therapy.71
Ruptures of the Biceps Tendon
Pathophysiology. Ruptures of the biceps tendon can be
classified into proximal and distal types. Distal rup-
CHAPTER 50 Shoulder
Figure 50-39. Yergason’s test. Flexion of the elbow and supination
of the forearm against resistance causes pain in the anterior and inner
aspect of the shoulder. (From DePalma AF: Surgery of the Shoulder,
3rd ed. Philadelphia, JB Lippincott, 1983.)
tures are rare and are not discussed. Proximally,
microtears and other age-related attritional changes
within the long head predispose it to rupture.69 The
rupture can be spontaneous or may follow a traumatic
event involving either forced extension or resisted
supination and flexion.
Clinical Features. The classic history of an acute
rupture is that of a sudden snap or pop, followed by
pain and ecchymosis in the region of the bicipital
groove. The tendon usually ruptures at its weakest
point, which is just distal to the exit from the gleno-
humeral joint cavity. With a complete rupture, distal
retraction of the muscle results in a “Popeye” appear-
ance of the arm. A difference in muscle contour (Lud-
ington’s test) also may be seen when both arms are
placed behind the head and the biceps muscles are con-
tracted.72 Functionally, forearm supination is weak-
ened, but elbow flexion stays strong because the
coracobrachialis and short head of the biceps remain
intact. Most ruptures also are associated with a rotator
cuff tear.
Diagnostic Strategies: Radiology. Radiographs are
usually unremarkable, and the confirmatory test of
choice is MRI.
Management. The injured arm should be immobilized
in a sling with the elbow in 90 degrees of flexion. The
local application of ice may provide temporary relief.
Analgesia should be provided, and the patient should
be referred to an orthopedic surgeon within 72 hours
for further evaluation and treatment. Surgical repair is
a consideration in young, active individuals. In older
individuals, conservative therapy (range-of-motion and
strengthening exercise) is preferred because the cos- 697

PART TWO TRAUMA • Section III Orthopedic Lesions
698
metic deformity is minimal, and the mild functional
loss is usually acceptable.
Subluxation and Dislocations of the
Biceps Tendon
Subluxations and dislocations of the biceps tendon
usually are associated with a congenitally shallow
bicipital groove or atraumatic (attritional) tears of the
coracohumeral and transverse humeral ligaments. The
patient complains of a snapping sensation in the upper
arm with abduction and external rotation. External and
internal rotation of the abducted shoulder shows dis-
location and relocation of the tendon. With complete
dislocation, the arm may reflexively drop to relocate
the tendon. These conditions may require operative
repair and should be referred to an orthopedist.
Calcific Tendinitis
Pathophysiology
Rotator cuff calcific tendinitis is encountered fre-
quently in the emergency department. The condition
occurs in the 40s and 50s and is rare in individuals
younger than age 30 or older than age 60. Calcific
deposits occur primarily in the supraspinatus tendon
near its attachment to the greater tuberosity. Deposits
also may involve the infraspinatus, teres minor, or sub-
scapularis tendons. Initially the tendon undergoes
fibrocartilaginous transformation. The precipitating
factors for this change are unclear and may involve
hypoxia or stress-related degenerative changes within
the tendon.73 Calcium crystals are deposited and coa-
lesce within the matrix of the tendon. Subsequent inva-
sion of vascular channels into the deposit allows for the
influx of neutrophils and macrophages (inflammatory
response), which remove the calcification through
phagocytosis. Finally, fibroblasts migrate into the area
to create a postcalcification scar.74
Clinical Features
The clinical presentation can be divided into silent,
subacute, and acute phases based on the physical char-
acteristics of the calcific deposits and the nature of the
inflammatory response within the tendon and subacro-
mial bursa. The silent phase consists of a dry powdery
deposit with no surrounding inflammatory reaction. It
is usually an incidental diagnosis when shoulder radi-
ographs are obtained for other purposes. The deposits
may remain painless and eventually reabsorb.
The painful arc syndrome is a hallmark of the sub-
acute phase. Enlargement and softening of the deposit
narrows the subacromial space, resulting in impinge-
ment under the acromial arch. Pain between 60 and
120 degrees of abduction (see Figure 50-37) is
characteristic.
A severe inflammatory reaction within and around
the deposit produces the acute phase. The deposit
becomes milky and has the appearance of an acute
abscess. The patient has severe pain with the arm held
close to the chest. Active and passive range of motion
is severely limited. The shoulder is warm and
extremely tender to the touch. Severe pain is related to
increased intratendinous pressure, and spontaneous
rupture of the deposit into the subacromial bursa can
provide dramatic relief of symptoms.
Diagnostic Strategies: Radiology
Radiographs show calcific deposits in the involved
tendon. For the supraspinatus, calcific deposits are best
seen on the internal and external rotation anteroposte-
rior views. The axillary view is useful for showing cal-
cification within the other tendons of the rotator cuff.
Management
Subacute symptoms usually respond to NSAIDs and
measures to limit any offending activity. The acute
phase should be treated with sling immobilization,
NSAIDs, and analgesia. Subacromial injection of a local
anesthetic may provide dramatic temporary relief.
Needle lavage (puncturing of the calcific deposits to
decrease intratendinous pressure) also has been
described as an effective treatment.73 The subacromial
injection of corticosteroids for impingement symptoms
is controversial because these agents may delay the
process of calcium resorption and interfere with the
natural course of the condition. Patients with chronic
symptoms may benefit from extracorporeal shock wave
therapy or surgical removal of the calcific deposit.75
Early shoulder range-of-motion exercises should be
encouraged in all patients to minimize the risk of adhe-
sive capsulitis. All symptomatic patients should
receive orthopedic follow-up.
Adhesive Capsulitis
Pathophysiology
Adhesive capsulitis is a specific diagnostic entity char-
acterized by an inflammatory reaction within the
capsule and synovium of the glenohumeral joint. This
inflammatory reaction results in the formation of adhe-
sions within the capsule and inferior axillary fold.
Adhesive capsulitis must be differentiated from other,
more common causes of the painful stiff shoulder; this
is important because any painful condition of the
shoulder (e.g., calcific tendinitis, rotator cuff tear,
osteoarthritis, or trauma) may be associated with
decreased range of motion.76 Although the cause of
adhesive capsulitis is unknown, any condition associ-
ated with prolonged dependency of the arm can result
in capsular contraction, including voluntary immobi-
lization after calcific tendinitis, rotator cuff injury, mas-
tectomy, or a distal upper extremity injury (Colles’
fracture).
Clinical Features
The typical patient is a woman between 40 and 60 years
old. The nondominant arm is usually affected, and the
patient has trouble with the activities of daily living.
The pain is often severe at night and localized over the
deltoid area. There is uniform limitation of all gleno-
humeral movement, especially abduction and internal
and external rotation. On passive testing, a sense of
mechanical restriction of joint motion is present. The
shoulder radiographs are usually normal if there is no
associated condition.
 Table 50-3. Potency, Duration of Action, and Dose of Commonly Used Corticosteroid Preparations
Preparation (Trade Name) Relative Potency
Hydrocortisone acetate (Hydrocortone) 1 Short
Betamethasone sodium phosphate and 25
acetate (Celestone Soluspan)
Methylprednisolone acetate (Depo-Medrol) 5 Long
Triamcinolone acetonide (Kenalog-10) 5 Long
Triamcinolone hexacetonide (Aristospan) 5 Long
Triamcinolone diacetate (Aristocort) 5 Long
Dexamethasone acetate (Decadron-LA) 25
Management
The best form of therapy is preventive. Prolonged
immobilization must be avoided, and early motion of
the shoulder should be encouraged in all instances (see
Figure 50-14). Treatment of adhesive capsulitis in the
emergency department consists of NSAIDs and referral
to an orthopedic surgeon. The diagnosis usually is con-
firmed by an arthrogram, which shows obliteration of
the axillary fold and a reduction in the joint volume.
Initial therapy is usually conservative and consists of a
gentle assisted exercise program. Some patients require
shoulder manipulation under anesthesia to improve
the range of motion.
Injection Therapy
The local injection of corticosteroid preparations can
be useful in many painful conditions that affect the
shoulder, including rotator cuff tendinitis and sub-
acromial bursitis. Evidence-based research that sup-
ports or refutes the use of injection corticosteroid
therapy is limited.77 Although useful for relieving the
inflammatory reaction, corticosteroid injections in
general do not alter the underlying disease process.
Corticosteroids inhibit all phases of the inflammatory
response, including leukocyte migration, edema for-
mation, mediator release, vascular permeability, colla-
gen deposition, and fibroblast proliferation. Systemic
complications are rare after local injection therapy.
Site-specific complications include articular cartilage
damage and subcutaneous atrophy. The incidence of
local complications correlates with the injection tech-
nique, dose used, and frequency of administration.
Direct tendon injection must be avoided at all times,
and the frequency of injections should be limited to
four injections per year.78
Numerous corticosteroid preparations are available
on the market (Table 50-3). Injection of a long-acting
agent or a combination of a short-acting and long-acting
agent is preferred. The dose used depends on the size
of the joint or bursa and the response of the individual.
Concurrent use of a local anesthetic agent may provide
acute pain relief and allow for better diffusion of the
steroid preparation.
After injection, the shoulder should be immobilized,
and activity should be limited for several days to
protect against further injury. Improvement usually
begins within 1 to 7 days and can last weeks to months,
depending on the preparation and underlying condi-
Duration Preparation (Suspension) Subacromial
of Action (mg/mL) Dose (mg)
50 mg/mL 25-37.5
Short/long 6 6
40 40-80
10 mg/mL 10-20
20 mg/mL 20
25 25
Long 8 4-16
tion. Local anesthetic injection may result in a dramatic
temporary improvement in symptoms.
CHAPTER 50 Shoulder
KEY CONCEPTS
■ The most important aspect of scapular fractures is the high
incidence of associated injuries to the ipsilateral lung,
chest wall, and shoulder girdle complex.
■ Posterior SCJ dislocations can be associated with life-
threatening injuries within the superior mediastinum, and
the preferred imaging technique is a CT scan.
■ If the coracoclavicular distance exceeds 10 to 13 mm, or
there is a difference of more than 5 mm in this distance
between the injured and the uninjured sides, a grade III
ACJ dislocation should be suspected.
■ Most studies have concluded that conservative treatment
of type III ACJ dislocations provides equal or, in some
cases, better functional results than surgical intervention.
■ A compression fracture of the posterolateral aspect of the
humeral head (Hill-Sachs deformity) is present in a large
percentage of anterior glenohumeral dislocations.
■ Good muscle relaxation is the key to success in the reduc-
tion of anterior glenohumeral dislocations.
■ Axillary nerve function is best evaluated by motor function
of the deltoid muscle.
■ Recurrence is a common complication after anterior dislo-
cation, especially in patients younger than age 30 years,
and such individuals may benefit from arthroscopic repair.
■ A posterior dislocation should be suspected in any indi-
vidual who complains of shoulder pain after a convulsive
episode.
■ It is important to evaluate the relationship between the
spine of the scapula and the longitudinal axis of the
humerus to avoid missing an inferior glenohumeral
dislocation.
■ Early initiation of passive shoulder range-of-motion exer-
cises helps reduce the risk of adhesive capsulitis.
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CHAPTER
51 Musculoskeletal Back Pain
Michelle Lin
LOW BACK PAIN
PERSPECTIVE
Background
Approximately 70% to 90% of adults during their life-
time experience acute low back pain, defined as pain
lasting less than 6 weeks in duration.1,2 Frustrating for
the medical practitioner and the patient, 85% of these
patients have an unknown etiology for their pain.3
These patients frequently are diagnosed with “acute
lumbosacral strain,” “lumbago,” or “mechanical back
pain.” These nonspecific, catch-all terms reflect the
diagnostic challenge and lack of pathognomonic tests
for low back pain. More accurately, these patients
should be diagnosed with “idiopathic low back pain.”
Regardless, most of these cases resolve spontaneously
within 6 weeks. Based on more recent studies regard-
ing the management of acute low back pain, the most
significant discovery, contradictory to traditional teach-
ing from the 1980s, is to avoid bed rest for these
patients, including patients with sciatica symptoms.4,5
Management recommendations for chronic back pain
remain controversial, however, and the condition
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73. Hurt G, Baker CL Jr: Calcific tendinitis of the shoulder.
Orthop Clin North Am 34:567, 2003.
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CHAPTER 51 Musculoskeletal Back Pain
77. Buchbinder R, Green S, Youd JM: Corticosteroid injections
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accounts for a significant proportion of costs to the
health care system.
Epidemiology
In the ambulatory care setting, the medical complaint
of back pain is the fifth most common reason for a visit
to a physician’s office, with 15 million annual visits in
the United States.6 Low back pain primarily affects
adults 30 to 60 years old and has a tremendous impact
on the economy and workforce productivity. Approxi-
mately 14% of all Americans take at least 1 day off of
work secondary to back pain. For people younger than
age 45 years, persistent chronic back pain ranks as the
leading cause of disability among chronic ailments. For
people age 45 to 64, it ranks third behind coronary
disease and arthritis.7 Patients with back pain generate
an estimated $24 billion in annual medical expenses
and $50 billion to $100 billion in total direct and indi-
rect costs in the United States.1,2,8,9
The natural history of most cases of low back pain
follows a benign and self-limited course. Approxi-
mately 70% to 90% of patients have complete resolu-
tion of pain within 6 weeks.10 If the pain does not
resolve within 3 months, however, it is unlikely to
resolve after 12 months. The recurrence rate for pain is
66% to 84% within the first 12 months.11 701