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KIN 191B – Advanced Assessment of Upper Extremity Injuries Shoulder Injuries
Shoulder Pathologies <ul><li>Sternoclavicular (SC) joint injuries </li></ul><ul><li>Acromioclavicular (AC) joint injuries ...
Sternoclavicular Joint Injuries <ul><li>Common etiology is via longitudinal force application (fall on outstretched arm, e...
Sternoclavicular Joint Injuries <ul><li>Signs/symptoms include point tenderness, crepitus, displacement, pain/limitation t...
Acromioclavicular Joint Injuries <ul><li>Horizontal stability (A/P) from AC ligaments and vertical stability (superior) fr...
Acromioclavicular Joint Injuries <ul><li>Signs/symptoms include point tenderness, displacement (step-off), pain/limitation...
Acromioclavicular Joint Injuries <ul><li>AC sprain classifications </li></ul><ul><ul><li>Grade I – point tenderness, no di...
AC Sprain Classifications
Acromioclavicular Joint Injuries <ul><li>Ligamentous stress tests include “piano key” test (step-off at distal clavicle), ...
Glenohumeral Joint Injuries <ul><li>Can be due to ligamentous and/or labral pathology, capsular instability (“freaks”), or...
Glenohumeral Joint Injuries <ul><li>Severity of injury classified as with previous ligamentous injury discussion </li></ul...
GH Injury Management <ul><li>If sublux/dislocate prior to age 30, >90% likelihood of recurrent episodes, so typically repa...
Glenohumeral Joint Injuries <ul><li>Anterior instability </li></ul><ul><li>Posterior instability </li></ul><ul><li>Inferio...
Anterior GH Instability <ul><li>Primary etiology is abduction and external rotation – can also result from P-A forces </li...
Anterior GH Dislocation
Anterior GH Instability <ul><li>Bankart lesion </li></ul><ul><ul><li>Inferior GH ligament avulsed with/without correspondi...
Bankart Lesion
Hill-Sachs Lesion
Anterior GH Special Tests <ul><li>Apprehension sign/test </li></ul><ul><ul><li>Abduction/external rotation (90/90) positio...
Apprehension/Relocation Tests
Posterior GH Instability <ul><li>Much less common than anterior instability </li></ul><ul><li>Primary etiology is posterio...
GH Dislocation
Posterior GH Special Tests <ul><li>Posterior apprehension test </li></ul><ul><ul><li>90/90 position, scapula stabilized by...
Posterior Apprehension Test
Inferior GH Instability <ul><li>Signs/symptoms include anterior shoulder pain/tenderness, limited/painful ROM, weakness/pa...
Inferior GH Special Test <ul><li>Sulcus sign </li></ul><ul><ul><li>In “neutral” position, distraction (inferior) force app...
Sulcus Sign
Rotator Cuff Injuries <ul><li>Impingement syndrome </li></ul><ul><li>Rotator cuff tendonitis </li></ul><ul><li>Subacromial...
Impingement Syndrome <ul><li>Impingement and inflammation of rotator cuff tendons in subacromial space essentially represe...
Impingement
Impingement Syndrome <ul><li>Most commonly caused by anatomical changes/abnormalities that compromise those tissues (anoma...
Impingement Syndrome <ul><li>Signs/symptoms dominated by limitations/pain/weakness to shoulder motions (esp. IR/ER) above ...
Painful Arc
Impingement Tests <ul><li>Neer test </li></ul><ul><ul><li>Performed standing or sitting, shoulder passively flexed and int...
Impingement Tests
Rotator Cuff Tendonitis <ul><li>Anatomically predisposed to injury </li></ul><ul><ul><li>Poor vascular supply to tendons i...
Types of Acromion Processes
Rotator Cuff Tendonitis <ul><li>Classification of rotator cuff tendonitis </li></ul><ul><ul><li>Grade I (mild) – pain afte...
Rotator Cuff Tears <ul><li>Arise secondary to inflammatory conditions and associated microtrauma – may occur from single e...
Rotator Cuff Tear
Rotator Cuff Tests <ul><li>Drop arm test </li></ul><ul><ul><li>Positive if individual unable to control adduction of GH jo...
Rotator Cuff Tests
Subacromial Bursitis <ul><li>Often occurs concurrently with rotator cuff tendonitis/tears – all present as impingement syn...
Subacromial Bursitis
Management of Impingement Syndromes <ul><li>Conservative management focuses initially on rest, NSAIDs, modalities to contr...
Biceps Tendon Injuries <ul><li>Bicipital tendonitis </li></ul><ul><li>SLAP lesions </li></ul>
Bicipital Tendonitis <ul><li>May occur secondary to rotator cuff injury, overuse of biceps and/or impingement </li></ul><u...
Biceps Tendon Tests <ul><li>Yergason’s test </li></ul><ul><ul><li>Evaluates for biceps tendonitis and instability </li></u...
Biceps Tendon Tests <ul><li>Speed’s test </li></ul><ul><ul><li>Evaluative for biceps tendonitis </li></ul></ul><ul><ul><li...
Biceps Tendon Tests
SLAP Lesions <ul><li>S – superior </li></ul><ul><li>L – labrum </li></ul><ul><li>A – anterior to </li></ul><ul><li>P – pos...
SLAP Lesions <ul><li>Classifications of SLAP lesions </li></ul><ul><ul><li>Type I – labrum frayed near biceps attachment <...
Types of SLAP Lesions
SLAP Lesions <ul><li>Active compression (O’Brien) test </li></ul><ul><ul><li>Shoulder flexed 90 and horizontally add 15 </...
Thoracic Outlet Syndrome <ul><li>Pressure on brachial plexus and/or subclavian artery/vein from: </li></ul><ul><ul><li>Pre...
Thoracic Outlet Anatomy
Thoracic Outlet Syndrome <ul><li>Cervical rib is outgrowth of C7 vertebrae, only ~10% with cervical rib suffer TOS </li></...
Thoracic Outlet Syndrome <ul><li>Signs and symptoms: </li></ul><ul><ul><li>Neurological – numbness, paresthesia, pain (esp...
Thoracic Outlet Syndrome Tests <ul><li>Adson’s test </li></ul><ul><ul><li>Attempts to stretch neurovascular bundle and com...
Adson’s Test
Thoracic Outlet Syndrome Tests <ul><li>Allen test </li></ul><ul><ul><li>Evaluates for TOS from pec minor origin </li></ul>...
Allen Test
Fractures <ul><li>Scapula </li></ul><ul><ul><li>rare occurrences, can involve body but most common to processes, can be fr...
Fractures
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Kin 191 B – Shoulder Injuries

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Transcript of "Kin 191 B – Shoulder Injuries"

  1. 1. KIN 191B – Advanced Assessment of Upper Extremity Injuries Shoulder Injuries
  2. 2. Shoulder Pathologies <ul><li>Sternoclavicular (SC) joint injuries </li></ul><ul><li>Acromioclavicular (AC) joint injuries </li></ul><ul><li>Glenohumeral (GH) joint injuries </li></ul><ul><li>Rotator cuff injuries </li></ul><ul><li>Biceps tendon injuries </li></ul><ul><li>Thoracic outlet syndrome </li></ul><ul><li>Fractures </li></ul>
  3. 3. Sternoclavicular Joint Injuries <ul><li>Common etiology is via longitudinal force application (fall on outstretched arm, etc.) to distal clavicle </li></ul><ul><li>Most common direction of dislocation is anterior – potential concerns if posterior </li></ul>
  4. 4. Sternoclavicular Joint Injuries <ul><li>Signs/symptoms include point tenderness, crepitus, displacement, pain/limitation to ROM especially during 0-90 degrees of abduction (SC axis of movement) </li></ul><ul><li>Ligamentous tests evaluate for abnormal glide/motion at SC joint (multidirectional) </li></ul><ul><li>Usually managed conservatively (immobilized) and then PRE as tolerated </li></ul>
  5. 5. Acromioclavicular Joint Injuries <ul><li>Horizontal stability (A/P) from AC ligaments and vertical stability (superior) from coracoclavicular ligaments </li></ul><ul><li>Common mechanisms include: </li></ul><ul><ul><li>Landing on outstretched arm </li></ul></ul><ul><ul><li>Landing on or direct blow to acromion process (“tip of shoulder”) </li></ul></ul><ul><ul><li>Force on distal clavicle when scapula is fixed </li></ul></ul>
  6. 6. Acromioclavicular Joint Injuries <ul><li>Signs/symptoms include point tenderness, displacement (step-off), pain/limitation to ROM, especially at 90+ degrees of abduction (AC axis of movement) – horizontal adduction (cross arm test) is good evaluative and return to play test) </li></ul>
  7. 7. Acromioclavicular Joint Injuries <ul><li>AC sprain classifications </li></ul><ul><ul><li>Grade I – point tenderness, no displacement (AC ligament microtrauma) </li></ul></ul><ul><ul><li>Grade II – some laxity and step-off present (AC ligament ruptured and some damage to CC ligament) </li></ul></ul><ul><ul><li>Grade III – significant laxity and step-off (rupture of AC and CC ligaments) </li></ul></ul>
  8. 8. AC Sprain Classifications
  9. 9. Acromioclavicular Joint Injuries <ul><li>Ligamentous stress tests include “piano key” test (step-off at distal clavicle), AC traction test (vertical instability), AC compression test (horizontal instability) </li></ul><ul><li>Usually managed conservatively (immobilized) although some grade II/III sprains managed surgically </li></ul>
  10. 10. Glenohumeral Joint Injuries <ul><li>Can be due to ligamentous and/or labral pathology, capsular instability (“freaks”), or muscular weakness </li></ul><ul><li>Normal GH function is delicate balance between static and dynamic stabilizers of structurally unstable joint </li></ul>
  11. 11. Glenohumeral Joint Injuries <ul><li>Severity of injury classified as with previous ligamentous injury discussion </li></ul><ul><ul><li>Grade I – microtrauma </li></ul></ul><ul><ul><li>Grade II – partial tear </li></ul></ul><ul><ul><li>Grade III – complete rupture </li></ul></ul><ul><li>Grades then contribute to differing amounts of humeral head displacement on glenoid relative to nature of ligamentous injury </li></ul>
  12. 12. GH Injury Management <ul><li>If sublux/dislocate prior to age 30, >90% likelihood of recurrent episodes, so typically repair surgically </li></ul><ul><li>If occurs after age 30, can decide between surgical and conservative management </li></ul><ul><ul><li>Conservative management must focus on strengthening dynamic stabilizers since static stabilizers have been compromised </li></ul></ul>
  13. 13. Glenohumeral Joint Injuries <ul><li>Anterior instability </li></ul><ul><li>Posterior instability </li></ul><ul><li>Inferior instability </li></ul><ul><li>Multidirectional instability </li></ul>
  14. 14. Anterior GH Instability <ul><li>Primary etiology is abduction and external rotation – can also result from P-A forces </li></ul><ul><li>Signs/symptoms generally include generalized pain/tenderness in shoulder, limited/painful ER ROM, pain/weakness to ER, anterior glide/translation of humerus on glenoid, flattened deltoid contour </li></ul>
  15. 15. Anterior GH Dislocation
  16. 16. Anterior GH Instability <ul><li>Bankart lesion </li></ul><ul><ul><li>Inferior GH ligament avulsed with/without corresponding portion of glenoid labrum </li></ul></ul><ul><li>Hill-Sachs lesion </li></ul><ul><ul><li>Defect in posterior humeral head from impact on glenoid fossa as humerus attempts to reduce </li></ul></ul>
  17. 17. Bankart Lesion
  18. 18. Hill-Sachs Lesion
  19. 19. Anterior GH Special Tests <ul><li>Apprehension sign/test </li></ul><ul><ul><li>Abduction/external rotation (90/90) position from supine position </li></ul></ul><ul><ul><li>Positive if pain and/or apprehension </li></ul></ul><ul><li>Relocation test </li></ul><ul><ul><li>Apprehension test secondary to manual A-P force to humeral head </li></ul></ul><ul><ul><li>Positive if pain with apprehension and no pain with relocation </li></ul></ul><ul><li>Anterior GH glide/translation/drawer </li></ul><ul><ul><li>May be done supine, side laying, sitting </li></ul></ul>
  20. 20. Apprehension/Relocation Tests
  21. 21. Posterior GH Instability <ul><li>Much less common than anterior instability </li></ul><ul><li>Primary etiology is posterior force application with shoulder flexed and internally rotated – usually cumulative trauma that presents with a single event </li></ul><ul><li>Signs/symptoms include generalized shoulder pain/tenderness, limited/painful IR, weakness/pain to IR, posterior glide/translation of humerus on glenoid </li></ul>
  22. 22. GH Dislocation
  23. 23. Posterior GH Special Tests <ul><li>Posterior apprehension test </li></ul><ul><ul><li>90/90 position, scapula stabilized by the table, posterior (A-P) force applied to proximal humerus </li></ul></ul><ul><li>Test for posterior instability in the plane of the scapula </li></ul><ul><ul><li>Abducted to 90, horizontally adducted to 30 (plane of scapula), posterior (A-P) translation to proximal humerus </li></ul></ul><ul><li>Posterior GH glide/translation/drawer </li></ul><ul><ul><li>May be done supine, side laying, sitting </li></ul></ul>
  24. 24. Posterior Apprehension Test
  25. 25. Inferior GH Instability <ul><li>Signs/symptoms include anterior shoulder pain/tenderness, limited/painful ROM, weakness/pain to IR/ER, increased GH glide in all directions </li></ul><ul><li>Essentially becomes indicator for multidirectional GH instability – rarely if ever present in isolation </li></ul>
  26. 26. Inferior GH Special Test <ul><li>Sulcus sign </li></ul><ul><ul><li>In “neutral” position, distraction (inferior) force applied to humerus </li></ul></ul><ul><ul><li>Positive if sulcus (“divot”) appreciated beneath the acromion process – indicative of multidirctional GH instability </li></ul></ul><ul><ul><li>If sulcus sign positive at 90 degrees of flexion, more indicative of inferior GH instability </li></ul></ul>
  27. 27. Sulcus Sign
  28. 28. Rotator Cuff Injuries <ul><li>Impingement syndrome </li></ul><ul><li>Rotator cuff tendonitis </li></ul><ul><li>Subacromial bursitis </li></ul>
  29. 29. Impingement Syndrome <ul><li>Impingement and inflammation of rotator cuff tendons in subacromial space essentially represent vicious cycle (cause and effect) </li></ul><ul><li>Caused by reduction in space beneath coracoacromial arch </li></ul><ul><ul><li>RTC tendons (supraspinatus), long head of biceps brachii tendon, subacromial bursa </li></ul></ul>
  30. 30. Impingement
  31. 31. Impingement Syndrome <ul><li>Most commonly caused by anatomical changes/abnormalities that compromise those tissues (anomaly, scarring, etc.) </li></ul><ul><li>Fatigue/weakness from overuse can impinge under acromion since humeral head depression is affected </li></ul><ul><li>Also may have problems if scapular motion (rhythm) is compromised (weakness, muscle imbalances, biomechanical issues) </li></ul>
  32. 32. Impingement Syndrome <ul><li>Signs/symptoms dominated by limitations/pain/weakness to shoulder motions (esp. IR/ER) above 90 degrees, also may have localized tenderness/pain </li></ul><ul><li>Often present with painful arc of motion between ~45-120 degrees of flexion and/or abduction </li></ul>
  33. 33. Painful Arc
  34. 34. Impingement Tests <ul><li>Neer test </li></ul><ul><ul><li>Performed standing or sitting, shoulder passively flexed and internally rotated </li></ul></ul><ul><ul><li>Positive if pain with motion, esp. at end range </li></ul></ul><ul><li>Hawkins-Kennedy test </li></ul><ul><ul><li>Performed standing or sitting, shoulder in 90/90 position (scapular plane is best), shoulder passively internally rotated </li></ul></ul><ul><ul><li>Positive if pain with motion, esp. at end range </li></ul></ul>
  35. 35. Impingement Tests
  36. 36. Rotator Cuff Tendonitis <ul><li>Anatomically predisposed to injury </li></ul><ul><ul><li>Poor vascular supply to tendons in subacromial space – “wringing out” with rotation movement </li></ul></ul><ul><ul><li>Shape and location of acromion process also can compromise </li></ul></ul><ul><ul><ul><li>Type I – flat </li></ul></ul></ul><ul><ul><ul><li>Type II – gently curved </li></ul></ul></ul><ul><ul><ul><li>Type III – “beaked” or hooked – high likelihood of contributing to rotator cuff pathology </li></ul></ul></ul><ul><ul><ul><li>Type IV – inferior spurs off acromion – almost certain to experience rotator cuff pathology </li></ul></ul></ul>
  37. 37. Types of Acromion Processes
  38. 38. Rotator Cuff Tendonitis <ul><li>Classification of rotator cuff tendonitis </li></ul><ul><ul><li>Grade I (mild) – pain after activity only </li></ul></ul><ul><ul><li>Grade II (moderate) – pain during and after activity </li></ul></ul><ul><ul><li>Grade III (severe) – pain with ADLs </li></ul></ul><ul><li>Signs/symptoms include tenderness to subacromial area, greater tuberosity, biceps tendon, pain/weakness/limitation to abduction, IR, ER ROMs </li></ul>
  39. 39. Rotator Cuff Tears <ul><li>Arise secondary to inflammatory conditions and associated microtrauma – may occur from single event, but typically overuse and cumulative conditions </li></ul><ul><li>Partial-thickness tears </li></ul><ul><ul><li>Short, longitudinal lesions in superficial or midsubstance of tendons </li></ul></ul><ul><li>Full-thickness tears </li></ul><ul><ul><li>Complete disruption of tendinous structure and funtion </li></ul></ul>
  40. 40. Rotator Cuff Tear
  41. 41. Rotator Cuff Tests <ul><li>Drop arm test </li></ul><ul><ul><li>Positive if individual unable to control adduction of GH joint from abducted position </li></ul></ul><ul><ul><li>Indicative of at least partial rotator cuff tears </li></ul></ul><ul><li>Empty can test </li></ul><ul><ul><li>Shoulder abducted to 90 in scapular plane with thumb down, resistance applied (“isolates” supraspinatus) </li></ul></ul><ul><ul><li>Positive if weakness and/or pain elicited </li></ul></ul><ul><ul><li>“ Full can” modification – better for exercise </li></ul></ul>
  42. 42. Rotator Cuff Tests
  43. 43. Subacromial Bursitis <ul><li>Often occurs concurrently with rotator cuff tendonitis/tears – all present as impingement syndromes </li></ul><ul><li>Difficult to isolate one condition vs. another clinically – requires advanced evaluative techniques </li></ul>
  44. 44. Subacromial Bursitis
  45. 45. Management of Impingement Syndromes <ul><li>Conservative management focuses initially on rest, NSAIDs, modalities to control sx </li></ul><ul><li>Then must focus on flexibility and strengthening of rotator cuff muscles and scapular stabilizers </li></ul><ul><li>Surgical intervention can include debriding subacromial space or resection of C-A ligament/distal clavicle </li></ul>
  46. 46. Biceps Tendon Injuries <ul><li>Bicipital tendonitis </li></ul><ul><li>SLAP lesions </li></ul>
  47. 47. Bicipital Tendonitis <ul><li>May occur secondary to rotator cuff injury, overuse of biceps and/or impingement </li></ul><ul><li>May involve transverse humeral ligament injury which causes instability of long head of biceps tendon in bicipital groove </li></ul>
  48. 48. Biceps Tendon Tests <ul><li>Yergason’s test </li></ul><ul><ul><li>Evaluates for biceps tendonitis and instability </li></ul></ul><ul><ul><li>Arm at side, elbow at 90, resistance to ER and supination – often also includes elbow flexion </li></ul></ul><ul><ul><li>Positive if pain and/or “snapping” in bicipital groove </li></ul></ul>
  49. 49. Biceps Tendon Tests <ul><li>Speed’s test </li></ul><ul><ul><li>Evaluative for biceps tendonitis </li></ul></ul><ul><ul><li>Resistance to shoulder flexion with elbow extended and forearm supinated </li></ul></ul><ul><ul><li>Positive if painful in bicipital groove </li></ul></ul><ul><li>Ludington’s test </li></ul><ul><ul><li>Evaluative for long head of biceps brachii rupture </li></ul></ul><ul><ul><li>Hands on head, patient applies downward force to top of head while clinician palpates tendon for tension </li></ul></ul><ul><ul><li>Positive if no tension is present and/or with pain </li></ul></ul>
  50. 50. Biceps Tendon Tests
  51. 51. SLAP Lesions <ul><li>S – superior </li></ul><ul><li>L – labrum </li></ul><ul><li>A – anterior to </li></ul><ul><li>P – posterior </li></ul><ul><li>Represent tears in glenoid labrum near attachment of long head of biceps tendon </li></ul><ul><li>Often associated with deceleration during throwing, but not consistent in presentation </li></ul>
  52. 52. SLAP Lesions <ul><li>Classifications of SLAP lesions </li></ul><ul><ul><li>Type I – labrum frayed near biceps attachment </li></ul></ul><ul><ul><li>Type II – labrum avulsed from glenoid with associated tear of biceps tendon </li></ul></ul><ul><ul><li>Type III – non-displaced bucket-handle tear of labrum with no biceps involvement </li></ul></ul><ul><ul><li>Type IV – bucket-handle tear of labrum with associated tear of biceps tendon </li></ul></ul>
  53. 53. Types of SLAP Lesions
  54. 54. SLAP Lesions <ul><li>Active compression (O’Brien) test </li></ul><ul><ul><li>Shoulder flexed 90 and horizontally add 15 </li></ul></ul><ul><ul><li>Resistance applied with shoulder IR, then ER </li></ul></ul><ul><ul><li>Positive if pain/clicking with IR, but absent with ER </li></ul></ul><ul><li>May also evaluate with MRI/CT </li></ul><ul><li>Most SLAP lesions identified at surgery – may be debrided or repaired </li></ul>
  55. 55. Thoracic Outlet Syndrome <ul><li>Pressure on brachial plexus and/or subclavian artery/vein from: </li></ul><ul><ul><li>Presence of cervical rib </li></ul></ul><ul><ul><li>Impingement between clavicle and 1 st rib </li></ul></ul><ul><ul><li>Compression between pec minor and rib cage </li></ul></ul><ul><ul><li>Tightness in anterior and middle scalenes </li></ul></ul>
  56. 56. Thoracic Outlet Anatomy
  57. 57. Thoracic Outlet Syndrome <ul><li>Cervical rib is outgrowth of C7 vertebrae, only ~10% with cervical rib suffer TOS </li></ul><ul><li>Other compressions are due to anatomical location and influenced by poor posture, forward shoulders, wearing a backpack </li></ul><ul><li>Increased risk with repetitive overhead activities (throwing, swimming, etc.) </li></ul>
  58. 58. Thoracic Outlet Syndrome <ul><li>Signs and symptoms: </li></ul><ul><ul><li>Neurological – numbness, paresthesia, pain (especially in C8 and T1 distributions) </li></ul></ul><ul><ul><li>Arterial – cool, pale skin, cyanosis to UE </li></ul></ul><ul><ul><li>Venous – edema in UE, swollen/prominent veins, thrombophlebitis (blood clots) </li></ul></ul>
  59. 59. Thoracic Outlet Syndrome Tests <ul><li>Adson’s test </li></ul><ul><ul><li>Attempts to stretch neurovascular bundle and compress under anterior scalene </li></ul></ul><ul><ul><li>Patient sits with shoulder abd to ~30 and ER, elbow ext, forearm supinated, clinician palpates for radial pulse </li></ul></ul><ul><ul><li>Clinician ER and extends patient’s shoulder and neck is ext and rotated toward involved side, patient instructed to hold breath </li></ul></ul><ul><ul><li>Positive if radial pulse disappears/diminishes with maneuver – many false positive results </li></ul></ul>
  60. 60. Adson’s Test
  61. 61. Thoracic Outlet Syndrome Tests <ul><li>Allen test </li></ul><ul><ul><li>Evaluates for TOS from pec minor origin </li></ul></ul><ul><ul><li>Patient sits with shoulder in 90/90, clinician palpates for radial pulse </li></ul></ul><ul><ul><li>Clinician horizontally abd and ER shoulder, patient turns head toward opposite shoulder </li></ul></ul><ul><ul><li>Positive if radial pulse disappears/diminishes with maneuver – many false positive results </li></ul></ul>
  62. 62. Allen Test
  63. 63. Fractures <ul><li>Scapula </li></ul><ul><ul><li>rare occurrences, can involve body but most common to processes, can be from direct trauma or associated with avulsion/dislocation </li></ul></ul><ul><li>Clavicle </li></ul><ul><ul><li>most common in central 1/3 at curvatures, can be from direct trauma or fall on outstretched arm </li></ul></ul><ul><li>Humerus </li></ul><ul><ul><li>humeral head fractures associated with GH dislocation, humeral shaft fractures rare and usually from trauma, some with rotational force </li></ul></ul>
  64. 64. Fractures
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