2. ANATOMY
SHOULDER GIRDLE
Comprises of clavicle,scapula,and humerus.
These three bones articulate with one another to
give the freedom of movement in all directions.
3. CLAVICLE
The only long bone with membranous
ossification.
The muscles attached to its medial and
lateral thirds are responsible for
displacement following a fracture .
Medial end articulate with sternum to form
sternoclavicular joint.
Lateral end articulates with acromian process
to form acromio clavicular joint.
4. SCAPULA
It is a flat bone , thickly covered by
muscles,so do not allow displacement of
fractures of this bone .
Because of rich vascularity scapular
fractures usually unite.
5. HUMERUS
Proximal end consists of the head
articulating with glenoid cavity of the scapula
(gleno-humeral joint or the shoulder joint
proper).
The head seperated from greater and lesser
tuberosities by anatomical neck.
The globular upper end of the bone joins
tubular shaft of the bone called surgical neck
.
Fractures are more common at the surgical
neck.
6. SHOULDER JOINT
(GLENO –HUMERAL JOINT)
Ball and socket joint.
Only one third of the humeral head is in
contact with the glenoid cavity at any time.
The capsule of the shoulder joint is lax and
permits freedom of movement.
Strong muscles surrounding the joint
contributes stability of this joint.
The important among this are rotator cuff
muscles .
9. INSPECTION
1) ATTITUDE
In fracture of clavicle the patient supports the
flexed elbow of the injured side with the other
hand .
Similarly in the anterior dislocation of the
shoulder.
10. 2)DEFORMITY OR SWELLING.
Abnormal swelling on the line of the clavicle
at its middle or at junction of lateral one third
and medial two third-fracture clavicle .
Undue prominence in clavicle bone
acromial end-dislocation of
acromioclavicular joint .
sternal end –dislocation of sternoclavicular
joint.
In subcoracoid dislocation -abnormal swelling
in deltopectoral groove ,undue prominence of
the acromian process with flattening of
shoulder.
In fracture of neck of scapula –drooping of
shoulder with undue lengthening of arm.
11. 3) CONTOUR OF THE SHOULDER
Inspection performed from all aspects
-anterior
-posterior
-lateral
Undue flattening and loss of roundness of the shoulder
just below the acromian process occurs in dislocation
of the shoulder .
Commonest type of dislocation is sub coracoid
dislocation ,i.e the head of humerus lies below the
coracoid process .
Here there is flattening of the anterior axillary fold.
Swelling just below the acromian process occurs in
fracture neck of the humerus , without any loss of
roundness .
12. 4) BONY ARCH
Formed by clavicle in front,acromian process
laterally ,and spine of scapula posteriorly.
Carefully inspect for any irregularity or
abnormal swelling –suggest fracture at that
site.
13. PALPATION
The patient is seated on a stool.
Examiner should stand behind the patient.
Palpate all the bones take part in formation
of shoulder girdle.
14. 1)CLAVICLE
Place the hands on the sternal ends of the clavicle of
the both sides .
First palpates sternoclavicular joints then proceeds
laterally on both sides to palpate the entire length of
the clavicle simultaneously.
Any break in the line or abnormal prominence
suggests fracture of this bone .
The sternal end is mostly anteriorly displaced in
sternoclavicular dislocation .
Acromial end is subluxated upwards in acromio –
clavicular joint dislocation.
15. 2)UPPER END OF THE HUMERUS
First palpate the acromian process of the both sides with the
fingers,gradually slide the fingers downwards to palpate the
greater tuberosity of the humerus on both sides .
Disappearance of greater tuberosity and loss of resistance
indicate dislocation of shoulder.
Then gradually slides fingers downwards along the line of
humerus on both sides.
Local bony tenderness and bony irregularity at the surgical neck –
fracture of neck of humerus.
Then palpate the shaft.
In an unbroken bone medial epicondyle shows direction of head
of humerus,and lateral epicndyle shows direction of greater
tuberosity.
This relation is disturbed in fracture f neck or the shaft of
humerus.
16. 3)PALPATION OF SCAPULA
First palpate the subcutaneous parts
-spine of scapua
- acromian process.
The vertebral border and inferior angle can be easily
palpated .
Axillary border is difficult to palpate ,localised bony
tenderness and swelling suggest fracture of scapula .
The coracoid process situated1/2 inch below the clavicle
at junction between the medial 2/3 rd and lateral 1/3rd.
Drooping of shoulder with tenderness and crepitus by
axial pressure upward through the flexed elbow is a
diagnostic feature of fracture neck of the scapula.
17. 4)RELATIVE POSITION OF 3 BONY POINTS
The tip of the coracoid process , the
acromial end of the clavicle and the greater
tuberosity of the humerus are compared with
those of the healthy side .
In acromioclavicular dislocation the acromial
end of clavicle more prominent and come
closure to the greater tuberosity. But
distance b/t tip of coracoid process and
acromial end of the clavicle become
increased.
18. MEASUREMENTS
1) The length of the arm
It is shortened in subcoracoid dislocation of
shoulder and fracture neck of humerus.
It is longer in subglenoid dislocation and fracture
neck of scapula.
2)Vertical circumference of scapula
Increased in any dislocation of the shoulder
3) Hamilton’s ruler test : a straight ruler can be
made to touch with acromian process and the
lateral epicondyle of the humerus.
19. MOVEMENTS
A full movement of the shoulder joint
excludes the possibilty of any bony injury
near this point.
DUGA’S test : in dislocation of shoulder the
patient is unable to touch the opposite
shoulder with the hand of the affected side
while the arm is kept in contact by the side of
the chest.
22. DIFFERENTIAL DIAGNOSIS
Fracture of the clavicle
Sternoclavicular dislocation
Acromio-clavicular dislocation
Fracture of the scapula
Dislocation of the shoulder joint
Fracture of the neck of humerus and the greater
tuberosity
Dislocation of the shoulder joint with fracture of
the uper end of the humerus .
