This document discusses common injuries around the shoulder joint, including dislocations, fractures, and ligament injuries. It begins with the anatomy of the shoulder girdle bones and joints. Shoulder dislocations, especially anterior dislocations, are the most common injuries described. Fractures of the clavicle and scapula are also discussed. The diagnosis and treatment of each injury is explained, with treatments ranging from immobilization and physical therapy to surgical repair depending on the severity of the injury.

1. INJURIES AROUND THE
SHOULDER
Dr. Joseph kartheek

2. CONTENTS
• Anatomy of shoulder girdle
• Shoulder dislocation
• Fractures of scapula
• Fractures of clavicle
• Sterno clavicular joint dislocation
• Acromio clavicular joint dislocation

3. Anatomy of shoulder girdle
The shoulder complex are made up of 4 joints
• Glenohumeral joint
• Acromioclavicular (AC) joint
• Sternoclavicular (SC) joint
• Scapulothoracic joint

4. Bones
The bones that are involve in the formation of
the shoulder joint are
• Humerus
• Scapula
• Clavicle
• Ribs
• Sternum

5. Muscles
The muscles that were involved in the functional
part of the shoulder joint are
• Pectoralis
• Deltoid
• Trapezius
• Serratus
• Rhomboid

6. Glenohumeral joint
• The glenohumeral joint is the most mobile joint in
the body.
• The ‘socket’ (glenoid fossa) is very shallow, and
doesn’t hold on to the ‘ball’ (humeral head) very well
• Joint type: ball and socket synovial joint
• It is therefore up to a group of muscles (called the
Rotator Cuff) to ‘hold the ball in the socket’,
providing stability and some movement.

7. Acromioclaviclar joint
• Joint type: plane or sliding synovial joint Bones
involved in the articulation
• Acromion of the Scapula
• Distal end of the Clavicle
Movements: only small translations
Anterior/Posterior glide
• Superior/Inferior tilt
• Rotation Acromioclavicular
Joint

8. STERNOCLAVICULAR (SC) JOINT
• Joint type: saddle synovial joint
Bones involved in the articulation:
• Manubrium of sternum
• Proximal end of clavicle
Movements:
• Anterior/Posterior glide
• Superior/Inferior tilt
• Rotation

9. SCAPULOTHORACIC JOINT
• Joint type: not a ‘true’ joint, but known as a
‘pseudo’ joint.
• Bones involved in the articulation:
Anterior surface of the Scapula
Ribcage of the Thorax

10. LIGAMENTS of SHOULDER JOINT
• Coracohumeral ligament - attaches the
coracoid process to the anterior region of the
greater tubercle of the humerus
• Transverse humeral ligament – covers the
intertubercular groove
• Glenoid labrum – fibrocartilaginous ring that
add depth to the Glenoid fossa.

11. Rotator cuff muscles
• The rotator cuff muscles (supraspinatus,
infraspinatus, teres minor and subscapularis)
help to stabilize the humeral head in the
glenoidfossa, plus have roles in shoulder rotation.

12. SHOULDER DISLOCATION
• Commonest joint to dislocate in humans
• Mc in adults and rare in children
• Anterior dislocation much more commoner
than posterior

13. SHOULDER INSTABILITY
• Broad term used for shoulder where head of
humerus is not stable in glenoid cavity.
• It has a wide spectrum from minor instability to a
frank dislocation
• In minor instability, pt presents with pain in
shoulder due to stretching of the capsule,as the
head moves out in some direction without
actually dislocating,
• A pt with frank instability presents with abnormal
movement of head of humerus. This could be
partial movement which gets spontaneously
reduced or a dislocation

14. • The instability may be in one
direction(unidirectional) or more
(bidirectional)
It may be in multiple directions- anterior,
inferior, posterior where it is called Multi
directional instability (MDI)

15. MECHANISM
• A fall on out stretched hand with the shoulder
abducted and externally rotated, is the most
common mechanism of injury.
• Ocassionally it results rom a direct force pushing
the humerus into glenoid cavity
• A posterior dislocation may result from a direct
blow on front of shoulder, driving the head
backwards’
• Often posterior dislocation is a consequence of
electric shock or epilepsy

16. ANTERIOR DISLOCATION POSTERIOR DISLOCATION

17. CLASSIFICATION
Anterior dislocation: classified into three sub types
preglenoid : head lies infront of glenoid
subcoracoid : head below coracoid and is
most common
subclavicular : head lies below clavicle
Posterior dislocation: head of humerus comes to lie
posteriorly, behind the glenoid
Luxatio erecta(inferior dislocation): rare type, head
comes to lie in subglenoid position

19. POSTERIOR SHOULDER DISLOCATION
(adducted and internally rotated arm)
ANTERIOR DISLOCATION
(Slight abducted and internal
rotated arm)
INFERIOR DISLOCATION

20. BANKARTS LESION
Seen in anterior dislocation.
Stripping of glenoid labrumalong with
periosteum .
Antero inferior Surface of glenoid and
scaular neck.
Avulsion of anteroinferior Glenoid rim
causes Bony Bankart Lesion.

21. HILL SACHS LESION
Depresson on humeral
head in its postero lateral
quadrant
Due to impingment by
the anterior edgeof
glenoid on the head as it
dislocates

22. OTHERS
ROUNDING OFF OF ANTERIOR GLENOID RIM: in
chronic cases due to repeated dislocation of head over
it
ASSOCIATED INJURIES like Fracture greater
Tuberosity ,Rotator Cuff Tear,Chondral Damage etc .

23. HILL SACH LESION
BANKART LESION

24. DIAGNOSIS
Clinical features:
patient comes to casualty with his shoulder
abducted and elbow supported with opposite
hand with pain and inability to move.
H/0 fall or previous episodes
On examination:
Normal round contour is lost and becomes
flattened
Fullness below clavicle due to displaced head, this
can be felt by rotating the arm

25. signs
1)LIGHTBULB SIGN :In Posterior Dislocation
2) GLENOID RIM:Distance between the medial
border of the humeral head an anterior glenoid
rim is >6mm.

26. Signs associated with dislocation:
DUGAS test: Instability to touch the opposite
shoulder
HAMILTON RULER TEST: because of flattening
of shoulder, it is possible to place a ruler on
lateral side of arm. This touches the acromian
and lateral condyle of humerus simultaneously.
Diagnosis can be made on a shoulder xray and in
posterior dislocation CT scan may be needed

27. Dugas test

28. • ANTERIOR DISLOCATION INFERIOR DISLOCATION

29. TREATMENT
• Acute dislocation can be reduced under
sedation or GA followed by immobilisation of
shoulder for three weeks
• Techniques of reduction
• Kochers manoeuvre: MC used method
• Milche technique
• Hippocrates technique
• Stimpson technique

30. Kochers manoeuvre
(TEAM)
• T-Traction: with elbow flexed to right angle and applying
steady traction along humerus
• E-External rotation
• A-Adduction- ER arm is adducted by carrying elbow towards
midline
• M-Medial rotation

31. Hippocrates manoeuvre:
• surgeon applies a firm and steady pull on as
semi abducted arm.
• With foot in axilla against the chest wall, head
of humerus is levered back into the position
using foot as fulcrum

32. Milch technique
• The arm is abducted and the physician's
thumb is used to push the humeral head
into its proper position. Gentle traction in
line with the humerus is provided with the
physician's opposite hand.

33. Stimson technique
• The patient is placed prone on the
stretcher with the affected shoulder
hanging off the edge. Weights (10-15 lbs)
are fastened to the wrist to provide gentle,
constant traction.

34. COMPLICATIONS
• Early complications:
Injury to axillary nerve resulting in deltoid muscle
paralysis with small area of anaesthesia over lateral
aspect of shoulder.
Diagnosis can be done by asking the shoulder to abduct,
which the patient cannot perform and absence of deltoid
contraction can be felt.
Treatment is conservative and has a good prognosis
Late complications:
recurrence of dislocation

35. SURGICAL OPTIONS
• If the disability is troublesome, operation may
be required. Following are the available
options
Putti platt operation
Bankart operation
Bristow operation
Arthroscopic bankart
repair

36. • Putti platt operation: Double breasting of the
subscapularis tendon is performed in order to
prevent external rotation and abduction,
preventing recurrences.
• Bankarts operation: Glenoid labrum and
capsule are reattached to the front of the
glenoid rim.
simple technique with the use of Anchors
• Bristows operation: In this coracoid process,
along with its attached muscles, is
osteotomized at its base and fixed to lower
half of anterior margin of glenoid.

37. Fracture of clavicle
Relavant Anatomy
• Sternoclavicular Joint.
• Acromioclavicular Ligament.
The Muscles Related To Clavicle Are :
• Sternocleidomastoid(origin) And
• Subclavius Muscle(insertion) .
The Subclavian Vessels And Brachial Plexus Lie
Posterior To Clavicle.

38. MECHANISM OF INJURY :
• Direct traumatic impact or fall on the shoulder
87% .
• Direct impact to clavicle
• Fall on outstretched hand
• Fall on the side .
• Vigorous muscle contraction , seizures.
• Pathological fracture [rare]

40. Pathonatomy:
• The junction of middle and outer third of the
clavicle is commonest site
• The outer fragment- displaces medially
downwards and outwards (gravity and pull by
pectoralis major)
• The inner fragment- displaces upwards ( pull
by sternocleidomastoid )

41. DIAGNOSIS
• History Of Trauma Followed By
Pain,swelling, Crepitus At Fracture Site
• Confirmed By Xray.

42. TREATMENT
FRACTURE CLAVICLE
MINIMAL
DISPLACEMENT
TRIANGULAR SLING
FOLLOWED 20-
25DAYS BY ACTIVE
SHOULDER
EXERCISES WHEN
THE PAIN SUBSIDES
SEVERE
DISPLACEMENT OR
NEUROVASCULAR
DEFICIT
OPEN REDUCTION
AND INTERNAL
FIXATION

43. Surgical treatment :
Rarely indicated in :
- lateral one third fracture .
- presence of neurovascular injury .
- non union cases .
Internal fixation plate .
Closed Reduction & Internal
Fixation by nailing .

44. Complications:
EARLY : [subclavian or carotid artery injury
,pneumothorax and hemothorax ,brachial injury ]
LATE :
Malunion .
Nonunion(rarely) : treated by internal fixation and
bone grafting .
Neurovascular injury [rare] .
Stiffness of shoulder in elderly .
Ulnar neuropathy .
Refracture .

45. FRACTURES OF SCAPULA
• Fractures of scapula are uncommon, because
od scapula location and surrounding muscles
which covering it.
• Fractures of scapula are result of high energy
trauma and high incidence of associated
injuries.

46. Scapula fractures at four common sites:
• The body
• The neck
• The coracoid process
• The acromion process
Mostly these ractures are undisplaced because
fragments held in position by surrounding
muscle

47. Clinical picture
• Brusing over scapula or chest area .
• Pain in movement .
• Swelling around back of shoulder .
• Tenderness at site of # .
• Arm is held immobile .

48. TREATMENT
• Reduction Is Usually Unnecessary .
• Mainstay of treatment is to restore
shoulder mobility by active exercises as
soon as pain subsides.
• A triangular sling for period of almost
1week to 10 days.

49. STERNO CLAVICUAR JOINT
DISLOCATION
Rare injury
Medial end of clavicle is displace forward or rarely
backward.
Clinical diagnosis is easier
Treated by reduction by direct pressure on
dislocated end which is then maintained by figure
of 8 bandage.

50. ACROMIO CLAVICULAR JOINT DISLOCATION
MECHANISM:
FALL ON
OUTSTRETCHED HAND

51. • The injury results in a partial or complete rupture
of acromio clavicular or coraco-clavicular
ligaments.
Grades of AC joint injury:
• Grade I : Minimal strain to acromioclavicular
ligament and joint capsule
• Grade II : Rupture if acromio clavicular ligament
and joint capsule
• Grade III: Rupture of acromio clavicular ligament,
joint capsule and coraco clavicular ligaments

53. TREATMENT
• REST IN TRIANGULAR
SLING
• ANALGEICS
Grade I
and II
• SURGICAL REPAIR
Grade III

54. THANK YOU