The Shoulder

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Chapter 5 The Shoulder

The shoulder is a complex series of joints that provide an extraordinary range of motion. This extreme mobility is accomplished, however, at the expense of some stability. This lack of stability, combined with its relatively exposed position, makes the shoulder vulnerable to injury and degenerative processes. Pain may develop not only from primary disease of the shoulder but also by referral from disorders of thoracic and abdominal origin, and these sources should be kept in mind, especially when more obvious causes are not apparent.

Anatomy

The shoulder is composed of three bones: the scapula, the clavicle, and the humerus. The scapula is a thin bone that articulates widely and closely with the posterior chest wall. It also articulates with the humerus by way of a small, shallow glenoid cavity and with the clavicle at the acromion process. The clavicle and scapula are suspended from the cervical and thoracic vertebrae by the trapezium, levator scapulae, and rhomboid muscles.

Four articulations constitute the shoulder joint: the glenohumeral, scapulothoracic, acromioclavicular (AC), and sternoclavicular joints. The stability of these joints is provided by a series of ligaments and muscles (Fig. 5-1).

FIG. 5-1 Bones and ligaments of the shoulder. R, Rotator cuff; B, long head of the biceps; AC, acromioclavicular joint capsule; CC, coracoclavicular ligaments; A, acromion; C, coracoid process; CA, coracoacromial ligaments.

Motion of the arm results from the coordinated efforts of several muscles. With the initiation of shoulder motion, the scapula is first stabilized. The muscles of the rotator (musculotendinous) cuff, especially the supraspinatus, then steady the humeral head in the glenoid cavity and cause it to descend (Fig. 5-2). This prevents the rotator cuff from impinging against the acromion. Elevation of the arm results from a combination of scapulothoracic and glenohumeral joint movements. One third of total shoulder abduction is provided by forward and lateral movement of the scapula. The remaining two thirds occurs at the glenohumeral joint through progressively increasing activity of the deltoid and supraspinatus muscles. Thus, even in the complete absence of glenohumeral motion, scapulothoracic movement can still abduct the arm approximately 60 to 70 degrees.

FIG. 5-2 Abduction of the shoulder. By stabilizing the humeral head in the glenoid (arrow), the superior portion of the rotator cuff (the supraspinatus muscle) prevents it from being forced into the acromion by the deltoid muscle. Rupture of this portion of the tendon may allow upward movement of the humeral head.

The coracoid, coracoacromial ligament, and underneath surfaces of the acromion and AC joint form a structure sometimes called the “coracoacromial arch.” The muscles of the rotator cuff (supraspinatus, teres minor, infraspinatus, and subscapularis) are separated from this overlying arch by the subacromial space. Bursal tissues occupy some of this space and may be affected by lesions of the musculotendinous cuff, AC joint, and adjacent structures (Fig. 5-3). They are frequently referred to as the subacromial bursa. Primary diseases of this bursa are rare, although secondary involvement is quite common. If bony abnormalities encroach on the subacromial space from above, the rotator cuff could be compressed as abduction occurs. When injections are given for rotator cuff disorders, it is the subacromial space that is injected.

FIG. 5-3 The subacromial space or “bursa” (B) is shown between the deltoid (D) and supraspinatus (S) muscles. Deep to the rotator cuff is the glenohumeral joint cavity (J).

Examination

The examination is performed with both shoulders widely exposed (Fig. 5-4). The general contour of the shoulder is noted, as well as any atrophy or swelling. The shoulder is thoroughly palpated, and any areas of tenderness are determined. These are frequently located over the AC joint and the rotator cuff.

FIG. 5-4 Superficial landmarks of the shoulder. The spine of the scapula lies at the level of the third dorsal vertebra. The inferior angle lies at the level of the seventh rib and eighth dorsal vertebra. The rotator cuff is palpated just distal to the acromion process.

Active and passive ranges of motion are tested and compared with those of the opposite arm. The examiner should determine whether the scapula and humerus move together or independently. Any crepitus during the examination is also noted. Active motion is measured in abduction, forward flexion, and extension. External and internal rotation can be measured by instructing the patient to reach behind the head and then backward behind the shoulder blades. Limited internal rotation is often seen in conjunction with rotator cuff disorders. Involvement of the AC joint is tested by directing the patient to adduct the arm across the front of the chest and touch the opposite shoulder (Fig. 5-5). Pain with this test suggests AC or sternoclavicular disease. The strength of the shoulder, especially at 90 degrees of forward flexion and then at 90 degrees of abduction, is tested and compared with the opposite arm.

FIG. 5-5 The crossover maneuver. Testing for acromioclavicular pain by having the patient touch behind the opposite shoulder (arrow). Local AC tenderness may also be present.

Roentgenographic Anatomy

The shoulder is routinely examined by anteroposterior views with the arm rotated externally and internally (Fig. 5-6). A lateral view of the shoulder joint should always be taken. This may be obtained by utilizing a transaxillary or lateral scapular Y exposure. The scapular Y view is helpful in evaluating the shape of the acromion as well as assessing any bony abnormalities that could narrow the subacromial space. It is also valuable in determining if the humeral head is dislocated or not.

FIG. 5-6 Roentgenographic anatomy of the shoulder. A, The AP view. S, surgical neck of the humerus; A, anatomic neck of the humerus; T, greater tuberosity; C, coracoid process; AC, acromion process; G, glenoid fossa. B, The scapular Y view. The humeral head should be centered at the intersection of the coracoid, spine, and body. This view also can visualize any bony abnormalities of the underneath surface of the acromion which could cause impingement.

Disorders of the Rotator Cuff

The tendons of the rotator cuff muscles fuse together near their insertions into the tuberosities of the humerus to form a musculotendinous cuff. Conditions affecting these tendons comprise the majority of all problems causing shoulder pain. Concepts regarding the etiology of rotator cuff disorders continue to evolve, but degeneration related to aging plays a major role. This degeneration is probably the result of many factors. Repetitive microtrauma, impairment in cuff vascularity because of advancing age, and shoulder instability with secondary overload of the cuff all may play a role. External abnormalities that narrow the subacromial space (subacromial osteophytes or an abnormal downward-shaped acromion) can also threaten the rotator cuff and predispose to impingement.

Degeneration is most severe near the tendon insertion. The supraspinatus is affected most often, and weakness of this tendon may allow the humeral head to migrate upward and lead to impingement against the acromion. Secondary changes in the form of thickening and chronic inflammation frequently develop in the overlying bursa, and with abduction, the tendon and bursa may be compressed against the coracoacromial arch. The throwing motion or “overhead” work are often factors in the development of these conditions. (Overhead work is work performed above shoulder height.)

A wide spectrum of disorders may affect the rotator cuff, and some difficulty may be encountered in separating them. Tendinitis, complete and incomplete rotator cuff ruptures, and calcific deposits are all capable of producing similar signs and symptoms. A variety of terms have developed to describe these diseases: supraspinatus syndrome, chronic impingement syndrome, painful arc syndrome, and internal derangement of the subacromial joint. The treatment for all of these lesions tends to be similar, except for that of complete rupture of the capsular rotator muscles, which may cause loss of motor function. Surgical repair is sometimes necessary for this lesion.

TENDINITIS

A painful rotator cuff can develop at any age, although it is rare in children. It is sometimes related to chronic overuse. The term tendinitis has typically been used for this diagnosis, but the terminology is changing to reflect knowledge regarding the underlying pathology. Because the cellular changes associated with inflammation are often absent in these cases, the terms tendinopathy or tendinosis have been proposed. Small degenerative separations or “tears” of the rotator cuff may even develop over time. Scarring and thickening of the involved area of tendon and bursa occur, decreasing the distance between the cuff and the overlying coracoacromial arch. Bony abnormalities of the acromion may also be a factor in compromising this space. Pain and crepitus (“impingement”) may be noted when motions of the arm, especially abduction, squeeze and pinch these tissues between the humerus and the overlying arch. Even with an intact cuff, impingement may develop if the supraspinatus does not function effectively, allowing the humeral head to be pulled upward with deltoid contraction.

CLINICAL FEATURES

The major clinical manifestations are pain (especially at night for unknown reasons), tenderness, and occasionally atrophy. The patient is often unable to lie on the affected shoulder and may feel a locking or catching sensation with certain motions, especially abduction. The pain is often referred down the deltoid muscle. When abducting the shoulder, the patient may automatically turn the palm up, thereby externally rotating the shoulder, a maneuver that gives the rotator cuff more room beneath the coracoacromial arch. Active, palm-down abduction is frequently painful. Forced passive elevation of the arm may cause the supraspinatus to impinge against the acromion, causing pain. Pain may also be reproduced by internal rotation and forward flexion (Fig. 5-7).

FIG. 5-7 The impingement test. Forced internal rotation of the abducted, slightly flexed arm may impinge the supraspinatus tendon against the coracoacromial ligament.

Maximum tenderness is usually noted over the supraspinatus insertion at the acromiohumeral sulcus because this is the most common area of involvement, although palpable tenderness may be difficult to elicit in obese or muscular individuals. Internal rotation is often decreased because of contracture of the posterior capsule (Fig. 5-8). There is usually little actual loss of muscle power. The pain and crepitus are most severe in the arc of motion between 60 and 120 degrees of abduction. This is where the traumatized soft tissues are maximally compressed between the tuberosity and the overlying arch.

FIG. 5-8 Internal rotation of the shoulder. Note how high the thumb can reach and compare with the opposite side.

The roentgenogram is usually normal, but some sclerosis may be present in the tuberosity secondary to long-standing local irritation. Osteophytes or abnormalities in the shape of the acromion may be noted (Fig. 5-9).

FIG. 5-9 Outlet or Y view of the shoulder revealing a downward angled acromion (arrows) with osteophyte formation at its tip projecting into the subacromial space. Normally, the acromion is flat on this view.

TREATMENT

1 Relief of pain and restoration of function are the therapeutic goals. An important part of the treatment program is rest. This allows the inflammatory process to subside, relieves pain, and restores function. Simply avoiding excessive use of the arm may constitute sufficient rest, but occasionally a sling is needed for a short time. The patient should avoid all “overhead” work until pain free.

2 Antiinflammatory medication is usually helpful.

3 Moist heat or other counterirritants are used several times each day.

4 Local steroid injections often dramatically relieve pain and swelling but should be used with caution, especially in the young patient: 1 to 2 mL of steroid mixed with 2 to 3 mL of lidocaine is injected, under sterile conditions, into the subacromial space (Fig. 5-10). The injection may be repeated two to three times every 3 weeks.

5 Function is restored by a careful, gentle exercise program directed at preserving muscle tone and preventing stiffness. Range-of-motion exercises are important, especially those that stretch the posterior capsule and correct any internal rotation contracture (Fig. 5-11). Stretching the posterior capsule is particularly important because a tight posterior capsule can aggravate the symptoms of rotator cuff tendinitis. Exercises are begun early but are performed only within the limits of pain. Work habits, especially overhead activities, that cause impingement should be avoided. If needed, a sling may be worn initially between the exercises to rest the shoulder, but it is gradually discontinued as the exercises are increased. Gentle strengthening exercises for the rotator cuff, especially the supraspinatus, may be helpful. A good program can result in better humeral head depression, thereby increasing the subacromial space, offsetting the powerful deltoid and preventing impingement. These exercises may be performed with simple elastic tubing or bungee cord obtainable at any hardware store. These exercises need to be performed carefully and may not be possible if there is too much pain. They are also not indicated in the presence of a known rotator cuff rupture since they may worsen the problem.

FIG. 5-10 Injection of the subacromial space. A slightly posterior approach is often best because there is more room. The needle is angled slightly upward and placed in the sulcus between the head of the humerus and the acromion (marked). It should be able to be inserted completely, and, if the needle tip is properly positioned, the fluid should flow easily without resistance. If not, the needle should be repositioned.

FIG. 5-11 Exercises for rotator cuff tendinitis. A, Elastic band exercises for strengthening. In addition to external rotation with abduction (shown), flexion, extension, and internal rotation are performed by attaching the strap to a door or wall. Always keep the arms below shoulder level. B and C, Internal rotation stretching exercises to correct any contracture of the posterior capsule.

Improvement is usually seen within 3 to 5 weeks (Fig. 5-12). If it is not, a more serious cuff lesion, such as a rupture, should be suspected. At this point, the patient should be referred for orthopedic evaluation and possible magnetic resonance imaging (MRI). Surgery is reserved for those cases that fail to respond to conservative treatment and patients who have reparable underlying pathology.

FIG. 5-12 Algorithm for rotator cuff inflammation.

RUPTURES OF THE ROTATOR CUFF

Ruptures of the rotator cuff are almost always chronic in nature and result from continued deterioration and degeneration (Fig. 5-13). The separation may be partial or complete. Ruptures are uncommon before the age of 40 years, although they may occur in young athletes. Acute tears are rare. Many ruptures are completely asymptomatic.

FIG. 5-13 Rupture of the rotator cuff (arrow). Full-thickness rupture allows joint fluid to escape from the glenohumeral joint into the subacromial region. This is often an MRI clue to a full-thickness tear.

CLINICAL FEATURES

Obtaining a history sometimes reveals a fall on the outstretched hand or an attempt to lift a heavy object, but usually there is no obvious injury. Pain and weakness may become progressively worse, and the patient notes an inability to abduct or flex the shoulder, depending on the area of the rupture. The pain is often referred down the deltoid muscle. Occasionally, the patient may have had a previous history of chronic impingement pain, and the diagnosis of rupture is often considered only when the patient fails to respond to the usual treatment for tendinitis.

If the rupture is partial, the clinical findings are similar to those seen in chronic tendinitis, and even with complete rupture, the shoulder may have a full range of motion because of continued function of the other rotator muscles and deltoid. Usually, however, with both partial and complete ruptures, there is at least some weakness in abduction or flexion. The weakness is usually most severe in abduction, because the muscle most commonly torn is the supraspinatus. (Supraspinatus rupture or weakness causes loss of the depressor effect, allowing the head to ride up, which increases the sense of grinding.) If the rupture is more anterior into the subscapularis, forward flexion may also be weak. Weakness against external rotation suggests rupture of the infraspinatus. It may be impossible to actively abduct the arm more than 45 to 50 degrees, after which further abduction is obtained by scapulothoracic motion. Tenderness at the site of the tear is a common finding, and with complete ruptures a defect in the cuff may be palpated through the deltoid muscle. Passive range of motion is frequently normal in the pain-free shoulder, although there is usually a positive impingement sign. Sometimes in complete massive tears, the patient can only “shrug” the shoulder and may have to use the opposite hand to raise the arm any further.

Atrophy of the cuff muscles is frequently present, and the “drop-arm” test may be positive if the tear is significant (Fig. 5-14). In this test, the arm is passively abducted to 90 degrees with the thumb pointing down, and then released. If the shoulder can maintain abduction, slight downward pressure is applied to the forearm, and the strength of the affected shoulder is compared with the normal shoulder. If pain is severe during the examination, lidocaine infiltration of the tender area can relieve the pain. The strength is then measured again. Inability to maintain shoulder abduction with this test is suggestive of a significant rotator cuff tear. Atrophy in the young is rare and should suggest nerve injury.

FIG. 5-14 The drop-arm test. The patient is asked to lower the arm from full elevation to 90 degrees and hold it. With large tears, the arm may drop, or the patient cannot hold the arm against resistence. It may also be difficult to slowly lower the arm to the side. Compare with the opposite side.

On rare occasions, the majority of the cuff may gradually become ruptured, along with all of the adjacent capsular structures. This completely destabilizes the joint, thus allowing the head of the humerus to sublux in and out of the joint when the arm is moved around. The patient will complain of the abnormal movement, which can be easily reproduced on clinical examination.

Acute hemarthrosis and prominent ecchymosis down the arm may occasionally accompany long-standing rotator cuff tears, especially those with cuff-tear arthropathy (a term used to describe end-stage rotator cuff disease caused by a large defect with additional humeral head roughening and glenohumeral joint changes). This is probably the result of further rupture with bleeding of remaining rotator cuff musculature.

Chronic subdeltoid swelling usually means that a large amount of synovial fluid has escaped from the glenohumeral joint to the subacromial space and indicates an extensive rotator cuff rupture. The entire deltoid may appear grossly enlarged.

SPECIAL STUDIES

In patients who have shoulder pain that clearly originates in the shoulder, it may be difficult to differentiate tendinitis from partial or complete rotator cuff tears on a clinical basis. Roentgenographic evaluation as described below may be of assistance.

1 Plain films should be obtained within the first few weeks of symptoms although they may not be necessary on the first visit. They are often indicated simply because of the nonspecific nature of rotator cuff symptoms and to rule out other obvious causes of shoulder pain. In long-standing cases, the examination may reveal calcific deposits or chronic changes in the tuberosity of the humerus (Fig. 5-15). Degenerative arthritis may also be present in the AC or glenohumeral joint.

2 Arthrography of the shoulder may help distinguish between complete and incomplete tears (Fig. 5-16). Its primary drawback is its invasive nature. It is often combined with MRI or computed tomographic (CT) scan. It should probably only be performed if there has been serious discussion regarding surgery.

3 Ultrasonography has some popularity in the evaluation of the rotator cuff. It is safe and noninvasive and is most accurate in large and moderately large tears. Its value is largely dependent on the interest and experience of the radiologist.

4 MRI now plays a major role in diagnosing rotator cuff disease. It can diagnose if a tear is present and may help determine if the tear is reparable or not by elucidating the amount of separation and atrophy (Fig. 5-17). Because of the expense and discomfort involved, it should not be used as a “screening test.” In addition, it is probably not indicated unless surgery is a consideration and only after the appropriate medical treatment.

FIG. 5-15 Radiologic changes with large rotator cuff tears. There is proximal migration of the humeral head with narrowing of the subacromial space (arrow). The head becomes eburnated and sclerotic (triangles) because it now articulates against the underside of the acromion. A small spur on the lateral head is also present. These changes occur because the cuff can no longer stabilize the head in the glenoid. The deltoid, acting alone in abduction, pulls the head proximally. Some limited abduction can then be achieved by a fulcrum effect with the head stabilized against the underneath side of the acromion. After the head migrates upward, subacromial injection is more difficult because very little space remains for needle insertion.

FIG. 5-16 Arthrography of the shoulder reveals a large leakage from the shoulder joint through the rotator cuff into the subacromial space beneath the deltoid when dye is injected into the shoulder joint itself; this indicates a complete rupture.

FIG. 5-17 MRI of a complete rotator cuff tear. In this case, there is considerable separation of the tendon ends (arrows). This usually means that repair is not possible because scarring and atrophy of the muscle have occurred, preventing the tendon ends from being able to be brought together for suturing. Smaller amounts of separation are amenable to repair.

Electromyography (EMG) may be helpful to rule out the rare case of suprascapular nerve compression, which can mimic rotator cuff disease. It is especially indicated in young patients when weakness and atrophy are present.

TREATMENT

Partial or small complete tears may respond to the conservative treatment program outlined for chronic tendinitis including occasional injections. Physical therapy (PT) and exercise are probably contraindicated in the presence of a separation. Occasionally, it is necessary to surgically repair the rupture and remove any impinging structures beneath the coracoacromial arch, especially in the young, active patient with high functional needs. Complete tears may also need repair if they are sufficiently disabling at any age. Often, however, there is very little loss of function and minimal pain, even with a complete rupture. In these patients, especially if they are relatively inactive, operative intervention is probably not justified.

In many cases, repair of the rupture is simply not possible due to the amount of retraction of the tendon ends and atrophy of involved muscle. For these patients, functional treatment with gentle strengthening and injections is all that can be offered. Surprisingly, many of them do remarkably well.

NOTE: There is no way to predict whether a small rupture will progress once it is identified. It is reasonable to simply monitor symptoms. If there is recurrence, repeat MRI may be indicated to determine if there has been any change in the status of the separation.

CALCIFIC DEPOSITS IN THE ROTATOR CUFF

Calcium deposits in the rotator cuff tendon may be associated with pain and stiffness in the shoulder. Whether the calcific changes are a cause of symptoms or simply the result of degeneration is not known. Benign calcific deposits are a common incidental finding and probably result from degenerative changes in the same area where ruptures take place. They are most frequently found in the supraspinatus tendon. Most deposits remain small and deep in the tendon, and pain may be absent. Others may produce an inflammatory reaction and swelling, perhaps as the process of resorption takes place. Impingement of these swollen tissues against the overlying coracoacromial arch may then occur.

CLINICAL FEATURES

The signs and symptoms are identical to simple tendinitis. The pain is characteristically severe and accentuated by the slightest motion. Night pain and an inability to sleep on the shoulder are common complaints. The pain may radiate to the deltoid and even down the arm.

Examination in the acute stage reveals markedly limited motion and exquisite tenderness over the bursa and calcific deposit. The findings in chronic cases are less pronounced. Shoulder motion is frequently normal. However, symptoms of intermittent impingement and tenderness of the rotator cuff may be present.

Roentgenographic examination in internal and external rotation usually reveals the deposit (Fig. 5-18). If the deposit is anterior in the subscapularis muscle or posterior, a transaxillary or Y view may be necessary to demonstrate it.

FIG. 5-18 Large calcific deposit in the rotator cuff.

TREATMENT

Treatment is directed at relief of the inflammation. A subacromial injection of 1 mL of steroid mixed with 4 to 5 mL of lidocaine often provides dramatic relief. If the deposit appears soft, fluffy, and irregular on roentgenographic examination, aspiration and needling of the deposit may also be attempted. However, if the deposit is dense, round, and well circumscribed, this procedure is less helpful.

Aspiration and needling are performed with the use of local anesthesia. A syringe with an 18-gauge needle is partially filled with lidocaine and inserted directly into the deposit. Multiple areas are then injected and aspirated. A fine, flaky material may be withdrawn. The aspiration and needling are repeated over several areas until all accessible material is withdrawn. A second large needle placed in the calcific mass can be used for aspiration while the first needle is used for injection. At the end of the procedure, 2 mL of steroid is left in the bursa.

Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) are given as necessary. Warm, moist packs are applied to the shoulder. The arm is allowed to hang in a sling until the acute pain subsides, and pendulum exercises are then initiated within the limits of pain. Motion progresses as can be tolerated.

Surgical excision of the calcific deposit is rarely performed. The calcific material often resorbs on it own, and the tendon reconstitutes itself.

Disorders of the Biceps Tendon

TENOSYNOVITIS

Tenosynovitis of the long head of the biceps is a common cause of shoulder pain in adults older than 40 years of age. It may also occur in the young athlete from repeated strains, such as those caused by the throwing motion. The basic lesion is an inflammation in the tendon and its sheath in the bicipital groove. The disorder may be primary or secondary to disease of the overlying rotator cuff. It may be difficult to differentiate from rotator cuff disorders.

CLINICAL FEATURES

The most common symptom is pain over the anterolateral aspect of the shoulder that may be referred down the anterior aspect of the arm. (Rotator cuff disorders usually refer pain down the lateral arm.) The most constant physical finding is tenderness to palpation over the bicipital groove. Active and passive shoulder motions are often restricted because of pain. Maneuvers that stretch the biceps tendon or cause it to glide in the groove may be painful. Forceful extension or abduction against resistance with the elbow extended and the forearm supinated may reproduce the pain (Fig. 5-19). Backward movement with the elbow extended may also be painful. The roentgenograms are usually normal.

FIG. 5-19 Speed’s test. The patient holds the elbow in extension at 30 degrees of forward elevation and supinates the forearm. Further elevation is attempted against resistance. Pain in the region of the bicipital groove is suggestive of bicipital tenosynovitis.

TREATMENT

In the acute stage, treatment consists of rest, moist heat, and gentle range of motion exercises. All motions that stretch the biceps tendon should be avoided. A sling may be used temporarily. NSAIDs may be helpful, and local steroid injections into the tendon sheath are frequently beneficial (Fig. 5-20). The majority of cases respond well to conservative treatment. Surgery is recommended for those cases that fail to improve.

FIG. 5-20 Injecting the bicipital groove. The elbow rests in the flexed position with the upper arm in neutral rotation. The biceps groove faces forward. The area of point tenderness is injected.

RUPTURE OF THE BICEPS TENDON

The long head of the biceps tendon may rupture as a result of advanced degeneration from chronic tendinitis. The rupture is usually complete and may follow a forceful contraction of the biceps muscle.

CLINICAL FEATURES

The onset is usually sudden. A sharp snap may be felt by the patient, followed by pain and weakness of the arm. The diagnosis is easily made by the observation of an abnormally large mass in the arm that represents the retracted muscle belly of the long head of the biceps (Fig. 5-21). There may be some loss of elbow flexion power, but after the discomfort subsides, the amount of weakness is usually minimal.

FIG. 5-21 Rupture of the long head of the biceps. A localized bulge (arrow) that is more prominent when the elbow is flexed against resistance is present in the distal part of the biceps (the “Popeye” sign).

TREATMENT

No treatment is necessary in most cases. There is only minimal loss of function and usually little pain associated with rupture. Frequently, if the patient has had chronic anterior shoulder pain consistent with biceps tendinitis, the pain will actually be relieved by the rupture. In the rare case in the young patient, however, surgical repair of the rupture may be indicated.

SUBLUXING BICEPS TENDON

The biceps tendon may occasionally sublux or dislocate out and back from its bed in the bicipital groove (Fig. 5-22). The usual cause is a tear in the overlying subscapularis tendon as the result of degenerative changes, but the condition may result from a congenitally shallow groove. The disorder may also occur in young patients on forceful external rotation and abduction of the shoulder. Recurrences are frequent and may be reproducible by the patient. Tenosynovitis frequently develops and leads to pain.

FIG. 5-22 Subluxing biceps tendon. A snap may be felt or heard in the bicipital groove as the arm is externally rotated with the elbow flexed.

The only cure for this lesion is anchoring the tendon in the bicipital groove surgically. The results are uniformly good.

Frozen Shoulder (Adhesive Capsulitis)

Frozen shoulder is a disorder characterized by the insidious onset of pain and restriction of motion. The disease tends to be chronic, and full recovery may take several months. It is more common in women and diabetics, and it is also more recalcitrant in diabetics, especially those who are insulin dependent. The cause is unknown, but bicipital tenosynovitis, rotator cuff tendinitis, and reflex sympathetic dystrophy have all been blamed. It is often found in association with ischemic heart disease, thyroid disease, and lung disease. The term capsulitis is probably a misnomer because inflammation is not a constant finding. A posttraumatic form follows surgery or local injury.

CLINICAL FEATURES

The onset is usually gradual and begins in the fifth decade. Three stages are sometimes described: freezing, frozen, and thawing. The disorder may develop during a period of inactivity in the use of the extremity or after a relatively minor injury to the shoulder, but usually there is no precipitating event. Pain is a constant symptom but frequently does not occur until much of the shoulder motion has already been lost. Pain is usually well localized in the region of the rotator cuff and may radiate down the deltoid and anterior aspect of the arm. It frequently interferes with sleep, especially when the patient attempts to lie on the affected shoulder.

Examination reveals an apprehensive patient who holds the arm protectively at the side. Varying degrees of deltoid and spinatus atrophy may be noted. Generalized tenderness is present around the rotator cuff and biceps tendon. Active and passive shoulder motions are restricted to varying degrees, depending on the stage of the disease. Loss of internal rotation (active and passive) is a hallmark finding. The signs of reflex sympathetic dystrophy may be present in the involved extremity (edema of the hand, coolness, and discoloration).

Roentgenograms should always be performed. Although their findings are usually normal, a missed posterior shoulder dislocation should always be ruled out.

The course of the disease is variable. Some patients recover relatively early in the disorder, but in many cases the condition is progressive over several months. In these patients, shoulder motion gradually decreases, and the pain subsides. As soon as the pain diminishes, the shoulder begins to regain its motion. Recovery is slow, and complete recovery in less than 6 months is rare. Most patients will eventually regain full motion of their shoulder, although some mild loss of motion and discomfort may persist for years.

TREATMENT

The most important facet of treatment is prevention. Every attempt should be made to maintain motion in the shoulder during periods when the patient may be inactive because of disease or injury. Once the disease process has begun, treatment is directed at the relief of pain and restoration of motion. Moist heat, sedation, and analgesics are prescribed as necessary. Because rotator cuff dysfunction is often a significant source of pain, a local injection of a steroid–lidocaine mixture into the subacromial space may also prove beneficial. Injection of the shoulder joint itself may also be helpful. Pendulum and overhead pulley exercises are begun as soon as possible and initially are performed on an hourly basis (Fig. 5-23). (Frequency of exercise is far more important than duration.)

FIG. 5-23 Shoulder stretching exercises. A, Pendulum exercises. B, Wall-climbing exercise. C, Rope and pulley exercises. The normal arm assists in the elevation of the stiffened arm. D, Exercise for restoring internal rotation. E, Exercise for restoring external rotation. Each exercise should be performed hourly or at least four times a day. Applying moist heat before the exercise may be helpful. In addition, activities that aggravate the pain, such as overhead work, should be avoided. For sitting work, a chair that supports the arms and shoulders should be used, and the patient should sit as close to the working surface as possible.

The initial stage of pain followed by stiffness may last several months. The recovery, or “thawing,” phase may also last several months. Complete recovery is usually the case. Recurrence in the same shoulder is rare, although the opposite limb may develop the same symptoms, sometimes months to years later. Most patients eventually respond to a well-supervised program of PT and home exercise. Some will have mild permanent residual loss of motion, but usually without any significant functional impairment. Those patients whose injuries fail to respond may benefit from careful manipulation of the shoulder under general anesthesia followed by aggressive range of motion exercises. Surgical intervention is rarely indicated.

Snapping Scapula

Snapping scapula is an uncommon disorder in which an audible grating sound occurs with motion of the scapulothoracic joint. Normally, the serratus anterior and subscapularis muscles cushion the scapula from the underlying rib cage. The scapula is poorly protected at its medial border and at its superior and inferior angles, however. Abnormal angulations at these locations may cause pain and snapping sensations. Tumors of the scapula or ribs, bursae between these bones, and poor posture with sagging of the shoulder joint are other causes of crepitus in this area. In most cases, however, no cause is found.

CLINICAL FEATURES

The onset is usually gradual, but the process is frequently precipitated by a traumatic event. The snapping is often palpable and painful. The origin of these noises can frequently be well localized by the patient to a specific area in the scapulothoracic articulation. Roentgenograms of the scapula, including oblique views, are obtained to discover such lesions as exostoses and tumors when they are present (Fig. 5-24).

FIG. 5-24 A Y view of the scapula revealing an osteochondroma (arrow) of the inner wall.

TREATMENT

If the roentgenograms are normal, PT, rest, and local steroid injections often relieve the pain. An exercise program is important. Correction of poor posture is also frequently beneficial. If the snapping is secondary to tumor or exostosis and the pain and disability are sufficient to justify surgery, the involved area of the scapula is removed surgically. Most patients seem to tolerate the symptoms, which appear to resolve on their own most of the time, and surgery is rarely required.

Distal Clavicle Osteolysis

This is a disorder in which pain and tenderness develop at the AC joint, often in individuals who are weightlifters. The etiology is unknown, but the condition may be related to microfractures that cause hyperemia, a destructive synovitis, and localized osteopenia.

Clinically, there is local tenderness and a positive cross-body adduction test.

Plain roentgenographic evaluation reveals loss of bone detail of the distal tip of the clavicle because of hyperemia and osteopenia (Fig 5-25). Bone scanning is abnormal, although the test is usually not required to establish the diagnosis.

FIG. 5-25 Distal clavicle osteolysis (arrow). Lytic erosions are present.

Treatment is symptomatic. NSAIDs and heat are helpful. Weightlifting activities may need to be discontinued temporarily. Steroid injection into the AC joint is often helpful. Excision of the tip of the clavicle may rarely be required. How much treatment is appropriate for the recreational athlete is considered on a case-by-case basis.

Unicameral Bone Cyst

The unicameral (simple, solitary) bone cyst is a condition that frequently develops in the upper humerus. It is the only true fluid-filled cystic lesion and develops only in growing bone. The most common age of presentation is between 8 and 14. The etiology is unknown. The humerus is the most common site of development, although cases have been reported in the femur and other long bones. Unicameral cysts probably originate in the metaphysis, adjacent to the growth plate.

CLINICAL FEATURES

The condition is usually diagnosed in late childhood by the development of a pathologic fracture caused by the weakness of the surrounding bone. This often occurs under simple circumstances and with minimal trauma, such as the act of throwing a ball. The child hears a noise, and there is immediate pain. The upper arm is unable to be moved.

The roentgenographic appearance is usually characteristic (Fig. 5-26). The lesion appears as a relatively large radiolucent mass that is wider at the growth plate and narrower at the diaphysis. The cortex is usually expanded and thinned, but the lesion never penetrates into the soft tissue. A pathologic fracture is commonly present. As the lesion matures over time, it “migrates” away from the growth line and shrinks in size. It commonly disappears completely as it drifts toward the midshaft, although some lesions are said to survive into adulthood. There is very little periosteal new bone reaction around the cortex. MRI is helpful in disputed cases but is rarely needed because of the typical radiographic appearance of the lesion.

FIG. 5-26 Unicameral bone cyst of the upper humerus. The lesion is unilocular. The overlying cortical bone is thinned, and the shaft appears expanded. A pathologic fracture is seen (arrow), There is very little periosteal new bone.

TREATMENT AND PROGNOSIS

The initial treatment is related to the pathologic fracture. Wearing a simple sling for 5 to 6 weeks is usually sufficient. Biopsy is rarely needed. After the fracture heals, contact sports should be avoided, and the cyst can be monitored by repeat radiographs. Occasionally (in 15% to 20% of cases), the lesion will heal after the initial fracture. Recurrent fractures may require active intervention. Instillation of the cyst with methylprednisolone has been successful in some cases. Another option is the percutaneous injection of bone graft material. The asymptomatic lesion discovered incidentally is usually not observed unless it is quite large.

Serratus Anterior Paralysis

The serratus anterior pulls the scapula forward, stabilizing it when pushing. Paralysis of the long thoracic nerve can lead to the characteristic winging, which is most obvious when the patient does a push-up against a wall (Fig. 5-27). The etiology may be direct trauma, but usually no cause is found.

FIG. 5-27 Winging of the scapula. Paralysis of the serratus anterior is most prominent when the patient pushes against the wall or tries to do a push-up.

Treatment is usually by observation and an exercise program to maintain strength. Many cases recover spontaneously, but full return of function may take 6 months to a year.

Glenohumeral Dislocation and Instability

The shoulder is the major joint most commonly dislocated as a result of trauma. It is also the joint most likely to develop problems with instability (recurrent dislocations or subluxations).

Ninety-five percent of dislocations of the shoulder are anterior in direction and usually result from a fall on the externally rotated, abducted arm (Fig. 5-28). This force levers the humerus out of the glenoid cavity into its anterior position. Anterior dislocation is the most common cause of instability.

FIG. 5-28 Anterior dislocation of the shoulder, AP (A) and lateral Y views (B). On the lateral, the head (H) is anterior to the glenoid (G).

Posterior dislocations are less common and may result from a force directed against the internally rotated arm. Many posterior dislocations occur at the time of a seizure in patients with convulsive disorders. Occasionally, some individuals can reproduce a posterior dislocation voluntarily and use this maneuver to attract attention.

Glenohumeral instability may develop either as a result of trauma (usually acute dislocation or repeated stretching) or from nontraumatic causes. It is commonly classified by direction (anterior, posterior, or multidirectional). Most cases of anterior and posterior instability are the result of trauma, usually an acute dislocation.

Multidirectional instability is a condition in which glenohumeral dislocation or subluxation can occur in multiple directions. The main abnormality in this form of instability is generalized excessive laxity of the joint capsule, and the disorder is considered to be nontraumatic in nature, in contrast to the unidirectional type. These patients often have signs of ligamentous laxity in other joints.

CLINICAL FEATURES

The diagnosis of the acute dislocation is usually not difficult. Clinically, the acromion is much more prominent than normal, and there is an absence of the normal fullness of the humeral head beneath the deltoid and acromion process. Little movement of the shoulder is possible without severe pain. With anterior dislocations, the arm is held externally rotated; the anterior shoulder is full; and internal rotation is painful. In posterior dislocations, the arm is held in internal rotation with the forearm resting on the abdomen; the anterior portion of the shoulder is flat; and external rotation is painful (the arm is locked in internal rotation). The integrity of the neurovascular structures of the arm should always be assessed, especially the axillary nerve. Numbness in the middle of the deltoid may be the only obvious finding of axillary nerve damage because motor function is often difficult to test due to pain (Fig. 5-29).

FIG. 5-29 Testing for axillary nerve sensation. A pin or brush is commonly used.

Roentgenographic evaluation is mandatory. The radiographic diagnosis in cases of anterior dislocation is usually easy, but interpretation is sometimes difficult with posterior dislocation, and the diagnosis is commonly missed (Fig. 5-30). A “true” anteroposterior view of the shoulder may be helpful, but a lateral view of the glenohumeral joint is essential. A variety of lateral views may be performed (transaxillary, transscapular Y). If there is any doubt about the diagnosis, some type of lateral view of the glenohumeral joint must be taken. Some dislocations may only be apparent on the lateral view (Fig. 5-31).

FIG. 5-30 A, The “normal” AP roentgenographic anatomy of the glenohumeral joint. There is normally a 50% elliptical overlap or “half moon” of increased density where the humeral head overlaps the posterior glenoid rim. The anterior edge of the glenoid should parallel the medial border of the humeral head, and the distance between these two lines should not exceed 6 mm. B, Anterior dislocation, which is usually not a problem in diagnosis. C, Posterior dislocation. Up to 50% of these are missed initially. The humeral head barely overlaps the glenoid and may be higher or lower than normal. The greater tuberosity is usually internally rotated, and the area of overlap is abnormal. D, The “true” AP view of the glenohumeral joint is taken 25 degrees toward the midline. E, A true lateral (the scapular Y) view may be taken at a right angle to this film. (The Y is formed at the glenoid fossa where the bases of the coracoid and spine of the scapula join the distally projecting body.) The humeral head should be present at the intersection.

FIG. 5-31 A and B, Transaxillary lateral views of the glenohumeral joint. Even with a fracture or dislocation, the arm can be gently abducted enough to obtain a view from below or above. It may be done in a standing or supine position. C, The roentgenographic appearance. Also present is a displaced fracture of the surgical neck of the humerus, but the humeral head is properly positioned in the glenoid (G). D, A posterior fracture-dislocation. E, The injury in D is reduced and the fracture has been internally fixed.

The diagnosis of instability may be difficult if there is no clear history of an acute dislocation. Unidirectional instability following posterior dislocation is rare, but anterior instability commonly develops in the young patient following an anterior dislocation. It may even result from stretching of the anterior capsule by the repetitive throwing motion. Anterior dislocation in the young often causes damage to the labrum and capsular ligaments, usually called the “Bankart lesion.” This injury can lead to instability and even recurrent dislocations, often with minor shoulder movement, such as simply turning off a light from bed. The common complaint is that the shoulder “goes out” when the arm is placed in the throwing position. In these cases, there may be apprehension when this maneuver is reproduced on clinical examination (Fig. 5-32).

FIG. 5-32 Apprehension test. To test for anterior instability, abduct and externally rotate the arm, and apply a gentle anterior force against the posterior shoulder. The test is positive if there is the feeling of imminent subluxation and the patient becomes apprehensive and resists further motion.

The diagnosis of multidirectional instability may be difficult if there is no history of frank dislocation, which is commonly the case. The sulcus test is helpful. This test assesses inferior movement of the humeral head. With the patient standing and the arms hanging, the arms are pulled inferiorly (Fig. 5-33). A sulcus will form between the acromion and humeral head in cases of multidirectional instability. Examination of other joints may reveal generalized laxity.

FIG. 5-33 The sulcus sign. The relaxed arms are pulled inferiorly, causing a deepening of the acromiohumeral sulcus (S) in the patient with joint laxity.

TREATMENT AND PROGNOSIS

Shoulder dislocations are usually reducible without use of general anesthesia. Intravenous sedation or analgesia is often helpful. Gentle, straight traction on the arm is usually sufficient to reduce both the anterior and posterior dislocation (Fig. 5-34). If straight traction does not reduce the dislocation, Stimson’s method may be used for the anterior dislocation. The patient is placed in a prone position with the affected arm hanging over the side of the table. A 5- to 10-kg weight is tied to the wrist for traction. As the shoulder muscles relax, spontaneous reduction frequently occurs. If the shoulder remains dislocated, reduction with the patient under a general anesthetic is usually necessary. Open reduction is rarely required.

FIG. 5-34 Reduction of shoulder dislocation. A, Straight traction is applied to the wrist with countertraction to the axilla. If straight traction fails, try pulling upward. B, Stimson’s method for anterior dislocations. Kocher’s maneuver is usually not necessary. Relaxation, explanation, and reassurance often help more than high doses of narcotics.

Primary dislocations in either direction in patients younger than 30 years have a high rate of recurrence, often with little trauma. It had been theorized that prolonged immobilization for 3 to 4 weeks would encourage better capsular healing and prevent recurrent dislocation. It now appears that extended protection offers no benefit against recurrence and that the likelihood of recurrence is determined primarily by the age of the patient at the time of the injury, regardless of the form of treatment after the reduction. Patients younger than the age of 30 have a 50% recurrence rate, irrespective of the type or length of immobilization following reduction. Thus, following reduction, the arm is simply rested in a sling for a few days, and motion is gradually allowed as symptoms subside. Rehabilitative exercises are often helpful (Fig. 5-35). The patient is educated to avoid positions of known instability, usually external rotation and abduction with the common anterior dislocation. Recurrence risk is directly proportional to the level of activity and inversely to age. There is almost a 100% rate of recurrence after a third dislocation, and recurrent dislocations in either direction usually require corrective surgery.

FIG. 5-35 Exercises for shoulder strengthening following dislocations. These should be performed with the arm below shoulder level. A simple rope and pulley system is all that is needed, with the pulley being attached to the wall or stud with an eye bolt. Exercises are performed two to three times a day, and each is repeated 15 to 30 times beginning with a 2-kg weight and progressing to 10 kg. A, Flexion. B, Extension. C, Abduction. D, Internal rotation. E, External rotation.

Primary dislocations in patients older than 40 years of age are not generally complicated by recurrence but may result in shoulder joint stiffness. In this age group, light immobilization with a sling for a few days is all the treatment that is necessary, and active motion is then encouraged to prevent stiffness.

Occasionally, an old anterior dislocation is seen in the older patient. The length of time the shoulder has been dislocated may be impossible to determine. Closed reduction may be attempted, but if the injury is more than 2 to 3 weeks old, enough soft tissue healing will probably have occurred to make the procedure unsuccessful. If it fails, accepting the disability and working to improve motion may be the most logical treatment in this age group. In the young, open reduction or even arthroplasty will be needed.

Unidirectional instability (recurrent dislocation or subluxation) is often treatable by lifestyle changes and an exercise program. Persistent symptoms, especially in the athlete, respond well to surgical intervention. Multidirectional instabilities can be difficult to diagnose, especially when only subluxation occurs. These cases are usually treated nonsurgically with strengthening exercises. Voluntary dislocators are always treated nonsurgically.

Acromioclavicular Dislocation

AC dislocations and “separations” usually occur as a result of a fall on the shoulder or from a direct blow to the top of the shoulder. The acromion is driven away from the clavicle. They are graded I through V. Grade I is a simple AC contusion or strain. In grade II, there is rupture of the AC ligaments. Grade III includes the additional rupture of the coracoclavicular ligaments. The uncommon, severe grades IV and V involve more significant displacement, often with penetration through the overlying muscle. Grades I and II are sometimes called incomplete, and grades III through V called complete (Fig. 5-36).

FIG. 5-36 A, Incomplete dislocation of the acromioclavicular joint. The coracoclavicular ligaments are intact. B, Complete dislocation.

CLINICALFEATURES

These injuries are characterized by tenderness and swelling over the AC joint. The outer clavicle is usually elevated in both complete and incomplete dislocations (Fig. 5-37). Downward traction on the arm may increase the deformity.

FIG. 5-37 Clinical deformity with acromioclavicular dislocation.

Complete dislocations may be differentiated from incomplete dislocations by an anteroposterior roentgenogram taken while the patient has a 10-kg weight hanging from both arms. (The patient should not hold the weights.) If complete rupture of the coracoclavicular ligaments has occurred, widening between the coracoid process and the clavicle will be present on the affected side (Fig. 5-38).

FIG. 5-38 Complete acromioclavicular dislocation. Widening is present between the coracoid process and the clavicle.

TREATMENT

Usually, no treatment is necessary for incomplete separations. A sling is used for a few days to minimize the pain, and active shoulder motion is begun as can be tolerated. The outer end of the clavicle will remain prominent, but this is usually painless and does not interfere with function. Even grade III complete AC dislocations are treated nonsurgically in most cases. The rare grade IV and V injuries usually require surgery.

Sternoclavicular Dislocation

Sternoclavicular dislocations are uncommon injuries that occur as the result of a fall on the shoulder. The anterior dislocation is more common than the posterior dislocation. The rare posterior dislocation may cause pressure on the anterior structures of the neck and lead to dyspnea and vascular compression that may require immediate reduction.

The injury usually produces a tender, visible prominence at the sternoclavicular joint. Some discomfort with shoulder motion is usually present.

This is an area that is difficult to visualize roentgenographically. A view angled upward including the uninjured side may give some information. MRI may be required.

Anterior dislocations can be reduced by traction and manipulation, but the reduction is difficult to maintain. Recurrence after the reduction is common, but except for minor cosmetic deformity, no function is lost. Surgical intervention, therefore, is rarely justified in the acute case, and therefore, most injuries are treated simply with a sling.

Spontaneous anterior sternoclavicular (SC) dislocation may occasionally occur without any clear history of trauma. The patient may present with a relatively painless “mass,” the enlargement being the sternal end of the clavicle. This is most commonly seen in the older adult. Reassurance is usually the only treatment, following routine examination and plain films.

In the child, an epiphyseal fracture can also occur in this area, sometimes causing confusion with an SC dislocation. Reduction may be able to be obtained by manipulation but is difficult to maintain. Fortunately, some remodeling eventually occurs that will diminish the size of the fracture bump. As with SC dislocations, only nonsurgical management is needed in most cases.

Avascular Necrosis (Osteonecrosis)

Avascular (aseptic) necrosis refers to the death of bone caused by interruption of blood supply. The etiology is unknown (idiopathic) in most cases, but the condition can be associated with chronic renal disease and prolonged oral steroid use. It also occurs in deep-sea divers because of prolonged exposure (caisson disease, dysbarism). The most common site of involvement is the head of the femur, followed by the humeral head.

CLINICAL FEATURES

The early stage is asymptomatic, but later, nonspecific symptoms such as joint pain and stiffness develop. Later in the disease, the clinical findings are similar to osteoarthritis as deformity and collapse of the head occur. By this time, plain films usually reveal the extent of the disorder (Fig. 5-39). MRI is highly sensitive to the vascular changes in early cases. In late stages, bony collapse of the humeral head occurs, and arthritic changes develop involving the entire joint.

FIG. 5-39 Avascular necrosis of the head of the humerus. The head is fragmented, and loose bodies have collected in the inferior capsule. The joint space has not yet been affected.

TREATMENT AND PROGNOSIS

Once the diagnosis is confirmed, referral to an orthopedic surgeon is indicated. Treatment is similar to osteoarthritis. Many patients will respond to a program of gentle exercises and symptomatic treatment. Joint replacement is occasionally required. Patients with humeral head involvement seem more likely to respond to medical management and tolerate their symptoms than when the same condition develops in the hip.

Degenerative Arthritis

Primary degenerative arthritis of the glenohumeral joint is relatively uncommon. Most often, it is a secondary process, usually the end stage of chronic rheumatoid arthritis, avascular necrosis, or long-standing chronic rotator cuff disease (cuff-tear arthropathy; Fig. 5-40). It may also be the result of recurrent shoulder dislocations or severe fractures of the shoulder joint. Chronic pain and limited shoulder motion are common, and atrophy and crepitus are frequently present.

FIG. 5-40 Osteoarthritis of the glenohumeral joint. The joint space is severely narrowed, and irregular sclerosis of the joint surfaces is present.

Treatment is usually directed at providing symptomatic relief by injections, antiinflammatory medication, and stretching exercises. Failure to respond to medical treatment is an indication for referral.

The AC joint is a common site of osteoarthritis. Local tenderness is usually present, and the crossover maneuver is painful. Symptomatic treatment with NSAIDs and local injections of cortisone into the joint are helpful (Fig. 5-41). Distal clavicle resection is the surgical treatment of choice and offers a high success rate with low morbidity.

FIG. 5-41 AC joint injection.

Fractures of the Shoulder Region

FRACTURES OF THE CLAVICLE

The clavicle is the only rigid, bony connection between the shoulder and the chest, and it functions to hold the shoulder upward and backward. Clavicle fractures are common injuries in both children and adults (Fig. 5-42). Examination usually reveals a tender deformity. Some tenting of the skin may be present, but the skin is rarely penetrated. Neurovascular disruption is uncommon.

FIG. 5-42 Fracture of the clavicle.

Historically, treatment has been directed at reduction with immobilization using a canvas figure-8 strapping system (Fig. 5-43). Reduction can sometimes be obtained by manipulation, but it is difficult to maintain, and some element of overriding and overlap seem inevitable in most cases. The strapping system must be constantly retightened to function properly, and pressure problems in the axilla sometimes occur (discomfort, venous congestion, skin pressure, nerve dysfunction), which often requires frequent readjustment of the dressing, often to the point that it loses its effectiveness. As a result, the use of a simple sling has been evaluated as an alternative treatment method, and it was found that the healing rate was the same using the sling alone. If the figure-8 bandage is used, discomfort can be relieved by having the patient lie down and temporarily abduct the arms. The addition of a sling may also be helpful.

FIG. 5-43 The clavicle fracture is immobilized by a figure-8 dressing. The dressing should remain snug and may have to be tightened from time to time.

The fracture should be protected for 4 to 5 weeks in the child and 8 weeks in the adult. A prominence at the fracture site often persists in the adult, but it usually disappears in the child a few months after remodeling of the bone has occurred. Open reduction is never indicated in the child and only rarely in the adult (usually when fragments are markedly displaced). Nonunion is rare regardless of age.

Fractures lateral to the coracoclavicular ligament may be managed conservatively if they are relatively undisplaced (Fig. 5-44). A sling only is used. The figure-8 dressing should not be used for these since it can cause further displacement. The treatment of displaced lateral fractures is controversial because of the high nonunion rate and should be referred for orthopedic consultation.

FIG. 5-44 Fracture of the lateral clavicle distal to the coracoid (C).

FRACTURES OF THE SCAPULA

Fractures of the scapula usually result from a direct blow or fall (Fig. 5-45). Fractures that do not involve the articular surface of the glenoid cavity require little treatment. A sling or shoulder immobilizer may be used for 1 to 2 weeks until the pain subsides. Gentle motion of the shoulder is encouraged as soon as possible, and the results are usually excellent. The rare fracture that involves the shoulder articulation may require more extensive surgical treatment (Fig. 5-46).

FIG. 5-45 Fracture of the scapula.

FIG. 5-46 Various fractures of the scapula.

NOTE: A sling worn under a snug undershirt (to keep the arm against the body) is often more comfortable than the shoulder immobilizer.

FRACTURES OF THE PROXIMAL HUMERUS

Minimally displaced or impacted fractures of the surgical neck of the humerus are common in older patients, especially women (Fig. 5-47). Slight degrees of malalignment may be accepted. Treatment consists of a sling for 4 weeks. Pendulum exercises are performed in the sling after 2 weeks. All immobilization is discontinued after 4 weeks, and range of motion exercises are increased. A hanging cast should not be used in these fractures because it may disimpact the bony fragments. The disability in this injury results not from the fracture itself, which usually heals readily, but from the secondary stiffness that develops in the shoulder, especially in the older patient. Range of motion may take several months to return. PT may be helpful if motion is slow to return. Because this fracture is often seen in the osteoporotic female, a workup for osteoporosis, including bone density studies, should be considered.

FIG. 5-47 Fracture of the surgical neck of the humerus.

Displaced fractures of the surgical neck may require manipulative reduction and a hanging long arm cast. If closed methods fail, open reduction is occasionally indicated.

Fractures of the tuberosities of the upper humerus may occur from a fall or in association with a shoulder dislocation (Fig. 5-48). Undisplaced fractures require only a sling for 7 to 10 days, followed by early range of motion exercises. Patients with fractures that are displaced more than 5 to 10 mm should be referred. Such fractures frequently require open reduction and internal fixation. If this is not performed, a bony impingement to abduction could result.

FIG. 5-48 Displaced fracture of the greater tuberosity of the humerus.

FRACTURES OF THE SHAFT OF THE HUMERUS

Fractures of the shaft of the humerus usually heal well with nonoperative treatment. The function of the radial nerve should always be evaluated because it may be injured in its course around the humeral shaft.

Manipulative reduction with the patient under local anesthesia may be required, but distraction of the fracture fragments should be avoided. With the patient sitting on a stool and leaning forward, the weight of the arm frequently reduces the fracture (Fig. 5-49). The wrist is supported to overcome apprehension, but the elbow should hang free. Gentle traction and countertraction are applied, and the fracture fragments are manipulated to correct any angulation. The fracture is immobilized by a cast brace or by the application of a U-shaped plaster splint (Fig. 5-50). Additional fixation may be obtained by strapping the humerus to the chest wall. Healing is usually complete by 10 to 12 weeks. (This form of fracture care requires frequent reevaluation and readjustment of the brace system. Unless the treating physician has a special interest and expertise in fracture care, this injury is best treated by an orthopedic surgeon.)

FIG. 5-49 Fracture of the humerus reduced by downward traction and countertraction. A “sugar-tong” or U-shaped splint is then applied and wrapped with gauze or elastic bandage. The splint begins in the axilla and ends over the shoulder. It may have to be tightened at intervals. A collar and cuff or sling is added.

FIG. 5-50 A, Transverse fracture of the humerus immobilized in a U-shaped splint. B, The end result.

INFERIOR SUBLUXATION OF THE HUMERAL HEAD

Inferior displacement of the head of the humerus may occur as a result of the following: (1) fractures about the shoulder area (Fig. 5-51), (2) local neurogenic impairment, such as brachial neuritis, and (3) strokes or other central nervous system (CNS) disorders. The most common cause is “hypotonicity,” which may develop in conjunction with fractures of the upper humerus or dislocations of the glenohumeral joint. When the musculoskeletal injury heals, muscle tone usually returns to normal, and the abnormal increase in acromiohumeral distance disappears. Simple strengthening and range of motion exercises after the injury has healed are the only necessary treatment. The position returns to normal in a few weeks.

FIG. 5-51 Inferior “subluxation” of the humeral head following a fracture of the upper humerus. If there is any concern about whether or not a dislocation is present, a lateral view is needed.

If the subluxation is atraumatic, EMG may be needed to determine whether a neurogenic disorder is the cause.

Shoulder Pain From Other Origins

ABDOMINAL CAUSES

Pain may be referred to the shoulder via the phrenic nerve. This pain may refer to any part of the shoulder but is most commonly on top of the shoulder, in the supraspinous fossa, or over the acromion or clavicle; that is, in the region of distribution of the cutaneous branches of the fourth cervical nerve. Lesions affecting a certain portion of the diaphragm may cause pain over the corresponding part of the shoulder on the same side of the body.

When a gastric or intestinal ulcer perforates, the escaping fluid may impinge on the lower surface of the diaphragm. This may irritate the terminations of the phrenic nerve on one or both sides and can be the cause of pain on top of one or both shoulders. In the case of pyloric duodenal ulcer, the shoulder pain is usually felt in the right supraspinous fossa or on the corresponding side.

Referred shoulder pain may also develop in cases of subphrenic abscess, diaphragmatic pleurisy, acute pancreatitis, gallstones, ruptured spleen, and appendicitis with peritonitis. It may be the only signal with a liver abscess that is threatening to perforate the diaphragm. Pelvic inflammatory disease with perihepatic inflammation (so-called Fitz–Hugh–Curtis syndrome) is also an occasional cause of shoulder pain. In addition, shoulder pain may be a sign of damage to solid viscera in the patient who has sustained blunt abdominal trauma.

NOTE: In summary, although most shoulder pain is musculoskeletal in origin, it is important to be suspicious of abdominal causes of the pain. This is especially true if the pain is not aggravated by neck or shoulder movement and the patient has a history of gastrointestinal symptoms. In these cases, further studies and referral to a gastroenterologist may be indicated.

THORACIC CAUSES OF SHOULDER PAIN

Although most disorders of intrathoracic origin will cause chest pain, shoulder discomfort is not uncommon and may even be the main presenting complaint. Diseases of cardiac origin (such as pericarditis) commonly cause left arm and shoulder pain. Cardiac pain may also be referred to the neck, lower jaw, and interscapular area. The pain associated with ischemic disease is usually exertional but may occur at rest and cause more confusion. Clinically, there is usually no tenderness or aggravation of the pain by neck or shoulder motion.

Pulmonary diseases (such as carcinoma, pneumonia, abscess) may also result in shoulder pain. Of special interest are tumors of the superior sulcus of the lung (Pancoast). This tumor produces a syndrome by virtue of its growth in the thoracic inlet. This region is bounded roughly by the first rib, the first costal cartilage, the manubrium, and the body of T1. The apex of the lung occupies most of the area. The superior pulmonary sulcus is a groove in the lung tissue made by the subclavian artery as it crosses the apex of the lung, and because the majority of apical lung tumors occur in relation to this sulcus, they are often called superior sulcus tumors. The structures in this area are the internal jugular and subclavian veins; the vagus, phrenic, and recurrent laryngeal nerves; the subclavian and common carotid arteries; the eighth cervical and first thoracic nerves; and the stellate ganglion and sympathetic chain. Any of these structures may be involved, and therefore the symptoms may be variable and complex. Pain is the most common initial complaint. Its distribution is often wide and unusual, frequently being present throughout the shoulder, scapular or infrascapular area, upper anterior portion of the chest, arm, neck, and axilla. Other components of this syndrome include Horner’s syndrome, weakness and sensory disturbances on the involved side (possibly because of involvement of the lower portion of the brachial plexus), supraclavicular fullness, venous distention, and edema of the extremity. A superior sulcus tumor should always be kept in mind in patients with neck or shoulder pain, especially if there is a history of smoking. Shoulder roentgenograms may reveal the lesion, but usually a more complete roentgenographic examination is needed (Fig. 5-52).

FIG. 5-52 Pancoast tumor (arrows). A, Plain film. Note the difference in the density of the apical lung tissue on the two sides. B, CT appearance.

Other diseases of thoracic origin that may cause shoulder pain are disorders of the mediastinum, aorta, and esophagus. The pain of hiatus hernia and gastroesophageal reflux disease, in particular, can radiate to the top of both shoulders and down the arms.

MISCELLANEOUS CAUSES

Malignant tumor, either primary, locally spread, or metastatic from a distant origin, may also be the cause of shoulder pain. The diagnosis may be obvious in the patient with a known history of malignancy. The major sources are tumors of thyroid, prostate, breast, lung, and kidney and Hodgkin’s disease. The most common primary tumor that metastasizes to bone is multiple myeloma. The shoulder is less commonly involved than the ribs, spine, and pelvis. Pathologic fractures may occur but are uncommon in the upper extremity. Plain roentgenograms may be normal because more than 50% bone destruction is needed before destructive changes become apparent on plain films. Bone scanning is usually helpful, but myeloma and some aggressive sarcomas may destroy bone so fast that repair cannot occur, thereby resulting in a false-negative study.

Paget’s disease may also cause localized bone pain (see Chapter 18). As a result of periosteal bone formation impinging on cranial and spinal nerves, impairment of nerve function may even occur. Most patients with Paget’s disease have minimal or no symptoms. The onset of increased pain in an area of Paget’s disease should suggest sarcomatous degeneration.

Shoulder-hand syndrome, a form of reflex neurovascular dystrophy (sometimes called complex regional pain syndrome), is a poorly understood disorder (see Chapter 18). The disease is probably caused by reflex sympathetic stimulation analogous to that proposed for causalgia. The patients are usually older than 50 years and often have had a recent acute illness, frequently a myocardial infarction, cerebrovascular accident (CVA), pulmonary disorder, or minor musculoskeletal trauma. The patient develops pain, stiffness in the shoulder, and swelling and vasomotor phenomena in the involved extremity. There is a marked variability in the intensity of the pain, duration of acute symptoms, and extent of dystrophic change. A frequent complication is frozen shoulder. Treatment is nonspecific and includes (1) an active exercise program facilitated by analgesics, (2) physical therapy, (3) a trial of a corticosteroid (prednisone, 10 to 20 mg/day) for a short time, and (4) stellate ganglion blocks if all other forms of medical management are unsuccessful. The condition usually resolves on its own in the course of several months.

Herpes zoster (“shingles”) is an acute viral infection that produces an inflammatory reaction in a segmental nerve. Initially, fever with unilateral pain and paresthesias may be present. Within a few days, an erythematous rash appears that becomes vesicular. Early, before the rash develops, its symptoms may be confused with other painful disorders.

Brachial neuritis is an unusual disorder of unknown cause that can also be confused with other causes of shoulder pain or weakness, especially rotator cuff disease. Many terms have been used to describe this syndrome: shoulder-girdle syndrome of Parsonage and Turner, acute brachial radiculitis, neuralgic amyotrophy, and brachial plexus neuropathy. The cause is unknown, but a viral or allergic reaction is suspected. It may be preceded by a febrile illness and is characterized by acute severe pain, usually in the shoulder but frequently in the arm and neck. The pain is often worse at night. Shoulder weakness follows the pain, usually within a month and sometimes as soon as a day. The pain is typically of short duration. The deltoid, rotator cuff, biceps, and triceps are commonly involved, and EMG usually demonstrates changes of neurogenic atrophy. The prognosis is usually good, although recovery may take 2 to 3 years. Treatment is symptomatic.

Carpal tunnel syndrome (see Chapter 7) is a common cause of shoulder pain. Although the predominant symptoms occur in the hand, they are frequently accompanied by arm and shoulder pain that radiates upward from the arm and forearm. Carpal tunnel syndrome and cervical disc syndrome with radiculopathy also occasionally occur at the same time and involve the same extremity. This situation is called the “double-crush” syndrome. Under this circumstance, then, there may be two causes of shoulder pain, neither of which has its origin in the shoulder itself.