Tx Approaches Vary for Acute Shoulder Injuries

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.

LAS VEGAS – Four common acute shoulder injuries can occur during sports or as a result of a fall, according to Dr. Gregory L. Landry, who is professor of pediatrics and head team physician at the University of Wisconsin, Madison.

Dr. Landry presented his overview of these acute injuries, along with treatment tips:

▸ Clavicle fractures. A lateral blow to the shoulder is typically the cause of a clavicle fracture, Dr. Landry said.

The injury is characterized by tenderness, often with deformity. The treatment usually includes a plain sling, which is now preferred over the old figure-eight.

Surgeons are getting more involved in comminuted fractures, especially if they are not midshaft. “If there's more than 2 cm overlap, especially if it's the dominant shoulder, you should usually refer,” he said at the meeting.

Athletes with clavicle fractures should not return to collision sports for a minimum of 10-12 weeks, he said.

▸ Acromioclavicular sprains. These injuries most often occur with a fall on an outstretched hand or a direct blow to the joint just above or to the side of the shoulder.

There are multiple degrees of acromioclavicular sprains, ranging from first degree – tenderness over the joint – to sixth degree with severe tenderness, swelling, and deformity, Dr. Landry said.

With the exception of mild cases, he advised ordering x-rays including axillary views.

For grade 1-3 sprains, surgery isn't usually needed unless there is severe swelling, pain, and deformity or the patient desires it for cosmesis, Dr. Landry said. Grade 4-6 injuries need to be referred to an orthopedic surgeon.

For mild to moderate cases, a sling provides comfort, but the patient should begin rehabilitation as soon as possible, he recommended. This includes range of motion exercises, such as Codman exercises, or wall walks in which patients face a wall and gradually walk their hands up the wall.

As for returning to activity, “as long as they have good function and strength, I let them go back,” he said.

▸ Sternoclavicular sprains. Common in football and wrestling, these sprains usually result from a side blow. Patients with anterior sprains experience anterior pain and deformity. Posterior sprains are tender without much deformity. Anterior-posterior x-rays won't usually show these sprains, though you can try a serendipity view. Usually, a computed tomography (CT) scan is needed to image a posterior sternoclavicular sprain.

Posterior sprains can be life threatening if they impair the trachea, so it's important to recognize them on the field during sports. The impairment can be reduced with posterior traction of the shoulder.

Most of these sprains don't require surgery, unless the airway is compromised.

In adolescents, this injury is usually physeal; the proximal clavicle is one of the last to close.

▸ Glenohumeral subluxations and dislocations. These injuries sometimes occur as the result of a football tackle. Patients feel their shoulder go out or their arms go numb.

Subluxation is more common than full dislocation. A dislocation usually results in an obvious deformity; typically, the head of the humerus ends up inferior and anterior to the glenoid.

Although posterior dislocations are rare, posterior subluxations are not. These occur with a slide into base or from a football block using an extended arm. The patient may feel the shoulder slide.

Patients generally feel tenderness posteriorly, and experience pain loading the joint posteriorly (which you can assess with a posterior glide test).

If there is acute anterior dislocation, check for axillary nerve involvement.

At the time of the injury, pain typically limits examination. If the physician is certain of the diagnosis, sometimes he or she can relocate the shoulder immediately after the injury, before more pain and spasms occur. But it is important to make sure the pain is not below the head of the humerus, which could indicate a fracture. Although there are many methods of relocation, the key is traction inferiorly.

If the patient has good range of motion and only mild pain, assess the instability of the joint using the apprehension sign, the posterior glide (jerk test), and the sulcus sign.

Take a minimum of two x-ray views: the acromioclavicular joint, usually anterior and posterior; and an axillary view of the glenoid.

Once the shoulder has been reduced, check the x-rays for the presence of a Bankart lesion (an avulsion of the glenoid) or Hill-Sachs lesion (a dent in the head of the humerus).

For acute anterior dislocation, a sling will provide some comfort. The patient should begin an aggressive rehabilitation program as soon as he or she is able. Surgery is usually necessary only if the rehabilitation fails or if the injury recurs, according to Dr. Landry.

If locking or catching occurs along with the instability, a labral tear might be the cause. Labral tears can usually be diagnosed with an MRI arthrogram, he said.

Dr. Landry said that he had no relevant financial disclosures.