Your shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). Your shoulders are the most movable joints in your body. They can also be unstable because the ball of the upper arm is larger than the shoulder socket that holds it. To remain in a stable or normal position, the shoulder must be anchored by muscles, tendons, and ligaments.

Because your shoulder can be unstable, it can be easily injured. Common problems include

• Sprains and strains
• Dislocations
• Separations
• Tendinitis
• Bursitis
• Torn rotator cuffs
• Frozen shoulder
• Fractures
• Arthritis

Health care providers diagnose shoulder problems by using your medical history, a physical exam, and imaging tests.

Often, the first treatment for shoulder problems is RICE. This stands for Rest, Ice, Compression, and Elevation. Other treatments include exercise and medicines to reduce pain and swelling. If those don't work, you may need surgery.

Most shoulder problems happen when soft tissues in the joint and shoulder region break down.

Points To Remember About Shoulder Problems

• Most shoulder problems happen when the soft tissues in the shoulder break down.
• Shoulder problems vary widely and can include; dislocation, separation, rotator cuff disease, rotator cuff tear, frozen shoulder, fracture, and arthritis.
• The symptoms of your shoulder problems will depend on the specific type of problem you are having.
• Your doctor will recommend treatment depending on your type of shoulder problem.

Shoulder problems vary widely. Doctors usually describe the problem by the type, for example:

• Dislocation, happens when the ball of your top arm bone pops out of the socket.
• Separation, happens when the ligaments between the collarbone and the shoulder blade area tear.
• Rotator cuff disease, such as tendinitis and bursitis, happens when tendons in the shoulder inflame or become red, sore or swollen.
• Torn rotator cuff, a tear in the tendon in the rotator cuff.
• Frozen shoulder or adhesive capsulitis, happens when movement of the shoulder is restricted.
• Fracture, is a crack or break in a bone, usually in the collarbone or upper arm bone.
• Arthritis, can be one of two types:
  • Osteoarthritis, happens when over time the cartilage in the joint wears down and the bones rub together.
  • Rheumatoid arthritis is a disease that happens when your immune system causes inflammation in a joint.

Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. Your arms are also made up of muscles, joints, tendons, and other connective tissue. Injuries to any of these parts of the arm can occur during sports, a fall, or an accident.

Types of arm injuries include

• Tendinitis and bursitis
• Sprains
• Dislocations
• Broken bones
• Nerve problems
• Osteoarthritis

You may also have problems or injure specific parts of your arm, such as your hand, wrist, elbow, or shoulder.

The brachial plexus is a network of nerves that sends signals from the spine to the shoulder, arm, and hand. Damage to the brachial plexus can cause symptoms such as

• A limp or paralyzed arm
• Lack of muscle control in the arm, hand, or wrist
• Lack of feeling or sensation in the arm or hand

Brachial plexus injuries can happen because of shoulder trauma, tumors, or inflammation. Sometimes they happen during childbirth when a baby's shoulders become stuck during delivery and the nerves stretch or tear.

Some brachial plexus injuries may heal without treatment. Many children who are injured during birth improve or recover by 3 to 4 months of age. Treatment includes physical therapy and, in some cases, surgery.

What is a dislocated shoulder?

Your shoulder joint is made up of three bones: your collarbone, your shoulder blade, and your upper arm bone. The top of your upper arm bone is shaped like a ball. This ball fits into a cuplike socket in your shoulder blade. A shoulder dislocation is an injury that happens when the ball pops out of your socket. A dislocation may be partial, where the ball is only partially out of the socket. It can also be a full dislocation, where the ball is completely out of the socket.

What causes a dislocated shoulder?

Your shoulders are the most movable joints in your body. They are also the most commonly dislocated joints.

The most common causes of shoulder dislocations are

• Sports injuries
• Accidents, including traffic accidents
• Falling on your shoulder or outstretched arm
• Seizures and electric shocks, which can cause muscle contractions that pull the arm out of place

Who is at risk for a dislocated shoulder?

A dislocated shoulder can happen to anyone, but they are more common in young men, who are more often involved in sports and other physical activities. Older adults, especially women, are also at higher risk because they are more likely to fall.

What are the symptoms of a dislocated shoulder?

The symptoms of a dislocated shoulder include

• Severe shoulder pain
• Swelling and bruising of your shoulder or upper arm
• Numbness and/or weakness in your arm, neck, hand, or fingers
• Trouble moving your arm
• Your arm seems to be out of place
• Muscle spasms in your shoulder

If you are having these symptoms, get medical treatment right away.

How is a dislocated shoulder diagnosed?

To make a diagnosis, your health care provider will take a medical history and examine your shoulder. Your provider may also ask you to get an x-ray to confirm the diagnosis.

What are the treatments for a dislocated shoulder?

The treatment for dislocated shoulder usually involves three steps:

• The first step is a closed reduction, a procedure in which your health care provider puts the ball of your upper arm back into the socket. You may first get medicine to relieve the pain and relax your shoulder muscles. Once the joint is back in place, the severe pain should end.
• The second step is wearing a sling or other device to keep your shoulder in place. You will wear it for a few days to several weeks.
• The third step is rehabilitation, once the pain and swelling have improved. You will do exercises to improve your range of motion and strengthen your muscles.

You may need surgery if you injure the tissues or nerves around the shoulder or if you get repeated dislocations.

A dislocation can make your shoulder unstable. When that happens, it takes less force to dislocate it. This means that there is a higher risk of it happening again. Your health care provider may ask you to continue doing some exercises to prevent another dislocation.

Your rotator cuff is located in your shoulder area. It is made of muscles and tendons. It helps your shoulder to move and stay stable. Problems with the rotator cuff are common. They include tendinitis, bursitis, and injuries such as tears.

Rotator cuff tendons can become inflamed from frequent use or aging. Sometimes they are injured from a fall on an outstretched hand. Sports or jobs with repeated overhead motion can also damage the rotator cuff. Aging causes tendons to wear down, which can lead to a tear.

Some tears are not painful, but others can be very painful. Treatment for a torn rotator cuff depends on age, health, how severe the injury is, and how long you've had the torn rotator cuff.

Treatment for torn rotator cuff includes:

• Rest
• Heat or cold to the sore area
• Medicines that reduce pain and swelling
• Electrical stimulation of muscles and nerves
• Ultrasound
• Cortisone injection
• Surgery

Thoracic outlet syndrome (TOS) causes pain in the shoulder, arm, and neck. It happens when the nerves or blood vessels just below your neck are compressed, or squeezed. The compression can happen between the muscles of your neck and shoulder or between the first rib and collarbone. You may feel burning, tingling, and numbness along your arm, hand, and fingers. If a nerve is compressed, you may also feel weakness in your hand. If a vein is compressed, your hand might be sensitive to cold, or turn pale or bluish. Your arm might swell and tire easily.

TOS is more common in women. It usually starts between 20 and 50 years of age. Doctors do nerve and imaging studies to diagnose it.

There are many causes of TOS, including

• Injury
• Anatomical defects
• Tumors that press on nerves
• Poor posture that causes nerve compression
• Pregnancy
• Repetitive arm and shoulder movements and activity, such as from playing certain sports

Treatment depends on what caused your TOS. Medicines, physical therapy, and relaxation might help. Surgery may also be an option. Most people recover.

The impaction of the fetal shoulder into the symphysis pubis or sacral promontory, preventing the delivery of the fetus is called shoulder dystocia . It occurs in less than 3 percent of births (ACOG, 2017a). The health-care provider attempts to deliver the anterior shoulder, but the shoulder lodges under the pubic bone and is not delivered. Figure 19.16 illustrates shoulder dystocia. Predicting shoulder dystocia is not always successful. Risk factors for shoulder dystocia are obesity, excessive weight gain, multiparity, increased birth weight, and diabetes (Hill & Cohen, 2016). However, 50 percent of shoulder dystocia occurs in normal-weight fetuses and persons who do not have diabetes; therefore, the nurse should always be prepared for shoulder dystocia. A good predictor of shoulder dystocia is a past shoulder dystocia.

Figure 19.16 Shoulder Dystocia Shoulder dystocia occurs when the anterior shoulder is stuck behind the pubic bone. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Complications of shoulder dystocia include increased risk of postpartum hemorrhage and perineal lacerations . Fetal complications include brachial plexus injuries and fractures of the clavicle and humerus (ACOG, 2017a). These injuries usually resolve; however, shoulder dystocia can cause fetal hypoxia and death.

Management of shoulder dystocia should be systematic and rapid. The nurse and health-care providers must act quickly to resolve the dystocia . The nurse positions the person to help the provider perform maneuvers. The first maneuver is McRoberts maneuver , which is the process of flexing the laboring person’s legs until the thighs touch the abdomen. Posterolateral suprapubic pressure is then provided in hopes of dislodging the shoulder from underneath the pubic bone. The nurse will need a stool to get above the person and give downward, lateral pressure with one or both hands toward the fetal-facing side. See Figure 19.17 for a demonstration of posterolateral suprapubic pressure. The nurse does not give fundal pressure because that impacts the shoulder further. If this maneuver is not successful, the health-care provider will attempt to deliver the posterior arm or attempt to turn the shoulders. The nurse is also prepared to turn the person to hands-and-knees position ( Gaskin maneuver ) if previous maneuvers are not successful. See Table 19.12 for a mnemonic, HELPERR, to remember the maneuvers for a shoulder dystocia.

Introduction

Shoulder pain is a common indication for visits to primary care or orthopedic clinic worldwide. The estimated prevalence of shoulder complaints is 7% to 34%, often with shoulder impingement syndrome as the underlying etiology. Since it was first described in 1852, shoulder impingement syndrome is believed to be the most common cause of shoulder pain, accounting for 44% to 65% of all shoulder complaints. Similarly, of the 20% to 50% of people within the United Kingdom who seek shoulder pain treatment from a general practitioner, 25% of these individuals are then diagnosed with shoulder impingement syndrome. Not only is shoulder pain common, but it is often a chronic and/or relapsing complaint, with 54% of patients affected by shoulder pain reporting persistent symptoms after 3 years.

Etiology

Shoulder external impingement should be recognized as a clinical entity that is separate from internal impingement. The most basic clinical differentiation between the former and the latter is defined by the rotator cuff as the anatomic boundary of the external and internal forms. The latter occurs secondary to a repetitive impingement in overhead throwers or manual laborers and constitutes articular-sided rotator cuff pathology, glenohumeral internal rotation deficit (GIRD), and SLAP tears.

External impingement, often commonly referred to by clinicians and providers as, shoulder impingement is best described as a painful condition of the shoulder that results from the inflammation, irritation, and degradation of the anatomic structures within the subacromial space. Previously, shoulder impingement syndrome was thought to be a sole diagnosis itself but is now considered to be a cluster of symptoms and anatomic characteristics.

Its anatomic borders define the subacromial space. The acromion and coracoacromial ligament provide the anterior border, the acromioclavicular (AC) joint acts as the superior border, and the humeral head serves as the inferior border. The acromion shape is thought to play a role in the development of external, or "outlet-based" impingement syndrome. Bigliani and Morrison classified the shape of the acromion by its three most common morphologies:

• Class I: flat acromion

• Class II: curved acromion

• Class III: hooked acromion

During the actions of shoulder abduction, forward flexion, and internal rotation, normal shoulder girdle movement results in narrowing of the subacromial space. This subacromial space, which is normally 1.0 to 1.5 cm in width, narrows with the superior migration of the humeral head, allowing it to approach the anteroinferior edge of the acromion. The symptom of pain associated with shoulder impingement results with this movement due to the humeral head applying a compressive force to either the rotator cuff, the subacromial bursa, or both structures.

Repetitive pathologic compression, degeneration, and fraying of the rotator cuff tendons are known to contribute to the narrowing of the subacromial space, but it is unknown whether or not the inflamed and damaged tendons cause impingement, or if the narrowed subacromial space causes the tendon inflammation.

Shoulder impingement syndrome can be described according to either the location of the impingement, characterized as external or internal and/or the underlying cause of the impingement, referred to as primary or secondary impingement. External, or subacromial impingement, results from a mechanical or physical encroachment of the soft tissue located within the subacromial space. Conversely, internal impingement results when the tendons of the rotator cuff encroach between the humeral head and glenoid rim. Internal impingement is most commonly associated with the supraspinatus and infraspinatus tendons.

In primary impingement, there is a structural narrowing of the subacromial space. Examples of primary shoulder impingement syndrome include those attributable to abnormal acromion anatomy, such as a hooked class III acromion, or swelling of the soft tissues. Secondary shoulder impingement syndrome is characterized by normal anatomy at rest and onset of impingement during shoulder motion, likely secondary to rotator cuff weakness, permitting uncontrolled cranial translation of the humeral head. Another potential cause of secondary impingement syndrome is a weakness of the trapezius and serratus anterior muscles, limiting the external rotation and rise of the scapula with the abduction of the upper extremity, further narrowing the subacromial space.

Neer classified shoulder impingement in three categories or stages of severity. In stage I, impingement primarily results from edema, hemorrhage, or both and is classically seen with overuse type mechanisms. Stage II is characterized by greater fibrosis and irreversible tendon changes. A rupture or tear of the tendon may result from the chronic, longstanding fibrosis and is seen in stage III shoulder impingement syndrome.

Epidemiology

Shoulder impingement syndrome is most commonly seen in individuals who participate in sports and activities that require repetitive overhead activities, including but not limited to handball, volleyball, swimming, carpenters, painters, and hairdressers. Other extrinsic risk factors that may predispose to the development of impingement syndrome include bearing heavy loads, infection, smoking, and fluoroquinolone antibiotics. The incidence of shoulder impingement syndrome rises with age, with peak incidence occurring in the sixth decade of life.

History and Physical

A thorough history and physical examination are key to the diagnosis of shoulder impingement syndrome. Individuals will often present with complaints of pain upon lifting the arm or with lying on the affected side. They may report loss of motion as the primary reason they came to see you, or that nighttime pain prevents them from sleeping. Weakness and stiffness often result secondary to the pain. Onset is usually gradual or insidious, typically developing over weeks to months, and patients are often unable to describe a direct trauma or inciting event that resulted in the pain. Pain is commonly described as being located over the lateral acromion, frequently with radiation to the lateral mid-humerus. Attempt to obtain details regarding the nature of the shoulder pain, such as onset, quality, exacerbating and remitting factors, and interventions attempted thus far with clinical response and history of prior injuries to the affected extremity. Special attention should be made by the clinician to inquire about overhead activities, repetitive activities, and activities. Relief may be noted with rest, anti-inflammatory medications, and ice, but symptoms often recur upon return to activity.

Physical examination should consist of inspection, palpation, passive, and active range of motion, and strength testing of the neck and shoulder, all of which are compared bilaterally. Often, patients will have weakness of abduction and/or external rotation of the affected side. Scapular dyskinesis can be seen with forward elevation of the arm. Tenderness to palpation is usually present over the coracoid process of the affected arm.

Special tests are key components to the physical examination. Those tests specific to shoulder impingement syndrome include the Hawkins test, Neer sign, Jobe test, and a painful arc of motion. Individually, these tests have low sensitivity and specificity, but when combined, they can help complete the picture of shoulder impingement syndrome.

Hawkins test: The Hawkins test is performed when the patient's arm is passively internally rotated with the shoulder in 90 degrees of shoulder forward flexion and elbow flexion. Pain over the acromion indicates subacromial impingement but may be negative in internal impingement.

Neer sign: With the scapula fixed into a depressed position, this test is performed by the examiner maximally forward flexing the patient's arm (passive range of motion testing). Localized pain on the anterior shoulder suggests subacromial impingement, whereas posterior shoulder pain suggests internal impingement.

Jobe test: Also known as the empty can test, this test is performed by placing the patient's arms at 90 degrees of abduction within the scapular plane, maximally internally rotating the arms and resisting further abduction by the patient. A positive test occurs with localized pain to the affected arm.

Painful arc of motion: The painful arc is a physical exam finding in which pain is appreciated with abduction of the arm between 70 and 120 degrees and forced overhead movement.

Special tests to evaluate for shoulder instability include sulcus sign, anterior apprehension, and relocation. Classically, these tests are negative in shoulder impingement syndrome.

Sulcus sign: With the patient sitting upright with arm resting at their side, the clinician stabilizes the shoulder proximally and applies an inferiorly-directed force at the elbow. A positive test is noted based on the inferior displacement of the humeral head.

Anterior apprehension: With the patient lying supine, this test is performed by placing the patient's shoulder in 90 degrees of abduction and 90 degrees of external rotation. While supporting the proximal shoulder, the clinician then applies greater gentle external rotation movement. The exam is considered positive when the patient reports a subjective feeling of impending subluxation or near dislocation.

Relocation test: This test for shoulder instability requires a positive anterior apprehension test. After the patient reports the prodrome of dislocation or subluxation described above, the clinician applies a posteriorly directed force on the anterior humeral head, which relieves the patient's symptoms.

Evaluation

While the overall diagnostic sensitivity of the physical exam is reportedly as high as 90%, imaging studies are often performed to confirm the diagnosis and rule out other pathologies. If the decision to obtain radiographs is made, they should be obtained bilaterally, rather than only on the affected side, to evaluate potential anatomic differences and to rule out other pathologies such as calcific tendinitis or arthritic changes.

Plain radiographs standard shoulder films include 2 views (AP and lateral/scapular Y) The AP view of the shoulder can be used to determine the critical shoulder angle (CSA), which involves the extent of lateral coverage by the acromion and the inclination of the glenoid. At CSA’s greater than 35 degrees, there is an increased likelihood that a rotator cuff is contributing to impingement syndrome. Similarly, measurements such as the acromiohumeral distance (AHD) can help to detect rotator cuff pathologies and defects. The AHD is measured from the inferior edge of the acromion to the humeral head. The normal range is approximately 7 to 14 mm in men and 7 to 12 mm in women. A lower AHD suggests RTC pathology. The scapular Y view allows for the assessment of the humeral head on the glenoid. Additional plain radiographs featuring the outlet view will best visualize and evaluate the shape of the acromion.

Other imaging modalities to consider include ultrasound and magnetic resonance imaging (MRI). Consideration for advanced imaging with MRI is recommended after 6 weeks of therapy without clinical improvement. MRI allows for a detailed evaluation of bony and soft tissue structures within the shoulder girdle ultrasound is a bedside imaging option that primarily enables assessment of the soft tissue contributing factors such as bursitis, tendinopathy, and/or tendon ruptures.

Treatment / Management

Classically, the foundation of management for shoulder impingement syndrome has been rehabilitative exercise programs with subsequent surgical intervention if indicated by underlying anatomy, pathology, or failure of response to physiotherapy. Without known structural damage, non-operative therapies with a controlled exercise program, NSAIDs, and subacromial injections are considered the treatment of choice for the first 3 to 6 months of treatment.

In one study, exercise therapy was found to have better results when compared to a control/placebo in the sub-acute injury phase. Physiotherapy for shoulder impingement syndrome should consist of exercises that focus on rotator cuff strengthening, with a special focus of the supraspinatus and infraspinatus rotator cuff muscles, the trapezius, and serratus anterior strengthening and retraining exercises to minimize scapular dyskinesia, and other exercises to correct strength imbalances of the upper extremities. The combination of exercise with other conservative therapy lead to greater improvements in pain score compared to either treatment alone. Physiotherapy plus localized injection resulted in a maximized treatment effect compared to solitary localized injection. Further, moderate strength evidence supports the effective addition of hyperthermia to physical therapy, though symptom relief was only noted to be short-term.

Numerous methodologies and approaches for corticosteroid injections exist, but the commonly used posterior subacromial approach requires less precision and is often viewed as most straight-forward. A 1.5 inch, 21, or 22 gauge needle with lidocaine and corticosteroid is commonly used. In this approach, the clinician locates the posterior shoulder portal, located 1 cm medial and inferior to the posterior corner of the acromion. While angling the needle in the direction of the underside of the acromion, the clinician advances the needle toward the acromion in an anterosuperior direction. Injection flow should be easy, without resistance, otherwise, the needle should be redirected slightly inferiorly to avoid directly injecting a rotator cuff tendon. While landmark-based approaches provide clinical benefit, ultrasound-guided injections may be superior in symptom relief.

A systematic review of randomized controlled trials comparing surgical intervention vs. conservative therapy yielded moderate evidence that surgical intervention was not more effective for reducing pain than impingement-directed physical therapy. Arthroscopic subacromial decompression (ASD) consists of acromioplasty at the anterolateral edge, bursal debridement, and resection of the coracoacromial ligament. The ASD or other similar procedure is recommended when a patient has severe, persistent subacromial shoulder pain with functional impairments that have not improved despite conservative therapy. Combined ASD and treatments such as radiofrequency ablation and arthroscopic bursectomy have more beneficial effects than open subacromial decompression (OSD) plus platelet-leukocyte gel injection. However, a 2018 systematic review found there was no additional benefit in pain reduction when comparing the results of ASD surgery to placebo surgery at 12 months. Alternative surgical options include acromioplasty or bursectomy alone, though, like ASD, these surgical interventions appear to provide minimal benefit to patients.

When comparing surgical intervention with physiotherapy to that of surgery alone, no statistically significant or clinically significant difference between the two arms was observed with respect to pain at 3 months, 6 months, 5 years, and 10 years. Further, no statistical or clinically significant difference in function was noted at 3 months, 6 months, and 1 year follow up between the groups.

Differential Diagnosis

• Adhesive capsulitis

• Rotator cuff tear

• Acromioclavicular joint arthritis

• Acromioclavicular joint sprain

• Trapezius muscle spasm

• Biceps tendonitis

• Biceps tendon rupture

• Calcific tendonitis

• Glenohumeral arthritis

• Distal clavicle osteolysis

• Cervical radiculopathy

• Thoracic outlet syndrome

Prognosis

In 60% of patients, physical therapy, NSAIDs, corticosteroid injections, and other means of conservative therapy yield satisfactory results within two years.

Complications

Due to the underlying etiology of shoulder impingement syndrome, complications that may arise predominantly result from structural damage within the subacromial space, altered biomechanics, or avoidance of use with subsequent atrophy. Potential pathologies that may result include rotator cuff tendonitis or tear, bicipital tendonitis or tear, or adhesive capsulitis.

Deterrence and Patient Education

Patient education should focus on the importance of not only adherence to physical therapy and home exercise program but also activity modifications, such as discontinuing overhead activities until the pain improves. Lifestyle modification such as “living within the window,” wherein movements are restricted to the anterior portion of one’s body in an approximate 2 to 3 feet rectangle, with attempts to minimize reaching overhead or behind the back.

Enhancing Healthcare Team Outcomes

Treatment and recovery from shoulder impingement syndrome rely heavily on interprofessional healthcare interaction. This includes the primary provider providing pain relief modalities such as NSAIDs or corticosteroid injections and providing education and referral for physiotherapy. Physiotherapy, as lead by a physical therapist, should involve office-based exercises in addition to a home exercise program. Communication between the physical therapist and primary care physician should occur on a routine basis to guide further imaging and treatment. If the patient is a candidate for surgical intervention, the primary care physician should refer to an orthopedic surgeon. Orthopedic nurses assist in assessment, provide patient education, and communicate changes in patient status to the orthopedist. [Level 5]

Treatment / Management

Most scapular fractures are managed effectively with closed treatment and medical management. In minimally displaced fractures, which account for more than 90% of scapular fractures, management is with short-term immobilization in a sling and swath. Patients should progress as quickly as possible to begin early range of motion exercises to prevent frozen shoulder as tolerated.

Scapular fractures themselves are rarely surgical emergencies, except for cases with thoracic penetration or dislocation causing rupture of nearby vascular structures. Fractures with significant displacement can cause long-term morbidity and poor outcomes of the shoulder which would be strong candidates for surgical techniques. Therefore, all scapular fracture should undergo evaluation for operative treatment.

Surgery is always recommended if there is a relevant alteration to the following:

1. Scapula suspensory systems (SSSC; C4 linkage), "Floating Shoulder"

2. Open Fracture

3. Position integrity of the glenoid

4. Lateral column displacement is present

Indications for open reduction and internal fixation are based on locations of fracture, displacement, angulation, and articular step-off.

Intraarticular surgical indications:

1. Articular step-off >5mm

2. Associated glenohumeral instability

3. Anterior rim fracture (>25% articular surface)

4. Posterior rim fractures (>33% articular surface)

Extraarticular body and neck fractures surgical indications:

1. Angular deformity (>40 degrees angulation)

2. Lateral border offset (>15mm plus angular deformity >35 degrees)

3. Lateral border offset (>20mm)

4. Glenopolar angle (22 degrees) on true Grashay AP

However, since scapular fractures are often associated with other high-energy trauma, any operative management of scapular fracture should be delayed until the patient is stable.

Prognosis

Fractures found to be non-operative and managed conservatively have been shown to have good to excellent functional outcomes 86% of the time. Less than 1% of fractures require operative treatment, but studies demonstrate that operative patients have excellent functional outcomes. Rehabilitation typically involves six weeks of the active and active-assisted range of motion; strength training begins approximately 3-4 months post injury or surgery. Patients can often expect virtually no functional deficits for non-operative fractures and good to excellent results in fractures requiring surgical intervention.

Pearls and Other Issues

1. Scapular fractures are usually the result of a significant force. Because of this, they often carry an association with other injuries.

Associated injuries include:

• Rib fractures

• Hips lateral lung injuries

• Injuries to the shoulder girdle complex

• Neurovascular injuries

• Suprascapular nerve injuries

• Vertebral compression fractures

2. The evaluation should include radiographic imaging and CT scan.

3. All scapular fractures should undergo evaluation by an orthopedic or trauma surgeon.

Enhancing Healthcare Team Outcomes

Since 1978, interprofessional teams have been identified by the World Health Organization as essential to high-quality care. Given that scapular fractures typically occur in association with other traumatic injuries, highly competent, professional trauma teams deliver the needed care. Trauma teams will often comprise trauma surgeons, orthopedic traumatologists, emergency physicians, nurse practitioners, physician assistants, nurses, physical therapy, occupational therapy, social work, and other specialized personnel. Effective communication and utilization of the skills of each of the members of the team result and higher quality care and better patient outcomes.

In frozen shoulder, the joint gradually becomes painful and stiff without there being any clear cause. It most commonly affects people around the age of 50.

Frozen shoulder usually gets better without treatment. It can take several months for the pain to go away completely, though, and a lot longer until you can move your shoulder normally again.

Medication and physiotherapy can help to relieve the pain and improve mobility. Surgery is only rarely considered because its effectiveness is doubtful and there are various risks involved.

The shoulder joint is called the glenohumeral joint. This is a ball-and-socket joint formed by the articulation between the head of the humerus and the glenoid cavity of the scapula (image). This joint has the largest range of motion of any joint in the body. However, this freedom of movement is due to the lack of structural support and thus the enhanced mobility is offset by a loss of stability.

The large range of motions at the shoulder joint is provided by the articulation of the large, rounded humeral head with the small and shallow glenoid cavity, which is only about one third of the size of the humeral head. The socket formed by the glenoid cavity is deepened slightly by a small lip of fibrocartilage called the glenoid labrum, which extends around the outer margin of the cavity. The articular capsule that surrounds the glenohumeral joint is relatively thin and loose to allow for large motions of the upper limb. Some structural support for the joint is provided by thickenings of the articular capsule wall that form weak intrinsic ligaments. These include the coracohumeral ligament, running from the coracoid process of the scapula to the anterior humerus, and three ligaments, each called a glenohumeral ligament, located on the anterior side of the articular capsule. These ligaments help to strengthen the superior and anterior capsule walls.

However, the primary support for the shoulder joint is provided by muscles crossing the joint, particularly the four rotator cuff muscles. These muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) arise from the scapula and attach to the greater or lesser tubercles of the humerus. As these muscles cross the shoulder joint, their tendons encircle the head of the humerus and become fused to the anterior, superior, and posterior walls of the articular capsule. The thickening of the capsule formed by the fusion of these four muscle tendons is called the rotator cuff. Two bursae, the subacromial bursa and the subscapular bursa, help to prevent friction between the rotator cuff muscle tendons and the scapula as these tendons cross the glenohumeral joint. In addition to their individual actions of moving the upper limb, the rotator cuff muscles also serve to hold the head of the humerus in position within the glenoid cavity. By constantly adjusting their strength of contraction to resist forces acting on the shoulder, these muscles serve as “dynamic ligaments” and thus provide the primary structural support for the glenohumeral joint.

Injuries to the shoulder joint are common. Repetitive use of the upper limb, particularly in abduction such as during throwing, swimming, or racquet sports, may lead to acute or chronic inflammation of the bursa or muscle tendons, a tear of the glenoid labrum, or degeneration or tears of the rotator cuff. Because the humeral head is strongly supported by muscles and ligaments around its anterior, superior, and posterior aspects, most dislocations of the humerus occur in an inferior direction. This can occur when force is applied to the humerus when the upper limb is fully abducted, as when diving to catch a baseball and landing on your hand or elbow. Inflammatory responses to any shoulder injury can lead to the formation of scar tissue between the articular capsule and surrounding structures, thus reducing shoulder mobility, a condition called adhesive capsulitis (“frozen shoulder”).