William W. Forgey, MD
Orthopedics part 5 - Collarbone, Shoulder and Shoulder Blade
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Evaluate for pain by palpation along the collarbone (clavicle). Separations of the clavicle from the sternum (breastbone), fractures of the clavicle, and separations of the shoulder can all be treated similarly with a sling and swathe, shown in figure 7-3.
The clavicle frequently fractures in the midportion. Proper reduction will occur if the shoulders are held back, like those of a Marine at attention. A figure eight (figure 7-4) will maintain this position. A stoop shoulder position will allow too much override of the fracture parts.
A fracture of the clavicle at the end near the shoulder may be hard to hold in proper position. In children there is a sleeve of tissue at this location that aids in holding the proper alignment. In adults this tissue is missing, and surgical pinning may be required for optimal
healing. However, even in the adult this fracture may be treated adequately, usually with a sling.
A fracture of the clavicle at the end near the breastbone (sternum) is best reduced and held in position with a figure-eight splint. In any clavicle fracture the use of a sling will aid greatly in decreasing pain. The sling can be eliminated in 2 weeks, but the figure-eight splint should be kept on for 3 to 4 weeks, or until there is no pain over the fracture site with free movement of the shoulder.
Shoulder separations are classified as grade I to grade III, depending upon the severity. Grade I has tenderness over the acromioclavicular joint, representing a strain of the ligaments but with no disruption or tear. A grade II is a rupture of the two acromioclavicular ligaments, while a grade III is disruption of both acromioclavicular ligaments as well as the coracoclavicular ligament. The latter case will allow elevation of the clavicle, as the entire suspension of the shoulder has been disrupted. There is no strong evidence that grade III separations do better with surgery than without if the patient is willing to accept slight deformity at the end of the clavicle. Functionally the patient should do fine from treatment with an arm sling for 3 to 6 weeks for comfort, with mobilization of the shoulder as early as possible and | return to activity.
Shoulder dislocations are separations of the humerus (the long bone of the upper arm) from the shoulder and are classified as either anterior or posterior. Anterior is by far the most common, at a ratio of 10:1. Fractures of the head, or top part, of the humerus may be associated with dislocations. A replacement (reduction) of the dislocation should be attempted as soon as possible. Muscle spasm and pain will continue to increase the longer the dislocation is allowed to remain untreated.
Anterior dislocations may be identified by comparison with the opposite side. The normal, smooth, rounded contour of the shoulder, which is convex on the lateral (outside) side, is lost. With anterior displacement the lateral contour is sharply rectangular and the anterior (or front) contour is unusually prominent. The arm is held away from the body, and any attempted movement will cause considerable pain. See figure 7–5.
A numb area located at the insertion of the deltoid muscle means that the axillary nerve has been damaged. Numbness or tingling of the little finger could mean ulnar nerve damage, while decreased sensation to the thumb, index, and middle finger may mean the radial nerve is injured. These findings increase the urgency of attempting a reduction. The best method of reducing the anterior dislocation of the shoulder is the Stimson method. While other methods exist, this technique puts less force on the shoulder, which is particularly important in case a fracture of the head of the humerus coexists with the dislocation. The technique is illustrated in figure 7-6. After reduction has been obtained, the arm is placed in a sling and a swathe is wrapped around the arm and chest to hold the arm against the body for 3 weeks. Mobilization too soon after reduction will result in a weak, unstable shoulder. In a young person this sling and swathe may be maintained for 4 weeks prior to range-of-motion exercise. Holding the position longer than 4 weeks will not reduce the chance of recurrent dislocation, while holding it there longer may result in a frozen shoulder.
Fractures of the shoulder blade (scapula) are generally due to major trauma, and the patient may also require treatment for multiple fractures of the ribs, punctured lung (pneumothorax), or heart contusion. A direct blow to the scapula may fracture it without these other injuries. Diagnosis is difficult without an X-ray, but suspicion may be high if there is point tenderness to palpation over the scapula, particularly several days after the accident. An indication of scapular fracture is Comolli's sign, which is a triangular swelling corresponding to the outline of the scapula. Treatment uses a sling and early mobilization to prevent stiffening of the shoulder.
Next week's Orthopedic post will cover upper arm fractures, elbow trauma and forearm fractures.