Primary Surgery Vol.2 – Trauma: EXAMINING THE SHOULDER AND UPPER ARM

EXAMINING THE SHOULDER AND UPPER ARM

THE CLAVICLE EXAMINATION

Look carefully at either end of the patient’s clavicle. Are they same on both sides? (abnormal prominence suggests a dislocation).

Stand behind him, feel the entire subcutaneous surface of his clavicle, and the joints at either end. Where exactly is it swollen and tender? (fractures).

Is there any abnormal movement between his clavicle and his acromion? (acromio–clavicular dislocation). If so, can you reduce the dislocation by raising his humerus with your hand under his elbow, and depressing his clavicle?

THE SCAPULA EXAMINATION

Palpate the spine of the patient’s scapula and his acromion. Tenderness and swelling probably indicate a fracture.

Flex his arm to 90 $\ensuremath{^\circ }$ and rest it on your forearm. Gently move his whole arm up and down. Provided his clavicle is intact, abnormal mobility or crepitus in his shoulder suggests that he has fractured the neck of his scapula.

THE SHOULDER JOINT EXAMINATION

INSPECTION is the outline of the patient’s shoulder flattened, and the normal roundness of his deltoid muscle lost as in Fig. 71-4? (dislocation, or a circumflex nerve injury causing wasting of his deltoid).

Is his anterior axillary fold lowered, his deltopectoral groove swollen, or his elbow displaced away from his body? Does the axis of his humerus point towards the middle of his clavicle as in Fig. 71-4? (these are all signs of an anterior dislocation of the shoulder).

Is his shoulder grossly swollen? (the neck of his humerus is probably fractured, perhaps with dislocation of its head. In a fracture dislocation swelling of the shoulder joint hides the flattening caused by the dislocation, so this injury is often missed).

PALPATION Can you feel the head of the patient’s humerus dislocated into an abnormal position? Feel high up into his axilla. You may be able to feel a thickened capsule, or an effusion.

Are the tip of his acromion, the tip of his coracoid, and the greater tuberosity of his humerus in their normal places?

MOVEMENTS OF THE SHOULDER Stand behind him. Put one hand round in front of him and hold the outer end of his clavicle firmly. With your other hand hold the tip of his scapula still. With his scapula held, you can now be sure that any movements he makes are those of his shoulder, not those of his scapula moving over his chest. If pain begins as soon as he starts to move his arm in any direction, there is something seriously wrong with his shoulder.

Abduction

How far can the patient abduct his shoulder? He should be able to abduct it to 90 $\ensuremath{^\circ }$ before his scapula starts to move. If his scapula starts to move earner, abduction of his shoulder is limited.

Adduction

With his forearm flexed, and his scapula held, can he bring his elbow across to the midline in front?

Rotation

Can he externally rotate his flexed forearm, so that it reaches the coronal plane? Can he rotate it internally enough to scratch the small of his back? If any of the above active movements are limited, repeat them passively. Finally, ask him to lift his arm from his side, at first to 90 $\ensuremath{^\circ }$ and then above his head. If he can do this, he has no serious shoulder injury.

OTHER SIGNS IN THE SHOULDER Stand behind the patient and rest your hands on the point of each of his shoulders. Try to insert the tips of your fingers under the edge of each acromion, between it and the head of his humerus. You may be able to feel that the head of his humerus is dislocated on the injured side.

Put one hand on his shoulder, and grasp his elbow with your other one. Bring your hands together so as to compress his humerus. If this is painful it may be fractured.

Grasp the top of his shoulder, so that your thumb lies over the head of his humerus, and your fingers over the spine of his scapula. Flex his forearm and use it to rotate his humerus. If you cannot feel the head moving under your thumb, or if there is crepitus, the neck of his humerus has fractured. If the fracture is impacted, this sign is absent. If, at the same time, the head is displaced, he has a fracture dislocation.

The shoulder joint is hidden under muscles, so you cannot see if it is swollen, but you can see swelling of the subacromial bursa, especially if you look from behind and above, and compare both sides.

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Figure 71.1: SLINGS FOR AN INJURED ARM. Most injured arms are best in sling A. If a hand is injured, the St John sling B, will raise it. Fractures of the humerus need sling C, in which the patient’s elbow hangs free. Supracondylar fractures need the collar–and–cuff D. The narrow bandage sling E, is commonly used but is much less satisfactory.

UPPER ARM EXAMINATION

Palpate the lower half of the patient’s humerus for the signs of a fracture. This is more difficult in its upper half, which is hidden by muscles.

Support his forearm and gently abduct his arm. Pain, tenderness, angulation, or crepitus, indicate a fracture of the shaft.

On both sides, measure the distance from the tip of his acromion to his lateral epicondyle. Shortening indicates a fracture. This test is particularly useful if you suspect it is impacted.

NERVES AND VESSELS in any injury of a patient’s shoulder and upper arm, test his median, ulnar, radial and, axillary nerves (Fig. 55-6). If his clavicle is injured, check his subclavian vessels and listen to the breath sounds in his lungs.

X–RAYS Ask for the following views.

Clavicle

An X–ray is usually unnecessary for the clavicle.

Acromio–clavicular joint

Ask for an AP view of the injured shoulder. Dislocation may be difficult to see, so if you suspect it, ask for a distraction view in which the patient holds a weight.

Shoulder

Ask for an AP and a lateral view- if you suspect a posterior dislocation ask for an axillary view. This is difficult, because he may be holding his arm to his side, so you may have to take it yourself.

Shaft of humerus

Ask for an AP and a lateral view.