=====Shoulder injuries=====
  *when painful shoulder conditions present seemingly as trauma without obvious Hx of trauma think of other conditions:
    *[[wiki:neurology:nentrapments#brachial_neuritis|Parsonage Turner syndrome]]
====Shoulder dislocation====
  ***anterior >95%**
    *subcoracoid (majority)
    *subglenoid (1/3)
    *subclavicular (rare)
  *posterior 2-4%
  *inferior (luxatio erecta) <1%

  *post dislocations may be missed on AP film - transcapular view is therefore important if suspicious
  *<wrap em>axillary N is the most commonly injured N</wrap> - examine for signs of other brachial plexus injury also
  *axillary art damage may also occur esp in the elderly

----
^Associated injuries |||
^Hill-Sachs defect^Bankart Lesion ^AC lig injury|
|[{{:wiki:musculoskeletal:upperlimb:hillsachs.png?150|posterolateral humeral head depression fracture}}]|[{{:wiki:musculoskeletal:upperlimb:bankart_lesion.jpg?150|Impaction fracture of the anteroinferior glenoid margin or labrum injury}}]|[{{:wiki:musculoskeletal:upperlimb:acl_injury.jpeg?150|Normal AC joint width: 5-8mm\\ coraco-clavic jt width 10-13mm }}]|
===Techniques for reduction===
various techniques for reduction, but each should be slowly and gently. Too fast and M spasm will counter efforts!!
  ***Stimson**
    *patient lies prone with weight attached to hand of affected arm which is hanging over the side of the bed
  ***scapular manipulation method**
    *patient lies prone as with Stimson but scapula is then rotated clockwise
  ***external rotation method**
    *patient is supine or sitting. The flexed arm is adducted and then externally rotated
  ***Milch technique**
    *fully abduct the arm and apply longitudinal traction followed by external rotation
  ***FARES method**
    *supine or relaxed sitting position, applying longitudinal traction then slowly abduct and oscillate arm up and down
  ***Spaso technique**
    *with patient supine, affected arm held around the wrist or distal forearm & lifted vertically, applying upward traction & gentle external rotation
  ***Davos technique**
    *patient sits with ipsilateral hip & knee in full flexion. Fingers are then clasped (locked) beneath the knee and the patient is encouraged to relax and lean backward

====Acromio-clavicular joint injury====
{{ :wiki:musculoskeletal:upperlimb:rockwood.png?200|}}
^  Rockwood classification of injury  ||
^Type I |• clavicle not elevated with respect to the acromion\\ • all lig's intact|
^Type II |• clavicle elevated but not above the superior border of the acromion\\ • AC lig and capsule ruptured|
^Type III |• clavicle elevated above superior border of acromion but coraco-clavicular distance <2x normal (ie <25mm)\\ • all lig's and capsule ruptured\\ • deltoid and trapezius M's detached|
^Type IV |• clavicle displaced posterior into trapezius\\ • all lig's and capsule ruptured\\ • deltoid and trapezius M's detached|
^Type V |• clavicle is markedly elevated and coraco-clavicular distance >2x normal (ie >25mm)|
^Type VI |• rare - clavicle inferiorly displaced behind coraco-brachialis & biceps tendons|
^  ^//**Types IV, V, VI are effectively variants of Type III**//|
===Management===
**Non-operative**
  *brief sling immobilization, rest, ice, physio
  *type I, II & type III in most especially if clavicle displaced <2cm
  *with rehab early shoulder range of motion
    *functional motion usually within 6/52
    *normal activity usually within 12/52
**Operative**
  *for high grade injuries but some doubt over superiority of results
  *may be more for cosmetic reasons

====Proximal Humeral fractures====

  *2 types of classification:
    *<wrap em>Neer Classification</wrap>. Based on (a)parts fractured rather than the fracture line and (b) extent of displacement
      *1 Part fracture: 80% of proximal humeral fractures. Fracture lines involve 1-4 parts. None of the parts are displaced (i.e <1 cm and <45 degrees)
      *2 Part fracture: fracture lines involve 2-4 parts with 1 part displaced (i.e >1 cm or >45 degrees)
        ***4 subtypes** of two-part fractures (one for each part):
           -surgical neck: most common
           -greater tuberosity - frequently seen in the setting of anterior shoulder dislocation. A lower threshold of displacement (>5 mm) has been proposed
           -anatomical neck
           -lesser tuberosity: uncommon
       *3 Part fracture: fracture lines involve 3-4 parts, with 2 parts displaced (i.e >1 cm or >45 degrees)
        ***2 subtypes:**
          -greater tuberosity and shaft are displaced with respect to the lesser tuberosity and articular surface which remain together
          -lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together
       *4 Part fracture: uncommon. Fracture lines involve more than 4 parts with 3 parts displaced (i.e., >1 cm or >45 degrees) with respect to the 4th
    *<wrap em>AO classification</wrap>, each with subtypes, with the risk of avascular necrosis of the articular surface increasing from A to C:
      *type A: extra-articular unifocal (either tuberosity +/- surgical neck of the humerus)
      *type B: extra-articular bifocal (both tuberosities +/- surgical neck of the humerus or glenohumeral dislocation)
      *type C: extra-articular (anatomical neck) but with compromise to the vascular supply of the articular segment
==Management:==
  *the vast majority of proximal humeral fractures are managed conservatively with supportive sling with physiotherapy to support early (7-10/7) mobilisation
  *intervention usually for displaced articular and peri-articular fractures
  *most common definition of displacement is ≥1cm between fracture fragments or ≥45° of angulation between fragments

==References include:==
[[https://www.nuemblog.com/blog/2018/5/14/shoulder-reduction|alternative methods in shoulder reduction ]]\\ 
https://radiopaedia.org/articles/shoulder-dislocation?lang=gb\\ 
https://www.orthobullets.com/shoulder-and-elbow/3047/acromioclavicular-joint-injury\\ 
[[https://emedicine.medscape.com/article/109130-technique|Emed shoulder dislocation]]\\