• when painful shoulder conditions present seemingly as trauma without obvious Hx of trauma think of other conditions:
  • Parsonage Turner syndrome

• 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
• axillary N is the most commonly injured N - 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
posterolateral humeral head depression fracture	Impaction fracture of the anteroinferior glenoid margin or labrum injury	Normal AC joint width: 5-8mm coraco-clavic jt width 10-13mm

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

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

• 2 types of classification:
  • Neer Classification. 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):
        1. surgical neck: most common
        2. greater tuberosity - frequently seen in the setting of anterior shoulder dislocation. A lower threshold of displacement (>5 mm) has been proposed
        3. anatomical neck
        4. 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:
        1. greater tuberosity and shaft are displaced with respect to the lesser tuberosity and articular surface which remain together
        2. 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
  • AO classification, 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

• 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

alternative methods in shoulder reduction
https://radiopaedia.org/articles/shoulder-dislocation?lang=gb
https://www.orthobullets.com/shoulder-and-elbow/3047/acromioclavicular-joint-injury
Emed shoulder dislocation