Emergent evaluation of injuries to the shoulder, clavicle, and humerus

Shoulder injuries in polytraumatized patients: an analysis of the TraumaRegister DGU®

Background

The aim of the present study was to analyze the prevalence, epidemiology and relevance of shoulder injuries in polytraumatized patients in a large national trauma database.

We hypothesize a high prevalence of shoulder injuries in traffic accidents and a high prevalence of concomitant injuries of the thorax leading to an aggravated clinical course and higher Injury Severity Score (ISS). Furthermore, we hypothesize an increased rate of surgical treatment with the severity of the injury.

Materials and methods

The retrospective analysis is based on the database (2002–2013) of the TraumaRegister DGU® and includes statistical data from 608 hospitals. The severity of injuries and trauma were scaled using the Abbreviated Injury Scale (AIS), and the Injury Severity Score (ISS), respectively. Patients with an ISS ≥ 16 were included in the study, and injuries were subdivided according to their anatomical involvement and analyzed with respect to the trauma mechanism and the resulting injuries.

Results

In this study, 54,076 cases of patients with an ISS ≥ 16 were analyzed. Shoulder injuries occurred in 15,115 patients (27.9%). Of these, 68.5% were caused by traffic accidents, especially in motorbike, bicycle, and pedestrian accidents. We found more shoulder injuries in blunt trauma mechanisms. Moreover, patients with shoulder injuries spent on average 1.7 more days on the intensive care unit (ICU), or intermediate care unit (IMCU), according to the severity of the injury, and had longer overall hospital stays (26.2 vs. 24.1 days) than patients without shoulder injuries. The overall ISS was increased in patients with shoulder injuries, whereas an increase of mortality could not be identified. Concomitant thoracic injuries occurred significantly more often in patients with shoulder injuries (82.9% vs. 69.6%). Injuries of the abdomen, pelvis, and lower extremity showed no correlation with shoulder injuries, whereas head and spine injuries showed a significant correlation.

Conclusion

Shoulder injuries are very common in polytraumatized patients. Together with their distinctive concomitant injuries, they have an aggravating impact on the clinical progress. Our data confirm the correlation with thoracic injuries. Furthermore, we identified an increased risk of shoulder injuries in motorbike, bicycle, and pedestrian accidents. An increase in mortality could not be identified.

No incidence of glenohumeral joint dislocation in a review of 220 paediatric proximal humerus fractures

PURPOSE

Proximal humerus fractures in adults are approached with a high suspicion for potential associated glenohumeral dislocation. Axillary views of the shoulder can be painful and possibly even lead to dynamic angulation of the proximal humerus fracture. The incidence of associated glenohumeral dislocation in the paediatric population is unclear and it would be useful to determine whether children with proximal humerus fracture require specific axillary view imaging to rule out dislocation.

METHODS

We retrospectively reviewed 220 proximal humerus fractures in 218 total children. Imaging and follow-up clinic notes were reviewed for potential glenohumeral dislocation.

RESULTS

Average patient age was 9.8 years SD 3.8 with 55% of the patients male and a wide variety of mechanisms of injury. None of the 220 fractures evaluated showed radiographic evidence of a shoulder dislocation, and all 218 children had a follow-up appointment at least 21 days after the injury without any clinical concern of a missed shoulder dislocation.

CONCLUSION

No paediatric patients presenting with proximal humerus fractures had a corresponding glenohumeral joint dislocation in our relatively large series. We recommend obtaining this additional imaging only in cases with higher energy mechanisms, if there is suspicion of subluxation or dislocation on anteroposterior and scapular-Y views or if there is clinical concern.

LEVEL OF EVIDENCE

Level III Diagnostic.

Rotator cuff tear following long-standing axillary neuropathy in a female motocross racer

A 'terrible triad' of anterior shoulder dislocation, axillary nerve damage and rotator cuff tear has been previously described. However, we are unaware of any report of anterior shoulder dislocation, humeral fracture, axillary neuropathy and subsequent rotator cuff tear requiring surgery when the axillary neuropathy was deemed permanent. We report the case of a 20-year-old woman who fell in a motocross accident and had an anterior shoulder dislocation, humeral fracture and axillary neuropathy. The fracture was treated surgically with open reduction and internal fixation. The axillary nerve injury was ultimately permanent. Thirteen months after the motocross accident, the patient sustained a rotator cuff tear from seemingly minor trauma. However, several months of aggressive physical therapy preceded the rotator cuff tear. The tear was repaired and the patient was followed for 5 years after the initial injury. She returned to competing in motocross, even though the axillary neuropathy remained complete and permanent.

Shoulder pain

Shoulder pain is a frequent complaint encountered in the emergency setting. A brief review of shoulder anatomy and physical examination sets the foundation for evaluation of shoulder pain. Considerations of patient's age are helpful to predict injuries. Fractured clavicles are often seen in traumatic injuries in children and young adults, whereas fractures of the humeral head are more often seen in the elderly from traumatic injuries. Shoulder dislocations are more common in teens to fourth decade. This article reviews specific acute injuries, chronic conditions, and radiologic considerations of patients with shoulder complaints encountered in emergency settings.