Ep 136 Occult Shoulder Injuries and Proximal Humerus Fractures

Brought to you byIn this EM Cases main episode podcast Occult Shoulder Injuries and Proximal Humerus Fractures, Dr. Arun Sayal and Dr. Dale Dantzer answer questions such as: What should be included in the list of  key occult shoulder injuries that we should have in our back pockets when faced with a patient who has injured their shoulder and the x-ray appears normal? Which proximal humerus fractures are likely to require surgical management? Which shoulder injuries require a simple sling vs Velpeau sling vs collar and cuff vs sugar tong splint? When is an ultrasound of the shoulder indicated and how should they be interpreted? What is the best x-ray view to diagnose a sternoclavicular dislocation? What are the surgical indications for clavicle fractures? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Saswata Deb, edited by Anton Helman February, 2020 Cite this podcast as: Helman, A. Sayal, A. Dantzer, D. Episode 136 Occult Shoulder Injuries and Proximal Humerus Fractures. Emergency Medicine Cases. February, 2020. https://emergencymedicinecases.com/occult-shoulder-injuries-proximal-humerus-fractures. Accessed [date] Go to part 1 of this 2-part podcast on shoulder injuries ED management of proximal humerus fractures Surgery for proximal humerus fractures offer little benefit over conservative for the vast majority of proximal humerus fractures [1,2,3] and is associated with increased costs, adverse event rates, and risk of mortality [4]. There is geographical variation in the proportions of patients that undergo surgical management of proximal humerus fractures with rates ranging from 9%-21% [5]. There are four general considerations in the decision for surgical management of these fractures: The Neer classification suggest that the more bone fragments, the more likely surgery will benefit the patient [6]. Furthermore, the more displaced the humeral head, the more likely avascular necrosis may result (although AVN in rare), and the more likely a benefit from surgery. Greater tuberosity fractures that displace proximally enough to disrupt the joint usually require surgery, and head split fractures usually require surgery. Neer classification proximal humerus fractures, University of Washington Patients should be made aware that about 90% of recovery of the shoulder from proximal humerus fractures occurs in the first 3-4 months and the remaining 10% takes 6 months or longer – much longer than other major joints in the body [7]. In addition, simple range of motion exercises such as pendulum swings and wall walk-ups should be encouraged and can be quickly demonstrated in the ED. These exercises help to prevent adhesive capsulitis (frozen shoulder). Pitfall: Patients with proximal humerus fractures who are instructed to remain immobilized for more than three weeks are put at increased risk for adhesive capsulitis. Early range of motion exercises are key in preventing frozen shoulder. Methods of shoulder immobilization There are 4 ways to immobilize the shoulder: simple sling, Velpeau sling (‘shoulder immobilizer’), collar and cuff and sugar tong splint. The simple and Velpeau slings take the weight of the arm off the shoulder. In patients with clavicular fractures or acromio-clavicular (AC) separations,