Chapter 6

SHOULDER
JOINT
INJURIES:
DISLOCATION AND ROTATOR CUFF
INJURIES.
I. Glenohumeral
dislocation and
subluxation.
I.1. Anatomic review.

Glenohumeral ligament

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I.2. Injury mechanism.
Epidemiology:
- Anterior and internal shoulder dislocations: the most
frequent in the shoulder (80- 95%) and in the body.
- Adults 20-50 years old.
- ♂>♀ (2/1).
- Trauma / accident (ski +++, rugby, football, MVA…).

Mechanism:
- Fall on the hand with upper limb in retropulsion, external
rotation.
- Abduction and forced external rotation.
- Traction on the limb in abduction and external rotation.
- Rarely: direct trauma on the shoulder.

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Pathophysiology: 4 types:
 Extra-coracoidal.
 Sub-coracoidal.+++: Bankart’s injury (avulsion of
the anterior capsule and glenoid labrum from the
glenoid rim).
 Intra-coracoidal.
 Sub-clavicular.

Associated injuries:
 fracture of the greater tuberosity of the humeral
head (flap fracture).
 rotator cuff tear (partial and full-thickness tears).
 Hill-Sachs injury (compression fracture of the
posterosuperior humeral head).
 Injury of the axillary, musculocutaneous, or median
nerves.
 Vascular injuries are rare.

Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.

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 I.3. Clinical signs and examination.
 Complain: Pain.
 Inspection:
 Functional impairment:
- holds his arm
- Irreducible abduction ( Berger’s sign).
 Deformity of the shoulder’s shape.
 Shoulder pad sign.
 Depression of the sub-acromial region (empty coil):
Sulcus sign.
 Filling of the delto-pectoral fold.

 Palpation and mobilization:

 Instability?
• Apprehension test: 90° abduction, 90° elbow flexion, external rotation
 apprehension of the patient to reproduce the instability.
• Relocation test: apprehension test but the patient is lying down. When
apprehension, the examiner produces an antero-posterior translation
on the humeral head (relocation of the humeral head)  the
apprehension disappears.
Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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 Apprehension test. Relocation test.

 Vascular and nervous examination (anesthesia of

the shoulder stump: circumflex nerve++).

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I.4. Radiological diagnosis.
o AP + Lamy Profile.

o Humeral head displacement (internal).

o Vacuity of the coil.
o Disappearance of the joint line.
o Associated fractures: Greater tuberosity,
humeral neck, coil (after reducing the
dislocation).

Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.

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 I.5. Principle of treatment
 Urgent +++ Early.
 Orthopedic ++++
 Patient information about the injuries.
 Sedation.
 Reduction.
 Control X-ray.
 Nervous and vascular examination.
 Elbow to body splint:
 3 weeks sling (>20 years old).
 3-6 weeks sling (< 20 years old): less risk of retraction.

 PS: some studies suggest external rotation immobilization.

 Active rehabilitation: hand + fingers  articular amplitudes  muscular

reinforcement  proprioceptive rehabilitation.

 If humeral fracture or failure of orthopedic treatment: surgical reduction.

! High risk of humeral necrosis if humeral neck fracture.
Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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I.6. Complications.
 Immediate:
 Associated fractures: coil, humeral neck, greater tuberosity..
 Nerves compression: circumflex nerve +++, brachial plexus.
 Axillary vessels compression.
 Rupture of the rotators cuff/ long biceps tendon.

 Late:
 Recurrence +++
 Shoulder stiffness.
 CRPS.
 Sequels of rotators cuff rupture.

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 I.7.Posterior dislocation.
 Less common : Seizure or electrocution.

 Pain +++

 Almost no clinical deformity.

 Adduction, internal rotation of the shoulder.

 Impossibility of external rotation.

 Double line of the humeral head on the AP X- Ray view.

 Orthopedic treatment.

Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.

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Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
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II. Rotator cuff
Injuries.
II.1. Anatomic review.
Supraspinatus.

Infraspinatus.

Subscapularis

Teres minor.

Biceps brachii: long head.

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  Biceps brachii:
* Palm-up test:

Extension of arms. Supination. R

to elevation.

* Instability test:

Small retropulsion. 90° elbow

flexion. Upper-cut maneuver.

Palpation of a “ball” in the lower

part of the arm.

Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.

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II.3. Calcifications.
 Epidemiology:
80% suspraspinatus > infraspinatus tendon >
subscapularis tendon.
 Clinic:
Small  almost asymptomatic.
Important  Sub-acromial conflict  pain
(inflammatory).
• Radiological diagnosis: ++ therapeutic
decision.
X-Ray, Ultrasounds, arthroscan (arthrogram).
• Chronic phase: thick calcification with regular
edges. 20
Joelle KHADRA-EID, M.D. Elie Tabcharany M.D.
  Resorption phase: inhomogeneous and blurred calcification,
fuzziness of the edges.

 Evolution: chronic disease with acute recurrence.

Sometimes, spontaneous healing.
 Treatment:
 Acute inflammation  local infiltration (corticosteroids).
 Painful shoulder > 1 year  arthroscopic excision.

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 - Rest +/- sling.
- Limitation of painful activities.
- NSAIDs.
- Strengthening and stretching exercises in physical therapy.

Steroids injection. Arthroscopic treatment.

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II.4. Non calcified and non
ruptured tendinopathy.
Etiologies:

 Vascular: distal portion of the supraspinatus is few

vascularized (fragile zone).

 Degenerative osteoarthritis.
 Traumatic: sportsmen, workers with repetitive
movement of the shoulder (painters, carpenters…).

 Anatomical: acromion shape.

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II.5. Partial and complete
ruptures.
 Clinic:
 Pain.
 Leak or loss of strength
(muscular testing 5 0).

 Radiology:
 X-ray: Rise of the humeral
head.
 Ultrasound: discontinuity of
the tendon, edema.
 Arthroscan (-): high density.
 MRI (+++): ruptured
tendon(s).High signal T1.(++
T1 Flair/ T1 Fat Sat).

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  Treatment:
 Arthroscopic or surgical reattachment of the ruptured
tendon.

 Short immobilization then rehabilitation.

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 III. Adhesive
capsulitis
= frozen shoulder.
  ♀ > 40
 Clinic:
 Pain.
 Limitation of passive and active
mobilizations++++ (++abduction).

 Radiology:
 X-ray and scintigraphy (bone scan) non
contributive.
 Arthroscan and MRI (+++):
 Thickening of the capsule,
 Diminution of the articular volume.
 Filling of the retrocoracoidal fat triangle
(pathognomonic). Enhancement of the
signal after Gadolinium injection.
 Arthrography++
 Treatment:
 Analgesics, NSAIDs.
 Physical therapy.
 Arthroscopy: capsule dilatation (Chemical
synovectomy).
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 Bibliographie/ Webographie.
 BARSOTTI (J.), DUJARDIN (C.) Guide pratique de traumatologie. Masson édit.1990, 2è édition, 32-37

 • DEJEAN (O.). Orthopédie. Collection Med-line - Editions Estem et Med-line, 1994,77-88.

 • GAZIELLY D.F. L’épaule au quotidien. Sauramps médical, éditeur, 1999,131-149.

 • WALCH (G.), MOLE (D.) Instabilités et luxations de l'épaule (articulation glénohumérale). - Editions techniques - Encycl. Med. Chir. (Paris),
appareil locomoteur. 14037 A10, 1991, 14 pages.

 Hawkins RJ, Neer CS, Pianta RM, Mendoza FX (January 1987).Locked posterior dislocation of the shoulder.J Bone Joint Surg Am, 69 (1): 9–18.

 Murrell GA (October 2003). Treatment of shoulder dislocation: is a sling appropriate? Med. J. Aust. 179 (7): 370–1.

 Chalidis B, Sachinis N, Dimitriou C, Papadopoulos P, Samoladas E, Pournaras J (June 2007). Has the management of shoulder dislocation
changed over time? Int Orthop, 31(3): 385–9.

 Guide de l’examen clinique. Barbara Bates. Ed MEDSI, Paris 1985.

 L’épaule au quotidien. D. Gazielli. Ed Sauramps medical 1999

 http://www.chups.jussieu.fr/polys/orthopedie/polyortho

 http://www-ulpmed.u-strasbg.fr/medecine/cours_en_ligne/e_cours/pdf-locomoteur/11_Pathologie_de_la_coiffe_des_rotateurs.pdf

 http://www.medecinedusport.be/testepaule.htm

 http://www-sante.ujf-grenoble.fr

 http://www-ulpmed.u-strasbg.fr

 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553174/

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