EXAMINATION OF SHOULDER

ANATOMYSHOULDER GIRDLE Comprises of clavicle,scapula,and humerus. These three bones articulate with one

another to give the freedom of movement in all directions.

CLAVICLE The only long bone with membranous

ossification. The muscles attached to its medial and

lateral thirds are responsible for displacement following a fracture .

Medial end articulate with sternum to form sternoclavicular joint.

Lateral end articulates with acromian process to form acromio clavicular joint.

SCAPULA It is a flat bone , thickly covered by

muscles,so do not allow displacement of fractures of this bone .

Because of rich vascularity scapular fractures usually unite.

HUMERUS Proximal end consists of the head articulating

with glenoid cavity of the scapula (gleno-humeral joint or the shoulder joint proper).

The head seperated from greater and lesser tuberosities by anatomical neck.

The globular upper end of the bone joins tubular shaft of the bone called surgical neck .

Fractures are more common at the surgical neck.

SHOULDER JOINT(GLENO –HUMERAL JOINT)

Ball and socket joint. Only one third of the humeral head is in

contact with the glenoid cavity at any time. The capsule of the shoulder joint is lax and

permits freedom of movement. Strong muscles surrounding the joint

contributes stability of this joint. The important among this are rotator cuff

muscles .

ROTATOR CUFF MUSCLES Supraspinatus Infraspinatous Teres minor Sub –scapularis .

EXAMINATION OF THE

SHOULDER

INSPECTION

1) ATTITUDE In fracture of clavicle the patient supports the

flexed elbow of the injured side with the other hand .

Similarly in the anterior dislocation of the shoulder.

2)DEFORMITY OR SWELLING. Abnormal swelling on the line of the clavicle at

its middle or at junction of lateral one third and medial two third-fracture clavicle .

Undue prominence in clavicle bone acromial end-dislocation of acromioclavicular

joint . sternal end –dislocation of sternoclavicular

joint. In subcoracoid dislocation -abnormal swelling in

deltopectoral groove ,undue prominence of the acromian process with flattening of shoulder.

In fracture of neck of scapula –drooping of shoulder with undue lengthening of arm.

3) CONTOUR OF THE SHOULDER Inspection performed from all aspects -anterior -posterior -lateral Undue flattening and loss of roundness of the shoulder

just below the acromian process occurs in dislocation of the shoulder .

Commonest type of dislocation is sub coracoid dislocation ,i.e the head of humerus lies below the coracoid process .

Here there is flattening of the anterior axillary fold. Swelling just below the acromian process occurs in

fracture neck of the humerus , without any loss of roundness .

4) BONY ARCH Formed by clavicle in front,acromian

process laterally ,and spine of scapula posteriorly.

Carefully inspect for any irregularity or abnormal swelling –suggest fracture at that site.

PALPATION

The patient is seated on a stool. Examiner should stand behind the

patient. Palpate all the bones take part in

formation of shoulder girdle.

1)CLAVICLE

Place the hands on the sternal ends of the clavicle of the both sides .

First palpates sternoclavicular joints then proceeds laterally on both sides to palpate the entire length of the clavicle simultaneously.

Any break in the line or abnormal prominence suggests fracture of this bone .

The sternal end is mostly anteriorly displaced in sternoclavicular dislocation .

Acromial end is subluxated upwards in acromio –clavicular joint dislocation.

2)UPPER END OF THE HUMERUS First palpate the acromian process of the both sides with the

fingers,gradually slide the fingers downwards to palpate the greater tuberosity of the humerus on both sides .

Disappearance of greater tuberosity and loss of resistance indicate dislocation of shoulder.

Then gradually slides fingers downwards along the line of humerus on both sides.

Local bony tenderness and bony irregularity at the surgical neck – fracture of neck of humerus.

Then palpate the shaft. In an unbroken bone medial epicondyle shows direction of head of

humerus,and lateral epicndyle shows direction of greater tuberosity. This relation is disturbed in fracture f neck or the shaft of humerus.

3)PALPATION OF SCAPULA First palpate the subcutaneous parts -spine of scapua - acromian process. The vertebral border and inferior angle can be easily

palpated . Axillary border is difficult to palpate ,localised bony

tenderness and swelling suggest fracture of scapula . The coracoid process situated1/2 inch below the clavicle at

junction between the medial 2/3 rd and lateral 1/3rd. Drooping of shoulder with tenderness and crepitus by axial

pressure upward through the flexed elbow is a diagnostic feature of fracture neck of the scapula.

4)RELATIVE POSITION OF 3 BONY POINTS

The tip of the coracoid process , the acromial end of the clavicle and the greater tuberosity of the humerus are compared with those of the healthy side .

In acromioclavicular dislocation the acromial end of clavicle more prominent and come closure to the greater tuberosity. But distance b/t tip of coracoid process and acromial end of the clavicle become increased.

MEASUREMENTS 1) The length of the arm It is shortened in subcoracoid dislocation of

shoulder and fracture neck of humerus. It is longer in subglenoid dislocation and fracture

neck of scapula. 2)Vertical circumference of scapula Increased in any dislocation of the shoulder 3) Hamilton’s ruler test : a straight ruler can be

made to touch with acromian process and the lateral epicondyle of the humerus.

MOVEMENTS A full movement of the shoulder joint

excludes the possibilty of any bony injury near this point.

DUGA’S test : in dislocation of shoulder the patient is unable to touch the opposite shoulder with the hand of the affected side while the arm is kept in contact by the side of the chest.

COMPLICATIONS Injury to axillary nerve.

SPECIAL INVESTIGATIONS X-ray -antero-posterior and lateral view

DIFFERENTIAL DIAGNOSIS Fracture of the clavicle Sternoclavicular dislocation Acromio-clavicular dislocation Fracture of the scapula Dislocation of the shoulder joint Fracture of the neck of humerus and the

greater tuberosity Dislocation of the shoulder joint with

fracture of the uper end of the humerus .

THANK YOU