Shoulder

Fractures of the collar bone are quite common due to bone being superficial and acting as a strut between the shoulder girdle and the body. It is often caused by a fall onto an outstretched arm, a direct impact to the shoulder, or a blow to the clavicle itself. Cycling and football are common sports where these injuries occur.

Depending on the severity of the fracture and whether it is displaced (a fracture in which the two ends of the broken bone are separated from one another), treatment can vary.

In general, most clavicle fractures will heal in a sling for 4 weeks and this is the standard management for most clavicle fractures.

If the mechanism of fracture is high energy with fragmentation of the bone, healing can be delayed.

Clavicle fractures are generally uncomfortable in the first 2 weeks and some patients choose surgical fixation to speed up the recovery process.

If the fracture is significantly overlapped then surgery can be recommended to restore optimal shoulder function, especially in athletic patients.

Fixaton methods include a clavicle plate, which is specially molded for the bone or an intramedullary screw which is inserted through a minimally invasive approach.

Orthopaedics Victoria has the largest case series of intramedullary fixation of the clavicle in Victoria.

An AC joint dislocation is different to a true shoulder dislocation which is when the gleno-humeral joint is dislocated. AC dislocations are most commonly found in impact sports such as Aussie Rules Football and rugby but are also seen in sports such as bike riding and snow sports where the patient may have fallen onto an outstretched arm.

Depending on the grade of the dislocation, treatment can vary from simply immobilisation and rest for a short period to surgical fixation of the dislocation.

Surgical fixation can involve the use of a hook plate which is placed under the acromion bone and levers the displaced clavicle down. The ligaments will also need to be repaired.

The hook plate will need to be removed around the 3 month mark.

This is usually a day case procedure so you should be able to go home the same day of surgery. If pain is excessive or if surgery is performed late at night, an overnight stay can be arranged.

The arm will be in a sling for protection to avoid knocking it but it can be taken out of the sling as pain permits and to allow a physiotherapy exercise program.

The surgical incision will be closed with a dissolving stitch under the skin and covered with tapes over the wound to reinforce the wound.

A bulky, firm dressing is applied directly after your surgery to minimise bruising and haematoma. This can be removed 48 hours after your surgery. The waterproof dressing underlying this can get wet in the shower but should be left intact until your post operative review 10 to 14 days post surgery. If this latter dressing becomes loose, a fresh, waterproof dressing should be applied to cover the wound until your post operative review.

A combination of simple analgesics including Panadol (paracetamol) and Panadeine (paracetamol/codeine) can be used post surgery. Non steroidal anti-inflammatory medications including Indocid (indomethacin), Orudis (ketoprofen), Celebrex (celecoxib) etc and stronger tablet analgesics including Tramal (tramadol), Di-Gesic (dextropropoxyphene/paracetamol), and Panadeine Forte (paracetamol/codeine) may also be used. While in hospital injection analgesics can be given in the way of morphine or pethidine.

It is usual to review the fracture about 10 days to 2 weeks post reduction with a check x-ray to ensure maintenance of fracture alignment and review of surgical wound. Exercises in the pool can begin at this stage. You will require review at 6 weeks following injury to check that the fracture has united. You will then be checked at 2 months following surgery, at which stage increased activities including weight lifting can begin. A final check at 4 months post surgery is done to ensure full recovery.

It is usual to return to work within one week in a sedentary job but this may vary depending on your occupation.

When you can safely turn the steering wheel to avoid an accident. We recommend you practise this in a stationary vehicle in the driveway before driving on the road.

Please do not attempt to drive at all in the first two weeks post surgery.

This operation, as with any others, requires an anaesthetic which in a fit, healthy young person is relatively straight forward. Specific anaesthetic risks will be discussed with your anaesthetist. There is a small risk of infection following this operation and antibiotics are given during the peri-operative period to minimise this risk.

To avoid stiffness and to build up strength, you can attend physiotherapy but this is on an individual basis. Please discuss this in person with your surgeon.

The shoulder is a complex joint that consists of the humeral head (ball) and the glenoid (socket). The glenoid or socket is deepened by a fibrocartilaginous ring called the labrum, which has an attachment to the long head of biceps.

Shoulder movements involve many muscles and these include the deltoid which is a prime mover; as well as the rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis) which help stabilise and control the shoulder in all the different movements.

The shoulder can get injured in sporting activities or repetitive activities such as lifting or pulling.

The rotator cuff tendons lie under a bone called the acromion. This is called the subacromial space. Within this space is a pocket of tissue called the subacromial bursa. This space can get tight and lead to impingement syndrome, otherwise known as painful arc syndrome, swimmer’s shoulder or thrower’s shoulder.

This term covers a spectrum of conditions:

This condition occurs with repetitive overhead activites and is more common with age as the rotator cuff becomes more degenerative. The acromion can also be shaped with a bit of a hook, which can make the area more vulnerable.

Investigations include x-ray of the shoulder and ultrasound or MRI to look at the rotator cuff.

Initial management includes:

Failure of conservative treatment is an indication for surgery such as an arthroscopic subacromial decompression. This is keyhole surgery where the undersurface of the acromion is burred away to allow more room for the tendons.

Rotator cuff tears are tears of one or more of the tendons or muscles that make up the rotator cuff of the shoulder. Rotator cuff tears are one of the most common pathologies within the shoulder that upper limb specialists are exposed to and it is more common to tear the tendon rather than the belly of the muscle.

The supraspinatus is the most frequently torn muscle of the rotator cuff as it passes underneath the acromion and the tear is normally found on the humeral side of the tendon. Partial thickness tears can respond well to non-operative treatment but full thickness tears should be considered for repair, with the exception of elderly patients where the success rates are lower.

Failing conservative management, a surgical repair of the rotator cuff tendon tear may be performed whether it be arthroscopically or mini-open (depending on the specific presentation of the patient). This involves performing a subacromial decompression followed by a repair of the tendon to the bone using anchors (screws with sutures attached to them).

The shoulder joint has the greatest range of movement of any joint in the body and therefore is more predisposed to dislocation or subluxation (partial displacement of a joint).

The dislocation is most commonly anterior and usually damages the capsule and labrum. A posterior dislocation is usually associated with seizures or electric shocks.

The mechanism of an anterior dislocation occurs when the arm is raised above the head and pulled back such as in a football tackle or fall.

Shoulders are generally reduced in the emergency department under sedation. Once reduced, the affected arm is placed in a sling. Review is necessary to make sure the shoulder is in place and to initiate physiotherapy and investigations such as an MRI.

Younger patients are more likely to have a shoulder which becomes recurrently unstable. Dislocation and subluxations may continue to occur despite conservative management such as physiotherapy.

Surgery may be indicated to repair the labrum and tighten the shoulder capsule in this setting.

Most shoulder surgery can now be done arthroscopically through small keyhole incisions, less than 1 cm long. This is usually done through two or three small incisions but other incisions may be made if they are required for surgical approach. If a torn tendon is repaired, the keyhole incision may be slightly longer.

1 – 2 nights.

The small arthroscopic cuts will be closed with a dissolving stitch under the skin and covered with tapes over the wound to reinforce the wound.

A bulky, firm dressing is applied directly after your surgery to minimise bruising and haematoma. This can be removed 48 hours after your surgery. The waterproof dressing underlying this can get wet in the shower but should be left intact until your post operative review 10 to 14 days post surgery. If this latter dressing becomes loose, a fresh, waterproof dressing should be applied to cover the wound until your post operative review.

A sling will be provided following the surgery. This allows the arm to be rested in between exercise sessions and is recommended to be worn when at social activities as a visual warning to others of the recent surgery. This helps reduce the chance of the recently operated shoulder being knocked.

A physiotherapy program will be recommended and should begin within a week of the surgery. You can arrange the first appointment immediately to ensure continuity of care. Depending on the amount of damage requiring surgical repair, lifting may need to be avoided for up to 8 weeks if the rotator cuff tendon requires repair. A good guide in the early stages is not to lift more than a cup of tea to minimise risk of further damage to the shoulder. If there is no damage to the rotator cuff and no repair is required, an active assisted exercise program with the physiotherapist begins early and lifting strengthening exercises can begin earlier.

This operation, as with any others, requires an anaesthetic which in a fit, healthy young person is relatively straight forward. Specific anaesthetic risks will be discussed with your anaesthetist.

There is a very small risk of infection following this operation and antibiotics are given during the peri-operative period to minimise this risk.

This will depend on the type of work you do. No heavy, overhead lifting activities will be possible for two weeks following surgery. The rehabilitation period can be from six to twelve weeks depending on the individual.

The most important issue is whether you can stop to avoid an accident.You can be guided by sitting in a stationary car in the driveway and imagining a little boy chasing a ball, running in front of your car. If you can turn the wheel and apply the brakes 6 times in a row, you can proceed to responsible driving.

Please do not attempt to drive at all in the first two weeks post surgery.

Shoulder arthritis is a condition in which the smooth articular cartilage that forms the ball and socket joint in the shoulder wears out. The joint surfaces roughen and the bone beneath becomes exposed. As a result: pain, loss of movement, swelling and grinding/cracking can occur.

This can occur from generalised wear and tear or may occur as a result of previous trauma. Inflammatory arthritis like rheumatoid arthritis also cause joint degeneration. If the rotator is deficient for a long period, arthritis can also be an end result.

Conservative measures include:

Early arthritis can sometimes be treated with an arthroscopic debridement of the shoulder.

Total shoulder replacement involves replacing the joint surfaces with prosthetic components.

A reverse total shoulder replacement can be used if the rotator cuff is not working.

This procedure is a moderately large orthopaedic procedure and usually requires 4 to 5 days in hospital.

This operation, as with any others, requires an anaesthetic which in a fit, healthy young person is relatively straight forward. Specific anaesthetic risks will be discussed with your anaesthetist.

Risk of deep infection following this procedure is about one in 200. The risk is minimised by antibiotics given in your drip for 24 to 48 hours following your surgery.

A blood clot in the veins of the calf (deep venous thrombosis) is a potential risk but a blood thinning injection (heparin) will be given to you at the time of your operation to thin the blood enough to minimise this risk. If a blood clot should form, break off and go to the lungs, it can be serious and you must report any shortness of breath, coughing up of blood or severe chest pain. These are the signs of a pulmonary embolus.

Your surgeon has a strong team involved in managing your operation including a fully qualified consultant anaesthetist, surgical assistant and physician to help manage associated medical issues.

Following a procedure like this, it will be at least two months before you should consider being able to drive safely. The key to the decision on driving is whether you can safely stop in an emergency situation. You can be guided by sitting in a stationary vehicle in your driveway, imagining an emergency situation and attempting to make the appropriate avoidance procedures. If this is uncomfortable, you will know it is not safe to begin driving at this stage.

It will take 4 to 6 months to fully recover from this operation.