Acute Shoulder Injuries in Adults

 


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Am Fam Physician. 2016 Jul 15;94(2):119-127.

Author disclosure: No relevant financial affiliation.

Acute shoulder injuries in adults are often initially managed by family physicians. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acromioclavicular joint injuries and clavicle fractures mostly occur in young adults as the result of a sports injury or direct trauma. Most nondisplaced or minimally displaced injuries can be treated conservatively. Treatment includes pain management, short-term use of a sling for comfort, and physical therapy as needed. Glenohumeral dislocations can result from contact sports, falls, bicycle accidents, and similar high-impact trauma. Patients will usually hold the affected arm in their contralateral hand and have pain with motion and decreased motion at the shoulder. Physical findings may include a palpable humeral head in the axilla or a dimple inferior to the acromion laterally. Reduction maneuvers usually require intra-articular lidocaine or intravenous analgesia. Proximal humerus fractures often occur in older patients after a low-energy fall. Radiography of the shoulder should include a true anteroposterior view of the glenoid, scapular Y view, and axillary view. Most of these fractures can be managed nonoperatively, using a sling, early range-of-motion exercises, and strength training. Rotator cuff tears can cause difficulty with overhead activities or pain that awakens the patient from sleep. On physical examination, patients may be unable to hold the affected arm in an elevated position. It is important to recognize the sometimes subtle signs and symptoms of acute shoulder injuries to ensure proper management and timely referral if necessary.

Acute shoulder injuries, such as proximal humerus fractures, acromioclavicular separations, clavicle fractures, shoulder dislocations, and rotator cuff tears, are often initially managed by family physicians. Understanding shoulder anatomy (Figure 11), the physical and radiographic evaluation, and treatment options are essential for a successful outcome. Most of these injuries can be managed without surgery by a knowledgeable family physician. However, it is important to know when to refer patients to an orthopedist. Table 1 summarizes the evaluation and management of different types of shoulder injuries.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Decisions about conservative vs. surgical treatment of acute middle one-third clavicle fractures should be individualized, considering the relative benefits and harms of each intervention and patient preferences.

B

10, 14

Surgery should be considered in young athletes with shoulder dislocations because of a high recurrence rate in these patients.

B

18, 26

Older patients with proximal humerus fractures can be treated nonoperatively because these patients have equivalent or better outcomes compared with those who have surgery.

B

3436

The effectiveness and safety of surgery for chronic rotator cuff disease in older patients are unclear.

B

17


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Decisions about conservative vs. surgical treatment of acute middle one-third clavicle fractures should be individualized, considering the relative benefits and harms of each intervention and patient preferences.

B

10, 14

Surgery should be considered in young athletes with shoulder dislocations because of a high recurrence rate in these patients.

B

18, 26

Older patients with proximal humerus fractures can be treated nonoperatively because these patients have equivalent or better outcomes compared with those who have surgery.

B

3436

The effectiveness and safety of surgery for chronic rotator cuff disease in older patients are unclear.

B

17


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Figure

Figure 1.

Shoulder anatomy.

Reprinted with permission from Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. 2004;70(10):1948.


Figure 1.

Shoulder anatomy.

Reprinted with permission from Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. 2004;70(10):1948.

View/Print Table

Table 1.

Summary of the Evaluation and Management of Acute Shoulder Injuries

Injury

Evaluation and managementAcromioclavicular joint injuriesMidshaft clavicle fracturesGlenohumeral joint dislocationsProximal humerus fracturesRotator cuff tears

Initial management

Sling for comfort

The Authors

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JAMES MONICA, MD, is a clinical assistant professor in the Department of Orthopaedics at Rutgers University Robert Wood Johnson Medical School, New Brunswick, N.J....

ZACHARY VREDENBURGH, MD, is a resident in the Department of Orthopaedics at Rutgers University Robert Wood Johnson Medical School.

JEREMY KORSH, MD, is a resident in the Department of Orthopaedics at Rutgers University Robert Wood Johnson Medical School.

CHARLES GATT, MD, is program director and chairman in the Department of Orthopaedics at Rutgers University Robert Wood Johnson Medical School.

Address correspondence to James Monica, MD, University Orthopaedic Associates, 2 World's Fair Dr., Somerset, NJ 08873 (e-mail: jamiemonica@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliation.

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