Table of contents
- 1. Shoulder Overview
- 2. Shoulder Fractures
- 2.1. Proximal Humerus Fractures
- 2.1.1. Surgical Neck Fracture
- 2.1.2. Anatomic Neck Fractures
- 2.1.3. Greater Tuberosity Fractures
- 2.1.4. Lesser Tuberosity Fractures
- 2.1.5. Three/Four part fractures
- 2.1.6. Articular Surface Fractures
- 2.1. Proximal Humerus Fractures
- 3. Clavicle Fractures
- 4. AC Dislocation
- 5. Sternoclavicular Dislocation
- 6. Scapular Fractures
- 7. Shoulder Dislocations
- 8. Impingement Syndrome
- 9. Supraspinatus Tendonitis + Subacromial Bursitis
- 10. Rotator Cuff Tears
- 11. Bicipital Tendonitis
- 12. Bicipital Tendon Dislocation
- 13. Frozen Shoulder - Adhesive Capsulitis
- 14. Cervical Disease
- 15. Other
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Shoulder Overview
- 4 Bursae
- Imaging:
- AP view
- "True" AP view (Grashey view) [beam is 45° in medial to lateral direction - see subtle joint incongruity]
- Scapular Y view (body, spine, and coracoid process of scapula)
- Axillary view
- NOTE: often seen "fat fluid level" on AP often indicative of articular surface fracture. Often see pseudosubluxation of humeral head due to the secondary hemarthrosis.
- Attachments (important)
- Rotator cuff:
- Greater tuberosity: supraspinatus, infraspinatus, teres minor
- Lesser tuberosity: subscapularis (avulses lesser tuberosity)
- Rotator cuff:
Shoulder Fractures
Proximal Humerus Fractures
- commonly in elderly
- Attachments to greater tuberosity tend to pull fragments in superior direction (supraspinatus, infraspinatus, teres minor)
- Fracture classification developed by Neer:
- 1. Humeral Head
- 2. Humeral Shaft
- 3. Greater Tuberosity
- 4. Lesser Tuberosity
- Displacement defined as: 1cm displacement or 45° angulation to the remaining humerus.
- Each fragment that is "displaced" as per above definition... characterized as
- Classification:
- Important for prognostic and theraputic purposes
- If one-part fracture: usually sling
- Two/three/four part fractures
- Require reduction, could be unstable after.
- Three/Four part fractures associated with dislocation.
- May require prosthesis if significant fracture
- Fracture through articular surface not included in Neers classification - treated differently
-
Successful treatment of proximal humeral fractures is dependent on early mobility. A compromise in anatomic reduction may be accepted as long as prolongued mobilization is avoided. -
Surgical neck fractures usually present adducted. A patient who presents with surgical neck fracture with arm abducted. Must immobilize in same position before radiographs. Adducting can cause neurovascular damage. -
Surgical Neck Fracture
-
- Ensure angle btwn humeral head and shaft is 135°. If <90 or >135 needs reduction depending on age.
- Neurovascular compromise and axillary nerve damage COMMON. Esp if comminuted.
- Treatment depends on parts:
- One-part fracture:
- Sling
- Ice, elevate, analgesics.
- Circumduction exercises as soon as tolerated (see figure - circles, sideways pendulum etc.) followed by elbow and shoulder passive exercises at 2-3 weeks.
- Two-part
- Complications
- Joint stiffness (avoid by early mobilization)
- Malunion
- Myositis ossificans.
-
Anatomic Neck Fractures
-
Rare, more common in kids.
-
High complication of avascular necrosis - consult ortho
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Greater Tuberosity Fractures
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Upward displacement common due to rotator cuff attachment (supra, infra, teres minor)
-
Exception to Neers: only 0.5cm displacement enough for operative management.
-
Neurovascular injuries uncommon
-
Often anterior shoudler dislocations, and rotator cuff tears.
-
Tx:
-
Nondisplaced: Ice, analgesics, sling, early referral (high incidence of complications
-
Displaced (>0.5cm):
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If dislocated, then reduce (often corrects displacement). Then manage as nondisplaced.
-
If displacement remains or non-dislocated:
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Young: internal fixation + rotator cuff repair.
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Elderly: ice, immobilization with sling. EARLY MOBILIZATION is key.
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-
-
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Complications:
-
Often impingement (long head of biceps) = chronic tenosynovitis.
-
Nonunion
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Myositis ossificans.
-
-
-
Lesser Tuberosity Fractures
-
Uncommon, often with posterior shoulder dislocations.
-
Usually intense contraction of subscab avulses lesser tuberosity
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Neurovascular injuries rare, associated with surgical neck fractures, often posterior dislocations.
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Tx:
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Ice, analgesics, sling immobilization, ortho consult.
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If nondisplaced: treat non-operatively
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If two-part (>1cm displaced): require surgical repair.
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-
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Three/Four part fractures
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Often intense trauma (fall on arm)
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Tx: ice, analgesics, sling, emergent referral + admission.
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All require surgery (four-part require prosthesis)
High risk of neurovascular injury and avascular necrosis
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Articular Surface Fractures
- Generally "impression fracture" (Humeral head compressed and "impression" made on surface)
- <40% of articular involvement: immobilize in ext. rotation.
- >40% - surgical repair or insertion of prosthesis
- comminuted - surgical repair or insertion of prosthesis.
Clavicle Fractures
- Most common broken bone:
- Middle third: 80% (most force, associated with thoracic injury, subclavian injury, and brachial plexus)
- Lateral third: 15%
- Medial third: 5%
- Proximal fragment often pulled superiorly due to sternocleidomastoid attachment.
- Beware of subclavian and brachial plexus injuries (lie underneath).
- Mechanism:
- Direct blow (if inferior force: usually neurovascular compromise and comminuted)
- Blow from above (lateral third fracture)
- Fall on lateral shoulder (force transmitted - middle third fracture)
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- All displaced lateral-third clavicular fractures are associated with coracoclavicular ligament rupture and should be treated similar to a AC joint dislocation.
- Direct blow (if inferior force: usually neurovascular compromise and comminuted)
- Treatment
- In general:
- ice,
- analgesics,
- sling (unless non-displaced lateral third - already splinted by surrounding structures)
- Early Motion if non-displaced. (esp with articular to prevent degen arthritis)
- Ortho Referral (if displaced, b/c non-union high, and complications)
- Middle Third
- Non-displaced: Sling + ice (intact periosteum). Adults 6 weeks of immobilization, kids 3-5weeks.
- Repeat radiographs in 1 week.
- Displaced:
- Closed reduction do not improve outcomes.
- Immobilize with sling.
- figure-of-eight strap can be used. Placed behind patient, pulls shoulders back allows use of both hands such as typing, but uncomfortable and does not improve outcome).
- Ortho referral if completely displaced. (15-20% non-union is high)
- Non-displaced: Sling + ice (intact periosteum). Adults 6 weeks of immobilization, kids 3-5weeks.
- Lateral-Third
- Non-displaced: Ice, analgesics, early motion. No sling b/c already splinted by surrounding ligaments and muscles.
- Displaced: ice, analgesics, SLING, ORTHO REFERRAL
- Articular Surface: Ice, analgesics, sling for support. Early motion required to prevent degenerative arthritis.
- Medial-Third
- Non-displaced: Ice, analgesics, sling for support
- Displaced: same, but require ortho referral
- In general:
Fracture | Type | ice, analgesics | Sling | Ortho Referral |
---|---|---|---|---|
Medial Third | Non- Displaced | + | + (6 weeks) | - |
Displaced | + | + (or strap) | + if complete displaced | |
Lateral Third | Non-Displaced | + | - (early motion) | - |
Displaced | + | + | + | |
Articular # | + | + (++ early motion!) | - | |
Medial Third | Non-Displaced | + | + | - |
Displaced | + | + | + |
- Complications:
- Malunion (primary in adult, uncommon in kids due to extensive remodeling).
- Excessive callus (cosmetic defect)
- Nonunion
- Delayed union (esp lateral third)
- Degenerative arthritis (if articular fractures).
AC Dislocation
- Types:
- 1st Degree: Sprain of AC ligament and incomplete tear.
- 2nd Degree: Subluxation of AC joint, disruption of AC ligament. However coracoclavicular CC ligament is intact.
- 3rd Degree: Disruption of both AC and CC ligaments. (usually superior displacement)
- Type 4: clavicle displaced posteriourly through trapezius muscle.
- Type 5: displaced into neck.
- Type 6: I don't even know...
- Mechanism:
- Direct force on shoulder/arm or force from above on acromion.
- Xray Measurements:
- 1. AC joint width <3mm
- 2. Clavicle-Coracoid CC distance <5mm
- 3. Clavicle elevation (superior displacement compared to acromion)
- First degree: normal radiographs
- Second degree: subtle, AC joint width ≥3mm or 50% increase compared to other side). CC distance normal <5mm.
- Third degree: inferior border of distal clavicle is above midpoint of acromion. CC ≥5mm compared to other side.
- Can do stress views by hanging weight off arm to distinguish 2nd and 3rd, but not really done anymore.
- Treatment:
- 1st degree: rest, ice, sling, early ROM
- 2nd degree: same as 1st, but keep sling for 2 weeks (or until sx resolve) and no heavy lifting for 3 weeks. (otherwise conver to 3rd degree)
- early ROM is key to prevent adhesive capsulitis.
- 3rd degree: same as others, but early referral.
- Operative tx controversial (maybe in heavy labourers and younger pts). Surgery can cause impingement or neurovascular compromise. Based on degree of displacement (>2cm = treat?)
- Complications
- Pain syndromes due to degenerative joint disease are common (8-42%). Some people have clavicle resections due to pain syndromes.
Sternoclavicular Dislocation
- Two ligaments:
- Sternoclavicular
- Costoclavicular
- Joint moves if arm elevated past 110 degrees
- Dislocations can be anterior (more common) or posterior
- Mechanism:
- Huge force that thrusts shoulder forward. (MVA or sports)
- On Exam:
- Tenderness over joint
- Mild sprain: Pain by elevating arm above 110 degrees.
- Complete tear: Pain with any shoulder motion.
- On inspection: obvious deformity.
- Complications
- Anterior dislocations rarely have complications
- Posterior dislocations (25% complication rate):
- Tracheal compression (SOB)
- Tracheal rupture
- Pneumothorax
- Venous congestion (subclavian vein)
- Esophageal compression (dysphagia)
- Treatment
- Mild: ice 3-4x/day, sling for 3-4 days.
- Moderate: figure-of-eight clavicle strap and a sling (to keep clavicle in normal position to allow ligament healing)
- Continue strap + sling for 6 weeks, and advise that problems may develop that require surgery.
- Reductions:
- Patient supine, folded sheet between shoulders.
- Abduct arm, and apply traction + push anterior clavicle back into position or grab posterior clavicle and move forward.
- Posterior dislocations are difficult, often need sedation and use of towel clip to grab the clavicle.
- Place compression bandage over clavicle to prevent recurrence.
- Notes:
- If reduced: keep figure-of-eight sling for 6 weeks, and protected motion x2 weeks.
- Anterior dislocations are unstable, and can dislocate. No benefit from surgery.
Scapular Fractures
- Overview:
- Triceps inserts on inferior rim of glenoid (can displace)
- Short head of biceps, coracobrachialis, and pectoralis minor insert on coracoid process.
- Need ORIF if scapula and clavicle injured together.
- Types of fractures:
- Body or spine fractures
- Direct blow (little displacement)
- R/O thoracic aortic injury (1%), pneumothorax etc..
- Tx: sling, ice, analgesics, refer if displaced or functional impairment (ORIF)
- Acromion fractures
- Direct blow
- Nondisplaced: sling, early ROM exercises (to avoid restricted ROM)
- Displaced: ortho referral, b/c often compromises ROM.
- R/O brachial plexus injuries, AC join injuries. Often bursitis.
- Glenoid Neck fractures
- Uncommon
- Often with humerus #
- non-displaced: sling, ice, analgesics. Passive ROM at 48hrs as tolerated.
- Displaced: require surgery (If >40° angulation, and 1-2cm displacement) High malunion incidence.
- Glenoid rim fractures (glenoid rim with dislocations)
- Often with dislocation
- Rim: ortho referral. Will operate if >25% of glenoid surface or more than 5mm steop-off.
- Comminuted articular: ice, sling, analgesics, surgery.
- Coracoid process fractures
- Muscles: short head of biceps, coracobriachialis, pectoralis minor.
- Ligaments: coracoacromial, coracoclavicular, coracohumeral.
- Usually direct blow or violent contraction
- Tx: symptomatic: ice, sling, analgesics, early ROM as tolerated.
- R/O: clavicular #, AC injury, brachial plexus injury.
- Body or spine fractures
Shoulder Dislocations
- Anterior (95%) vs posterior (5%)
- 50% of all dislocations
- 25% of time there are concominant fractures.
- Xray views:
- Three types of anterior dislocations: (depending on where head of humerus ends up)
- Mechanism:
- Abduction and external rotation.
- Subglenoid: often hyper-abduction
- Subcoracoid: often hyper-ext rotation.
- On exam:
- Acromion prominent in absence of humeral head.
- Axillary nerve injury common! (12%) [abduction is best test, sensation unreliable]
- Absence of humeral head in the glenoid fossa.
- Associated injuries:
- R/O Hill-Sachs fracture where the soft base of the humeral head impacts against anteroir glenoid. (40% of anterior dislocations). Can see internal rotation views post-reduction
- R/O Bankart lesion - fracture of anterior glenoid rim. (can be soft-tissue if labral fracture)
- ALWAYS CHECK TEARS (good outcome if treated early). in 50% of young pts and 80% old.
- Rotator cuff tear: ask to abduct (can be either tear or axillary nerve injury)
- Biceps tendon tear.
- Treatment:
- Analgesia is key. Pt must relax muscles.
- Can do procedural sedation (i.e. fentanyl + prophofol)
- If contraindicated: intraarticular injection 20mL of 1% lidocaine using 20G needle. Inject 1cm inferior to lateral edge of acromion. Direct needle medial+inferior to depth of 2.5-3cm
- Intra-articular analgesia is better if presents 6h post-dislocation
- Reduction:
- Scapular Manipulation (simple, 80-100% success)
- pt lies prone on table with affected arm hanging down with 5-10lb weight. (similar to Stimson). Physician rotates scapula with tip medial and spine lateral.
- External Rotation: (80-90% success, and 81% w/o analgesia)
- Adduct arm (elbow to torso), and externally rotate.
- External rotation overcomes internal rotator spasm and unwind join capsule. allowing external rotators to pull humerus in position. Can allow shoulder muscles reduce dislocation with no analgesia.
- If discomfort during ext rotation, wait, allow muscles to relax and proceed slowly.
- Milch Technique (86-100%)
- Abduction (elevation), and if it does not do it alone, can elevate humeral head direct into glenoid.
- Spaso Technique
- Gentle vertical traction and external rotation.
- Stimson (70-90%)
- patient prone with affected arm hanging down off the table. 10-15lb weight applied to hand for 20-30min.
- Hard to sedate, can use intra-articular lidocaine.
- Traction-countertraction
- Use sheet to pull under affected axilla, and person #2 pulls on arm in opposite direction.
- if fails, can use a third sheet and pull humerus (from under axilla) up towards head. BE CAREFUL...slow traction, otherwise can fracture glenoid rim.
- Scapular Manipulation (simple, 80-100% success)
- Reduced?
- Fullness under acromion.
- Can put hand on opposite shoulder.
- After reduction
- Put pt in sling (adduction + int. rotation).
- In young pts <30yo: 3 weeks of immobilization.
- In older pts >30yo: immobilize 7-10 days + circumduction (Codman) exercises 4-5 days post-injury.
- All exercise within pain-free ROM.
- Caution against abduction and ext rotation.
- After 2months: strengthen internal rotator (subscapularis) to prevent re-dislocation. Can also do some ext. rotators to help further stabilize.
- Warn 60% recurrence,
- Put pt in sling (adduction + int. rotation).
- Surgery if:
- # of greater tuberosity >5mm displacement
- Glenoid rim (Bankard) # w/ >5mm
- Recurrent: >3 dislocations (90% Bankart lesions).
- Anterior glenohumeral instability: if subluxation on ant. apprehension test.
- Analgesia is key. Pt must relax muscles.
- Posterior Dislocation:
- Uncommon, but missed up to 60-70% of time
- Suspect if Block of ext. rotation, and limitation of abduction. (~100% sensitivity)
- Radiology:
- Rim sign - Superimposition of medial humeral head and ant. glenoid rim. (not in socket but superimposed posteriorly)
- Light bulb sign - interally rotated humerus
- Trough line sign: Reverse hill-sachs lesion (impaction site)
- NOTE; Isolated fracture of lesser tuberosity = post dislocation until proven otherwise
- Consult ortho for reduction. Surgery if significant lesser tub. fracture.
- Inferior Dislocation (aka Luxatio erecta) - arm abducted.
- Uncommon
- Hyperabduction injury, cannot abduct.
- Always detachment + tear of rotator cuff (inferior).
Impingement Syndrome
- Compression ofrotator cuff tendons as they pass between the acromion, rigid coracoacromial ligament and humerus.
- Acutely: inflammation, edema, hemorrhage
- Chronic: fibrosis, tendonitis, eventually tearing of rotator tendons.
- Supraspinatus most common: b/c close to coracoacromial arch and poor blood supply.
- Worse if bad posture: shoulders anterior, closes the subacromial space.
- Mechanism:
- Commonly: athletes with overhead motion (tennis, swimming, etc.), also whiplash injury.
- Others: hooked acromion, osteophyte formation, subacromial bursal fibrosis, and coracoacromial ligament thickening.
- Fibrosing tendon thickens, calcifies, can cause overlying subacromial bursitis, = worsening impingement.
- History:
- Pain referred to lateral aspect of joint, worse at night,
- Worse with overhead activities (abduction = outlet narrows)
- Painful arch: 60-120° abduction = acromial pathology. NOTE: If pain increases >120° abduction = AC disorder.
- Exam:
- Worse when shoulder in fwd flexion and int. rotation, and better w ext. rot. (Hawkin sign)
- Worse when passive fwd flexion of pronated arm to 180° (Neer sign).
- Diagnose:
- High resolution U/S
- MRI
- steroid or lidocaine injection = immediate relief. (needle under acromion into coracoacromial ligament).
- Treatment: (stabilize and balance shoulder and improve posture. )
- Strengthen back muscles (esp trap, rhoboids) b/c helps pull shoudlers back = better posture, open the subacromial space = less impingement.
- strengthen pectoralis muscles (these are int. rotators), evidence shows may be even more important than back muscles.
Supraspinatus Tendonitis + Subacromial Bursitis
- Supraspinatus tendon passes under acromion and coracoacromial arch in close proximity to the subacromion bursa (separates supraspinatus tendon and deltoid)
- Tendonitis can occur in any rotator cuff tendons, but most common in supraspinatus.
- Tendon gets injured (overuse, impingement, bad posture etc..), fibroses, calcifies, = worseining impingement.
- Inflammation in supraspin. tendon can cause inflammation of subacromial bursa.
- Inability to abduct >30deg --> chronic bursitis ---> eventually adhesive pericapsulitis or bursitis.
- Pain can radiate down entire limb.
- Point tenderness at "critical point" btwn acromion and greater tuberosity.
- Treatment:
- Avoid inciting activity
- NSAIDs, ice prevent pain/inflam/atrophy.
- ROM exercises: Codman (circumduction).
- NEVER IMMOBILIZE SHOULDER (if eldelry = adhesive capsulitis)
- Steroid/anesthetic injections. (move needle back/forth along tendon sheat for max analgesia).
- Methylprednisolone (40mg, 1mL) and bupivicaine (5-10mL) effective.
Rotator Cuff Tears
- Common with advancing age. Many asymptomatic (25%), many undetected (28% in >60yo).
- Any part of rotator cuff can be distrupted, but most common at supraspin. tendon.
- impingement --> chronic tears, intrinsic degeneration, overuse, overload.
- >30% tear required to produce decr in strength.
- No correlation btwn pain/disability and size of tear.
- full tear = cannot initiate abduction.
- Drop arm test - abduct arms to 90°, and examiner pushes down. If drops = positive = significant tear.
- Physical exam poorly predictive of degree of tear.
- Radiology:
- Cuff view: degenerative changes (erosion, periosteal reaction of greater tuberosity)
- MRI: 100% sensitivity and 95% spec.
- High-Res Ultrasound: also high sensitivity/spec (comparable to MRI)
- Treatment:
- Conservative (good outcome in 50%)
- Passive ROM important to decr stiffness.
- Initially Rest, Ice, NSAID.
- Surgery if:
- If young + complete tear (arthroscopic repair 90% good results).
- In study: moderate tears better for arthroscopic repair, massive tears better with open repair.
- Anterior tear is better candidate
- NO SURGERY if elderly, and sedentary.
- If young + complete tear (arthroscopic repair 90% good results).
- Conservative (good outcome in 50%)
Bicipital Tendonitis
- Long head of biceps passes within bicipital groove and inserts into glenoid rim. (constant trauma and irritation).
- History
- Pain in biceps region, and anterior shoulder radiates down forearm.
- Abduction and external rotation are most painful (compared to abd + int rot in supraspin tendonitis)
- On Exam:
- Tenderness in bicipital groove
- Yergason Test: Eblow at 90° flexion, resist patient supanation. Positive if pain in intertubercular groove.
- Treatment:
- Immobilize with sling, NSAIDs.
- Injection of bicipital canal. (see pictures on web). do not inject tendon, inject along the tendon sliding needle.
Bicipital Tendon Dislocation
- Tendon subluxates and dislocates out of groove between greater and lesser tuberosities.
- Congenital shallow bicipital groove = predisposes to this.
- Sharp, acute pain in anterior shoulder. Tendon can slip back and fourth
- Do Yergason Test (See Bicipital Tendonitis)
- Any supanation against resitance will move tendon in/out of groove =-> pain.
- Tx:
- Operative: anchor tendon to bone (Tenodesis) and release (tenotomy) are possibilities.
Frozen Shoulder - Adhesive Capsulitis
- Usually pts >40yo, onset can be insidious.
- history
- Pain in anterolateral aspect of shoulder. rad to arm.
- Worse at night, severe, interferes w sleep.
- RF's: diaetes, trauma, hypertriglyceridemia, and thyroid disease.
- Mechanism:
- Unclear. Calcific tendonitis of rotator cuff and bicipital tendon complexes implicated.
- Treatment:
- Physical therapy - intense, start with ROM in painless arc.
- NSAIDs
- Steroid injections - need multiple, helps ROM exercises.
- Surgery (remove calcific parts, or arthroscopically punch through calcific areas)
Cervical Disease
- Presents with shoulder pain, typically pain radiates down arm past elbow.
- Exacerbated by neck movements (esp rotation + extension on affected side).
Other
Long Thoracid Nerve Palsy (Winged Scapula)
- Injured due to length and superficial course.
- Paralyzes ant. serratus muscle.
- On exam: prominence of inferior and medial border of scapula "Winged Scapula"
- Mech:
- Overuse, improper using of crutches, trauma, idiopathic.
- Treatment:
- Conservative (analgesics, physio)
- Recovery long - 12-18mo
- Surgery if do not recover.
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