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ERcast Lite

Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Jan 26, 2013

Humerus fractures, shoulder dislocations, broken clavicles, shoulder separations and then some. We cover all the bases of acute shoulder injuries with sports medicine orthopedist Dr. Brett Andres. It's also ERcast's third anniversary, so raise a toast and thanks for listening.

Links mentioned in the podcast introduction

Splint Like a Pro

Cunningham technique for shoulder reduction

Broomedocs podcast on suicide risk assessment

Whit Fisher's frozen NG tube insertion technique

T-ring finger tourniquet


Which proximal humerus fractures need surgical repair?

There is no definite answer to this. New fixation technology gives results that were not possible a few years ago, so more and more of these are getting surgically managed. The main questions are whether or not the humeral head is still on top of the humerus and if the head articulates with the glenoid. I think of this in terms of an ice cream cone, with the humeral shaft the cone and the humeral head the ice cream. If the ice cream is still on the cone, it will probably heal OK. If the ice cream has fallen off the cone, that may benefit from surgical repair.

Ice cream still on the cone
Ice cream has fallen off the cone

A split humeral head will have a poor outcome with chronic arthitis- may benefit from surgery

Displaced greater and lesser tuberosity fractures may look benign, but those are the attachment sites  of the rotator cuff. May benefit from surgery.

Greater tuberosity fracture (minimally displaced)

Shoulder dislocations: How long to splint after reduction

Young patients, under 20, have a high re-dislocation rate (as high as 70%). Three weeks immobilization.

Age 20-45 will probably not dislocate again, but stiffness is a problem. Sling after reduction, but begin ROM when pain improves.

Older patients, 60 or greater, are unlikely to re-dislocate but have a higher incidence of rotator cuff repair. They probably don't need prolonged immobilization, but do need follow-up to evaluate for rotator cuff injury.

Clavicle fractures: Which need surgery?

There is a high non-union rate for displaced fractures (no cortical contact).

Brett considers surgery if there is : no cortical contact, overriding 2cm, butterfly type fracture.

How should we immobilize clavicle fractures?

A sling should be sufficient. Some patients like the figure of eight, but it can rest on the fracture fragment and be irritating. A sling for a clavicle fracture is not like a cast- it doesn't help with healing. Begin early ROM when the patient can tolerate.

Calcific tendonitis

Although a chronic problem, can cause acute intense pain. Calcium breaks loose and gets into the subacromial space, causing irritation. A patient can have so much pain that examination is difficult. A subacromial bursa injection may help to relieve symptoms.

Calcific tendonitis

Subacromial bursa injection (courtesy of Larry Mellick, MD)