The system of shoulder examination described in this chapter is as follows: Stand the patient and look, then feel, then move. Following this, examine the rotator cuff, perform impingement tests, then instability tests. In this chapter, examination of the acromioclavicular joint and examination of other muscles around the shoulder girdle such as pectoralis major are described. At the end of the chapter, in the ‘Advanced Corner’, other special tests are also described such as the bear-hug test for subscapularis tears and the upper cut test for biceps tendinitis.

The structured oral (viva) examinations are the second component of Section 2 of the Intercollegiate examinations, usually occurring over a two-day period after the clinical section, but for any individual candidate the four vivas will occur on the same day. It is perhaps worth putting the vivas into context: between them the vivas contribute 48 of the 96 marking episodes in Section 2. The clinicals (intermediate and short cases) together make up the other 48 episodes, but in general it is more common for a poor mark in the vivas to be compensated for by a good mark in the clinicals than vice versa. Employing the training principles of a heptathlete, effort may be better spent on the weaker disciplines than becoming better at one’s strengths.

Indications

• The indications for fixation of scapular fractures are not clearly defined. The literature is scant, outcome scores are variably used, and evidence-based choices are difficult. This is in large part due to the rarity of the injuries, as the scapula is well protected and supported by the rotator cuff muscles and other muscular attachments. Furthermore, these fractures most commonly occur in high-energy accidents and are therefore frequently associated with multiple injuries, particularly chest trauma, which may mitigate against intervention for a fracture that often gives few problems when managed non-operatively.

• There is some consensus that displaced fractures involving the glenoid fossa should be considered for fixation if they are associated with shoulder instability or if there is an articular step of 5 mm or more.

• The majority of fractures associated with instability are marginal fractures of the anteroinferior glenoid – bony Bankart lesions – which can be approached in the same way as soft tissue Bankart lesions, though usually fixation involves lag screws rather than soft tissue anchors. These injuries will not be considered further here.

• There is also consensus that combinations of injuries affecting the suspensory mechanism of the shoulder should be managed operatively, and one common pattern of these is a displaced fracture of the glenoid neck associated with a clavicle fracture (Fig. 2.1.1). However some argue that this ‘floating shoulder’ can be managed simply by plating the clavicle without addressing the glenoid neck. This remains one of the commoner indications for scapular surgery.

• Theoretically, medial displacement of the glenoid should defunction the rotator cuff, and it could be argued that these injuries should be treated to restore scapular width and cuff function. However, care should be taken to ensure that lateral displacement of the lateral column of the scapula, which is common, is not mistaken for medial displacement of the glenoid, which is rare.

Introduction

The practicalities of surgical management of proximal humeral fractures are common to the various injuries treated. A generic description of the investigations required and the practical set-up of the operating room will therefore be presented before discussing specific injuries.

Radiological assessment

• It is essential that all shoulder fractures be assessed with a minimum of two shoulder views – anteroposterior and axial views.

• A scapular lateral completes the trauma series but is not always essential.

• The axial view can be obtained successfully in most cases. In the rare instances where the patient will not permit sufficient movement of the injured limb away from the side, angled views (modified axial) should be obtained. Never miss a dislocation (too many are missed, and most of these have not had an axial view taken).

• In complex cases a CT scan might assist, particularly in assessing whether the humeral head is intact and has any tuberosity attachments remaining. A humeral head fragment with an attached tuberosity is much less likely to suffer avascular necrosis than one with no remaining tuberosity attachments. 3D CT is particularly useful for assessing glenoid fossa fractures.

Introduction

There is rarely a need to carry out a comprehensive examination of the shoulder including all of the tests described in this chapter. Described below are the elements that can be used to differentiate between possible diagnoses suggested by the clinical presentation. To be successful clinically and to demonstrate competence in professional examinations, interpretation of the available history is combined with an appropriately directed examination of the shoulder. Each test answers a specific question about the state and function of the components of the shoulder or the structures that enable it to work effectively. Pieced together, the clinical examination narrows down the differential diagnosis and may direct one to supplementary investigations that prove a diagnosis. Alternatively, the clinical examination may reassure that treatment can proceed without further expensive tests, pending review to confirm the expected progress. No description of clinical examination of the shoulder can therefore be complete without mention of the history that should be elicited, as this is primarily responsible for focusing the examination to those components that move one efficiently towards the correct diagnosis.

History

Patients often present with shoulders that are painful, unstable and/or stiff. Even basic demographic details are helpful, and it is important to document these for medicolegal reasons. Age, handedness and occupation should be noted. Although an open mind should be kept at all times, instability tends to dominate in the younger age group, impingement symptoms in middle age and rotator cuff tears and arthritis in the older group.

GENERAL CONSIDERATIONS

The practicalities of surgical management of proximal humeral fractures are common to the various injuries treated. A generic description of the investigations required and practical set-up of the operating room will therefore be presented before discussing specific injuries.

Radiological assessment

• It is essential that all shoulder fractures be assessed with a minimum of two shoulder views – the anteroposterior (AP) and axial views.

• A scapular lateral completes the trauma series but is not always essential.

• The axial view can be obtained successfully in most cases – in the rare instances where the patient will not permit sufficient movement of the injured limb away from the side, angled views (modified axial) should be obtained. Never miss a dislocation (too many are missed, and most of these have not had an axial view taken).

• In complex cases a CT scan might assist, particularly in assessing whether the humeral head is intact and has anytuberosityattachmentsremaining.Ahumeralhead fragmentwithanattached tuberosity ismuchless likely to suffer avascular necrosis thanonewithnoremaining tuberosity attachments. Three-dimensional CT is particularly useful for assessing glenoid fossa fractures.

Anaesthesia

• General anaesthesia or scalene blocks can be used. Even if general anaesthesia is selected, a scalene block can add useful analgesia.

• The risk of phrenic nerve palsy and pneumothorax should be considered if a scalene block is to be used, particularly if there is already chest trauma (which not infrequently accompanies shoulder trauma).

• Great care has to be taken to avoid interference with anaesthetic tubes and pipes by the surgeon or assistant in general anaesthetic cases.