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Early Shoulder Management

 

The management of shoulder injuries and pathologies is a big part of the caseload of orthopaedic surgeons and musculoskeletal physiotherapists. The shoulder has a long list of injuries, conditions and operations associated with it. As a significantly unstable joint with the most joint mobility of any bodily joint, it is at risk in many cases to repetitive stresses and injuries. Due to its instability it is more likely to dislocate in a fall or if overstressed at the end of its range. In repeated overhead or heavy work rotator cuff tears can develop and if the arm is used to protect the body in a fall fractures of the upper humerus can occur.

The precise diagnosis of the condition and a clear agreed treatment plan are essential in shoulder conditions as there is a very large number of different fractures, operations and injuries to the shoulder complex. Post-trauma and post-operative shoulder conditions are part of the core work of orthopaedic physiotherapists and they follow the agreed trauma and elective surgery protocols, referring patients for further treatment once they are discharged. Going over the case quickly from the beginning once we meet the patient is useful as this can throw up errors and missing facts which need addressing. Patients also appreciate an opportunity to tell their story.

After operation or injury the weight of the arm hanging from the shoulder may need to be supported in a sling to reduce pain and allow damaged tissues to rest. The broad arm, triangular bandages are cheap but not comfortable around the neck and difficult to customise to the patient's specific needs. Putting some foam round the strap at the neck may help slightly but a better solution is to use a Velcro based sling such as the Seton sling. Seton slings are greatly preferred by patients, are more comfortable and are easier to adjust to the specific requirements of the shoulder condition.

Fitting of the Seton sling is not difficult but needs a few pieces of special attention to get the best out of it for the patient's comfort. The arm gutter is the main part of the splint and the forearm should be placed as far back in it as possible with the cuff areas turned back so that the hand is free. The forearm gutter can be closed by the small Velcro strap but this should be done lightly to avoid cutting into the swelling in the arm which can occur with fractured upper humerus. Lastly the tightening up of the main support strap is slightly trickier if good elbow and shoulder support is to be achieved.

The Velcro straps are slightly elastic and also hold against clothing or skin by friction, making them less likely to slide when adjusted. Once the sling has been put on and the strap tightened it is very likely that the elbow is not being supported by the gutter. This can be checked by feeling under the elbow to see if the sling is taking the weight. Further tightening of the strap at the front just results in more tension in the strap and not more support for the elbow and thereby the shoulder.

Two people are needed to adjust the sling in co-operation, a helper and the patient. The patient is asked to relax the arm as much as they can while the helper lifts the weight of the arm at the elbow, holding it there as they pull the strap from its attachment at the back of the gutter up and over the shoulder, then fixing it there with one hand. Continuing to hold onto the strap which has been pulled forwards the helper unstraps the Velcro fastening of the main strap and tightens it up. Checking the support of the elbow now will show it to be much better supported.

Sling management advice is useful for washing and dressing, for which the sling can come off. Putting clothes on should be using the affected arm first and the arm needs to be kept in by the body during the process with no active lifting of the shoulder. For washing if the patient keeps the arm bent by the tummy and bends forward they can get access to wash their armpit easily.


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