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.

Due to the very large number of potential injuries, fractures and operations which can affect the shoulder it is very important to know the exact diagnosis and plan of treatment. Physiotherapists specialise in managing post-operative and post-trauma shoulder problems, following the surgical and trauma protocols agreed with the shoulder surgeons. On meeting the patient initially a good strategy is to review the progress of their case so far, as this can occasionally throw up unexpected anomalies which need exploring. The patient should have a short time to tell their story or they may not feel they have been heard.

The first consideration is supporting the shoulder to give it some rest or to achieve a particular anatomical goal. Broad arm slings are uncomfortable, difficult to fit (for me anyhow) and awkward to adjust to the patient’s requirements. If one is used it will pull on the neck with the narrow part of the sling and the knot, causing discomfort which can be only partly alleviated by applying some foam padding. A better solution is to use one of the more complex but much more comfortable and adjustable slings such as the Seton sling, a Velcro based sling which patients get on very well with.

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.

General advice to patients about sling management should be given to cope with daily activities, the sling only being off for dressing and washing. To wash the armpit the patient should hold their arm in a position as if the sling was on and then bend forward, allowing the arm to bend forward with gravity. To put clothes on the affected arm should be placed on first and with no significant movement of the arm involved.