The Relationship between Clinical Findings of Shoulder Joint with Bone Damage of Shoulder Joint in Patients with Isolated Shoulder Blunt Trauma


Zamani, A.; Sharifi, M.Davood.; Farzaneh, R.; Disfani, H.Feiz.; Kakhki, B.Rezvani.; Hashemian, A.Masoud.

Macedonian Journal of Medical Sciences 6(11): 2101-2106

2018


Due to the prevalence of shoulder injuries among athletes and other people and the prevalence of radiography for these injuries, there are still no valid criteria for indication of doing shoulder radiography. This study aimed to examine the relationship between some signs and clinical examinations of the shoulder with shoulder bone injuries and the need for radiography. This is a cross-sectional study. All patients aged 18-70 years who referred to the emergency ward of Imam Reza and Hasheminejad Hospital in the year 2014 due to blunt trauma and had criteria for entering the study and lacking exclusion criteria were included in the study process. Data on clinical symptoms, radiographic results, and final diagnosis were extracted from the patients' records through a questionnaire and analysed statistically. There was a significant relationship between the clinical signs of patients Existence of ecchymosis in the shoulder fractures with glenoid and humerus fractures (p = 0.029, p = 0.004 respectively). There was also a significant relationship between clavicle fracture and limitation in shoulder rotation and abduction (p = 0.000 and p = 0.001 respectively). Other clinical symptoms did not show any significant relationship with radiographs indicative of the problem requiring specific treatment. Although it is possible to define critters based on clinical symptoms that reduce the need for unnecessary radiographs that the does not reliably help inpatient treatment, but finding these critters to indicate the performance of the graphs in shoulder injuries requires further studies with the higher population and more clinical variables.

ID
Design
Press,
Skopje,
Republic
of
Macedonia
Open
Access
Macedonian
Journal
of
Medical
Sciences.
2018
Nov
25;
6(11):2101-2106.
https://doi.org/10.3889/oamjms.2018.478
eISSN:
1857-9655
Clinical
Science
ID
Design
Press
The
Relationship
between
Clinical
Findings
of
Shoulder
Joint
with
Bone
Damage
of
Shoulder
Joint
in
Patients
with
Isolated
Shoulder
Blunt
Trauma
Amin
Zamani,
Mohammad
Davood
Sharifi,
Roohie
Farzaneh,
Hamideh
Feiz
Disfani,
Behrang
Rezvani
Kakhki,
Amir
Masoud
Hashemian*
Department
of
Emergency
Medicine,
Faculty
of
Medicine,
Mashhad
University
of
Medical
Sciences,
Mashhad,
Iran
Abstract
Citation:
Zamani
A,
Shark)
MD,
Farzaneh
R,
Disfani
HF,
Kakhki
BR,
Hashemian
AM..
The
Relationship
between
Clinical
Findings
of
Shoulder
Joint
with
Bone
Damage
of
Shoulder
Joint
in
Patients
with
Isolated
Shoulder
Blunt
Trauma.
Open
Access
Maced
J
Med
Sci.
2018
Nov
25;
6(11)2101-2106.
https://doLorg/10.3889/oamjms.2018.478
Keywords:
Shoulder,
Radiography;
Blunt
Trauma;
Clinical
Symptoms
*Correspondence:
Amir
Masoud
Hashemian.
Department
of
Emergency
Medicine,
Faculty
of
Medicine,
Mashhad
University
of
Medical
Sciences,
Mashhad,
Iran.
E-mail:
hashemianam@mums.ac.ir
Received:
13-Oct-2018;
Revised:
07-Nov-2018;
Accepted:
08-Nov-2018;
Online
first:
20-Nov-2018
Copyright:
2018
Amin
Zamani,
Mohammad
Davood
Sharifi,
Roohie
Farzaneh,
Hamideh
Feiz
Disfani,
Behrang
Rezvani
Kakhki,
Amir
Masoud
Hashemian.
This
is
an
open-access
article
distributed
under
the
terms
of
the
Creative
Commons
Attribution-NonCommercial
4.0
International
License
(CC
BY-NC
4.0)
Funding:
This
research
did
not
receive
any
financial
support
Competing
Interests:
The
authors
have
declared
that
no
competing
interests
exist
BACKGROUND:
Due
to
the
prevalence
of
shoulder
injuries
among
athletes
and
other
people
and
the
prevalence
of
radiography
for
these
injuries,
there
are
still
no
valid
criteria
for
indication
of
doing
shoulder
radiography.
AIM:
This
study
aimed
to
examine
the
relationship
between
some
signs
and
clinical
examinations
of
the
shoulder
with
shoulder
bone
injuries
and
the
need
for
radiography.
METHODS:
This
is
a
cross-sectional
study.
All
patients
aged
18-70
years
who
referred
to
the
emergency
ward
of
Imam
Reza
and
Hasheminejad
Hospital
in
the
year
2014
due
to
blunt
trauma
and
had
criteria
for
entering
the
study
and
lacking
exclusion
criteria
were
included
in
the
study
process.
Data
on
clinical
symptoms,
radiographic
results,
and
final
diagnosis
were
extracted
from
the
patients'
records
through
a
questionnaire
and
analysed
statistically.
RESULTS:
There
was
a
significant
relationship
between
the
clinical
signs
of
patients
Existence
of
ecchymosis
in
the
shoulder
fractures
with
glenoid
and
humerus
fractures
(p
=
0.029,
p
=
0.004 respectively).
There
was
also
a
significant
relationship
between
clavicle
fracture
and
limitation
in
shoulder
rotation
and
abduction
(p
=
0.000
and
p
=
0.001
respectively).
Other
clinical
symptoms
did
not
show
any
significant
relationship
with
radiographs
indicative
of
the
problem
requiring
specific
treatment.
CONCLUSION:
Although
it
is
possible
to
define
critters
based
on
clinical
symptoms
that
reduce
the
need
for
unnecessary
radiographs
that
the
does
not
reliably
help
inpatient
treatment,
but
finding
these
critters
to
indicate
the
performance
of
the
graphs
in
shoulder
injuries
requires
further
studies
with
the
higher
population
and
more
clinical
variables.
Introduction
The
shoulder
joint
is
a
complex
and
intricate
joint
collection
[1].
This
joint
has
the
greatest
range
of
motion
in
the
joints
of
the
body
and
moves
in
an
area
more
than
one
hemisphere
[2].
In
Emergency
medicine,
we
commonly
encountered
with
shoulder
injuries
[3].
The
statistics
show
that
8-13%
of
all
athletes
injuries
are
related
to
shoulder
and
shoulder
dislocation
accounts
for
50%
of
total
dislocation
in
the
emergency
room
[4].
Damage
to
the
shoulder
can
be
caused
by
a
hit
(direct
or
indirect)
or
excessive
use.
Shoulder
injuries
are
common
in
most
sports
because
almost
every
major
sport
uses
a
shoulder
joint
in
some
way
[5].
Most
shoulder
injuries
are
evaluated
based
on
bone
damage
with
simple
radiography,
and
in
a
few
cases,
CT
scan,
MRI,
or
shoulder
ultrasound
are
needed
[6].
Shoulder
injuries
consist
of
a
large
percentage
of
athlete's
shoulder
injuries,
and
they
are
a
common
cause
for
emergency
attendance
[7].
Timely
diagnosis,
treatment,
and
management
of
these
patients
are
among
the
important
tasks
of
the
emergency
department
[8].
Getting
accurate
biography
and
physical
examination
in
the
first
place
Open
Access
Maced
J
Med
Sci.
2018
Nov
25;
6(11):2101-2106.
2101
Clinical
Science
is
the
most
important
and
most
complete
work
to
be
done,
including
physical
examination
of
the
clavicle,
shoulder,
arm
including
precise
inspection,
touch,
examination
of
active
and
passive
motion
of
the
joint,
neurovascular
evaluation,
muscular
strength
tests
and
diagnostic
tests
[9].
Deformities
due
to
glenohumeral
dislocation,
clavicle
fracture,
acromioclavicular
joint
separation
are
usually
clinically
apparent
[10].
Effusion,
ecchymosis,
and
erythema
should
be
taken
into
account
at
first
glance
[11].
Sternoclavicular
joint,
clavicle,
acromioclavicular
joint
and
proximal
humerus
should
be
investigated
in
line
with
tenderness
[12].
The
lack
of
early
diagnosis
of
shoulder
bone
damage
results
in
undesirable
long-term
outcomes
and,
in
some
cases,
permanent
in
the
shoulder
joint,
some
of
which
include
chronic
dislocation,
degenerative
injuries,
and
major
vascular
injuries
[13].
The
method
for
detecting
the
type
and
extent
of
injury
to
the
shoulder
joint
is
completed
at
first
in
the
clinic,
by
taking
into
account
the
patient's
precise
history
and
physical
examination,
and
it
is
used
in
the
post-imaging
phase
to
help
diagnose
that
the
simplest
of
which
is
standardised
radiographs
of
the
shoulder.
Performing
radiography
involves
spending
time
and
expenses
and
exposing
the
patient
to
radiation
[14].
Also,
researches
have
shown
that
in
many
cases
these
graphs
do
not
show
any
particular
problem
and
are
not
a
guide
to
treatment;
therefore,
researchers
have
always
sought
to
find
criteria
for
the
diagnosis
of
suitable
part
of
the
body
for
the
radiography
of
the
damaged
part
of
the
body.
In
this
regard,
Ottawa
and
Nexus
Critters
have
been
developed
as
criteria
for
knee
and
neck
radiography
in
trauma.
In
this
regard,
due
to
the
prevalence
of
shoulder
injuries
among
athletes
and
other
people
and
the
prevalence
of
radiography
for
these
injuries,
there
is
still
no
valid
indication
for
shoulder
radiography.
Therefore,
in
this
study,
we
aimed
to
investigate
the
relationship
between
some
signs
and
clinical
examinations
of
the
shoulder
with
shoulder
bone
injuries
and
the
need
for
radiography.
Material
and
Methods
This
study
was
a
cross-sectional
study.
All
patients
aged
18-70
years
who
referred
to
Emam
Reza
and
Hasheminejad
Hospitals
due
to
blunt
shoulder
trauma
and
had
criteria
for
entering
the
study
and
did
not
have
exclusion
criteria
were
studied.
On
admission,
the
clinical
criteria
were
evaluated
with
an
initial
examination
including
abduction,
rotation,
and
examination
of
the
localised
tenderness
of
the
acromioclavicular
joint,
clavicle,
humerus,
to
examine
shoulder
joint
ecchymosis.
Then,
the
results
of
the
examination
were
recorded
in
pre-prepared
forms,
followed
by
standard
shoulder
radiography
(three
posterior-anterior,
axillary,
Y-view
views).
Then
the
results
of
the
graphs
were
examined
and
recorded.
Then
the
findings
of
clinical
examination
were
compared
with
radiographic
findings.
Inclusion
criteria:
1.
Patients
with
shoulder
blunt
trauma.
2.
Patients
aged
18-70
years.
Exclusion
criteria:
1.
Previous
history
of
shoulder
bone
injury.
2.
Dissatisfaction
for
participating
in
the
study.
3.
Patients
with
previous
shoulder
deformity.
4.
Patients
with
previous
shoulder
surgery.
5.
Patients
with
inflammatory
and
degenerative
diseases
of
the
shoulder.
Based
on
n
=
z
2
pq/d
2
with
a
confidence
coefficient
of
95%
and
p
=
q
=
0.5,
in
the
most
conservative
mode,
the
sample
size
of
the
sample
can
be
calculated
for
a
high
value
and
finally
100
cases
were
considered.
The
results
after
being
recorded
were
analysed
by
SPSS
software,
MacAdam
test,
and
Kappa
coefficient,
the
agreement
between
clinical
examinations
and
radiographic
findings
was
assessed.
Results
In
this
study,
of
104
patients
referred
to
Emam
Reza
and
Hasheminejad
Hospital
during
the
2014
and
2015
due
to
blunt
shoulder
trauma,
67
were
males
(64%),
and
37
were
female
(34%).
This
number
of
patients
was
divided
by
age
into
four
groups:
in
the
first
group,
that
was
the
age
range
of
18
to
30
years,
59
patients
with
a
frequency
of
56.7%,
in
the
second
group
who
were
between
the
ages
of
31
and
43
years,
20
patients
with
a
frequency
of
19.2%,
in
the
third
group,
in
the
age
range
of
44
to
56
years
old,
14
patients
with
a
frequency
of
13.5%
and
the
fourth
group,
aged
between
57
and
70,
there
were
11
patients
with
a
frequency
of
10.6
%
that
the
highest
frequency
was
in
the
age
group
of
18-30
years
and
the
lowest
was
in
the
age
group
of
57
and
above.
These
104
patients
were
also
categorised
about
damage
in
five
groups:
falling
with
19
participants
(18.3%),
direct
hit
with
29
(27.9%),
pedestrian
and
vehicle
collisions
with
16
(15.4%),
bikers
with
25
(24%)
and
car
drivers
with
15
(14.4%)
In
the
clinical
examination
for
each
patient,
2102
https://www.id-press.eu/mjms/index
Zamani
et
al..
The
Relationship
between
Clinical
Findings
of
Shoulder
Joint
with
Bone
Damage
of
Shoulder
Joint
the
prevalence
of
clinical
signs
before
radiography
showed
that
18
(17.3%)
of
patients
were
affected
by
joint
ecchymosis,
92
(88.5%)
had
shoulder
joint
tenderness,
47
(45.2%)
had
limitations
Shoulder
joint
rotation
and
41
(39.4%)
had had
shoulder
joint
abduction
limitation.
According
to
radiographic
images,
it
was
shown
that
2
(1.9%)
patients
had
combined
fracture
of
shoulder
bones,
2
(1.9%)
had
glenoid
fracture,
2
patients
(1.9%)
had
acromion
fracture,
10
patients
(9.6
%)
had
a
clavicle
fracture,
4
(3.8%)
had
scapular
fracture,
and
3
(2.9%)
had
a
proximal
humerus
fracture.
Data
analysis
showed
that
there
was
no
significant
relationship
between
the
four
diagnostic
variables
in
clinical
examinations
including
joint
ecchymosis,
shoulder
joint
spotted
tenderness,
shoulder
joint
rotation
limitation,
shoulder
joint
abduction
limitation
with
a
combined
fracture
of
shoulder
bones
(P
>
0.05)
(Table
1).
Table
1:
Relationship
between
combined
fracture
of
shoulder
bones
and
clinical
examination
findings
Combination
fracture
of
shoulder
bones
Has
Does
not
have
Joint
ecchymosis
Has
0
18
P-value
Does
not
have
2
84
0.381
Shoulder
joint
spotted
tenderness
Has
2
90
Does
not
have
0
12
0.481
Shoulder
joint
rotation
limitation
Does
not
Has
2
45
have
0
57
0.202
Shoulder
joint
rotationrotation
Has
abduction
2
39
0.153
Does
not
have
0
63
Data
analysis
also
showed
that
there
is
a
significant
relationship
between
joint
ecchymosis
and
glenoid
fracture
(P
<
0.05),
but
there
is
no
meaningful
relationship
with
other
variables
of
clinical
symptoms
including
shoulder
joint
spotted
tenderness,
shoulder
joint
rotation
limitation
and
shoulder
joint
rotation
abduction
with
glenoid
fracture
(P
>
0.05)
(Table
2).
Table
2:
Relationship
between
glenoid
fracture
and
Clinical
examination
findings
Glenoid
fracture
Has
Does
not
have
Joint
ecchymosis
Has
2
16
P-value
Does
not
have
0
86
0.029
Shoulder
joint
spotted
tenderness
Has
2
90
Does
not
have
0
12
0.481
Shoulder
joint
rotation
limitation
Has
46
Does
not
have
56
0.891
Shoulder
joint
rotation
abduction
Has
0
41
0.518
Does
not
have
2
61
Data
analysis
showed
that
there
is
no
significant
relationship
between
any
of
the
diagnosed
clinical
symptoms
with
acromion
fracture
(P
>
0.05)
(Table
3).
Table
3:
Relationship
between
acromion
fracture
and
clinical
examination
findings
Acromion
fracture
Has
Does
not
have
Joint
ecchymosis
Has
3
15
P-value
Does
not
have
6
80
0.186
Shoulder
joint
spotted
tenderness
Has
9
83
Does
not
have
0
12
0.593
Shoulder
joint
rotation
limitation
Has
4
43
Does
not
have
5
52
0.962
Shoulder
joint
rotation
abduction
Has
5
36
0.518
Does
not
have
4
59
Also,
data
analysis
showed
that
there
is
a
significant
relationship
between
the
rotation
limitation
and
shoulder
joint
abduction
with
clavicle
fracture
(P
<
0.05)
(Table
4).
Table
4:
Relationship
between
Clavicle
Fracture
and
Clinical
Findings
Clavicle
fracture
Has
Does
not
have
Joint
ecchymosis
Has
2
16
P-value
Does
not
have
8
78
0.683
Shoulder
joint
spotted
tenderness
Has
8
84
Does
not
have
2
10
0.324
Shoulder
joint
rotation
limitation
Has
9
37
Does
not
have
0
57
0.000
Shoulder
joint
rotation
abduction
Has
9
32
Does
not
have
1
62
0.001
According
to
(Table
5)
and
P
value,
it
was
found
that
there
was
no
significant
relationship
between
any
of
the
findings
of
clinical
symptoms
with
Scapular
fracture
(P
>
0.05).
Table
5:
Relationship
between
scapular
fracture
and
clinical
examination
findings
Scapular
fracture
Has
Does
not
have
Joint
ecchymosis
Has
2
16
P-value
Does
not
have
2
84
0.683
Shoulder
joint
spotted
tenderness
Has
3
89
Does
not
have
1
11
0.324
Shoulder
joint
rotation
limitation
Has
1
46
Does
not
have
3
54
0.000
Shoulder
joint
rotation
abduction
Has
2
39
Does
not
have
2
61
0.001
Also
according
to
(Table
6)
and
P
value,
it
was
determined
that
there
was
a
significant
relationship
between
shoulder
joint
ecchymosis
and
humerus
fracture
(P
<
0.05).
However,
in
other
clinical
symptoms,
there
was
no
significant
relation
with
the
fracture
of
the
humerus.
Data
analysis
showed
that
none
of
the
trauma
mechanisms
included
falling,
direct
hit,
pedestrian,
and
collisions
with
the
vehicle,
bikers,
and
car
drivers
have
no
statistical
relationship
with
clinical
diagnostic
symptoms
including
shoulder
joint
ecchymosis
(P-
value
=
0.231),
the
shoulder
joint
spotted
tenderness
(P-value
=
0.136),
shoulder
joint
rotation
limitation
(P-
Open
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Maced
J
Med
Sci.
2018
Nov
25;
6(11):2101-2106.
2103
Clinical
Science
value
=
0.603),
and
shoulder
joint
abduction
limitation
(P-value
=
0.967).
Table
6:
Relationship
between
Humerus
Fracture
and
Clinical
Findings
Humerus
Fracture
Has
Does
not
have
Joint
ecchymosis
Has
3
15
P-value
Does
not
have
0
86
0.004
Shoulder
joint
spotted
tenderness
Has
3
89
Does
not
have
0
12
0.387
Shoulder
joint
rotation
limitation
Has
1
46
Does
not
have
2
55
0.672
Shoulder
joint
rotation
abduction
Has
0
41
Does
not
have
3
60
0.277
Also,
the
findings
of
the
relationship
between
gender
and
clinical
signs
of
diagnosis
including
ecchymosis,
tenderness,
rotation
limitation,
and
limitation
of
shoulder
abduction
showed
that
gender
was
significantly
correlated
with
shoulder
joint
ecchymosis
(P-value
=
0.017),
so
that
among
women
is
common
to
be
affected
by
ecchymosis,
gender
had
no
significant
relationship
with
other
clinical
diagnostic
symptoms.
Finally,
the
findings
of
the
relationship
between
age
and
clinical
symptoms
showed
that
the
age
of
patients
had
statistically
significant
relationship
with
shoulder
joint
ecchymosis
(P-value
=
0.001)
and
shoulder
joint
rotation
limitation
(P-value
=
0.002)
and
did
not
have
a
statistically
significant
relationship
with
shoulder
joint
spotted
tenderness
(P-value
=
0.131)
and
shoulder
joint
abduction
limitation
(P-value
=
0.313).
The
frequency
of
clinical
signs
of
patients
is
shown
in
(Table
7).
Table
7:
Table
of
Clinical
Symptoms
Frequency
Frequency
Percentage
Ecchymosis
2
1.9
Ecchymosis
and
tenderness
10
9.6
Ecchymosis
and
tenderness
and
abduction
1
1
Ecchymosis
and
Tenderness
and
Rotation
2
1.9
Ecchymosis
and
tenderness
and
routine
and
abduction
3
2.9
Rotation
2
1.9
Rotation
and
abduction
8
7.7
Tenderness
31
29.8
Tenderness
and
abduction
13
12.5
Tenderness
and
rotation
16
15.4
Tenderness
and
rotation
and
abduction
16
15.4
To
describe
or
find
a
pattern
between
clinical
signs
and
radiographic
findings
and
the
occurrence
of
these
symptoms,
the
Associate
rules
algorithms
are
used
that
is
one
of
the
data
mining
algorithms;
these
algorithms
are
variable
in
line
with
the
coordinated
occurrence
of
events
in
variables.
The
meaningful
and
interesting
rules
are
extracted
as
follows.
1.
In
42%
of
cases,
there
was
no
ecchymosis
and
rotation,
but
tenderness
was
positive.
2.
In
30%
of
the
cases,
there
was
no
ecchymosis
and
no
rotation
and
abduction,
but
tenderness
was
positive.
3.
In
96%
of
cases,
those
who
did
not
have
rotation
had
a
positive
tenderness.
4.
In
94%
of
the
cases,
those
who
did
not
have
an
addiction
had
positive
tenderness.
Discussion
The
shoulder
is
the
most
mobile
joint
that
performs
a
vast
range
of
actions,
but
on
the
other
hand,
it
can
be
unstable
and
can,
therefore,
be
at
increased
risk
of
injury
[15].
In
emergency
medicine,
we
commonly
encountered
with
shoulder
injuries
[16].
The
statistics
show
that
shoulder
joint
dislocation
accounts
for
half
of
the
total
dislocation
in
the
emergency
room
[4].
Timely
diagnosis,
treatment,
and
management
of
these
patients
are
among
the
important
tasks
of
the
emergency
department.
Getting
a
precise
biography
and
physical
examination
is
what
should
be
done
first
[17].
Failure
to
diagnose
shoulder
bone
injuries
leads
to
long-term
adverse
effects
of
the
shoulder
while
paying
attention
to
signs
and
symptoms
in
the
doctor's
examination
leads
to
timely
diagnosis,
even
in
rare
cases
[18].
Various
studies
have
been
conducted
to
assess
the
value
of
clinical
signs
and
different
physical
tests
of
shoulder
to
distinguish
between
types
of
shoulder
injuries.
Litaker
and
colleagues
conducted
a
study
to
determine
the
value
of
biographies
and
physical
examination
in
predicting
the
results
of
arthrography
in
older
patients
with
the
suspicion
of
Rotator
Cuff
Tear.
This
study
aimed
to
reduce
the
need
for
other
diagnostic
measures,
taking
into
account
the
age
of
patients
and
the
value
of
correct
diagnosis
along
the
patient's
bed.
In
their
study,
shoulder
pain
in
87.7%
of
cases
was
associated
with
Rotator
Cuff
Tear.
They
conclude
that
physical
examinations
can
effectively
show
the
rupture
of
Rotator
Cuff,
with
important
symptoms
including
the
presence
or
absence
of
specific
symptoms,
the
duration
of
symptoms,
and
the
mechanism
of
injury
[19].
Hedges
and
colleagues
also
conducted
a
systematic
study
of
the
diagnostic
value
of
physical
examination
tests,
and
they
concluded
that
it
was
not
clear
at
the
time
of
examination
that
the
usual
physical
examination
tests
were
useful
in
differentiating
shoulder
injuries
[20].
In
another
study,
they
updated
their
previous
study.
Hedges
has
stated
in
this
article
that,
based
on
the
results
of
the
previous
study
and
his
new
study,
he
does
not
recommend
using
any
shoulder
physical
examination
(SHPE)
alone
for
diagnosis.
Of
course,
there
are
some
tests
that
look
like
these,
but
they
should
be
evaluated
in
more
than
2104
https://www.id-press.eu/mjms/index
Zamani
et
al..
The
Relationship
between
Clinical
Findings
of
Shoulder
Joint
with
Bone
Damage
of
Shoulder
Joint
one
study.
Also,
the
use
of
several
physical
examinations
together
improves
the
accuracy
of
the
diagnosis.
The
findings
of
this
study
appear
to
suggest
that
more
emphasis
should
be
placed
on
a
comprehensive
clinical
evaluation,
including
biographies
and
physical
examination
[21].
After
the
biography
and
physical
examination,
the
next
diagnostic
procedure
is
usually
radiography
to
assess
the
type
of
shoulder
injury.
Most
of
the
shoulders
injuries
in
bone
damage
are
examined
with
simple
radiography,
and
in
rare
cases,
CT
scan,
MRI,
or
shoulder
ultrasound
are
needed.
In
this
regard,
some
studies
have
shown
that
the
use
of
shoulder
radiography
in
the
emergency
department
is
excessive,
which
imposes
cost
and
exposure
to
unnecessary
radiation
and
time
spent
[22]
[23].
In
a
study
published
by
Fraenkel
and
colleagues
in
1998,
the
results
showed
that
only
20%
of
patients
with
shoulder
radiography
showed
a
special
problem
that
needed
special
treatment
and
helped
treat
it
[22].
Another
study
by
Fraenkel
et
al.,
(2000)
found
that
88%
of
the
patients
with
shoulder
pain
who
received
radiography
in
the
emergency
ward,
radiography
was
not
helpful
therapeutically
and
did
not
provide
any
particular
information
to
the
therapist
[23].
With
regard
to
the
research
that
has
been
made
and
the
similar
studies
that
have
been
carried
out
with
regard
to
the
use
of
radiography
in
knee
trauma
(Ottawa
knee
rule)
and
neck
trauma
(NEXUS
Low-risk
Criteria),
it
seems
that
Criteria
can
be
defined
according
to
the
clinical
symptoms
of
the
patient
with
shoulder
pain,
which
reduces
the
unnecessary
use
of
radiography
[24]
[25].
This
study
aimed
to
investigate
the
relationship
between
some
clinical
signs
and
symptoms
of
the
patient
with
the
shoulder
with
the
type
of
shoulder
injury
and
the
usefulness
of
shoulder
radiography
in
the
next
therapeutic
intervention.
The
results
of
this
study
showed
that
28
patients
(27%)
out
of
104
patients
had
fractures,
and
therefore
their
radiography
was
helpful
in
treatment,
which
included
2%
glenoid
fracture
(2
patients),
9%
acromion
fracture
(9
patients),
10%
clavicle
fracture
(10
cases),
4%
Scapular
fracture
(4%),
3%
proximal
Humerus
fracture
(3
patients)
and
2
patients
with
combined
fractures.
These
results
are
roughly
the
same
and
close
to
the
results
of
Fraenkel's
study,
which
showed
that
about
20%
of
the
combs'
radiographs
are
medically
informative
and
show
a
fracture
or
dislocation.
Among
the
clinical
symptoms
of
patients,
there
was
a
significant
relationship
between
ecchymosis
in
the
shoulder
and
the
glenoid
and
humerus
fracture
(p
=
0.029
and
p
=
0.004,
respectively).
All
cases
of
Humerus
(3)
and
Glenoid
fractures
(2)
were
associated
with
ecchymosis,
but
the
total
number
of
cases
was
18.
In
total,
the
clinical
symptom
of
ecchymosis
was
useful
in
fractures
and
radiography
in
27%
of
cases.
In
the
present
study,
there
was
a
significant
relationship
between
Clavicle
fracture
and
limitation
in
shoulder
rotation
and
abduction
(p
=
0.001
and
p
=
0.001
respectively).
Of
the
10
cases,
the
fracture
of
the
clavicle
of
each
10
cases
was
associated
with
restriction
of
the
shoulder
joint
rotation
and
9
cases
with
the
limitation
of
abduction.
45%
of
the
subjects
had had
shoulder
joint
rotation
limitation
before
radiography,
and
39%
had
shoulder
joint
abduction
limitation
before
the
radiography.
In
Fraenkel's
study,
the
deformity
was
the
most
important
variable
in
shoulder
examination
with
radiography,
so
that
among
23
patients
diagnosed
with
deformity,
21
cases
had
suitable
radiographs
and
indicating
specific
damage.
Among
the
other
162
patients,
only
people
over
43.5
years
of
age
with
a
history
of
falls
(40)
had
a
great
chance
to
have
radiographs.
No
illness
without
deformity
and
a
history
of
the
crash
(90)
did
not
provide
radiographs
[22].
In
our
study,
the
relationship
between
ecchymosis
and
fracture
of
glenoid
and
humerus
was
significant,
but
in
general,
ecchymosis
was
useful
only
in
27%
of
cases
with
radiography.
Also,
in
the
present
study,
there
was
a
significant
relationship
between
Clavicle
bone
fracture
with
limitation
of
rotation
and
abdominal
aberration,
however,
with
45%
of
subjects
having
had
shoulder
rotation
limitation
and
the
total
fracture
with
limitation
was
15
(including
10
clavicle
fracture,
4
Acromion,
and
a
scapula)
and
39%
had
shoulder
joint
abduction,
while
the
total
fractures
with
it
were
13
(including
9
cases
of
clavicle
and
4
acromion
fractures).
Therefore,
it
can
be
said
that
the
limitation
of
joints
rotation
and
joint
abduction
in
approximately
1/3
of
the
cases
with
is
associated
with
fractures
and,
consequently,
radiographs
have
been
helpful.
In
Fraenkel
study,
the
deformity
was
found
in
91%
of
cases
with
fractures
and
helping
factors
in
radiography,
while
in
our
study,
the
association
between
abduction
and
rotation
and
radiotherapy
was
33%
and
ecchymosis
was
27%.
Regarding
these
results,
it
can
be
said
that
although
the
abnormalities
and
limitation
of
abduction
and
rotation
have
a
significant
relationship
with
radiography,
this
association
is
not
so
strong
that
it
can
be
used
as
a
guide
critter
to
perform
shoulder
radiography
and
in
case
of
using
them
as
radiographic
criterion,
again
in
66%
of
cases,
unnecessary
radiographies
have
been
done.
In
conclusion,
the
results
of
our
study,
along
with
the
results
of
Fraenkel's
studies
[22],
show
that,
although
based
on
critters
clinical
symptoms,
we
can
define
that
the
need
for
unnecessary
radiology,
which
does
not
help
the
patient
treatment,
is
reduced,
but
finding
these
critters
and
generalizing
the
using
them
like
the
Ottawa
and
Nexus
Critters
require
more
studies
with
higher
population
and
more
clinical
variables.
Open
Access
Maced
J
Med
Sci.
2018
Nov
25;
6(11):2101-2106.
2105
Clinical
Science
Acknowledgement
This
article
has
been
extracted
from
thesis
written
by
Dr.
Amin
Zamani
in
the
Faculty
of
Medicine,
Mashhad
University
of
Medical
Science,
and
this
article
has
IRCT
code
with
number:
I
R.mums.REC.1393.106.
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