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Introduction
The pectoral girdle or the shoulder girdle is in essence made up of three major bones namely; scapula, clavicle and the proximal humerus and this include the two core joints acromioclavicular joint as well as glenohumeral joint. These features are interrelated in that they link the upper extremities with the thorax and are critically linked to the traumatic injuries which can be defined as dislocations and fractures in any given individual. However, to determine the nature and degree of the damage on the concerned shoulder segment diagnostic radiology is needed for it plays a central role in establishing either the affected area or the cause of the damage .
Radiology is one of the key branches of medical science concerned with medical imaging. This may involve such devices as X-ray machines or other radiation related devices. Radiology also encompasses procedures that do not entail radiation, such as ultrasound or MRI. Basically, as a key medical specialty this discipline touches on two crucial subfields namely diagnostic and therapeutic radiology. Diagnostic radiology is concerned with the dynamics of diverse imaging aspects in diagnosis of diseases. This branch is also divided into various specialties. On the other hand, therapeutic radiology is more employed in treating such ailments as cancer through a form of unique treatment classified as radiation therapy.
Generally, diverse modalities are employed in radiography and they involve plain radiography, magnetic resonance imaging (MRI), nuclear imaging techniques, computed tomography (CT), and ultrasound.
However, these modalities do have their own unique strengths and weaknesses which determine their significance in the course of diagnosis.
From such observation it ought to be noted that shoulder trauma is one of the most common feature allied to the shoulder injuries. These injuries encompass injuries caused by falls onto the shoulder and this may either touch or fracture the clavicle (collar bone) or equally fracture the scapula (shoulder blade). Basically, the shoulder is a composition of three bones namely;
Scapula, clavicle, and the humerus (arm bone). These shoulder bones are boded by supple tissues such as the muscles, tendons, joint capsules and ligaments, to form a suitable domain for the arm to function. Hence, some of the joint found within the shoulder include; Glenohumeral joint, Acromioclavicular joint, and Sternoclavicular joint.
The shoulder sustains one of the key articulations, that is, the relationship concerning scapula and the chest wall. All in all, the shoulder is commonly covered by a number of layers which are classified as soft tissues. The uppermost layer is known as deltoid muscle and this is the layer that gives the shoulder its unique rounded appearance. This layer is essential in that it helps to bring the arm overhead.
Types of shoulder injuries
Shoulder injuries are many and diversified. Fractures, for instance, are broken bones, while dislocations take place or occur when the alternating bones fail to line up. Hence, dislocations entail three core joints, that is: a dislocation of acromioclavicular joint or as commonly known as separated shoulder. Another common injury involves the dislocation of sternoclavicular joint and this regards the interruption of the link touching the clavicle and the sternum (breastbone). The other shoulder related injury involves the dislocation of the glenohumeral joint. This takes place when the joint is dislodged and tends to lean inwardly or outwardly.
Causes
Direct blow to the clavicle or the proximal humerus may result in fracture and this could as a consequence of direct collision, accident or fall. However, scapula fractures are more correlated with injuries of the chest.
A-clavicle fractures are commonly defined by location and this is done with clavicle being divided into solid thirds: distal, proximal and the middle. B denotes a scapular fracture. As is in the above diagram.
Thus, shoulder trauma can be said to be caused by three elements that is, shoulder dislocation, shoulder separation, and fractures.
Significance of diagnostic radiology
From time to time doctors do use diagnostic radiology in examining body in such way that they cannot do so from the outside observation. Diagnostic radiology involves the use of diverse electronic procedures as well as medical equipments to generate images that expose or reveal what is wrong or is happening inside the patients body. Though, a number of the diagnostic tests have been established to be uncomfortable, majority of them are known to be painless and equally noninvasive. More so, the device the doctor opts to use depends with the nature of the patient needs. Some of the commonly preferred tests include MRI, CT , mammography, as well as ultrasound 3. These tests are carried out by radiologists. One of the basic significance of diagnostic radiology lies in its use in detecting any anomalies in the body.
By carrying out molecular imaging doctors are empowered to examine the body from a cellular level and equally pick out the disease before the diseases reaches a critical level. These inclusive tests expose the structures and the function of such features as the shoulder, chest as well as the function of the heart allowing the doctor to detect the abnormalities in the manner they function 4. One of the most typical diagnostic imaging or radiography tests entails digital mammography. This examination does allow the electronic image to be generated in order to determine or reveal existence of any variations regarding the normal and abnormal human tissues. Thus, diagnostic radiography is essential in detecting any changes in the human bone structures.
Analysis
Most of these anomalies are diagnosed by using x-rays as well as carrying out physical examination of the affection area. And this may sometime entail additional imaging procedures such as CT which is necessary. In essence, diagnostic radiology and in particular the plain radiology is the most popular choice in regard to examination of upper extremity.
And this is typically illustrated by the presence of acute shoulder trauma in the upper area of the body. This region harbors the shoulder, wrist, humerus and the forearm which forms a critical diagnostic pattern in detecting any acute fracture. Basically, such imaging procedures as CT, MRI, and ultrasound are not commonly exploited in the course of handling acute trauma, but are essential in dealing with the soft tissue pathology. When dealing with the upper extremity and in particular the shoulder, it would be essential to point out that the major pointer for plain radiography in regard to the shoulder is acute trauma . This is due to the fact that through radiography a number of abnormalities such as fractures of the scapula, humerus, scapula as well as the shoulder dislocation such as glenohumeral or shoulder separation (acromioclavicular) could be detected.
In such a situation most patients may present mixed signs of sub-acute, chronic, or non-traumatic pain, the use of plain radiographic films in such a situation is commonly insignificant. However, where chronic and non traumatic pain is suspected, plain radiographic film is employed to expose if the patient requires either prereduction or postreduction radiography or both.
Diverse studies have established that plain radiographic films used in diagnostic radiology do not show or expose any pathological findings. However, in such a situation most doctors opts to utilize MRI in order to detect any injuries correlated to ligaments such as the rotor cuff which are rarely indicated in the normal setting.
Some of the shoulder injury regards the fracture of the humerus. Humerus as is seen from the following image is the upper segment of the bone linking the shoulder with the elbow. Basically, their exists three major variations of the fractures that can be detected from this diagram;
From this diagram it is evident that there are a number of features allied to the defects spotted on the bone. These include:
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Fractures allied to the upper end of the bone-this anomaly touches both the head as well as the neck of the bone
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Fractures center piece of the bone.
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Fractures tied to the elbow as well as the bone and are commonly referred as supra-condylar fractures. This is due to the fact that they typically occur at the upper or above the condyles. These features are highly likely to affect the juveniles more than adults.
The initial two commonly comes as a consequence of express trauma relating to humerus, that is, a heavy fall or equally a direct collision with a blunt or weighty object. Shaft fractures specifically occur where bending forces are exerted. While supracondylar fractures are collated to the upper transfer of force which breaks affects the lower humerus and this forces the supracondylar to be affected or break. Also these observations touch on the upper humeral fractures. It ought to be noted that these fractures do persistently affect the neck of the concerned bone 9. However, the most essential aspect is to determine whether the fracture concerns dislocation, or is equally in stable position or not. This is due to the fact hat most stable fractures do not require any serious radiography. Also surgery is not commonly needed in such a situation. More or less displaced fractures do in some cases call for reduction that is, pulling under the anesthetic so as to make the bone fragments to be put together.
Exploring the core aspects of diagnostic radiology, it is widely accepted that these injuries are quite painful.
And in some instances they do tend to cause severe damages to the radial nerve. However conservative medication is known to be effectual, but it cannot guarantee that the bones could be fully restored to their normal position.
Summary
Basically, radiographic examination as is allied to the shoulder trauma happens to be one of the most occurring and frequently performed within the medical divisions.
The key objective being to examine the trauma patients, but in some cases it has been established to be providing unreliable and incorrect outcomes. Hence, a radiographic study allied to the shoulder thus requires two or more radiographs and this would entail having dissimilar projections, that is, fore Anteroposterior perspective or view as well as extra projections placed at right angles to each other. The shoulder radiograph of the patient investigated for acute trauma do reveals that the former examination lacked adequate both lateral and oblique view in unear6hing the shoulder fractures and this was due to the fact that they lacked anteroposterior perspective. It ought to be noted that antero-posterior view is the most effective projection in regard to diagnostic radiography, the reason this is seen to be can be allied to the fact that it helped in detecting over 90 % of the suspected injuries.
However, according to the radiographic images acquired it is evident that both the oblique apical as well as the lateral views were not fully sensitive as is with the antero-posterior view which aided in detecting 80% and 75% of the injuries. The glenohumeral dislocations whether with either the fracture including the clavicular fractures were basically exposed through the oblique apical approach, while in the same manner fractures linked to the body as well as the coracoid procedures of the scapula were highly exposed by the lateral view.
This demonstrates that for the diagnostic radiology to be of great value to the patient the radiologist may opt to work hand in hand with the orthopedist so as to make the right decisions in regard to the projections anticipated to be used for each and every patient on the basis of physical examination.
Limitations
Though acute shoulder injuries may be adequately and highly assessed through the use of a standard or average two-view shoulder procedure, posterior dislocation can be subtle or in the same manner hard to detect or diagnose. If posterior dislocation is detected or suspected as per the available examination, physical or the average radiographic as well as extra specialized views which may include both axillarys as well as oblique view becomes essential. All in all, most of the radiographic views can be adequately acquired even where the concerned patient has a limited or restricted mobility. However, the axillarys view has been established to require diverse degree of abduction and this may prove to be difficult in some instances.
Conclusion
Diagnostic radiography is paramount in regard to the medical profession. Despite the diverse challenges which have over the time been associated with this practice, diagnostic radiography have proved to be effective in as far as dealing with the trauma of the shoulder is concerned. It ought to be noted that by applying diverse imaging techniques doctors have over the time managed to examine or investigate any fractures or injuries affecting the entire shoulder. According to the available medical evidence it is highly recommended that shoulder dislocations do not necessarily need to be x-rayed before they are put back into place. Radiology does provide a number of benefits for both patients and physicians. It ought to be noted that general radiology such as x-ray do allow the doctors to examine the bones surrounding specific body parts such as the shoulder dislocations in order to make the suitable diagnosis. Also radiology helps in that it allows the concerned doctors to monitor any changes in regard to the changes in injury and equally make the right decision concerning the best way to follow.
Despite the advantages of diagnostic radiology there are also risk factors which are to be considered in the course of dealing with the aspects of imaging. This is due to the fact that unlike any other form of diagnosis radiology id predominantly anchored in the use of radiation, and this indicates that risks linked to exposure do exist. However, the risk of acquiring cancer due to radiology is predominantly low.
Works cited
Banh, Kenny and Hendley, Gregory. Plain Radiography. 2011. Web.
Brant, William and Helms, Antony., Fundamentals of Diagnostic Radiology, 2nd ed, Williams & Wilkins, Baltimore, MD, 1999.
Daffner, Richard. Clinical Radiology: The essentials. Baltimore, MD: Lippincott Williams & Wilkins, 2007.
Greenspan, Andy. Orthopedic Radiology: A Practical Approach, 3rd ed., Lippincott Williams & Wilkins, Philadelphia, PA, 2000
Gunderman, Richard. Clinical presentation, Pathophysiology and imaging. New York, NY: Thieme Medical Publishers, 2000
Herman, Gray. Fundamentals of computerized tomography: Image reconstruction from projection, 2nd edition. Springer, 2009
Kaplan, Patrick and Helms, Antony. Musculoskeletal MRI, Saunders, 2001.
MedlinePlus. Diagnostic Imaging. 2011. Web.
Mehta, Amit and Beall, Douglas. Radiology. Totowa, NJ. Humana Press, 2006
Novelline, Robert. Squires Fundamentals of Radiology. Harvard University Press. 5th edition, 1997
Articles and journal used
Broken Collarbone
A broken collarbone (fractured clavicle) is a common injury among two very different groups of people: children and athletes. Many babies are born with collarbones that broke during the passage down the birth canal. A childs collarbone can easily crack from a direct blow or fall because the collarbone doesnt completely harden until a person is about 20 years old. An athlete who falls may break the collarbone because the force of the fall is transmitted from the elbow and shoulder to the collarbone.
The collarbone is considered part of the shoulder and helps connect the arm to the body. It lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the collarbone breaks. The collarbone is a long bone, and most breaks occur in the middle section.
Signs of a break:
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Sagging shoulder (down and forward).
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Inability to lift the arm because of pain.
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A grinding sensation if an attempt is made to raise the arm.
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A deformity or bump over the fracture site.
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Although a fragment of bone rarely breaks through the skin, it may push the skin into a tent formation.
Diagnosis
Although a broken collarbone is usually obvious, your orthopaedist will do a careful examination to make sure that no nerves or blood vessels were damaged. An X-ray is often recommended to pinpoint the location and severity of the break.
Treatment
Most broken collarbones heal well with conservative treatment and surgery is rarely necessary.
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A simple arm sling can usually be used to immobilize the arm. A child may have to wear the sling for 3 to 4 weeks; an adult may have to wear it for 6 to 8 weeks.
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Depending on the location of the break, your physician may apply a figure-of-eight strap to help maintain shoulder position.
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Analgesics such as acetaminophen or nonsteroidal anti-inflammatory medications such as aspirin or ibuprofen will help reduce pain.
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A large bump will develop as part of the healing process. This usually disappears over time, but a small bump may remain.
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Range of motion and strengthening exercises can begin as soon as the pain subsides. However, you should not return to sports activities until full shoulder strength returns.
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In rare cases, depending on the location of the break and the involvement of shoulder ligaments, surgery is needed. Surgery usually gives good results.
Fracture of the Scapula
Triangular, mobile and protected by a complex of surrounding muscles, the shoulder blade (scapula) is rarely broken. Scapula fractures represent less than 1 percent of all broken bones. High-energy, blunt trauma such as a motorcycle or car crash or falling from significant height can fracture the scapula and cause other major injuries such as broken ribs or damage to the head, lungs or spinal cord. Symptoms include:
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Extreme pain when you move the arm.
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Swelling around the back of the shoulder.
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Skin abrasions.
Without treatment, a fractured scapula can result in chronic shoulder pain and disability.
Classification and evaluation
To give you appropriate treatment, your doctor will probably need to take X-rays of your shoulder and chest to describe and classify the location(s) of fracture to the scapula. In some cases, your doctor may also need to use other diagnostic imaging tools such as CT scan (computerized tomography).
One or more parts of the scapula may be fractured:
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Scapular body (50-60 percent of cases).
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Scapular neck (25 percent).
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Glenoid.
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Acromion.
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Coracoid.
Your doctor will evaluate the position and posture of the shoulder and treat any soft tissue damage (i.e., abrasions, open wounds, and muscular trauma). Your doctor may want a detailed neurovascular examination, which may not be possible if you have other severe injuries.
Treatment
Nonsurgical treatment with a simple sling works for most fractures of the scapula. The immobilization devices holds your shoulder in place while the bone heals. In many cases, your doctor may want you to start early range of motion exercises within the first week after the injury. Other fractures may need 2 to 4 weeks of immobilization. Your shoulder may feel stiff when the doctor removes the sling. Begin limited active use of your shoulder immediately. Continue passive stretching exercises until complete shoulder motion returns. This may take 6 months to a year.
If you have an isolated scapular body fracture, your doctor may want you to stay in the hospital. Certain types of scapular fractures may need further evaluation:
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Fractures of the glenoid articular surface (shoulder joint) in which bone has moved out of place (displaced) significantly.
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Fractures of the neck of the scapula with severe angular deformity.
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Fractures of the acromion process with impingement syndrome.
In these cases, you may need surgery in which the doctor uses plates and screws to hold together the bone.
Acute Shoulder Injuries
DAVID M. QUILLEN, M.D., MARK WUCHNER, M.D., and ROBERT L. HATCH, M.D., M.P.H., University of Florida School of Medicine, Gainesville, Florida Am Fam Physician. 2004 Nov 15;70(10):1947-1954.
The shoulder is the most mobile joint in the human body. The cost of such versatility is an increased risk of injury. It is important that family physicians understand the anatomy of the shoulder, mechanisms of injury, typical physical and radiologic findings, approach to management of injuries, and indications for referral. Clavicle fractures are among the most common acute shoulder injuries, and more than 80 percent of them can be managed conservatively. Humeral head fractures are less common and usually occur in elderly persons; 85 percent of them can be managed nonoperatively. Common acute soft tissue injuries include shoulder dislocations, rotator cuff tears, and acromioclavicular sprains. Acromioclavicular injuries are graded from types I to VI. Types I and II are treated conservatively, types IV to VI are treated surgically, and there is debate about the best approach for type III. Eighty percent of shoulder dislocations are anterior. Diagnosis of this injury is straightforward. The injury usually can be reduced by employing a number of nonsurgical techniques. Traumatic or acute rotator cuff tears can be managed conservatively or surgically, depending on the patient and the degree of injury.
Strength of Recommendations
The shoulder includes the proximal humerus, the clavicle and the scapula, and their connections to each other, to the sternum (clavicle), and to the thoracic rib cage (scapula). Together, these elements form the most mobile joint in the human body (Figure 1). It allows the upper extremity to rotate up to 180 degrees in three different planes, enabling the arm to perform a versatile range of activities. This mobility comes at a cost: it leaves the shoulder prone to injury. Family physicians often encounter patients with shoulder injuries. It is important to understand the anatomy of the shoulder, mechanisms of injury, evaluation and management of injuries, and indications for referral.
Clavicle Fractures
The only bony connection between the axial skeleton and the upper extremity occurs through the clavicle, which is held securely in place by ligaments at the sternum and acromion. The clavicle overlies and protects the brachial plexus, pleural cap, and great vessels of the upper extremity. Clavicle fractures are among the most common injuries, accounting for one in 20 adult fractures.1 The injury usually is caused by a fall on the lateral shoulder or, less commonly, by a direct blow or by falling on an outstretched arm.
The clavicle is relatively superficial and easily palpable along its entire length. Clavicle fractures usually can be diagnosed by careful inspection and palpation. Acute complications are uncommon, although pneumothorax, hemothorax, and injuries to the brachial plexus or subclavian vessels have been reported.2 Neurovascular and lung examinations should be performed to screen for these complications. A routine anteroposterior view usually is the only radiograph needed to confirm the fracture and specify its location. Nondisplaced fractures, however, may be difficult to detect on an anteroposterior view, particularly in children. In such cases, a 20-degree (Zanca view) or 45-degree cephalic tilt view usually demonstrates the fracture.
Clavicle fractures are classified by Allman1 into three groups by dividing the clavicle into thirds. Group 1 (middle one third of the clavicle) is the most common type of break (Figure 2)3 and represents 80 percent of clavicle fractures.1 Group 1 fractures are treated conservatively with an arm sling for comfort, even if significant displacement is present. Historically, a figure-of-eight bandage was applied, but they are uncomfortable, have a higher incidence of complications, and do not improve functional or cosmetic results.4 Ice and analgesics are helpful in the initial treatment. Elbow range-of-motion exercises should be started as soon as pain permits. Shoulder range-of-motion and strengthening exercises should begin once the fracture heals.
Nondisplaced group 2 (lateral one third of the clavicle) fractures usually can be treated conservatively. Group 2 fractures that extend to the articular surface, even if nondisplaced, often lead to osteoarthritis of the acromioclavicular (AC) joint.5 Displaced group 2 fractures generally require operative treatment because they are unstable and have a high incidence of nonunion. Surgical treatment generally results in good function.6
Displaced group 3 fractures (medial one third of the clavicle) and sternoclavicular dislocations require orthopedic referral. These injuries have a fairly high rate of significant intrathoracic or neurovascular injury that may require emergency surgery. Nondisplaced group 3 fractures without associated injuries can be treated conservatively with a sling for comfort.
Proximal Humerus Fractures
Proximal humerus fractures occur most commonly in elderly persons. They usually result from a fall onto an outstretched arm. In young adults, direct blows are a more common cause. Up to 85 percent of proximal humerus fractures can be treated nonoperatively.2 Evaluation of a patient with a proximal humerus fracture starts with a careful and focused physical examination. Neurologic and vascular examinations of the upper extremity should be completed and documented. Occasionally, the axillary nerve or axillary artery may be injured; rarely, the brachial artery, brachial plexus, or another nerve may be injured. Identification of an anterior or posterior bulge may suggest a dislocation. Tenderness and swelling often are diffuse, making it difficult to detect clear point tenderness.
Appropriate radiographs are an important part of diagnosing and evaluating proximal humerus fractures. A standard shoulder series includes anteroposterior, transscapular (YFigure 3), and axillary views.3 Instead of a true shoulder series, radiologic technicians sometimes obtain only internal and external rotation views of the humerus. Although these views may demonstrate the fracture, they are suboptimal for detecting associated fractures and shoulder dislocations.
Because of its bony structure and the insertion of the rotator cuff tendons, the proximal head of the humerus generally fractures with four predictable cleavage lines (Figure 4).3 Regardless of the number of fragments, proximal humerus fractures are classified by the displacement and degree of angulation.7 Neer 1-part fractures have no more than 1-cm displacement of any fragment and no more than 45 degrees of angulation. More than 80 percent7 of proximal humerus fractures are nondisplaced (i.e., Neer 1-part fractures) and can be treated conservatively, if stable.2 Open fractures and fractures with neurologic or vascular deficits require emergent orthopedic referral. Patients with displaced proximal humerus fractures should be referred because surgical intervention appears to improve the outcome.8 Fracture-dislocations and fractures of the anatomic neck (indicated by the line just below the humeral head in (Figure 4)3 also should be referred.
Treatment of Neer 1-part fractures includes a sling for comfort and early range-of-motion exercises, which should be started as soon as tolerated (about five to 10 days after the injury). Patients should begin with pendulum exercises with the injured arm in the sling. They perform this movement by bending at the waist, allowing the arm to fall toward the floor, and rotating it in a circle. With time, the size of the circle is increased, and the sling is removed during the exercise.
After two to three weeks, abduction (progressively walking fingers up the wall) and internal rotation (first touching hip, then progressing to mid-back) exercises are added. Elderly patients tend to lose elbow range of motion rapidly. To avoid this, patients should be encouraged to remove the sling and flex and extend the elbow as soon as this movement can be tolerated. To speed recovery and avoid iatrogenic loss of elbow range of motion, use of the sling should be discontinued completely by four to six weeks after injury. Formal physical therapy can be helpful in maximizing future function of the shoulder.
Glenohumeral Dislocation
The glenohumeral joint is one of the most commonly dislocated joints. Ninety pe
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