Management of shoulder dystocia has become a focus point for many obstetrical nursing units in North America. Courses such as the Canadian More-OB program encourage nursing units to do routine drills to prevent delays in delivery which adversely affect both mother and fetus. A common treatment mnemonic is ALARMER

- Ask for help. This involves preparing for the help of an obstetrician, for anesthesia, and for pediatrics for subsequent resuscitation of the infant that may be needed if the methods below fail.

- L hyperflexion (McRoberts' maneuver)

- Anterior shoulder disimpaction (pressure)

- Rubin maneuver

- M delivery of posterior arm

- Episiotomy

- Roll over on all fours

Typically the procedures are performed in the order listed above and the sequence ends whenever a technique is successful. Intentional clavicular fracture is a final attempt at nonoperative vaginal delivery prior to Zavanelli's maneuver or symphysiotomy, both of which are considered extraordinary treatment measures.

Magnetic resonance imaging (MRI) and ultrasound are comparable in efficacy and helpful in diagnosis although both have a false positive rate of 15 - 20%. MRI can reliably detect most full-thickness tears although very small pinpoint tears may be missed. In such situations, an MRI combined with an injection of contrast material, an MR-arthrogram, may help to confirm the diagnosis. It should be realized that a normal MRI cannot fully rule out a small tear (a false negative) while partial-thickness tears are not as reliably detected. While MRI is sensitive in identifying tendon degeneration (tendinopathy), it may not reliably distinguish between a degenerative tendon and a partially torn tendon. Again, magnetic resonance arthrography can improve the differentiation. An overall sensitivity of 91% (9% false negative rate) has been reported indicating that magnetic resonance arthrography is reliable in the detection of partial-thickness rotator cuff tears. However, its routine use is not advised, since it involves entering the joint with a needle with potential risk of infection. Consequently, the test is reserved for cases in which the diagnosis remains unclear.

If severe pain persists after the first 24hours it is recommended that an individual consult with a professional who can make a diagnosis and implement a treatment plan so the patient can return to everyday activities (Flegel, 2004). These are some of the tools that a professional can use to help make a full diagnosis;

Nerve conduction studies may also be used to localize nerve dysfunction ("e.g.", carpal tunnel syndrome), assess severity, and help with prognosis.

Electrodiagnosis also helps differentiate between myopathy and neuropathy.

Ultimately, the best method of imaging soft tissue is magnetic resonance imaging (MRI), though it is cost-prohibitive and carries a high false positive rate.

Musculoskeletal ultrasound has been advocated by experienced practitioners, avoiding the radiation of X-ray and the expense of MRI while demonstrating comparable accuracy to MRI for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. This modality can also reveal the presence of other conditions that may mimic rotator cuff tear at clinical examination, including tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis. However, MRI provides more information about adjacent structures in the shoulder such as the capsule, glenoid labrum muscles and bone and these factors should be considered in each case when selecting the appropriate study.

Impingement syndrome can usually be diagnosed by history and physical exam. On physical exam, the physician may twist or elevate the patient's arm to test for reproducible pain (Neer sign and Hawkins-Kennedy test). These tests help localize the pathology to the rotator cuff; however, they are not specific for impingement. Neer sign may also be seen with subacromial bursitis.

The physician may inject lidocaine (usually combined with a steroid) into the bursa, and if there is an improved range of motion and decrease in pain, this is considered a positive "Impingement Test". It not only supports the diagnosis for impingement syndrome, but it is also therapeutic.

Plain x-rays of the shoulder can be used to detect some joint pathology and variations in the bones, including acromioclavicular arthritis, variations in the acromion, and calcification. However, x-rays do not allow visualization of soft tissue and thus hold a low diagnostic value. Ultrasonography, arthrography and MRI can be used to detect rotator cuff muscle pathology. MRI is the best imaging test prior to arthroscopic surgery. Due to lack of understanding of the pathoaetiology, and lack of diagnostic accuracy in the assessment process by many physicians, several opinions are recommended before intervention.

X-rays may help visualize bone spurs, acromial anatomy and arthritis. Further, calcification in the subacromial space and rotator cuff may be revealed. Osteoarthritis of the acromioclavicular (AC) joint may co-exist and is usually demonstrated on radiographs.

MRI imagining can reveal fluid accumulation in the bursa and assess adjacent structures. In chronic cases caused by impingement tendinosis and tears in the rotator cuff may be revealed. At US, an abnormal bursa may show (1) fluid distension, (2) synovial proliferation, and/or (3) thickening of the bursal walls. In any case, the magnitude of pathological findings does not correlate with the magnitude of the symptoms.

The diagnosis is usually initially made by a combination of physical exam and MRI of the shoulder, which can be done with or without the injection of intraarticular contrast. The presence of contrast allows for better evaluation of the glenoid labrum.

While a transverse lie prior to labor can be manually versed to a longitudinal lie, once the uterus starts contracting the uterus normally will not allow any version procedure. A shoulder presentation is an indication for a caesarean section. Generally, as it is diagnosed early, the baby is not damaged by the time of delivery. With the rupture of the membranes, there is an increased risk of a cord prolapse as the shoulder may not completely block the birth canal. Thus the caesarean section is ideally performed before the membranes break.

Imaging features of adhesive capsulitis are seen on non-contrast MRI, though MR arthrography and invasive arthroscopy are more accurate in diagnosis. Ultrasound and MRI can help in diagnosis by assessing the coracohumeral ligament, with a width of greater than 3 mm being 60% sensitive and 95% specific for the diagnosis. The condition can also be associated with edema or fluid at the rotator interval, a space in the shoulder joint normally containing fat between the supraspinatus and subscapularis tendons, medial to the rotator cuff. Shoulders with adhesive capsulitis also characteristically fibrose and thicken at the axillary pouch and rotator interval, best seen as dark signal on T1 sequences with edema and inflammation on T2 sequences. A finding on ultrasound associated with adhesive capsulitis is hypoechoic material surrounding the long head of the biceps tendon at the rotator interval, reflecting fibrosis. In the painful stage, such hypoechoic material may demonstrate increased vascularity with Doppler ultrasound.

In patients with bursitis who have rheumatoid arthritis, short term improvements are not taken as a sign of resolution and may require long term treatment to ensure recurrence is minimized. Joint contracture of the shoulder has also been found to be at a higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).

In addition to history and exam, it has been recommended to perform projectional radiography of the neck, chest, shoulder, and thoracic inlet to rule out structural abnormalities such as malunited or greenstick fractures. Computed tomography (CT) or magnetic resonance imaging (MRI) are rarely indicated, but may be useful to rule out certain diagnoses if suspected, such as neurofibromatosis-related injury, intervertebral disc disorder, radiculopathy, and tumors.

Courses that teach procedures include ALSO and PROMPT. A number of labor positions and/or obstetrical maneuvers are sequentially performed in attempt to facilitate delivery at this point, including :

- McRoberts maneuver; The McRoberts maneuver is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled. The technique is effective in about 42% of cases

- suprapubic pressure (or Rubin I)

- Rubin II or posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the vagina

- Woods' screw maneuver which leads to turning the anterior shoulder to the posterior and vice versa (somewhat the opposite of Rubin II maneuver)

- Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled.

- Gaskin maneuver, named after Certified Professional Midwife, Ina May Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.

More drastic maneuvers include

- Zavanelli's maneuver, which involves pushing the fetal head back in with performing a cesarean section. or internal cephalic replacement followed by Cesarean section

- intentional fetal clavicular fracture, which reduces the diameter of the shoulder girdle that requires to pass through the birth canal.

- maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.

- abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates vaginal delivery of the impacted shoulder

The decisions involved in the repair of the Hill–Sachs lesion are complex. First, it is not repaired simply because of its existence, but because of its association with continuing symptoms and instability. This may be of greatest importance in the under-25-year-old and in the athlete involved in throwing activities. The Hill-Sachs role in continuing symptoms, in turn, may be related to its size and large lesions, particularly if involving greater than 20% of the articular surface, may impinge on the glenoid fossa (engage), promoting further episodes of instability or even dislocation. Also, it is a fracture, and associated bony lesions or fractures may coexist in the glenoid, such as the so-called bony Bankart lesion. Consequently, its operative treatment may include some form of bony augmentation, such as the Latarjet or similar procedure. Finally, there is no guarantee that associated non-bony lesions, such as a Bankart lesion, SLAP tear, or biceps tendon injury, may not be present and require intervention.

Arthroscopic repair of Bankart injuries have high success rates, with studies showing that nearly one-third of patients require re-intervention for continued shoulder instability following repair. Options for repair include an arthroscopic technique or a more invasive open Latarjet procedure, with the open technique tending to have a lower incidence of recurrent dislocation, but also a reduced range of motion following surgery.

Imaging diagnosis conventionally begins with plain film radiography. Generally, AP radiographs of the shoulder with the arm in internal rotation offer the best yield while axillary views and AP radiographs with external rotation tend to obscure the defect. However, pain and tenderness in the injured joint make appropriate positioning difficult and in a recent study of plain film x-ray for Hill–Sachs lesions, the sensitivity was only about 20%. i.e. the finding was not visible on plain film x-ray about 80% of the time.

By contrast, studies have shown the value of ultrasonography in diagnosing Hill–Sachs lesions. In a population with recurrent dislocation using findings at surgery as the gold standard, a sensitivity of 96% was demonstrated. In a second study of patients with continuing shoulder instability after trauma, and using double contrast CT as a gold standard, a sensitivity of over 95% was demonstrated for ultrasound. It should be borne in mind that in both those studies, patients were having continuing problems after initial injury, and therefore the presence of a Hill–Sachs lesion was more likely. Nevertheless, ultrasonography, which is noninvasive and free from radiation, offers important advantages.

MRI has also been shown to be highly reliable for the diagnosis of Hill-Sachs (and Bankart) lesions. One study used challenging methodology. First of all, it applied to those patients with a single, or first time, dislocation. Such lesions were likely to be smaller and therefore more difficult to detect. Second, two radiologists, who were blinded to the surgical outcome, reviewed the MRI findings, while two orthopedic surgeons, who were blinded to the MRI findings, reviewed videotapes of the arthroscopic procedures. Coefficiency of agreement was then calculated for the MRI and arthroscopic findings and there was total agreement ( kappa = 1.0) for Hill-Sachs and Bankart lesions.

The delivery of the second twin in a transverse lie with a shoulder presentation represents a special situation that may be amenable to a vaginal delivery. As the first twin has just been delivered and the cervix is fully dilated the obstetrician may perform an internal version, that is inserting one hand into the uterus, find the baby’s feet, and then bring the baby into a breech position and deliver the baby as such.

Diagnosis of tendinitis and bursitis begins with a medical history and physical examination. X rays do not show tendons or the bursae but may be helpful in ruling out bony abnormalities or arthritis. The doctor may remove and test fluid from the inflamed area to rule out infection.

Ultrasound scans are frequently used to confirm a suspected tendinitis or bursitis as well as rule out a tear in the rotator cuff muscles.

Impingement syndrome may be confirmed when injection of a small amount of anesthetic (lidocaine hydrochloride) into the space under the acromion relieves pain.

After an anterior shoulder dislocation, the risk of a future dislocation is about 20%. This risk is greater in males than females.

The best diagnosis for a SLAP tear is a clinical exam

followed by an MRI combined with a contrast agent

This method should be used within the first 48–72 hours after the injury in order to speed up the recovery process.

Heat: Applying heat to the injured area can cause blood flow and swelling to increase.

Alcohol: Alcohol can inhibit your ability to feel if your injury is becoming more aggravated, as well as increase blood flow and swelling.

Re-injury: Avoid any activities that could aggravate the injury and cause further damage.

Massage: Massaging an injured area can promote blood flow and swelling, and ultimately do more damage if done too early.

To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Physical therapy and occupational therapy can help with continued movement.

Following inspection and determination of the extent of injury, the basic labrum repair is as follows.

- The glenoid and labrum are roughened to increase contact surface area and promote re-growth.

- Locations for the bone anchors are selected based on number and severity of tear. A severe tear involving both SLAP and Bankart lesions may require seven anchors. Simple tears may only require one.

- The glenoid is drilled for the anchor implantation.

- Anchors are inserted in the glenoid.

- The suture component of the implant is tied through the labrum and knotted such that the labrum is in tight contact with the glenoid surface.

Since there is a variety of classifications of winged scapula, there is also more than one type of treatment. Massage Therapy is an effective initial approach to relax the damaged muscles. In more severe cases, Physical Therapy can help by strengthening affected and surrounding muscles. Physical therapy constitutes treatment options if there is weakness of the glenohumeral joint muscles, but if the muscles do not contract clinically and symptoms continue to be severe for more than 3–6 months, surgery may be the next choice. Surgery by fixation of the scapula to the rib cage can be done for those with isolated scapular winging. Some options are neurolysis (chordotomy), intercostal nerve transfer, scapulothoracic fusion, arthrodesis (scapulodesis), or scapulothoracis fixation without arthrodesis (scapulopexy).

Prompt medical treatment should be sought for suspected dislocation.

Usually, the shoulder is kept in its current position by use of a splint or sling. A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the distress associated with it.

There is evidence in literature to support both surgical and non-surgical forms of treatment. In some, physical therapy can strengthen the supporting muscles in the shoulder joint to the point of reestablishing stability.

Surgical treatment of SLAP tears has become more common in recent years. The success rate for repairing isolated SLAP tears is reported between 74-94%. While surgery can be performed as a traditional open procedure, an arthroscopic technique is currently favored being less intrusive with low chance of iatrogenic infection.

Associated findings within the shoulder joint are varied, may not be predictable and include:

- SLAP lesion – labrum/glenoid separation at the tendon of the biceps muscle

- Bankart lesion – labrum/glenoid separation at the inferior glenohumeral ligament

- Biceps Tendon - exclusion of pulley injury

- Bone – glenoid, humerus — injury or degenerative change involving joint surface

- Anatomical variants — sublabral foramen, Buford Complex

Although good outcomes with SLAP repair over the age of 40 are reported, both age greater than 40 and Workmen's Compensation status have been noted as independent predictors of surgical complications. This is particularly so if there is an associated rotator cuff injury. In such circumstances, it is suggested that labral debridement and biceps tenotomy is preferred.

SLAP (Superior Labral Tear, Anterior to Posterior)

- "Type 1"

- Fraying of Superior Labrum

- Biceps Anchor Intact

- "Type 2"

- Superior Labrum detached

- Detachment of the Biceps Anchor

- "Type 3"

- Bucket Handle type tear of Superior Labrum

- Biceps Anchor INTACT

- "Type 4"

- Bucket Handle tear of Superior Labrum

- Extension of tear in Biceps Tendon

- Part of Biceps Anchor still INTACT