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Shoulder Fracture

Shoulder Anatomy

The shoulder is a ball and socket joint made up of three bones, namely the humerus, scapula and clavicle. The end of the humerus or upper arm bone forms the ball of the shoulder joint. The scapula is a flat triangular-shaped bone that forms the shoulder blade. The clavicle bone or collarbone is an S-shaped bone that connects the scapula to the sternum or breastbone.

Shoulder Fractures

A fracture is a break in the bone that commonly occurs as a result of injury, such as a fall or a direct blow to the shoulder. The type of shoulder fracture depends of your age. Clavicle fractures are more common in children. A fracture of the upper part of the arm (proximal humerus) is more common in elderly individuals and its frequency increases with age.

Clavicle Fractures

A clavicle fracture, also called broken collarbone is a common fracture that occurs most commonly in children. A broken collarbone normally occurs after a fall onto the shoulder or a motor vehicle accident. The most common sports associated with clavicle fractures include football, hockey and skiing.

Symptoms of Clavicle Fractures

A broken collarbone most often causes pain, swelling and bruising over the collarbone. Pain increases with shoulder movement. Your shoulder may be slumped downward and forward. You may also have a bump around the area of the break. You may hear a grinding sound when you try to raise your arm.

Diagnosis of Clavicle Fractures

To diagnose a broken collarbone, your doctor will take a brief history, about the injury, and perform a physical examination of your shoulder. An X-ray of the clavicle is taken to identify the location of the fracture. Your doctor may also recommend a computerised tomography (CT) scan in some cases.

Treatment of Clavicle Fractures

Most broken collarbones heal without a surgery. An arm sling may support the arm and hold the bones in their normal position. You may also be given pain medications to relieve the pain.  After your pain reduces your doctor may recommend gentle shoulder and elbow exercises to minimize stiffness and weakness in your shoulder. Follow up with your doctor until your fracture heals.

Surgery may be required in case of displaced fractures. Surgery is performed to re-align the fractured ends and stabilize them during healing. Surgery often involves use of pins or plates and screws to maintain proper position of the bone during healing.

Proximal Humerus Fractures

The humerus is the upper arm bone and it forms two joints – the shoulder joint and elbow joint. The proximal humerus refers to the upper end of the arm bone, which forms the shoulder joint. Fractures of the proximal humerus are common in elderly individuals, suffering from osteoporosis.

Causes of Proximal Humerus Fractures

Fractures may be caused by traumatic injuries such as a fall on outstretched hand, from great heights or motor vehicle accidents. In younger individuals, a severe trauma can cause these fractures.

Types of Proximal Humerus Fractures

Proximal humerus fractures can be categorized into 4 groups:

  1. Greater tuberosity fractures: Greater tuberosity is the insertion site for attachment of rotator cuff tendons. Greater tuberosity fractures are less common and are seen in cases of shoulder dislocations and in those with osteoporosis.
  2. Lesser tuberosity fractures: These fractures often caused by posterior shoulder dislocations or traumatic muscle contractions by electrical shock or convulsions. If left untreated, these fractures cause subscapularis muscle (stabilizer and mobilizer muscle) deficiency and requires a major muscle transfer procedure.
  3. Surgical neck fractures: Fractures of the surgical neck are most common in patients with osteoporotic bone. These fractures also damage the axillary nerve that carries sensory impulses to the shoulder.
  4. Humeral head fractures: Humeral head fractures are very often in elderly individuals and chances are more in those with osteoporotic bone. These fractures occur in younger individuals by significant trauma whereas a mild traumatic injury can cause fracture in elderly individuals with osteoporosis.

In addition to the above, another type of proximal humerus fractures is two, three, and four-part fractures -  fractures that cause multiple fragmentation of the proximal humerus.

Signs and Symptoms of Proximal Humerus Fractures

Proximal humerus fractures may cause severe pain, swelling, and restricted motion of the shoulder.

Diagnosis of Proximal Humerus Fractures

Proximal humerus fracture is diagnosed by physical examination, X-ray of the affected area and/or computerized tomography (CT) scan.

Treatment of Proximal Humerus Fractures

Most proximal humerus fractures are minimally displaced and can be treated with conservative approaches such as use of sling to immobilize and early physical therapy to improve the functional outcome. Surgery may be necessary in displaced fractures. The multiple fragments are fixed with plates, screws, or pins and in severe cases a shoulder replacement surgery is performed.

Scapula Fractures

Scapular fractures are uncommon but do occur and require a large amount of force to fracture. They are usually the result of intense trauma, such as a high-speed motor vehicle accident or a fall from a height onto one’s back. They can also occur from a fall on an outstretched arm if the humeral head impacts on the glenoid cavity.

Symptoms of Scapula Fractures

Symptoms of a scapular fracture can include the following:

  • Pain: Usually severe and immediate following injury to the scapula.
  • Swelling: The scapular area quickly swells following the injury.
  • Bruising: Bruising occurs soon after injury.
  • Impaired mobility: Decreased range of motion of the joint occurs, often with inability to straighten the arm.
  • Numbness: Numbness, tingling, or coldness of the hand and forearm can occur if blood supply is impaired or nerves are injured.
  • Popping sound: A cracking or popping sound, also referred to as crepitus, can often be heard or felt at the time of the fracture.

Diagnosis of Scapular Fractures

Scapular Fractures should be evaluated by an Orthopaedic surgeon for proper diagnosis and treatment.

Treatments for Scapular Fractures

Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, a majority of scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement.

The conservative treatment options may include:

  • Immobilization: A sling is used for comfort and to support the shoulder to allow healing to take place. This is usually worn about 3-6 weeks depending on the type of fracture and
  • Prescription medications: Pain medications will be prescribed for your comfort during the healing process.
  • Physical therapy: Early progressive range of motion exercises is essential in restoring full shoulder function. Your physician will most likely refer you to a physical therapist for instruction on proper exercises and early motion of the shoulder to prevent complications.

Shoulder Dislocation

Playing more overhead sports activities and repeated use of your shoulder at the workplace may lead to sliding of the upper arm bone, the ball portion, from the glenoid–the socket portion of the shoulder. The dislocation might be a partial dislocation (subluxation) or a complete dislocation, causing pain and shoulder joint instability. Shoulder joint often dislocates in the forward direction (anterior instability) and it may also dislocate in backward or downward direction.

Symptoms of Shoulder Dislocation

Most common symptoms of shoulder dislocation are pain and shoulder joint instability. Other symptoms such as swelling, numbness and bruising may occur. At times, it may cause tear in the ligaments or tendons of the shoulder and nerve damage.

Diagnosis of Shoulder Dislocation

Your doctor will examine your shoulder and may order an X-ray to confirm the diagnosis.

Treatment of Shoulder Dislocation

The condition is treated by a process called closed reduction which involves placing the ball of the upper arm back into the socket. Following this, the shoulder will be immobilized using a sling for several weeks. Ice may be applied over the area 3-4 times a day. Rehabilitation exercises may be started to restore range of motion, once the pain and swelling decrease.

  • Royal Australasian College of Surgeons