Treatment of 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. Shoulder joint is the most flexible joint of the body. It allows different motions of the hands making it possible for us to do a vast array of different activities. However its flexibility makes it more prone to injuries. The type of shoulder fracture depends of the age of the patients. 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.
Proximal Humerus Fractures
Humerus is the upper arm bone and it forms two joints – shoulder joint and elbow joint. The proximal humerus refers to the upper end of the arm bone, which forms shoulder joint.
Fractures of proximal humerus are common in elderly individuals, suffering from osteoporosis. Fractures may be caused by traumatic injuries such as a fall on outstretched hand, from greater heights or motor vehicle accidents. In younger individuals a severe trauma can cause these fractures.
Proximal humerus fractures can be categorized into 4 groups:
- 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
- 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
- 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
- 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 above, another type of proximal humerus fractures is two, three, and four part fractures, a fracture that cause multiple fragmentation of the proximal humerus.
Patients with proximal humerus fracture experience severe pain, swelling, and restricted motion of the shoulder.
Proximal humerus fracture is diagnosed by physical examination, X-ray of the affected area and/or computerized tomography (CT) scan.
Conservative Treatment Options
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.
Types of Fractures
The glenoid is the socket that forms the ball and socket joint of the shoulder. Fractures of the glenoid are rare but can occur due to major trauma or during high-energy sports activities.
Symptoms of a glenoid fracture include shoulder pain, swelling, deformity at the site of the fracture and inability to move the arm. Your doctor will perform a thorough physical examination and order X-ray’s or a CT scan to determine the extent of the fracture and displacement of the joint.
Non-displaced fractures require immobilization in a sling for about six weeks. If the fracture has led to the displacement of the bones, then surgery may be required to correct and fix them with pins, plates or screws. Physical therapy may be recommended to aid recovery and improve range-of-motion and strength of the arm.
Clavicle fracture, also called broken collarbone is a very common sports injury seen in people who are involved in contact sports such as football and martial arts as well as impact sports such as motor racing. A direct blow over the shoulder that may occur during a fall on an outstretched arm or a motor vehicle accident may cause the clavicle bone to break. Broken clavicle may cause difficulty in lifting your arm because of pain, swelling and bruising over the bone.
Broken clavicle bone, usually heals without surgery, but if the bone ends have shifted out of place (displaced) surgery will be recommended. Surgery is performed to align the bone ends and hold them stable during healing. This improves the shoulder strength. Surgery for the fixation of clavicle fractures may be considered in the following circumstances:
- Multiple fractures
- Compound (open) fractures
- Fracture associated with nerve or blood vessel damage and scapula fracture
- Overlapping of the broken ends of bone (shortened clavicle)
Plates and Screws fixation
During this surgical procedure, your surgeon will reposition the broken bone ends into normal position and then uses special screws or metal plates to hold the bone fragments in place. These plates and screws are usually left in the bone. If they cause any irritation, they can be removed after fracture healing is complete.
Placement of pins may also be considered to hold the fracture in position and the incision required is also smaller. They often cause irritation in the skin at the site of insertion and must be removed once the fracture heals.
Patients with diabetes, the elderly individuals and people who make use of tobacco products are at a greater risk of developing complications both during and after the surgery. In addition to the risks that occur with any major surgery, certain specific risks of clavicle fracture surgery include difficulty in bone healing, lung injury and irritation caused by hardware.
Percutaneous elastic intramedullary nailing of the clavicle is a newer and less invasive procedure with lesser complications. It is considered as a safe method for fixation of displaced clavicle fractures in adolescents and athletes as it allows rapid healing and faster return to sports. The procedure is performed under fluoroscopic guidance. It involves a small 1 cm skin incision near the sternoclavicular joint, and then a hole is drilled in the anterior cortex after which an elastic nail is inserted into the medullary canal of the clavicle. Then the nail is passed on to reach the fracture site. A second operation to remove the nail will be performed after 2-3 months.
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 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 a scapular fracture 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.
Scapular fractures should be evaluated by an orthopaedic surgeon for proper diagnosis and treatment.
Your surgeon will perform the following:
- Medical history
- Physical examination
Diagnostic studies may include:
- X-rays: A form of electromagnetic radiation that is used to take pictures of bones.
- CT scan: This test creates images from multiple X-rays and shows your physician structures not seen on regular X-ray.
- MRI: Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.
Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, most scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement.
Conservative treatment options 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 how well you heal.
- 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.
Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. will usually require surgical intervention to realign the bones properly and restore a functional, pain free range of motion to the shoulder joint.
Scapular fracture repair surgery has historically been performed through a large, open incision. Newer, minimally invasive techniques have evolved and surgery to repair scapular fractures can now be performed through arthroscopy.