Fractures around the shoulder

What is it?

Fractures around the shoulder involve three bones – the ‘clavicle’, the ‘scapula’ and the ‘humerus’. These bones make many joints and form the shoulder girdle, which connects the upper limb to the body.  The girdle helps provide an extensive range of motion. 
The whole shoulder joint is made up of the head of the humerus (the upper arm bone) that nestles against the scapula (shoulder blade), in a shallow socket called the ‘glenoid fossa’. The shoulder blade is joined to the clavicle (collar bone), at the acromioclavicular or AC joint. Here, the acromion process of the scapula (spine of the shoulder blade) meets the clavicle (collar bone). The clavicle is anchored to the sternum (the chest bone in the middle), at the sternoclavicular joint. The scapula (shoulder blade) also slides over the ribs on the back, and this is called the ‘scapulothoracic joint’ but it is not an actual joint.
While any of these bones can break, the most common fractures are of the clavicle and the upper humerus (proximal humerus).

What is its cause?

Fractures of the clavicle: They are very common injuries, usually seen in the young, following contact sports or falls from a horse or bike.
Fractures of the upper humerus: These too are very common, but tend to occur in older people with osteopenic bone, mostly after simple falls from a standing height on outstretched hands. The broken pieces of the upper humerus can displace because of the force of the injury, or because of the pull of the muscles attached to the fragments. The fragments will also collapse into one another.
Fractures of the upper humerus can also occur in the young, but usually because of a high-energy injury.

What are the symptoms and how is the condition diagnosed?

Fractures of the clavicle: Immediate pain is felt over the collarbone. If the fracture is displaced, prominence of the displaced bone can be immediately seen or felt.

Fractures around the Shoulder

Fractures of the upper humerus: Immediately after the fall, there will be severe shoulder pain. Bruising will soon develop and it will painful to move the shoulder.
X-rays: The diagnosis of both these fractures can only be confirmed by an x-ray. The pattern of fracture seen on the x-rays will determine the treatment. The x-rays will show the Specialist how much the bones have moved apart (displaced) or collapsed (shortening), and the number of bone fragments (comminution).
In case of upper humeral fracture, the x-ray will also clarify whether the fracture has damaged the humeral head.
Sometimes patients may also sustain a wound, and the fracture is called an ‘open fracture’. Open fractures are treated urgently to prevent further soft tissue damage and infection.
Symptoms like tingling and numbness suggest pressure on the nerves (usually the median nerve) and need to be monitored.

Will further tests or investigations be needed?

In addition to the initial x-ray, your specialist may in certain cases of upper humeral fractures, advise further investigations (usually CT) before planning treatment.

Fractures around the Shoulder

What is the treatment for acute fractures?

The general principle in treating a fracture is to reduce the displaced fracture and hold it in place. The method by which this can be achieved is dependent on the location of the fracture; the degree of fracture displacement; the extent of comminution (fracture fragments); the quality of bone stock and the functional demands of the patient. If it is an open fracture the wound needs to be cleaned, debrided and the fracture fixed urgently.

Treatment of acute clavicle fractures:

  1. Conservative treatment in a sling:
    This is the conventional treatment for relatively undisplaced clavicle fractures that occur after low energy accidents, are minimally displaced, or in those patients in whom anaesthesia or surgery will carry a greater risk. The arm is put in a sling for about 4-6 weeks. Special clavicle fracture braces are also commercially available and can be used for increased comfort. 
  2. Surgical treatment by fracture reduction and internal fixation:
    Surgery is advised for open fractures; unstable fractures (significantly comminuted, shortened or displaced); fractures with associated nerve problems or in patients who have sustained multiple fractures.

    Open reduction and internal fixation by a plate:
    This technique is an open operation with an incision on the front of the collarbone. The main advantage is that after precise alignment is achieved, the fracture fixation is strong to allow immediate shoulder motion. This will shorten healing and rehabilitation time. Specially designed plates and screws for the clavicle are used to fix the fracture.

    Fractures around the Shoulder

    Open reduction and internal fixation by a clavicle pin or elastic nailing: This surgical technique is also an open operation using 2 incisions. It is advised for fractures of the middle third of the collarbone. The specially designed clavicle pin needs to be removed after a few months.

    Arthroscopically assisted internal fixation using tightrope: If the fractures are sustained at the very outer end of the clavicle, the fracture can be fixed with the aid of a telescope (key hole surgery). Using a special jigging system and strong sutures (Tightrope) the clavicle is stabilised with 3 small incisions (see x-ray below)

    Fractures around the Shoulder

Treatment of acute Upper Humeral fractures:

  1. Conservative treatment in a sling:
    Such treatment is practiced in the majority of fractures that occur after low energy accidents, are minimally displaced or in those patients in whom anaesthesia or surgery will carry a greater risk. Treatment is with a sling for comfort and therapy is started as soon as pain allows. An x-ray may be advised after one week with some patients to confirm that the position is maintained, since the fractures can slip.
  2. Surgical treatment by fracture reduction and internal fixation:
    If the fracture extends into the humeral head (ball of the shoulder); or is associated with a shoulder dislocation; or if the fragments are displaced by more than 1 cm, or angulated by more than 45 degrees, then surgical treatment needs to be considered. The humeral head, the greater and lesser tuberosities, and the surgical neck make up the fracture fragments. The fractures are described as 2-part, 3-part or 4-part fractures (with/without dislocation) depending on the number of fragments. In 4-part fractures the blood supply to the humeral head is damaged. Sometimes, the blood supply to one of the fragments is so poor that the cells in that fragment die. This is called ‘avascular necrosis’.

    Closed reduction and K-wire fixation (Palm tree technique):
    The fracture is reduced under anaesthesia, and then supported by 2-3 pins (k-wires). The K wires are not strong enough to hold the fracture by themselves and the shoulder needs to be supported for 4-6 weeks. Open surgery is not required.

    Open reduction and internal fixation by a plate:
    This technique is an open operation, requiring an incision either on the front or side of the shoulder. This procedure is practiced in high-energy fractures, fractures that extend into the joint, displaced fractures, open fractures, fractures with associated nerve or vascular problems or patients who have sustained multiple fractures.  The main advantage of this technique is that after precise alignment is achieved, the fracture fixation is strong enough to allow early shoulder motion. Specially designed plates and screws for the upper end of the humerus are used to fix the fracture.

    Shoulder replacement (Hemiarthroplasty or reverse geometry replacement):
    It may not be possible to reconstruct some of the fractures if they are 4-part fractures. In such circumstances shoulder replacement is considered. When only the ball of the shoulder is replaced it is called a ‘Hemiarthroplasty’. Results of hemiarthroplasty for fractures have unfortunately not been consistent. Hence in the elderly, consideration can also be given to replacing both the ball and the socket of the shoulder with a complex reverse geometry replacement. You will need to discuss this in detail with the Shoulder Specialist.

    Fractures around the Shoulder

What happens if it is not treated?

If appropriate advice is not sought for these fractures, the fractures may heal with a deformity. Clavicle fractures may heal shorter than before or may not heal at all. Significant shortening of the clavicle can give rise to problems of the shoulder, especially in patients with high demands on their shoulder.
Fractures of the upper humerus may heal in a poor position that the rotator cuff muscles will not be able to function properly. Significant shoulder stiffness may follow. In some cases, part of the humeral head may die because of poor blood supply (avascular necrosis) and in the long-term arthritis may develop. It is also possible that these issues may not cause any trouble, if the demands on the shoulder are low.

What is the success of treatment?

Both conservative and surgical management of appropriate clavicle fractures are usually successful. Recovery can take a long time especially with high-energy injuries because there has been significant soft tissue damage.
Success of treatment for fractures at the upper end of the humerus is unpredictable and depends on the nature of the fracture, and the age and functional demands of the patient. The aim of surgery is to regain functional range of motion and strength. It is unlikely that a full range of motion will be regained in the majority.

What are the complications of treatment?

  • Infection of the wound is possible and can usually be successfully treated with antibiotics.
  • Shoulder stiffness and poor strength.
  • Unsightly scar.
  • A patch of numbness around the scar.
  • Nerve (axillary) damage.
  • The implants may cause problems and need to be removed.
  • The bones may still fail to unite after surgery.
  • If the shoulder has to be replaced, the operation may fail in the long-term. If this does occur, the replacement will need to be revised. The replacement may fail to relieve the pain totally.
  • Any surgical intervention has the risk of developing complications that are unpredicted. These complications may have the potential to leave the patient worse than before surgery.

Is there anything I can do to improve the outcome?

  • Keep the wounds dry and clean until they have healed.
  • After the operation, the therapist will see you and start movements of the shoulder. It is important to do the prescribed exercises regularly both during the physiotherapy sessions and at home. It will help to keep the pain levels down with analgesics so as to keep your shoulder, elbow and hand fingers moving.
  • It is advised against wearing rings on the operated side for 4-6 weeks after surgery.

When can I do various activities?

Return to work depends on many factors including the nature of the job, hand dominance and the nature of your fracture. It will vary individually and this is best discussed with the Specialist.