Fractures

What is it?

This constitutes any break in a bone that makes up the shoulder joint, such as the proximal humerus (top of the arm), clavicle (collarbone) or scapula (shoulder blade). The latter acts as a strut between the sternum (breastbone) and scapula, keeping the arm to the side of the body.

Why does it occur?

A direct blow sustained after a fall, during contact sports, or as a result of a road traffic accident, is sufficient to cause fracture in these bones. Less traumatic impacts may cause injury in older patients, due to the weaker and more fragile  nature of the bones.

Scapula fractures are much less common, due to the protection garnered from the chest wall and surrounding muscles. As a result, this fracture will almost always only occur as a result of  high energy trauma, and is often accompanied with injuries to the chest.

Sometimes certain people may suffer instability when only a small force is applied to the shoulder. This is otherwise known as ‘atraumatic dislocation’, and occurs when the surrounding structures are lax as a result of overuse or due to congenital conditions. The joint will often relocate without need to attend hospital and such injuries are common in those who are double-jointed.

Finally, a subset of patients suffer with inappropriate muscle recruitment. Otherwise known as ‘muscle patterning’, this is when the muscles surrounding a joint are not working as they should in conjunction with each other.

What are the symptoms?

Severe pain, swelling and difficulty in moving the arm are the most common symptoms. A deformity may be evident (depending on which bone is affected), with surrounding bruising and a grinding sensation when attempts are made to move the arm.

How is it diagnosed?

In addition to taking a history and a physical examination, your surgeon will take radiographs of the shoulder to determine the correct diagnosis. Occasionally, a CT scan or MRI will be needed in order to obtain a more detailed view of the fracture pattern, and so plan appropriate treatment.

How is it treated?

Clavicle
The majority of such fractures can be managed without the need for surgery, but with the arm immobilised in a sling for a period of time. A plaster cast is not appropriate, due to the site and structure of the clavicle.

Surgery would be considered if the fracture is: shortened by 2 centimetres or more; displaced more than 100 per cent (the fractured ends aren’t touching at all); when there are specific fracture patterns (such as Z-type fractures); when the fractures are highly comminuted (splintered); or when there is overlying skin which is threatened by the pressure of bone pushing through. Surgery may also be necessary if a fracture has not healed after 3 to 6 months of if it is interfering with the function of other joints. 

Surgery in these cases would involve reducing the fracture and fixing the bone using either a rod or screws, and a plate.

Proximal humerus
The majority of fractures to this bone can be managed without surgery. An operation may be deemed necessary if the fractures involve the surface of the joint and are  particularly displaced. Any damage affecting the smooth articulate surface of the joint, which is not corrected, will cause uneven wear, and pain, over time.

Any decision to operate will  depend on the patient, including a consideration of their bone health, other health conditions and activity levels. Surgical options include fixing the fracture with a rod or plate and screws, and in some cases,  a complete joint replacement.

Scapula
The majority of injuries to the should blade can be managed conservatively. However, a thorough assessment should be made to ensure there are no other associated injuries. Adequate analgesia, rest and ice are needed to ensure pain is controlled, and in the small number of injuries requiring surgery, plates and screws are used.

Treatment options

Shoulder replacement

Shoulder replacement

Shoulder replacement

The One Orthopaedics team specialists

Anthony Hearnden

Consultant Orthopaedic Specialist FRCS (Tr & Orth)