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Shoulder Fractures
The shoulder is a joint suspended
by many muscles surrounding the upper extremity. The shoulder bones include
the clavicle (collarbone), the scapula (shoulder blade), and the humerus
(upper arm bone). (see Figure 1) The only connection of the shoulder
girdle to the remainder of the skeleton is the clavicle. The scapula
is an important part of the shoulder joint as it serves as an anchor
for many muscles and contains the socket part of the shoulder (glenoid).
The upper end of the humerus has a ball-like shape that articulates with
the socket, and the humerus also serves as an attachment point for many
muscles and tendons. One of the most important is the rotator cuff. Disruption
of any of these parts can create difficulty with the function of the
shoulder.
Shoulder anatomy
Fracture type about the shoulder varies by age. The majority
of fractures in children occur in the clavicle. In the adult, fractures
within the upper part of the arm (proximal humerus) occur with increasing
frequency with older age. Some fractures may occur with dislocation of
the shoulder joint.
The most common fracture about the shoulder
is of the clavicle, frequently the result of a fall onto the shoulder
(see Figure 2). These fractures can be quite painful and cause difficulty
in moving the arm. Classically, treatment has been non-operative. Treatment
can be a simple sling or a “figure 8” strap, worn for three
to eight weeks, depending on one’s pain. Once healed, there may
be a bump over the fracture site which may decrease with time, but
sometimes a deformity may remain permanently. Range of motion can begin
as soon as pain subsides; return to sports cannot occur until full
shoulder strength returns. Return to contact sports would be considered
only when the fracture is fully healed on X-ray. Recently, surgical
treatment of these fractures has been reconsidered. Surgical treatment
options may include plates and screws or even a rod placed into the
bone. The consideration of these treatment options depends upon one’s
activity level and the dominance of arm use, i.e. a right-handed athlete
with injury to the right clavicle versus an older individual not engaged
in “overhead” activities.
Clavicle fracture
Fractures of this bone rarely
occur. Usually they result from high-energy trauma, such as motor vehicle
accidents or a fall onto the back from a height. Diagnosis of the fracture
is often made by X-rays. At times, more definition of the fracture may
require a CT scan to assess the displacement of the fracture fragments.
Treatment can range from a simple sling for two to four weeks to open
surgery. Surgery is more often needed with an injury to the glenoid (shoulder
socket) with displacement of the joint surface, the acromion, or the
neck of the scapula, the connection of the shoulder blade to the shoulder
socket (see Figure 1).
These
fractures usually occur from a fall onto the arm. In the younger population,
these injuries can be simple fractures, often associated with dislocations
of the shoulder joint. In those instances, the fracture is often treated
by putting the shoulder joint back into place, i.e. reduced. If X-rays
show that the fracture is in good position, sling immobilization is often
the treatment of choice. If the fracture is out of position, surgery
may be recommended.
Fractures of the upper part of the arm (humerus) are more
common in the older (over 65 years of age) population. Sometimes, there
may be no significant displacement of the bone fragments. In other cases,
the fracture fragments may be more severely displaced or angulated. Non-displaced
fractures can be treated with a sling for four weeks, after which motion
can be started. Recovery may require the use of physical therapy to assist
in improving motion and strength. For those fractures with displacement,
surgery may be the best treatment option. Surgery may entail repair of
the fracture with various devices, such as plates, screws, and wires
(see Figure 3). In some cases, the fracture is sufficiently severe that
a shoulder replacement may be necessary (see Figure 4).
Fracture repair
Replacement of humeral head
These injuries often leave one with residual shoulder stiffness regardless
of how well the bone was reconstructed or joint replacement performed.
The stiffness results from associated injuries to the muscles and tendons
as well as the ligaments.
With any injury about the shoulder, there are often many different treatment
options. Whichever one is chosen to treat your injury, the recovery can
be arduous and prolonged. Formal therapy and home exercises are a mainstay
of recovery. Your upper extremity specialist will be able to help guide
you through to your best result.
© 2007 American Society for Surgery of the Hand
Developed by the ASSH Public Education Committee
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