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 (collar-bone) or scapula (shoulder blade). The latter acts as a strut between the sternum 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 a road traffic accident is sufficient to cause fracture in these bones. A lesser impact may cause injury in older patients due to its weakened osteoporotic nature.
Scapula fractures are much less common due to the protection garnered from the chest wall and surrounding muscles. As a result this fracture necessitates high energy trauma to occur and is often accompanied with injuries to the chest.
What are the symptoms?
Severe pain, swelling and difficulty in moving the arm. A deformity may be evident (site dependent on which bone is affected) with surrounding bruising and a grinding sensation when attempts are made to move the limb.
How is it diagnosed?
In addition to taking a history and examination, your clinician will take radiographs of the shoulder to determine diagnosis. Occasionally a CT or MRI will be needed for a more detailed view of the fracture pattern to plan management.
How is it treated?
Clavicle - The majority can be managed without operation with a period of time with the arm immobilised in a sling. A plaster cast would be unsuccessful due to the site and structure of the clavicle. Surgery is considered in the following cases:
- Shortening of the clavicle by >2cm by the ends overlapping
- Overlying skin threatened (tenting) by the pressure of bone pushing through
- Multi-fragmentary fracture pattern
- Fracture not healed (non-union) after 3-6 months
- Fractures interfering with the acromioclavicular joint
Surgery would involve reduction of the fracture and fixation using either a rod or screws and a plate.
Proximal humerus – The majority can be managed without surgery, with the main indication for operation including fractures involving the joint surface and those that are particularly displaced. Any damage affecting the smooth articulate surface of the joint will cause uneven wear over time and pain.
Decision to operate will also depend on the characteristics of the patient, including their bone health, comorbidities and activity levels. Surgical options include fixing the fracture with a rod or plate and screws, or in some cases a joint replacement is warranted.
Scapula – Once again the majority of these injuries can be managed conservatively, however a thorough assessment should be made to exclude other injuries. Adequate analgesia, rest and ice is needed to ensure pain is controlled. In the small number requiring surgery plates and screws are used.