Shoulder Fratures 1

‫ ناصح جواد‬.‫د‬

Upper Limb Injuries

The great problem with upper limb injuries is joint stiffness, specially the
shoulder joint. Two points should be considered during the management of
any upper limb injury:

 Whatever the injury – should encourage exercise from the start especially the
fingers.
 In elderly patients it is sometimes best to disregard the fractures and concentrate on
regaining movements.

1.Fractures:
1.1: Fractures of the Clavicle:
It is a common fracture. In children it is almost rapidly unites, often without complications.
In adults it can be a much more troublesome injury.

Mechanism of injury: commonly it occurs due to fall on the shoulder or the outstretched
hand.

Types: Middle 1/3 fractures: it is the commonest fracture account for 80% of cases, in
which the outer fragment is pulled down by the weight of the arm and the inner fragment
is held up by the sternomastoid muscle. Lateral 1/3 fractures: account for 15% of cases,
in which if the coracoclavicular ligaments are intact there is only little displacement, but if
torn, or if the fracture is just medial to these ligaments, displacement may be severe and
closed reduction is impossible. Medial 1/3 fractures: it is rare, often extra-articular and
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sometimes may threaten the mediastinal structures.
Clinical Features: the arm is held immobile, an acutely tender subcutaneous lump may be obvious
and occasionally a sharp fragment threatens the skin. Although vascular injury is rare, it is prudent to feel
the pulse and gently to palpate the root of the neck.

X-ray: at least an AP view. In fracture clavicle the ‘clinical’ union usually precedes ‘radiological’ union by
several weeks, so always should consider this fact when we assess the healing of a fractured clavicle. CT
scan sometimes indicated as to assess accurately the degree of shortening and to establish whether a
fracture has united or not.

Treatment: Non-operative: by arm sling for 1-3 weeks, followed by gradual shoulder exercise, it is
the usual line of treatment especially when the fracture is non-displaced or mildly displaced.

Surgery: is sometimes indicated when:

1.there is an associated major neurovascular injury.

2. Compound fracture.
3. Middle 1/3 fracture if grossly displaced or there is more than 2 cm shortening.
4. Displaced lateral third fracture.
5. Symptomatic non-union.
6. Medial 1/3 fracture displacement threatens the mediastinal structures. Fracture fixation can be
achieved by plate and screws, intramedullary nail, and sometimes external fixation may be used in
compound fractures.
 Complications: Early complications are very rare as pneumothorax, subclavian
vessels and brachial plexus injuries. Late complications are non-union, especially lateral
third fracture (11-40 %), malunion, it has been found that if there is bone shortening more
than 1.5cm may lead to periscapular pain. Stiffness of the shoulder joint, and sometimes
fingers also may occur.

1.2: Fractures of the Scapula:

Types: any part of the scapula may be broken as scapular body fracture, glenoid neck
(most common fracture), glenoid fossa (intra-articular fracture), acromion process, and
coracoid process fracture.

Clinical features: the arm is held immobile, and there may be severe bruising over the
scapula or the chest wall. Always look for associated serious injuries as injuries of the
chest, spine, abdomen, head, vessels, and brachial plexus.

X- ray: scapular fractures can be difficult to define on plain x-rays because of the
surrounding soft tissues. CT scan is more useful for demonstrating fractures especially
scapular body and glenoid fossa fracture.

Treatment: often indicated by using a sling, analgesia, and exercise. Surgery (open
reduction and internal fixation) sometimes indicated especially when there is grossly
displaced fracture or associated with shoulder instability and in combine fractures as
combination of glenoid neck and clavicle fractures called ‘floating shoulder’, should do
surgical fixation for both fractures or at least one of them.

3.: Fractures of Proximal humorous:

Pathology: It can be occur at any age, but it is most commonly seen after a middle age. Most of
the patients are osteoporotic, postmenopausal women. Fracture displacement is usually not
marked and only in about 20 % of cases there is considerable displacement of one or more
fragment.

Mechanism of injury: It is usually occur after a fall on outstretched hand.

Types (Neer’s Classification): the proximal humorous is divided into four fragments: the
shaft, head, greater tuberosity, and lesser tuberosity. The fragment considered to be displaced: if
there is more than 1cm separation or more than 45 degree angulation. According to Neer’s
principles the fractures of proximal humorous are divided into the following types:

1. One-part fracture: even if there are many fracture lines, if the fragments are undisplaced. It is
the most common type.
2. Two-part fracture: if one major fragment is displaced, as displaced fracture of anatomical
neck, surgical neck.
3. Three-part fracture: if two major fragments are displaced.
4. Four-part fracture: if all the major fragments are displaced.
5. Fracture-dislocation: if the head of humorous is dislocated plus two-, three-, or four- part
fracture.
Clinical Features: because the fractured fragments are often firmly impacted, pain
may not be severe. However, the appearance of a large bruise is suspicious of fracture.

Radiology: plain x-ray has high level of inter-observer variation. CT scan greatly
clarifies the fracture fragments.

Treatment:
 One-part fracture: only 1-2 weeks arm sling then exercise; passive then active.
 Two- part fracture: Surgical neck fracture: the fragments are gently manipulated
into alignment and the arm is immobilized in a sling or cast for 4 weeks. If the
fracture cannot be reduced closed or very unstable, then fixation is required.
Greater tuberosity fracture: it is often associated with anterior dislocation and
usually it reduces to a good alignment when the shoulder is relocated. Anatomical
neck fracture: if the patient is young: fixation with a screw is the option, and if the
patient is an old one usually with a high risk of avascular necrosis of the humeral
head, then prosthetic replacement may be considered.
 Three-part fracture: the best treatment is open reduction and internal fixation.
 Four-part fracture: is very difficult to treat. In general, in young patient: can do open
reduction and internal fixation, while in elderly patient better to choose prosthetic
implant.
 Fracture dislocation: With two-part fracture: closed reduction. With three-part
fracture: open reduction and internal fixation. With four-part fracture: young active:
open reduction and internal fixation, old patient: prosthetic replacement.
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Complications:
 Early: vascular injury, nerve injury, axillary nerve is at particular risk; brachial
plexus may be also injured. Associated chest wall injury also should be
considered during the management of fracture proximal humorous.
 Late complication: 1.Avascular necrosis of humeral head, especially in three and
four part fractures. 2. Stiffness of the shoulder especially in old age. 3. Malunion:
in children even considerable displacement or angulation can be accepted,
because of the marked growth and remodeling of the proximal humorous. 4.
Downward subluxation of humeral head: it is due to muscle atony and it usually
recovers once exercises begun.

1.4: Fracture Shaft of Humorous:

Mechanism of injury: fracture shaft of humorous can be occur due to fall on the
hand (spiral fracture), fall on the elbow (oblique or transverse fracture), direct blow
(transverse or comminuted fracture). Pathological fracture should be considered as a
cause of fracture shaft of humorous especially when it occurs due to a trivial trauma.

Pathological anatomy: If the fracture level is above the deltoid insertion on the
humeral shaft, the proximal fragment is adducted by pectoralis major muscle pull. If the
fracture is lower down, then the proximal fragment is abducted by the deltoid muscle
action.

Clinical features: the arm is painful, bruised, and swollen. It is important to

test for radial nerve function before and after treatment, best by assessing
the active extension of the metacarpophalangeal joint especially of the thumb
(Thumb up sign).

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Treatment:
 Conservative treatment: the fracture shaft humorous usually does not
require perfect reduction, so it often does well with conservative treatment. The
weight of the arm with an external cast (hanging cast) is usually enough. This cast
is usually replaced after 2-3 weeks by a short cast (shoulder to elbow- U-shape) or
a functional brace for a further 6 weeks.

 Operative treatment: surgery is indicated in the following situations: severe

multiple injuries, open fracture, associated major vascular injury, segmental
fracture, displaced intra-articular extension of the fracture, pathological fracture,
floating elbow (simultaneous unstable fracture of the humorous and forearm), radial
nerve palsy after manipulation, and when there is non-union. Sometimes surgery is
considered also when there is a problem with nursing care. Types of fixation of
humeral shaft fracture are: plate and screws, intramedullary nail, and external
skeletal fixation.

Complications: early: vascular injury (brachial artery), nerve injury: radial nerve
injury is common especially in oblique fractures at the junction of middle and distal thirds
of the bone (Holstein-Lewis fracture). Late complications are: delayed union, non-union,
and joint stiffness.
 2. Dislocations:
2.1: Acromioclavicular joint (ACJ) injuries:
ACJ injury is an injury to the ligaments that hold the acromioclavicular joint together.
Acute injury to ACJ is common and usually follows direct trauma or fall on the shoulder
with the arm adducted.

Pathological Anatomy: Strain or tear of the acromioclavicular ligament may lead to

subluxation of the ACJ., but if the coracoclavicular ligament also torn, this will lead to
complete dislocation of the joint creating a visible and palpable ‘step’.

Clinical Features: there is localized pain, which will be worse when trying to move the
arm above the shoulder. There is bruising, prominent “step” and tenderness over the
joint.

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X-ray: AP view with cephalic tilt and axillary view are advisable. Stress view
sometimes necessary to assess the severity of displacement.