What is a Shoulder Fracture?
A shoulder fracture is a break of one of the bones that make up the shoulder. Fractures are almost always due to an acute, traumatic injury. Most often, a shoulder fracture is caused by a fall, with someone landing directly on the shoulder or landing on one’s outstretched hand with the energy dissipated in the shoulder. Contact sports like hockey and football, and motor vehicle accidents are the most common causes of shoulder fractures. The shoulder structures that can be injured include:
Three bones:
- Humerus (arm)
- Scapula (shoulder blade)
- Clavicle (collarbone)
Three joints:
- Glenohumeral joint
- Acromioclavicular joint
- Sternoclavicular joint
The most common fracture about the shoulder is a clavicle fracture, followed by a fracture of the upper end of the humerus (proximal) and a scapula fracture. Dr. Cunningham is a shoulder specialist at Vail Summit Orthopaedics and Neurosurgery. He is an expert at diagnosing and treating shoulder fractures for patients in Vail, Summit County, Aspen, and Denver, CO.
What is a Proximal Humerus Fracture?
A proximal humerus fracture indicates a fracture at the top of the arm bone (humerus). The head of the humerus is the ball-like structure at the top of the humerus that fits into the shoulder socket–or glenoid– of the scapula, thus making the connection of the arm to the torso. A common fracture of the proximal humerus involves a fracture directly below the humeral head, resulting in a separation of the humeral head from the shaft of the humerus. Like all fractures, this fracture is classified as either displaced or non-displaced. If the fractured bone is still in a normal anatomical position, then it is classified as non-displaced. If the fractured bones are no longer in proper alignment, then it is classified as displaced. Displaced fractures will usually require surgery to restore normal positioning of the bone fragments as well as plates and screws to hold these fragments in the proper position so the humerus heals properly.
Patients with proximal humerus fractures experience:
- Immediate and severe shoulder pain
- Increased pain with any shoulder motion
- Severe swelling of the shoulder
- Subsequent Bruising
- Grinding sensation with motion
- An appearance of deformity
- Bleeding if fracture is open (bone fragments have penetrated the skin)
How Does a Shoulder Fracture Happen?
The majority of shoulder fractures are the result of a fall. Adults age 65 and older are more susceptible to ground level falls due to decreased balance and vision acuity. Furthermore, most older people suffer from decreased bone mass (osteopenia or osteoporosis), putting them at high risk of fracturing following a low energy fall. On rare occasion, there may even be a benign or malignant tumor in the bone which weakens the bone making it more susceptible to fracture.
How Painful is a Shoulder Fracture?
Most shoulder fractures cause severe pain. The pain is worse with even the slightest shoulder motions, so most people like to hold their arm at their side or keep it in a sling. Small motions like coughing increases pain. Pain also increases with even light touch to the fracture site.
Shoulder fractures commonly involve the tuberosities, which are small bumps of bone just off of the humeral head onto which the rotator cuff tendons attach. With fractures of the tuberosities, the rotator cuff function is then also compromised. The rotator cuff comprises the following 4 muscles and their attached tendons: supraspinatus, infraspinatus, subscapularis and teres minor.
It is important to seek immediate medical care when a shoulder fracture is suspected.
How to Treat a Shoulder Fracture?
The initial step for a shoulder fracture is an accurate diagnosis. A brief history and then a physical exam is performed. The shoulder is palpated to identify where the pain is located. Shoulder range of motion is assessed. Peripheral nerve function and blood flow to the upper extremity is checked.
Diagnostic imaging is then ordered to first check the bony structures for fracture. Simple xrays will demonstrate if a fracture is present. If the fracture is complex, then a CT scan may be ordered which shows bony details much better than an xray.
Treatment options will vary based on the severity of the fracture. Orthopedists who care for fractures are trained to know what fractures heal well without surgery and which would do better with surgery. Fractures that are minimally displaced or which have shifted minimally usually do not require surgery. These fractures are then treated with:
- Immobilization of the arm for a period of four to eight week using a sling
- Pain management, including Tylenol or narcotics if needed but usually avoiding non-steroidal anti-inflammatory medications which have been shown to slow bone healing.
- Ice to the affected area
- Gentle Physical therapy to help limit shoulder stiffness
- Treatment of any collateral injury to soft tissue damage.
- A graduated return to activities according to how much bone healing is seen on followup xrays at various intervals, and ultimately a return to normal activity with clearance by your orthopedist.
Compliance with non-surgical treatments often results in a good outcome. However, not uncommonly, patients can be left with some shoulder stiffness and decreased range of motion after having had a shoulder fracture. Some patients can also develop some premature arthritis in the shoulder if the cartilage in the shoulder was damaged at the time of the fracture.
Which Shoulder Fractures Require Surgery?
While many shoulder fractures improve with non-surgical management, there are several types of shoulder fractures which will have better outcomes with surgery:
- Clavicle Fractures: Surgery is indicated when the fractured ends of the clavicle are separated by 15mm or greater or when the skin has been punctured by a fractured bone end. Clavicle fractures are usually aligned and held in proper position with a special metal plate that has a contour which matches the normal curved shape of the clavicle and then small screws that thread into the plate.
- Scapula Fractures: Scapula fractures typically recover without surgery. However, if the fracture of the scapula extends into the shoulder socket (glenoid) and this surface is displaced, then surgery is indicated to line up the cartilage of the glenoid so this heals properly.
- Proximal Humerus Fractures: Fractures below the top of the humerus (humeral head) in which the head is separated from the shaft are often treated without surgery if there is minimal angulation or displacement. However, often these fractures involve the tuberosities (where the rotator cuff tendons attach adjacent to the humeral head) and then surgery is required to place all the fracture fragments back into the proper positon and then holding the fracture in proper position with a special locking plate and screws.
- Acromioclavicular (AC) Joint Separations: Tearing of the ligaments resulting in the end of the clavicle being displaced in various different directions and to different degrees of severity. Mild AC joint separations are treated without surgery and the ligaments can heal. More severe AC joint separations require surgery in order to have good outcomes.
Following surgery and a period of immobilization and physical therapy, most shoulder fracture surgery patients can return to all their normal activities within several months and do well. Dr. Cunningham is a shoulder specialist at Vail Summit Orthopaedics and Neurosurgery. He is an expert at diagnosing and treating shoulder fractures for patients in Vail, Summit County, Aspen, and Denver, CO.