Common Shoulder Fractures

Your shoulder girdle comprises your collarbone (clavicle), your shoulder blade (scapula), your arm bone (humerus) and all the muscles and ligaments that support and move these bones.  Injury to this area is fairly common.  Thankfully, many injuries do not require surgery, but shoulder injuries can take a long time to recover from.  Sometimes, surgery is the better option to allow a better functional outcome.

This section covers:

Proximal humerus fracture
Clavicle Fracture
Humeral Shaft Fracture
Scapula Fracture

Proximal Humerus Fracture

• This is a break to the upper end of your arm bone
• It’s often sustained after a simple fall in patients with brittle bones (Osteoporosis), but it may be a result of higher-energy trauma (e.g. car accident)
• Dislocation of your shoulder may happen at the same time 
• Your break may be simple or complex
• The bony displacement and degree of fragmentation can influence bony healing and functional outcome and may determine your need for surgery

What recovery should I expect?

If you do not need surgery

• Most proximal humerus fractures do not require surgery
  • You will be given a collar and cuff sling and asked to wear this for the first 6 weeks
  • Initially, your activities will be restricted to protect your bones as they knit together
  • After about 6 weeks, you will normally wean off your sling and begin more active movements
  • Your strength will start to recover from about 3 months, but these injuries take a long time to recover fully and it often takes a year to settle down
  • Your shoulder may always be stiff compared to your uninjured side

If you require surgery

• fixation (plate and screws or metal rod with bolts)
  • The aim of surgery is to restore the correct position of your proximal humerus to optimise the mechanics of your shoulder joint and reduce the chance of arthritis and failure of your fracture to heal
  • Depending on you and your particular injury pattern, your surgeon may recommend either plate-and-screw, or nail fixation of your fracture
  • In very severely damaged shoulders, fixation may not be feasible
• Replacement surgery for proximal humerus fracture
  • Replacement surgery may involve changing either part or all of your shoulder joint; it may even involve altering the mechanics of your shoulder to improve function (reverse geometry replacement)
  • After shoulder replacement surgery you will require a period in a sling with limited activity to allow your muscles to heal
  • The functional outcome after fracture replacement varies between patients. However, most patients regain useful shoulder function and improved pain

Clavicle Fracture

•  Your collarbone (clavicle) is the narrow curved bone that connects your breastbone to your shoulder blade. It is easy to feel at the top of your chest

What are the symptoms of Clavicle fracture?

• A fall onto the shoulder or a direct blow to the clavicle
• Pain, possible deformity and reduced shoulder function
• Occasionally associated with other injuries (shoulder/ribs etc.)
• Very rarely bone ends poke out from the skin

Does my Clavicle need to be fixed?

• Most clavicle fractures heal well without surgery
• Overall, 85% of displaced (where the bone ends are not well aligned) clavicle fractures will heal
• If your fracture is significantly displaced or fragmented, there is more chance that your bone won’t heal and that your function will be impaired
• Surgery can restore alignment to the collarbone and improve healing rates in fragmented and displaced fractures
• Fixation improves pain as your broken bones are stabilized and it generally allows earlier return to normal activities
• The surgery is not without risk however, and many fractures can be managed successfully without an operation
• If you initially opt for non-operative treatment, and your fracture doesn’t go on to heal, your fracture can normally be fixed later

Non operative management of clavicle fracture

• Painkillers are often required for the first two weeks or so
• You will be given a polysling to help control your pain
  • Your sling should support the weight of your elbow
  • Wear this sling until normal daily activities are comfortable
• Physiotherapy may be required if you are struggling with motion, but it’s often not required
• Your fracture will gradually get less painful and bony healing will take place over the first two months
• You will have X-rays in clinic to confirm healing

Surgery for Clavicle Fracture

If you require fixation of your clavicle fracture, the most predictable treatment is to plate you broken bone

• This is usually a day-case procedure under general anaesthetic
• You will have a scar over your fracture site  
• Your broken collar bone is restored to its correct position and fixed in place with a specially-designed metal (Titanium or stainless steel) plate and screws

Will my plate need to be removed?

• Your plate is designed to be low-profile and can stay in forever
• Sometimes patients find the metalwork prominent and irritating
  • In this case, your plate can be removed, ideally a year after surgery once your fracture has healed fully

What can go wrong?

• The complication rate with clavicle plating is low, but serious complications can very rarely happen
• Infection (1 in 100) – may need revision surgery and antibiotics
• Major bleeding (less than 1 in 100) – major blood vessels lie close beneath your collarbone. Every precaution is taken to avoid injury, but there is the potential for major bleeding if these vessels are injured. This is very uncommon.
• Pneumothorax (punctured lung) (less than 1 in 100) – the top of your lung sits behind your collar bone.  While very uncommon, it is possible to puncture the lung during clavicle surgery. If this happens, you may need a drain placed into your chest for a few days
• Non-union (1 in 100) – the bone almost always heals after plating surgery.  Very rarely is revision surgery required

What is my Prognosis?

• People generally make an excellent recovery
• Without surgery, outcomes are good as long as your bone heals
• With surgery, the bone healing rate is above 95%
• Full functional return will take between 3 and 9 months

Humeral Shaft Fracture

• This often follows a minor fall in patients with weakened bone (osteoporosis), but it may follow a high-energy injury (e.g. a car crash or a fall from height) in young people too
• In high-energy trauma, you may injure other parts of your body at the same time as your arm; these may be more urgent than your arm initially

Do I need to have surgery?

The majority of humeral fractures are managed without surgery

• Initially you will be given a collar and cuff sling to wear
• You may also be fitted with a custom-moulded plastic brace to help stabilise your arm as it heals
• You will be encouraged to keep your elbow and shoulder supple with gentle exercises as your arm heals

If you do need surgery

• Some fractures do better with surgery and your functional demands and health will also influence decision making
• If you have surgery, your fracture will be fixed either with a plate and screws, or with a rod placed inside your bone
• Your surgeon will discuss options and pros and cons of each type of technique

What if my hand isn’t working properly?

It is fairly common (10-20% of patients) for patients with a broken humerus to have signs of nerve injury in their arm.  The radial nerve runs round the back of your arm bone and can get stretched or damaged by your humerus bone as it breaks. Injury to this nerve causes your wrist and fingers to droop and also numbness over the back of your thumb and hand.  If your fracture is fixed, your surgeon will identify the nerve and confirm whether it is intact or not (it is normally intact but bruised).  If you do not otherwise need surgery, a watch and wait policy is recommended for your nerve initially.

Thankfully an injured radial nerve recovers in 90% of cases, but this can take many months and you may need to wear a splint and have therapy until your movement returns. Your surgeon may order special nerve testing after a few weeks to confirm that your nerve is beginning to recover. Very occasionally the nerve doesn’t recover and surgery to restore function is then indicated.

What can go wrong?

Complications of humeral fracture surgery include:

• Infection (approx.1 in 100)
  • May require plate removal/re-fixation and antibiotics
• Nerve damage (approx. 1 in 100)
  • The Radial nerve is identified and protected during surgery, but as it lies close to the humerus it is at risk
• Non-union (<5% with surgery)
  • After fixation, non-union is uncommon, but repeat fixation may be required if your fracture doesn’t heal
• Stiffness
  • Your elbow and shoulder can become stiff.  You will be encouraged to do gentle range of motion exercises to preserve supple joins above and below your injury

Scapula fracture

Your shoulder blade is hard to break because it is covered in lots of protective muscle.  Injury therefore involves significant force (e.g. car crash or fall from mountain bike).  Other injuries commonly co-exist and may require hospitalisation (e.g.ribs/lungs). Most scapula fractures do not require surgery as it heals well in the majority of fracture patterns.  Those few that do are indicated based on your functional demands, other injuries, health and the pattern of your fracture.  If you do require surgery, this involves an incision over the back of your shoulder blade. Plates are applied to stabilise your scapula.  You will rest your arm in a sling for a few weeks after surgery, before beginning more active movements.

Making the right choice about the best treatment for you means getting the right information. During your consultation, please do feel free to ask Mr Granville-Chapman to explain anything that you do not fully understand, and for his advice about the pros and cons of any treatment.