Shoulder Joint Fracture

Shoulder joint consists of Gleno-Humeral joint and Acromio-Clavicular joint. Gleno-Humeral joint links humerus and glenoid socket of scapula. Acromio-Clavicular joint is a link between Acromion bone of scapula and clavicle. Shoulder joint fracture includes fracture of proximal (close to shoulder joint) part of humerus, glenoid cavity, acromion, coracoid process, neck of scapula, body of scapula and clavicle bone. Gleno-Humeral joint is the ball and socket synovial joint. Most of the movements of the shoulder joint occur at Gleno-Humeral joint. Fracture of the lateral (outer- near shoulder joint) end of clavicle is the most common shoulder joint fracture observed in children. Fracture of upper end (proximal) of humerus is the common fracture in adult patient. Fracture of glenoid cavity is observed with dislocation or in older patient.

Shoulder Joint Fracture

Types Of Shoulder Joint Fracture

Type of Shoulder Joint Fracture involving clavicle, scapula and humerus are as follows-

a. Hairline Fracture-

Hairline Fracture

  • Fracture involves partial circumference and partial depth of the bone.
  • The two fracture ends are not separated.

b. Non-Displaced Fracture-

Non-Displaced Fracture

Non-displaced fracture is a break in complete thickness of the bone without any separation.

c. Displaced Fracture-

Displaced fracture ends up with separation of two end of the broken bone creating an angle alignment or overlapping two ends.

d. Compound Fracture-

Compound Fracture

  • Compound fracture is a displaced fracture with open skin and soft tissue wound.
  • One or both the ends of fractured bone or broken bone protrudes outside through the skin.
  • Compound fracture is often seen with fracture of humerus and clavicle.
  • Other types of shoulder joint fracture do not end up in compound fracture unless injury is severe and associated with multiple body injury.

Classification Of Shoulder Joint Fracture

1. Clavicle Fracture-

Clavicle Fracture

  • Lateral end of clavicle is a part of shoulder joint.
  • Fracture of lateral (outer) end of clavicle causes severe pain with shoulder joint movements.
  • Skin over fractured site is often bruised.
  • The area over fracture is swollen because of hematoma (blood clot) or outward protrusion of broken (fracture) clavicle.

2. Scapular Fracture

Scapular fracture is classified as follows-

  • Scapular Body Fracture- Fracture of body of scapula is non-displaced and partial fracture. Fracture involves partial length of body of scapula.
  • Scapular Neck Fracture- Fracture is outside glenoid socket. Fracture is either partial or complete involving neck of scapula.
  • Glenoid Socket Fracture- Fracture may extend to rim of glenoid socket (fossa), articulating cartilage and scapula.

Scapular Neck Fracture

  • Acromion Fracture- Acromion bone (part of scapula) forms an Acromio-clavicular joint with clavicle bone. Acromion bone is located at the highest point on the shoulder blade. Acromio-clavicular joint allows arm to rise above shoulder joint.

Acromion Fracture

  • Coracoid Fracture- Coracoid is a protrusion of scapula adjacent to Gleno-Humeral and Acromio-clavicular joint. Fracture of coracoid is very uncommon.

3. Humerus Fracture

Humerus Fracture

Proximal (near shoulder joint) humerus fracture is classified as follows-

  • Fracture of head of humerus
  • Fracture of proximal shaft of humerus
  • Fracture of greater tuberosity
  • Fracture of lesser tuberosity

Causes Of Shoulder Joint Fracture

  • Domestic Fall
  • Sports Injury
  • Automobile Accident
  • Work Accident.

Symptoms and Signs Of Shoulder Joint Fracture

Chronic Pain-

Pain at Rest-

  • Moderate to severe pain seen following fracture of acromion, coracoid process, body of scapula and clavicle
  • Severe to very severe pain is observed in fracture of humerus, fracture of neck of scapula and glenoid socket fracture.

Pain with Activities-

  • Moderate to severe pain is observed following fracture of coracoid process and acromion bone fracture
  • Severe to very severe pain follows fracture of humerus, neck of scapula and glenoid socket fracture.

Painful Shoulder Joint Movement-

Pain With Attempt of Abduction (Outward Stretching) of Arm-

  • Fracture of Clavicle
  • Fracture of Humerus
  • Fracture of Glenoid Socket

Pain With Attempt of Flexion (Forward Bending) of Arm-

  • Fracture of Humerus
  • Fracture of Glenoid Socket
  • Fracture of Acromion

Pain While Arm is Tried To Extend Backward-

  • Fracture of Humerus
  • Fracture of Glenoid Socket
  • Fracture of Neck of scapula
  • Fracture of Body of Scapula

Pain When Arm is Raised Above Shoulder Joint-

  • Fracture of Acromion
  • Fracture of Humerus

Shoulder Joint Swelling-

Shoulder joint swelling is caused by post-traumatic soft tissue edema and hematoma (blood clot). Hematoma is either subcutaneous or intra-articular (inside and surrounding the joint).

Swelling and Bruises Over Anterior Side of Shoulder Joint

  • Fracture of Clavicle (lateral 1/3rd of clavicle.)
  • Fracture of Anterior Glenoid Cavity

Swelling and Bruises Over Lateral Side of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Acromion

Swelling and Bruises Over Back (Posterior) of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Coracoid Process
  • Fracture of Glenoid Socket of Scapula
  • Fracture of Neck of Scapula
  • Fracture of Body of Scapula

Tenderness Over Shoulder Joint-

Pain is felt or intensity of pain is increased during examination of the joint. Light touch or palpation can elicit severe pain suggesting joint is tender.

Tenderness Over Anterior Side Of Shoulder Joint

  • Fracture of Clavicle
  • Fracture of Anterior Glenoid Cavity

Tenderness Over Lateral Side Of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Acromion

Tenderness over back (posterior) of shoulder joint

  • Fracture of Humerus
  • Fracture of Coracoid Process
  • Fracture of Glenoid Socket of Scapula
  • Fracture of Neck of Scapula
  • Fracture of Body of Scapula

Shoulder Joint Deformity-

Protrusion of broken (fracture) end of the bones through soft tissue causes uneven hard "bump" of shoulder joint.

Deformity Over Anterior Side Of Shoulder Joint

  • Fracture of Clavicle
  • Fracture of Anterior Glenoid Cavity With Anterior Dislocation Of Humerus

Deformity Over Lateral Side Of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Acromion

Tenderness Over Back (Posterior) Of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Coracoid Process
  • Fracture of Glenoid Socket of Scapula
  • Fracture of Neck of Scapula
  • Fracture of Body of Scapula

Stiffness of Shoulder Joint-

Patient is unable to move shoulder joint because of muscle spasm and disruption of joint link.

Skin Abrasion Over Shoulder Joint

  • Skin laceration or abrasion causes purple discoloration and skin injury.
  • Purple discoloration is caused by bleeding in subcutaneous tissue either from direct trauma to blood vessels or profuse bleeding at the fracture side spreading into subcutaneous tissue and muscles.

Skin Abrasion And Bruises Over Anterior Side Of Shoulder Joint

  • Fracture of Clavicle
  • Fracture of Anterior Glenoid Cavity With Anterior Dislocation Of Humerus

Skin Abrasion And Bruises Over Lateral Side Of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Acromion

Skin Abrasion And Bruises Over Back (Posterior) Of Shoulder Joint

  • Fracture of Humerus
  • Fracture of Coracoid Process
  • Fracture of Glenoid Socket of Scapula
  • Fracture of Neck of Scapula
  • Fracture of Body of Scapula

Investigations And Diagnostic Tests for Shoulder Joint Fracture

X-Ray

Following type of fracture of humerus, clavicle and scapula are diagnosed with X-Ray-

  • Non-Displaced Fracture (NDF) - NDF of clavicle, humerus, acromion and body scapula are seen with X-ray.
  • Displaced Fracture (DF)- DF of clavicle, humerus, acromion, coracoid and body of scapula are seen with X-Ray.
  • Compound Fracture (CF)- CF of humerus and clavicle are diagnosed with X-Ray.
  • Most of the hairline fracture of the shoulder joint is difficult to diagnose with X-ray.

MRI and CAT Scan

All the fractures of shoulder joint are diagnosed with MRI and CAT scan.

Ultrasound Examination

Ultrasound examination is performed to diagnose following conditions-

  • Fracture of Humerus
  • Fracture of Body of Scapula
  • Fracture of Neck of Scapula
  • Subcutaneous Hematoma
  • Intra-Articular Hematoma

Treatment Of Shoulder Joint Fracture

Conservative Treatment of Shoulder Joint Fracture

Conservative treatment with NSAIDs is often adequate to treat hairline fracture and non-displaced fracture of the shoulder joint.

Choice of Conservative Treatments Is As Follows-

  • Restriction of shoulder joint movement by using sling. Shoulder Joint Sling is a "figure 8" strap. Shoulder joint movement is restricted and supported by a Sling for 6 to 8 weeks.
  • Cold Therapy- Ice pack is applied over clavicle 2 to 3 times a day immediately following injury for 1 to 2 weeks. Cold therapy prevents and reduces bleeding thus prevents or restricts hematoma.
  • Moist Heat Therapy- Heat therapy is useful during healing of the fracture. Heat therapy or infra red light therapy is used for 3 to 4 weeks after wound and fracture is healed. Heat therapy improves blood supply to wounded area and assists in rapid wound healing.

Physical Therapy (PT) For Shoulder Joint Fracture

Physical therapy is advised immediately following injury and after fracture is healed.

Physical Therapy (PT) Immediately Following Injury-

  • Physical therapy is advised while shoulder joint movement is restricted with sling and rest.
  • The exercise is mostly directed to prevent forearm and hand muscle atrophy and weakness.
  • Exercises are performed while arm is in sling and shoulder joint movements are restricted.

Physical Therapy (PT) After Fracture is Healed-

Physical Therapy (PT) is Indicated To Accomplish Following Goals:

  • Stretching of shoulder muscles
  • Strengthening of shoulder joint muscles
  • Prevent muscle, ligament and tendon atrophy
  • Improve range of joint movement
  • Prevent joint stiffness

Medications for Shoulder Joint Fracture

a. Non-Steroidal Anti-Inflammatory Medications (Drugs)- NSAIDS

  • Prescribed for inflammation and to assist healing of wound
  • Prescribed for pain
  • Precautions- Watch for stomach pain, gastric ulcer and bleeding disorder
  • NSAIDs medications prescribed are Motrin, Naproxen, Daypro and Celebrex

b. Opioids (Narcotics)

  • Used as Analgesics (Anti-Pain Medication)
  • Precautions- Nausea, Vomiting, Constipation, Dependence and Addiction
  • Opioids Prescribed For Pain Are As Follows-
    • Short Acting- Acts for 3 to 4 hours
      • Hydrocodone, (Vicodine, Lortab and Norco)
      • Oxycodone (OxyIR)
      • Morphine (MS IR)
    • Long Acting- Acts for 12 to 24 hours.
      • Oxycodone (Oxycontin)
      • Morphine (MS Contin), Avinza
      • Methadone

c. Muscle Relaxants

Most common muscle relaxants prescribed are as follows-

  • Baclofen
  • Flexeril
  • Skelaxin
  • Robaxin

Interventional Therapy for Shoulder Joint Fracture

Cortisone Injection

Cortisone injection is performed to treat chronic inflammation and pain.

Surgery for Shoulder Joint Fracture

1. Plates and Screws

Plates and Screws

  • Fractured Humerus
  • Fractured Clavicle
  • Fractured Acromion
  • Fractured Coracoid Process
  • Fractured Body of Scapula

2. Shoulder Joint Replacement-

Shoulder Joint Replacement

Shoulder joint replacement surgery involves replacement of head of humerus and glenoid socket with plastic or metal prosthesis.

Following fractures are treated with shoulder joint replacement-

  • Fracture of Humerus
  • Fracture of Glenoid Socket

3. Reverse Replacement-

Reverse Replacement

Surgery involves reversal of anatomical position of ball and socket. The socket is placed over humerus, and plastic or metal ball is placed over scapula to replace glenoid cavity.

Surgery Is Performed To Treat Following Shoulder Joint Fracture-

  • Fracture of Humerus
  • Fracture of Glenoid Socket
  • Fracture of Neck of Scapula

4. Hemiarthroplasty

Hemiarthroplasty

Head of humerus and cartilage is replaced with metal prosthesis. Glenoid socket is normal. Following fracture is treated with hemiarthroplasty-

  • Fracture of head of humerus.

Complications Following Surgery-

Shoulder Joint Deformity-

  • Fracture may heal with deformity.
  • Deformity is because of slight overlapping of fracture end during healing of the fracture.

Bleeding

Profuse bleeding may occur during and following surgery needing follow up surgery to evacuate blood clot

Infection of Shoulder Joint

  • Infection may occur following surgery.
  • Infection is common following surgery and joint hematoma.
  • If infection continues and does not respond to antibiotics then prosthesis (surgical metal instrument) will have to be removed.

Restricted Joint Movement and Continuous Severe Pain-

  • Several muscles are attached to humerus and scapula.
  • Pain often continues and is felt at severe intensity after complete healing of fracture site because of muscle attachment getting scarred following injury and during healing of the fracture.
  • Muscles end or tendon is trapped in calcified bone around fracture site and muscle contraction causes severe pain.

Precaution During And Following Treatment Of Shoulder Joint Fracture

Avoid Smoking

Smoking interferes with wound healing

Avoid Driving

Driving is not safe during treatment. Sling and pain will interfere with use of wounded arm and steering the car.

Avoid Manual Work

  • Recurrence of injury may cause displaced fracture of compound fracture and severe injury.
  • Table work is possible if side effects of medications are not interfering with concentration and cognitive behavior.

Avoid Sports

  • Avoid sports until wound is completely healed.
  • Avoid sports until all the medications are eliminated and wound is completely healed.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: September 30, 2014

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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