Shoulder and Clavicle Fractures
Fractures of the shoulder most commonly include either clavicle (collarbone) fractures or proximal humerus (ball) fractures. Less commonly involved fractures of the shoulder include the glenoid (socket) and the scapula (shoulder blade). Fractures are broken bones and can range in severity from a mild crack to a large break including multiple broken pieces. They are most commonly caused by accidents such as: motor vehicle accidents, a fall, or a direct blow to the area.
Proximal Humerus Fractures
Possible symptoms of a proximal humerus fracture include pain, inability to move the arm at the shoulder joint, severe bruising and swelling, noticeable deformity, grinding sensation with attempted shoulder movement.
If you think you have broken your shoulder, you should seek medical attention immediately. You should call 911 or go to the closest emergency department. If your symptoms are not severe, and you are not having any numbness or loss of sensation-you may also seek care at an urgent care facility or orthopedic office. You should be seen as soon as possible from the time of your injury.
Your emergency medical provider will do an x-ray to evaluate for shoulder fracture. They will check to make sure your nerves and blood vessels have not been injured. If your fracture is deemed “stable”, then you will likely be provided with a sling and referred to an orthopedic specialist for further evaluation and discussion of treatment options.
Evaluation by orthopedic specialist: It is likely that you will need new x-rays taken, even if you already had x-rays taken at an emergency department or urgent care facility. There are specific views necessary to guide treatment, often these views are not obtained at an emergency visit. Additionally, you may need further imaging such as a CT scan. Your orthopedic provider will do a physical exam and review all imaging, together they will help you come up with the best treatment option for your proximal humerus fracture.
Non-Surgical: If your orthopedic specialist feels your shoulder fracture may be treated without surgery-then you will likely spend 3-4 weeks in a sling followed by a course of physical therapy to help regain your motion. This is only an estimate, some people need less time or more time in a sling. Actual fracture healing time is much longer and can take up to 12 weeks to heal. You will likely need to come in for frequent follow-ups early on in the course of treatment to make sure your fracture is showing signs of healing and is not moving. Pain is best controlled with a combination of over the counter medications including Tylenol and NSAIDS.
Surgical: Based on your fracture type, surgery may either be strongly recommended to you or you may have a fracture type that could be treated with or without surgery based on your preference.
Types of surgery include:
- Open Reduction and Internal Fixation with metal hardware-this may include a metal plate and screws or a special procedure called a CAGE to hold the fracture in place while it heals
- Reverse Total Shoulder Replacement-replacing both the ball and socket sides of your joint with metal components. A metal ball is placed on the socket side, and the arm side becomes a flat surface.
- Hemiarthroplasty- replacing the humeral head (ball) side only with a metal component.
- Arthroscopic reduction and internal fixation: Best reserved for certain types of greater tuberosity fractures. Does not use metal components.
In situations where either surgical or non-surgical treatment of your fracture is offered-It is best to consider the risks/benefits of both.
Things to consider with a surgical approach:
- Benefits include: immediate fracture stabilization, quicker path to pain relief, quicker path to regaining shoulder function
- Surgical risks (including but not limited to): bleeding, infection, damage to blood vessels or nerves, developing a medical complication during or following the procedure
- With some fracture patterns, it is possible that even with surgery, you still may still face ongoing shoulder stiffness and reduced range of motion
Things to consider with a non-surgical approach:
- May be a better option for your non-dominant arm
- May take longer for fracture to heal
- If your bones move further apart on repeat follow-up x-rays, surgery may be advised at that time
- May take longer until pain improves
- If the proposed procedure is a joint replacement, you may be able to attempt non-operative treatment and then choose to have surgery at a later date if needed
- Whether you choose surgery or not, it is possible you will have some level of stiffness and reduced range of motion indefinitely in the affected shoulder
Clavicle (collarbone) fractures are typically categorized as either proximal (closer to the midline of your body), midshaft, and distal (closer to your shoulder). The majority of these fractures can be treated by wearing a sling while the bone heals. Sometimes, if the bones have moved too far apart, then you may need surgery to realign the bones.
Most commonly includes pain at the collar bone and pain with raising and moving the arm. There may be a visible deformity such as a lump at your collarbone. There may be bruising and swelling.
Evaluation by your provider will include x-rays and physical exam to determine if there is a fracture present, and to help guide treatment.
Non-Surgical: most clavicle fractures can be treated without surgery. This treatment involves resting your arm in a sling while the bones heal. You may need some physical therapy to help you regain your motion and strength. You may permanently have a noticeable bump in your clavicle after it heals. Sometimes you can develop a “non-union” fracture where the bones fail to heal after a period of time in the sling. This is not common, but if it does happen, you may end up needing surgery to repair the fracture at that time.
Surgical: If your bones are too far apart to heal properly, or if the fracture is too close to the joint-then you are more likely to need surgery. Surgery most commonly involves an open incision to realign the bones back to their normal position. A metal plate and screws are then applied to hold the bones in place while they heal.
- After surgery, it is common to have some numbness over and around the incision site. The numbness generally improves over several months. You will also likely be able to feel the metal plate as it sits right beneath your skin. Many people leave the metal hardware in place indefinitely and do not have any issues with it. Sometimes, the metal plate can become irritating or uncomfortable with activities such as carrying a bag strap or backpack over that shoulder. If this happens, it is possible to remove the hardware at a later time after the bones have fully healed. We recommend waiting three years from surgery before removing the metal hardware.
Return to activity: Whether you have surgery or not, it will be about 3 months before you can get back to routine regular activity with the affected arm. Ask your provider for specific guidelines regarding when you can return to work, lifting, and physical activity. Returning to physical activity or lifting things with that arm too soon can cause further damage and prevent/delay healing. Your provider will want to make sure your fracture is healed and stable prior to you returning to regular activity.
AC (Acromioclavicular) Joint Separation
The AC joint is where the collar bone meets the acromion of the shoulder blade. The joint is held together by a series of ligaments: The acromioclavicular ligament, the coracoclavicular ligaments (coronoid and trapezoid ligaments), and the coracoacromial ligament. There are different types of AC joint separations. Depending on the type of tear and which ligaments are torn, you may or may not need surgery.
Most commonly includes pain at the AC joint or collar bone and pain with raising and moving the arm. There may be a visible deformity such as a lump at the AC joint. There may be bruising and swelling.
Evaluation by your provider will include x-rays and physical exam to determine the extent of the injury and to help guide treatment.
Non-Surgical: Some AC joint separations can be treated without surgery. This treatment involves resting your arm in a sling to allow healing. You may need some physical therapy to help you regain your motion and strength. You may permanently have a noticeable bump in your AC joint after it heals.
Surgical: If your bones are too far apart to heal properly, surgery may be required.
There are two basic types of surgery. One surgery is called an AC joint reconstruction and involves aligning the bones with the use of sutures and a tendon graft from a cadaver for stability. The other is a surgery used to control pain and involves cutting off a small portion of the collarbone.
Return to activity: Whether you have surgery or not, it will be about 3 months before you can get back to routine regular activity with the affected arm. Ask your provider for specific guidelines regarding when you can return to work, lifting, and physical activity. Returning to physical activity or lifting things with that arm too soon can cause further damage and prevent/delay healing. Your provider will want to make sure your AC joint is healed and stable prior to you returning to regular activity.