Shoulder Fractures

Written and edited by Aruna Seneviratne, M.D

Fractures around the shoulder joint mainly involve the upper portion of the humerus bone termed the proximal humerus. These fractures occur in the elderly population due to low energy trauma, or in the younger patient due to high-energy trauma.

Symptoms:
The most common symptoms are pain and swelling in the shoulder. Frequently there are black and blue discoloration of the skin indicating a fracture has occurred. There is very limited range of motion of the shoulder due to pain. The lower part of the arm including the hand can get quite swollen. For this reason, it is strongly recommended to remove all jewelry, particular rings, from the affected extremity.

Biology: Why does it occur?
Fractures about the shoulder occur as a result of trauma. In the elderly, a simple fall onto the shoulder can result in a fracture. The humeral head maybe dislocated from the shoulder socket during this injury. Rarely, seizures can cause fracture dislocations of the shoulder. High energy-trauma such as motor vehicle accidents are responsible for these fractures in the younger patients. There maybe other associated injuries in this setting such as a collapsed lung, internal bleeding, and other fractures. Evaluation in an emergency room setting is necessary for these high-energy injuries. Frequently the rotator cuff is injured, and can be problematic to the patient.

Common Diagnostic Techniques:
History: Diagnosing the problem begins with a detailed history that your surgeon will obtain from you.
Physical Exam: A thorough physical examination is then conducted by Dr. Seneviratne.
X-Rays: Plain radiographs (X-Rays) are the most important diagnostic study that is performed initially. Several views will be obtained to diagnose the condition.
CAT Scan: Your surgeon may obtain additional studies such as a CAT Scan especially if you have a complex fracture.

Treatment:
Non-operative:
A significant percentage of proximal humerus fractures can be treated non-operatively with a sling, pain control, and edema control. Dr. Seneviratne will monitor you carefully with weekly or biweekly X-Rays to ensure the fracture is healing without displacing.

Operative:
Surgical intervention is required for displaced fractures, and when the humeral head is dislocated in addition to the fracture. Two main categories of surgery exists to treat these injuries.

ORIF (Open Reduction Internal Fixation)
This operation involves putting the fracture together like a puzzle and holding it with metal plates and screws, or a special device called an intramedullary nail (IM Nail). A variety of approaches can be utilized depending on your particular fracture. The size of the incision also varies depending on your anatomy and your fracture.

HEMIARTHROPLASTY
If the fracture is complex, and extensive, the upper portion of your humerus bone is replaced with a shoulder prosthesis. The implant is usually fixed to the bone with bone cement. The incision is usually in the front of your shoulder and can vary in length from 6 inches to 10 inches depending on your anatomy.
Reverse Shoulder Arthroplasty.
A reverse shoulder arthroplasty places the ball on the opposite side to normal anatomy. This allows better function of the arm. This option is being used more and more to treat fractures of the shoulder due to favorable results. Dr. Seneviratne will carefully evaluate each patient before indicating them for this procedure.

The postoperative hospital course
If you were admitted on the day of surgery for ORIF of your shoulder fracture you maybe discharged home on the same day depending on the extent of the surgery. For the most part you will be admitted to the hospital. You will be given medication to control the pain. Foot pumps will also be placed on your feet to pump blood back to your heart and prevent blood clots. You will be given an incentive spirometer - a breathing incentive device to help expand your lungs. Antibiotics will be administered to prevent infection. Physical therapists will work with you to begin your rehabilitation process immediately. Typically you will be in a sling. Patients are discharged from the hospital within 1 to 3 days of the operation. Depending on your condition and progress you may be discharged to home or to an inpatient rehabilitation facility. The decision where you will be discharged to will be made by the team comprised of your surgeon, physical therapist, nurse, and case manager/social worker.

After Surgery
If you are discharged to home you will need to make arrangements for someone to help you with your activities of daily living. You will follow up with your surgeon in 7 to 10 days after surgery for suture removal and further care.
If you are discharged to an inpatient rehabilitation facility your skin staples will be removed at the facility. Typically you will spend 1 to 2 weeks in such a facility after which you will be discharged.
During the first six weeks you will begin physical therapy to rehabilitate your shoulder. You may require physical therapy to rehabilitate your joint for up to 6 months.

FAQ's
What other fractures can occur around the shoulder?
Clavicle (collar bone) fractures, and scapular (shoulder blade) fractures may also occur either in isolation or in conjunction with proximal humerus fractures. Most clavicle fractures can be treated non-operatively as are scapular fractures. If the clavicle fracture is close to the shoulder (distal 1/3) these are typically treated surgically. Scapular fractures that extend into the shoulder socket (glenoid) usually require surgery.

Can I get arthritis in after these fractures?
Yes - especially the fracture extends into the articular surfaces.

Will I need a blood transfusion after surgery?
Typically the answer is no. However, it all depends on your clinical situation.

What are the risks of the fracture surgery?
Infection, bleeding, damage to nerves and blood vessels, blood clots that form in your legs (DVT), blood clots that can break off and travel to your lungs causing a pulmonary embolus (PE), and a remote chance of death either due to a PE or from cardiac complications.

What are the risks after surgery?
DVT, PE, and infection remain a possibility for several months after surgery. In addition shoulder stiffness and decreased range of motion can occur.

Do I need antibiotic prophylaxis for dental procedures and endoscopic procedures (colonoscopy and upper gastrointestinal endoscopy) after fracture surgery?
For ORIF - no. For hemiarthroplasty -yes. Your surgeon can provide you with more details

Will my hardware off metal detectors at airports?
Typically no, but newer more sensitive machines may pick up the metal. Dr. Seneviratne's office can provide you a letter stating you have metal hardware in your shoulder.

How soon after surgery:
  1. Can I drive?
    Usually in 6 weeks.
  2. Can I return to work?
    About 6 to 12 weeks depending on your occupation.
  3. Can I shower?
    Soon after discharge from the hospital. Cover wound with plastic until the skin
    staples are removed.
  4. Can I resume sexual activity?
    Usually after 2 to 4 weeks after surgery.
  5. Can I fly in an airplane?
    In about 6 weeks - you must arrange for an aisle seat, have your bags handled by someone else, and you MUST do ankle pumps every 15minutes, as DVT is a major concern. You must also take Aspirin to prevent DVT.