INJURIES OF THE SHOULDER AND UPPER ARM

FRACTURES OF THE CLAVICLE In children the clavicle fractures easily, but it almost invariably unites rapidly and without complications. In adults this can be a much more troublesome injury. In adults clavicle fractures are common, accounting for 2.64 per cent of fractures and approximately 35 percent of all shoulder girdle injuries. Fractures of the mid-shaft account for 69 82 per cent, lateral fractures for 2128 per cent and medial fractures for 23 per cent.

Mechanism of injury
A fall on the shoulder or the outstretched hand may break the clavicle. In the common mid-shaft fracture, the outer fragment is pulled down by the weight of the arm and the inner half is held up by the sterno-mastoid muscle. In fractures of the outer end, if the ligaments are intact there is little displacement; but if the coracoclavicular ligaments are torn, or if the fracture is just medial to these ligaments, displacement may be severe and closed reduction impossible.

Clinical features The arm is clasped to the chest to prevent movement. A subcutaneous lump may be obvious and occasionally a sharp fragment threatens the skin. Though vascular complications are rare, it is prudent to feel the pulse and gently to palpate the root of the neck. Outer third fractures are easily missed or mistaken for acromioclavicular joint injuries.

Imaging

Radiographic analysis requires at least an anteroposterior view and another taken with a 30 degree cephalic tilt. The fracture is usually in the middle third of the bone, and the outer fragment usually lies below the inner. Fractures of the outer third may be missed, or the degree of displacement underestimated, unless additional views of the shoulder are obtained. With medial third fractures it is also wise to obtain x-rays of the sterno-clavicular joint. In assessing clinical progress, remember that clinical union usually precedes radiological union by several weeks. CT scanning with three-dimensional reconstructions may be needed to determine accurately the degree of shortening or for diagnosing a sternoclavicular fracture-dislocation, and also to establish whether a fracture has united

Classification Clavicle fractures are usually classified on the basis of their location: Group I (middle third fractures), Group II (lateral third fractures) and Group III (medial third fractures). Lateral third fractures can be further subclassified into (a) those with the coraco clavicular ligaments intact, (b) those where the coracoclavicular ligaments are torn or detached from the medial segment but the trapezoid ligament remains intact to the distal segment, and (c) factures which are intra-articular.

FRACTURES OF THE SCAPULA Mechanisms of injury The body of the scapula is fractured by a crushing force, which usually also fractures ribs and may dislocate the sternoclavicular joint. The neck of the scapula may be fractured by a blow or by a fall on the shoulder; the attached long head of triceps may drag the glenoid downwards and laterally. The coracoid process may fracture across its base or be avulsed at the tip. Fracture of the acromion is due to direct force. Fracture of the glenoid fossa usually suggests a medially directed force (impaction of the joint) but may occur with dislocation of the shoulder.

Clinical features
The arm is held immobile and there may be severe bruising over the scapula or the chest wall. Because of the energy required to damage the scapula, fractures of the body of the scapula are often associated with severe injuries to the chest, brachial plexus, spine, abdomen and head. Careful neurological and vascular examinations are essential.

Classification Fractures of the scapula are divided anatomically into scapular body, glenoid neck, glenoid fossa, acromion and coracoid processes. Scapular neck fractures are the most common.