Shoulder Fracture

Virginia A Nugroho (188071700011003)

PPDS IKFR FKUB Malang
Pembimbing: dr. Samiah Rachmawati, SpKFR
09 Agustus 2019
Fractures of The Clavicula
INTRODUCTION
 Overview
• clavicle shaft fractures are common traumatic injuries that
occur in the middle third of the clavicle

• other fractures of the clavicle include

- adult distal third clavicle fracture
- pediatric medial clavicle physeal injury
- pediatric distal clavicle physeal injury
 Epidemiology
• incidence
clavicle fractures account for 2.6-4% of all adult
fractures
• demographics
often seen in young, active patients
most common in males < 30 years old
• location
75-80% of all clavicle fractures will occur in the middle
third segment
 Pathophysiology
• mechanism of injury
fall on an outstretched arm or direct trauma to the shoulder

• pathoanatomy
a) 75-80% of all clavicle fractures will occur in the middle third segment
-the junction of the outer and middle thirds is the thinnest part of the bone and is the
only area
not protected by or reinforced with muscle and ligamentous attachments
- it is therefore prone to fracture, particularly with axial loading
b) displaced fractures
- medial fragment: sternocleidomastoid muscle pulls the medial fragment
posterosuperiorly
- lateral fragment: pectoralis and weight of arm pull the lateral fragment inferomedially
c) open fractures usually the result of the medial fragment as it "buttonholes" through the
platysma
CLASSIFICATION
PRESENTATION
• Symptoms
- anterior shoulder pain
• Physical exam
- may have deformity
- may have skin tenting (impending open
fracture)
- important to perform careful neurovascular
exam
IMAGING
• Radiographs
a) recommended views
- upright AP of bilateral shoulders
- 15° cephalic tilt (zanca view)
:helps to determine superior/inferior displacement

• CT
a) views : coronal, saggital, axial
3D reconstruction views
b) findings : may help evaluate displacement, shortening,
comminution, articular extension, vascular injury, and nonunion
TREATMENT
 Non - Operative

- sling immobilization with gentle ROM exercises at 2-4 weeks

and strengthening at 6-10 week
indications :
a) < 2cm shortening and displacement
b) < 1cm displacement of the superior shoulder suspensory
complex
c) no neurovascular injury
 Sling Immobilization
Technique
- immobilize using sling or figure-of-eight brace
-) prospective studies have not shown a difference in functional or
cosmetic outcomes between sling and figure-of-eight braces
- no attempt at reduction should be made
- after 2-4 weeks begin gentle range of motion exercises
- strengthening exercises begin at 6-10 weeks
• outcomes
a) nonunion (1-5%)
- risk factors : - comminution
- > 100% displacement
- > 2cm shortening
- advanced age
- female gender
b) poorer cosmesis
c) decreased shoulder strength and endurance
-) seen with displaced midshaft clavicle fractures healed with > 2cm of
shortening
 Operative
- closed reduction and intramedullary fixation vs. open reduction internal fixation
indications :
a) absolute
- open fractures
- displaced fracture with skin tenting
- subclavian artery or vein injury
- floating shoulder (clavicle and scapular neck fracture)
- symptomatic nonunion
- symptomatic malunion
b) relative and controversial indications
- displaced with > 2cm shortening
- bilateral displaced clavicle fractures
- brachial plexus injury (questionable because 66% have spontaneous return)
- closed head injury
- seizure disorder
- polytrauma patient
COMPLICATION
 Nonoperative treatment
malunion
• nonunion (1-5%) a) definition : shortening > 3cm
angulation > 30°
a) risk factors translation > 1cm
- fracture comminution - b) presentation
- increased fatigue with overhead activities
fracture displacement - thoracic outlet syndrome
b) treatment - dissatisfaction with appearance
- difficulty with shoulder straps, backpacks
- if asymptomatic, no
treatment necessary and the like
c) treatment
- if symptomatic, ORIF -clavicle osteotomy with bone grafting, if
with plate and bone graft symptomatic
(particularly atrophic
nonunion)
Proximal Humerus
Fractures
INTRODUCTION
 Epidemiology
• Incident
- 4-6% of all fracture  proximal humerus fracture
- third most common non-vertebral fracture pattern
seen in the elderly (>65 years old)

• Demographics
- Male : Female = 2: 1
- increasing age associated with more complex
fracture types 
 Pathophysiology

• mechanism
– low-energy falls
• elderly with osteoporotic bone
– high-energy trauma
• young individuals
• concomitant soft tissue and neurovascular injuries
• pathoanatomy
– pectoralis major displaces shaft
anteriorly and medially
– supraspinatus, infraspinatus, and teres
minor externally rotate greater
tuberosity 
– subscapularis interally rotates articular
segment or lesser tuberosity
 Associated conditions
• nerve injury
– axillary nerve injury most common

• arterial injury
– uncommon (incidence 5-6%), higher likelihood in
older patients 
ANATOMY
 Osteology 
• anatomic neck 
– represents the old epiphyseal plate
• surgical neck 
– represents the weakened area below head
– more often involved in fractures than anatomic
neck 
 Vascular anatomy 
• anterior humeral circumflex artery 
– large number of anastamoses with
other vessels in the proximal
humerus 
– branches
• anterolateral ascending branch
– is a branch of the anterior
humeral circumflex artery
• arcuate artery
– is the terminal branch and
main supply to greater
tuberosity
• posterior humeral circumflex artery 
– recent studies suggest it is the main
blood supply to humeral head  
CLASSIFICATION
 AO/OTA

 
• organizes fractures into 3 main
groups and additional
subgroups based on 
• fracture location
• status of the surgical neck
• presence/absence of
dislocation
 Neer classification
• based on anatomic relationship of 4 segments 
– greater tuberosity
– lesser tuberosity
– articular surface
– shaft
• considered a separate part if
– displacement of > 1 cm
– 45° angulation
anatomical
Greater tuberocity
Lesser tuberocity
Fracture dislocation
Head split
EVALUATION
 Symptoms & Physical Exam
• Symptoms
• pain and swelling
• decreased motion
• Physical exam
• inspection
• extensive ecchymosis of chest, arm, and forearm
• neurovascular exam
• axillary nerve injury most common
• determine function of deltoid muscle (axillary n.)
• arterial injury may be masked by extensive collateral
circulation preserving distal pulses
• examine for concomitant chest wall injuries
IMAGING
 Imaging

• Radiography
(true AP (Grashey), scapular Y, axillary
• findings
• pseudosubluxation (inferior humeral head subluxation)
CT scan
• indications
• humeral head or greater tuberosity position uncertain
• intra-articular comminution
• MRI
• indications
• useful to identify associated rotator cuff injury
TREATMENT
 Nonoperatives
• sling immobilization followed by progressive rehab
– indications 
• most proximal humerus fractures can be treated nonoperatively including 
– minimally displaced surgical and anatomic neck fractures
– greater tuberosity fracture displaced < 5mm
– fractures in patients who are not surgical candidates
• additional variables to consider

– age
– fracture type
– fracture displacement
– bone quality
– dominance
– general medical condition
– concurrent injuries
– technique
• start early range of motion within 14 days
Scapula Fractures
INTRODUCTION
• Uncommon fracture pattern with high energy
trauma2-5% associated mortality rate

• Epidemiology
- incidence : less than 1% of all fractures
- location : 50% involve body and spine
CLASSIFICATION
TREATMENT
• Nonoperative • Operative
- sling for 2 weeks, followed by - open reduction internal fixation
early motion indications
indications - glenohumeral instability
- indicated for vast majority of - displaced scapula neck fx
scapula fractures - open fracture
- 90% are minimally displaced - loss of rotator cuff function
and acceptably aligned - coracoid fx with > 1cm of
outcomes displacement
- union at 6 weeks outcomes
- can expect no functional - 70% good to excellent results
deficits with operative treatment