Common fractures of the shoulder
A mid shaft clavicle fracture is the most commonly seen clavicle fracture. These occur with a fall or a direct blow to the middle of the clavicle. Often, these heal fine on without any surgical intervention. The need for surgery would only come if the fracture opened the skin and increased the risk for an infection or if the fracture is so far out of place that it will not heal well without fixation.
A fracture at the end of the clavicle closest to the shoulder joint is the next most common clavicle fracture and can sometimes disrupt ligaments like the coracoclavicular ligament, which would cause the collarbone to ride higher than the uninjured side. This often gets surgical attention if required for quality of life or participation in sport.
A fracture at the end of the clavicle closer to the center of the chest is uncommon. But when it happens we worry about injuries to internal organs as well.
There are several different fracture patterns that involve the shoulder blade or scapula. These would include the glenoid (most common), the acromion and the scapular body. The glenoid fracture is most commonly associated with a shoulder dislocation. Xrays and CT scans can help the specialist determine if the glenoid fracture requires surgical attention depending on the amount of the glenoid that is fractured. Obviously, the larger the fracture, the more instability of the shoulder would occur.
The acromion is commonly fractured with an AC joint separation. Normally, these are treated along with the AC joint separation and not separately.
A fracture to the body of the scapula most commonly occurs through the middle of the bone and occurs with very high velocity impact or trauma. These are treated non-operatively and the function of the shoulder is not disrupted very much once the pain is reduced and physical therapy can begin.
These are not funny or humorous. A fracture to the arm is painful and limit movement of the shoulder for quite some time. Like scapula fractures, there are different fracture patterns that can occur. We will include the greater tuberosity (where the rotator cuff attaches), lesser tuberosity (where the subscapularis attaches) and the shaft of the bone or the neck of the bone. When any of these fracture patterns occur an orthopaedic specialist shoulder be consulted as any more than 1cm of displacement of the fracture should be considered for surgery. A sling will be appropriate initially with frequent pendulum motion of the shoulder to avoid stiffness of the joint.
Shoulder ligament injuries
The most common ligament injury in the shoulder is an acromioclavicular ligament injury causing elevation of the clavicle at that joint. Trauma to this part of the shoulder can come from a fall to the side or a large enough force into the side of the shoulder like from a football tackle.
An AC joint separation can range from mild to severe. Mild sprains of the AC joint can be tender to touch and painful with reaching overhead or across the body until rehabilitation helps regain full function. Symptoms of a more severe tear of the AC joint can also involve close by ligaments like the coracoclavicular ligament as well and allow the clavicle to be unstable. This leaves a visible bump at the top of the shoulder. Even someone with this severe AC/CC joint tear can return to normal function without surgery. Often times, an orthopedic surgeon will suggest rehabilitation before suggesting surgery to see if function can be returned without the risk of surgery.
Treatment and risks
Nonsurgical treatment would include ice, wearing a sling for a short period of time, anti-inflammatory medicines to help manage pain and physical therapy. There are risks of continued pain with motion and development of arthritis at the AC joint with this approach. Surgical treatment of this type of injury would only be considered in patients who have tried conservative treatment, but continue to have persistent pain with motion and severe deformity. Several different methods of surgical treatment are considered depending on the patient and type of AC joint injury. After surgery, physical therapy will be necessary to restore function again once healing has taken place.
Diagnosis for an AC joint separation is simply done with an Xray view of both shoulders to compare and measure the distance between the coracoid and clavicle. Greater than 25% of the normal side is significant displacement of the clavicle and is treated based on the patient.
The sternoclavicular joint injury occurs from a blow to the chest or clavicle with the arm out extended which can cause the SC joint to sustain a posterior dislocation or from a blow to the shoulder with the risk of anterior dislocation of the SC joint.
Symptoms and Treatment
The clavicle will be visibly poking forward with an anterior dislocation. Initially, there is discomfort with too much movement.
Spontaneous anterior subluxation of the SC joint is visible when someone raises their arm above their head then reduced into place again when their arm is below the shoulder. This can occur without any trauma and is also not associated with any pain.
Posterior dislocation of the SC joint is much more worrisome as this can cause difficulty breathing, swallowing or vascular compromise. The structures that lie right behind the sternum are at risk for injury and so a posterior SC joint dislocation must be reduced quickly without delay. Once the joint is back in place, there is 3 to 4 weeks of healing time needed before range of motion above the head can begin.
Clavicle epiphyseal Fractures in the skeletally immature patient (under 16 years) can occur and are normally treated conservatively unless there is severe displacement of the joint. These are fractures that occur through the growth plate located at the end of the clavicle on the SC joint and do not effect growth or function.
These are mostly a diagnosis made with physical exam as they are challenging to recognize on plain X-rays. A CT scan might be ordered on rare occasion if the X-ray and physical exam makes the diagnosis unclear.
Symptoms and Treatment
This injury might cause difficulty with breathing or swallowing. This has to be pulled back into place quickly. It is important to get seen by a physician immediately.
The rotator cuff is made up of four tendons and serve as the main stabilizer of the shoulder joint. Each muscle and rotator cuff tendon plays a different role. The supraspinatus tendon is a common place for injury in the shoulder. There are different severities of tears and not all tears needs surgery. Many tears started as fraying of the tendon or wear and tear and progressively got worse. There are partial tears where the tendon has damage, but still functions. When there are complete or full-thickness tears then the tendon is torn from bone or a large hole in the tendon and it may not function correctly.
- Rotator cuff tears can occur from overuse (degeneration of the tendon over time) or an injury like from a fall or sudden pull on the shoulder. Massive rotator cuff tears often occur in the dominant arm and degenerative tears can occur in either dominant or non-dominant sides.
- Athletes like baseball players, tennis, rowing and weight lifters are at higher risk for rotator cuff tears from repetitive stress on the shoulder. There are manual labor jobs that also have this risk like painters, hair dressers or cleaning.
- Traumatic tears will be acutely painful, maybe even be heard with a snap and the arm will feel very weak.
- Daily activities like reaching for a glass of water or getting dressed can become difficult due to pain in the shoulder.
- Pain at rest or pain with sleeping on the effected side.
The doctor will perform a few physical exam tests to check your range of motion and strength specific to the muscles in the shoulder. X-rays are helpful in seeing the alignment of the humerus to the glenoid and any other potential problems. Clavicle fractures can often be coupled with a rotator cuff tears. If the X-ray is inconclusive then an MRI of the shoulder with contrast is the next most helpful step in evaluating the rotator cuff closer for the severity of the tear and the quality of tendon left. The MRI can also show if the tear is old or new.
Treatment is heavily dependent on multiple factors at the same time including age of patient, activity level and job, your health and type of tear. About 80% of rotator cuff tears can be rehabilitated back to function and symptom relief. There is no risk or proof of improved outcomes to attempt surgical repair sooner than later. Hence, most of the time physical therapy is attempted first to avoid surgery.
Too much time in a sling can have the reverse effect and stiffen the shoulder more. Early range of motion and stretching is important in order to avoid shoulder stiffness in the setting of a rotator cuff tear. Modifications to activity if the dominant arm is affected are sometimes necessary as well as taking anti-inflammatory medication is very helpful for symptom relief. Steroid injections should not be done frequently as exposing the tendon to corticosteroid medication can weaken the muscle and tendon further.
Surgical treatment is reserved if function is not improving with physical therapy or if their job or sport requires 100% recovery. If the patient’s type of tear is a full thickness tear involving too much of the tendon to have a good prognosis with just physical therapy then surgical intervention might be discussed before physical therapy. There is risk with surgery which includes anesthesia complications, infection and stiffness of the shoulder joint. Surgery also includes a long recovery period of about 6 months. All of this is important to consider before proceeding with surgery.
The goal is to reduce pain and regain function of the shoulder again. Stretching, range of motion and strengthening are all gradually introduced with physical therapy. Each scenario might be different and the rehab should be tailored to each patient.
Biceps tendon rupture
The biceps muscle of the arm has a long head and short head tendon that each insert into the shoulder and elbow respectively. The long head of the biceps tendon runs over the head of the humerus and into the shoulder joint. The short head of the biceps attaches to the coracoid process outside of the shoulder. Commonly, the long head of the biceps tendon can rupture at the shoulder insertion which will appear as a “Popeye” muscle as the muscle falls lower with gravity. When the biceps tendon at the elbow ruptures
- As we age (over 40) we place more wear and tear on our bodies, including tendons.
- A sudden lift of an overly heavy object can cause a rupture.
- Corticoid steroid medication use places increased risk to muscle and tendon weakness.
- Sudden sharp pain.
- A loud pop.
- Bruising in the middle of the arm or down to the elbow.
- A noticeable bulging in the arm like a “popeye muscle” or cramping of the muscle or pain with lifting objects or turning your palm down and palm up.
The diagnosis is fairly obvious on inspection, but if there is uncertainty the doctor may ask you to bend your arm towards you to watch the action of the biceps muscle. They may test your ability to turn your palm or down as well. If the rupture is at the elbow then the “hook test” can be performed to feel whether the tendon is attached at the elbow or not while your arm is bent. X-rays are helpful in seeing if there is an avulsion off the bone when the tendon ruptured. An MRI is only needed if there is suspicion of a partial tear.
Non operative treatment is appropriate for an isolated biceps tendon rupture if the patient feels the rupture does not effect their daily life or activity. The pain from the rupture resolves over time and physical therapy can be helpful in regaining function. Anti inflammatory medication, ice packs and rest from overhead activity is the mainstay of treatment until symptoms subside.
Operative treatment is reserved for those that require complete recovery of the strenthg of their biceps because they are an athlete or their job will require it. If a patient cannot fully recover from non operative treatment then surgical treatment might be discussed. The incisions are small for this procedure for the tendon to be re-anchored to bone. Temoporary immobilization in a sling is necessary and full recovery is achieved in about 6 months.
Flexibility and range of motion is important to regain first. Then strengthening the muscle will be gradually added in the rehabilitation process either after injury or after surgery.
Shoulder dislocation & Instability
The shoulder is extremely mobile and can move in more directions than any other joint in the body. This is an advantage of the shoulder, but also a disadvantage making it easier for dislocation to occur. Shoulder dislocations can happen in several different directions including forward, backward or downward and need help in placing them back in the joint.
The position of the shoulder at the time of an anterior dislocation is in a throwing position. Overhead throwing athletes in contact sports, like football, are at an increased risk of shoulder dislocation.
X-rays of the shoulder are normally taken to confirm that the shoulder is properly placed back in the socket and to examine if there are any fractures.
During a dislocation, the labrum around the rim of the socket (glenoid) is often injured and the ball (humeral head) is left with an indention in the bone (Hill Sachs lesion). It is common for the shoulder to feel like it will come out of socket again when the arm is high and reaching back. If the shoulder does come out of socket with simple movements, this is called shoulder instability. There is often pain in the front and the back of the shoulder that feels dull or throbbing after the dislocation.
An MRI of the shoulder might be ordered to help diagnose tears in the labrum or rotator cuff after a dislocation.
Evaluation and treatment
A doctor will most likely order X-rays of the shoulder and examine you. Most shoulder dislocations are towards the front of the shoulder (anterior instability). Once the shoulder is placed back into the socket (closed reduction) the pain goes away. After one dislocation, the shoulder can more easily come out of socket the next time. Physical therapy to strengthen the muscles and tendons that were stretched during the dislocation are important for preventing another dislocation.