Injuries of the shoulder

and upper arm

24
Andrew Cole

The great bugbear of upper-limb injuries is stiffness – complications are rare, it is prudent to feel the pulse
particularly of the shoulder but sometimes of the and gently to palpate the root of the neck. Outer third
elbow and hand as well. Two points should be con- fractures are easily missed or mistaken for acromiocla-
stantly borne in mind: vicular joint injuries.
• Whatever the injury, and however it is treated, all
Imaging
the joints that are not actually immobilized – and
especially the finger joints – should be exercised Radiographic analysis requires at least an anteroposte-
from the start. rior view and another taken with a 30 degree cephalic
• In elderly patients it is sometimes best to disregard tilt. The fracture is usually in the middle third of the
the fracture and concentrate on regaining movement. bone, and the outer fragment usually lies below the
inner (Figure 24.1). Fractures of the outer third may
be missed, or the degree of displacement underesti-
FRACTURES OF THE CLAVICLE mated, unless additional views of the shoulder are
obtained. With medial-third fractures it is also wise to
In children the clavicle fractures easily, but it almost obtain X-rays of the sternoclavicular joint. In assess-
invariably unites rapidly and without complications. ing clinical progress, remember that ‘clinical’ union
In adults this can be a much more troublesome injury. usually precedes ‘radiological’ union by several weeks.
In adults clavicle fractures are common, accounting
for 2.6–4% of fractures and approximately 35% of all
shoulder girdle injuries. Fractures of the midshaft
account for 69–82%, lateral fractures for 21–28% and
medial fractures for 2–3%.

Mechanism of injury
A fall on the shoulder or the outstretched hand may
break the clavicle. In the common midshaft fracture,
the lateral fragment is pulled down by the weight of
the arm and the inner, medial half is held up by the (a)
sternomastoid muscle. In fractures of the lateral 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, displace-
ment may be more severe and closed reduction impos-
sible. The clavicle is also a reasonably common site for
pathological fractures.
(b)
Clinical features
Figure 24.1 Fracture of the clavicle (a) Displaced
The arm is clasped to the chest to prevent movement. fracture of the middle third of the clavicle – the most
A subcutaneous lump may be obvious and occasionally common injury. (b) The fracture usually unites in this
a sharp fragment threatens the skin. Although vascular position, leaving a barely noticeable ‘bump’.
 CT scanning with three-dimensional reconstruc- unite uneventfully with a non-union rate below 5%
3 tions may be needed to determine accurately the and a return to normal function.
degree of shortening or for diagnosing a sternocla- Non-operative management consists of apply-
vicular fracture-dislocation, and also to establish ing a simple sling for comfort. It is discarded once
whether a fracture has united. the pain subsides (after 1–3 weeks) and the patient
is then encouraged to mobilize the limb as pain
TRAUMA

Classification allows. There is no evidence that the traditional

figure-of-eight bandage confers any advantage and
Clavicle fractures are usually classified on the basis of it carries the risk of increasing the incidence of pres-
their location: sures sores over the fracture site and causing harm
• Group I – middle-third fractures to neurological structures; it may even increase the
• Group II – lateral-third fractures risk of non-union.
• Group III – medial-third fractures. There is less agreement about the management of
displaced middle-third fractures. Treating those with
While it is helpful to describe the position of the frac- shortening of more than 2 cm by simple splintage is
ture, this does not describe any of the prognostic indica- now believed to incur a considerable risk of symptom-
tors such as comminution, shortening or displacement. atic malunion – mainly pain and lack of power during
Lateral-third fractures can be further sub-classified into shoulder movements – and an increased incidence
Neer type I, those with the coracoclavicular ligaments of non-union. There is, therefore, a growing trend
intact, Neer type II, those where the coracoclavicular towards internal fixation of acute clavicular fractures
ligaments are torn or detached from the medial seg- associated with severe displacement, fragmentation or
ment but the trapezoid ligament remains intact to the shortening (Figure 24.2). Methods include plating
distal segment, and Neer type III factures, which are (specific contoured locking plates are available) and
intra-articular. An even more detailed classification of intramedullary fixation.
midshaft fractures, proposed by Robinson, is useful for
managing data and comparing clinical outcomes.
LATERAL-THIRD FRACTURES
Treatment Most lateral clavicle fractures are minimally displaced
and extra-articular. The fact that the coracoclavicu-
MIDDLE-THIRD FRACTURES lar ligaments are intact prevents further displacement
There is general agreement that undisplaced fractures and non-operative management is usually appropri-
should be treated non-operatively. Most will go on to ate. Treatment consists of a sling for 2–3 weeks until

(a)

(c)

(b)

Figure 24.2 Severely displaced fracture (a) A com-

minuted fracture which united in this position (b)
leaving an unsightly deformity (c). This fracture may
(d)
have been better managed by (d) open reduction
756 and internal fixation.
 Complications
EARLY
24
Despite the close proximity of the clavicle to vital
structures, a pneumothorax, damage to the subcla-
vian vessels and brachial plexus injuries are all very

Injuries of the shoulder and upper arm

rare.

LATE
Non-union In displaced fractures of the shaft non-
(a)
union occurs in 1–15%. Risk factors include increas-
ing age, displacement, comminution and female sex,
but accurate prediction of those fractures most likely
to go on to non-union remains difficult.
Symptomatic non-unions are generally treated
with plate fixation and bone grafting if necessary.
This procedure usually produces a high rate of union
and satisfaction.
Lateral clavicle fractures have a higher rate of
(b) non-union (11.5–40%). Treatment options for
symptomatic non-unions are excision of the lateral
Figure 24.3 Fracture of the outer (lateral) third part of the clavicle (if the fragment is small and
(a) The shaft of the clavicle is elevated, suggesting the coracoclavicular ligaments are intact) or open
that the medial part of the coracoclavicular ligament reduction, internal fixation and bone grafting if the
is ruptured. (b) This was treated by open reduc- fragment is large. Locking plates and hooked plates
tion and internal fixation, using a lateral clavicular
are used.
locking plate.
Malunion All displaced fractures heal in a non-an-
the pain subsides, followed by mobilization within atomical position with some shortening and angula-
the limits of pain. tion, although most do not produce symptoms. Some
Displaced lateral-third fractures are associated with may go on to develop periscapular pain and this is
disruption of the coracoclavicular ligaments and are more likely with shortening of more than 1.5 cm. In
therefore unstable injuries (Figure  24.3). A num- these circumstances the difficult operation of correc-
ber of studies have shown that these particular frac- tive osteotomy and plating can be considered.
tures have a higher than usual rate of non-union if Stiffness of the shoulder This is common but usu-
treated non-operatively. Surgery to stabilize the frac- ally temporary.
ture is often recommended. However, the converse
argument is that many of the fractures that develop
non-union do not cause any symptoms and surgery FRACTURES OF THE SCAPULA
can therefore be reserved for patients with symptom-
atic non-union. Operations for these fractures have
higher complication rates and no single procedure has
Mechanisms of injury
been shown to be better than the others. Techniques Fractures of the scapula are often as a consequence
include the use of a coracoclavicular screw and plate, of high-energy trauma and considerable force due
hook plate fixation, suture and sling techniques with to its protected position. Common causes include
Dacron graft ligaments and the more recent lateral direct blunt trauma, crushing injuries, falls and sei-
clavicle locking plates. zures. Other associated injuries such as rib fractures
and other intra-thoracic injuries are common. The
MEDIAL-THIRD FRACTURES neck of the scapula may be fractured by a blow or by
Most of these rare fractures are extra-articular. They a fall on the shoulder; the attached long head of tri-
are mainly managed non-operatively unless the frac- ceps may drag the glenoid downwards and laterally.
ture displacement threatens the mediastinal struc- The coracoid process may fracture across its base
tures. Initial fixation is associated with significant or be avulsed at the tip. Fracture of the acromion
complications, including migration of the implants is due to direct force. Fracture of the glenoid fossa
into the mediastinum, particularly when K-wires are usually suggests a medially directed force (impac-
used. Other methods of stabilization include suture tion of the joint) but may occur with dislocation of
and graft techniques and the newer locking plates. the shoulder. 757