Shoulder and Elbow Fractures
Fractures about the shoulder are also known as breaks, cracks and broken bones. The shoulder joint is composed of the interaction among 3 intersecting bones, all of which can be broken. This include the humerus, clavicle and scapula. The elbow joint is composed of the interaction among 3 intersecting bones, the lower part of the humerus, the radius and the ulna.
Collar Bone (Clavicle)
The clavicle (collar bone) connects the arm and shoulder joint to the chest wall or thorax at the sternum (breast bone). When broken, the fracture usually occurs at the middle of the bone in the majority of cases. Occasionally, the fracture can involve the lateral or distal 1/3 of the collar bone where it attached to the shoulder blade. This can also be associated with an injury to the coracoclavicular ligaments which attach the clavicle to the coracoid, a separate area of the shoulder blade. These fractures often do not heal and are best treated with surgery.Occasionally, this can be done arthroscopically. Rarely, the clavicle is fractured where it attaches to the sternum (medial third). This injury is very uncommon and can usually be treated with non-operative measures.
Shoulder Blade (Scapula)
The scapula is a flat bone connecting the rib cage and spine to the humerus. There are 17 separate muscles attached to the scapula which allows the interaction to produce complex movements of the arm in space. There are four distinct regions of the scapula that can be fractured. The body, acromion, glenoid and coracoid. The body is the region of the bone where the very important rotator cuff muscles originate. Thankfully, these fractures can usually be treated without surgery with good results. The coracoid is an attachment site for many important ligaments and muscles(tendons). This fracture is rare and treatment depends on the amount of displacement. The acromion is usually fractured in two types of injuries. An acute injury is usually associated with a significant trauma and often requires surgical repair. Occasionally, a stress fracture can occur in the acromion associated with the forces of a reverse total shoulder replacement. Lastly, the glenoid (cup) of the shoulder blade can also be fractured. Often this is associated with a dislocation of the shoulder. This is often referred to as a Bankart fracture.
The humerus, or arm bone can be fractured or broken in three distinct areas. The proximal humerus (upper) which is part of the bone at the shoulder joint, the middle shaft of the bone and the distal part of the bone at the elbow.
The Proximal humerus provides the axis for shoulder movement via the head (ball) of the humerus’ interaction with glenoid (cup) of the scapula. This movement is driven by the complex interaction of multiple ligaments and muscles about the shoulder. The proximal humerus is where four of these muscles attach that are essential for this movement; the rotator cuff. These fractures often require surgical repair. Occasionally, depending on the complexity of the fracture, the degree of osteoporosis and the functional needs of the patient, a shoulder replacement may be necessary.
The shaft of the humerus connects the shoulder to the elbow. These fractures can often be treated with bracing alone. Occasionally it is necessary to repair this area of the bone. When done, this usually requires a larger incision and placement of metal hardware, referred to as plates and scores, to repair the bone. This is determined by the fracture pattern.
The distal humerus is the region of the bone that forms a joint at the elbow with the bones of the forearm, the radius and ulna. These fractures often involve the articular surface of the elbow and small disruptions of the surface can lead to lasting disability. For this reason, the fracture often require repair.
Radius and Ulna
The radius and ulna are the two bones that form the forearm. At the elbow the radial head is the area that is most commonly fracture. Most of these are non-displaced and can be treated with non-operative management. Occasionally, with worse injuries the fractures require surgical repair or at times replacement of the radial head. The ulna is the other bone of the forearm forming the elbow joint with the radius and humerus. At the elbow it is the attachment of the triceps as well as important ligaments which give the elbow stability. When fractured, the ulna often requires surgical repair.
In fractures that can be treated non-operatively, a period of immobilization is often required. After which a period of therapy is used to aid in restoration of range of motion and function.
Usually, fractures of the shoulder and elbow that require operative treatment are significantly displaced or are known to have very poor outcomes with non-operative care. This is especially true with fractures involving the joint surfaces where a small amount of step off can lead to long lasting impairment and even arthritis.
Occasionally, fractures can be treated with arthroscopic measures. These are usually fractures of the end of the clavicle, fractures of the glenoid (cup) called Bankart fractures, or fractures of small area of the proximal humerus where the rotator cuff tendons insert.
Usually, fractures require an open treatment through a regular incision. With this a larger metal implant in inserted with screws that connect the implant to the bone. These implants then stabilize the bone while it heals. The implants are usually left in place after healing of the bone.This implants are usually referred to a plates or nails (rods).
At times the fracture is not repairable or would be expected not to heal secondary to significant comminution or very poor bone quality secondary to osteoporosis. When this occurs, it is often necessary to perform a shoulder replacement called a hemiarthroplasty or at times a reverse shoulder arthroplasty. In the case of an elbow (distal humerus) fracture it is at times necessary to replace the elbow as well. More information regarding this procedure is available on the following link Total Elbow Arthroplasty