Background and Etiology
A fracture is defined as a partial or complete crack in a bone. Fractures can be minor with little or no displacement of the bone, or more severe with complete displacement of the two ends of the bone that requires surgery to realign. There are closed fractures that do not break the skin, and open fractures that do break the skin.
Fractures of the shoulder are usually caused by direct trauma or a fall on outstretched hand (FOOSH). In the event a person suspects a shoulder fracture, radiographic study (X-Ray) of the shoulder is essential.
The shoulder is comprised of three bones: the humerus, scapula (shoulder blade) and clavicle (collar bone). These bones form three joints: the glenohumeral joint, sternoclavicular joint, and acromioclavicular joint. Fractures in the shoulder area can involve any of the bones that form the shoulder, therefore a shoulder fracture can be:
- Fracture of the scapula or shoulder blade (scapular fracture)
- Fracture of the clavicle or collar bone (clavicular fracture)
- Fracture of the humerus or upper arm (humeral fracture)
- Little League Shoulder is a fracture of the proximal shoulder at the growth plate, usually from over head throwing.
Fractures of the Clavicle
The clavicles are the most commonly fractured bones in children and adolescents. Between the medial two-thirds and lateral one-third of the clavicle is where 80% of clavicle fractures occur. Based upon the location of the fracture, Clavicle fractures are classified as being one of the following: proximal, middle or distal.
- Of concern is injury to the nearby brachial plexus
- In children injury to the far proximal end of the clavicle may be an epiphyseal injury (one that affects the growth plate) making surgical intervention by an open reduction hazardous.
Clavicle fracture is generally caused by a fall on the shoulder, but direct trauma can also result in a clavicular fracture.
Symptoms of clavicular fracture will vary depending on the severity but they may include some or all of the following:
- Moderate to severe pain
- Decreased ability to move or lift arm, often results in holding the effected arm at ones’ side in a protective manner
- Redness, discoloration or bruising over the fractured area
- Deformity of the area due to misalignment of displaced bone or muscle
Typically a figure-of-eight bandage or sling is appropriate. An open reduction is rarely necessary, but when a compound fracture occurs or there is a neurovascular compromise the procedure may be needed. Clavicle fractures take six weeks to heal in children, eight weeks to heal in adults, and may heal with a bump. Patients should avoid heavy contact and stress for a minimum of two to four additional weeks.
Treatment of clavicular fracture will require a period of immobilization in a sling. More severe clavicular fractures may require surgery to realign and stabilize the injury. How much movement should be restricted following the fracture will depend on the severity of the break. Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore shoulder motion. In more involved fractures recovery can be long and arduous. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the shoulder.
Physical therapy interventions
Post clavicular fracture immobilization can have detrimental effects that can be improved through physical therapy including:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased mobility of the joint capsule and periarticular connective tissues
- Decreased circulation
- Loss of active and passive motion
Goals for physical therapy post clavicular fracture immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the shoulder, rotator cuff and scapula muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: throwing) in use of the involved upper extremity in daily activities especially overhead activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the shoulder joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Clavicular fracture can be diagnosed with X-Ray studies and when necessary a CAT scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or those that affect the integrity of the shoulder joint.
Clavicle: This is the most common type of fracture and most often requires immobilization in a figure eight strap for 3-8 weeks. Range of motion is started when the pain subsides. In severe cases surgery with plates and screws may be considered.
Rate of recovery and the prognosis from clavicular fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to recover. Patients may have residual motion and strength deficits, especially if the rotator cuff is involved.
- Age– Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance– Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.