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.
Each type of shoulder fracture has unique characteristics. Below is a description of the common fractures in each area of the shoulder.
Fractures of the Proximal Humerus
(Proximal Humeral Fractures) are common injuries in both the young and elderly.
- Elderly and adult population: osteopenic bone can fracture from minimal trauma or as the result of a shoulder dislocation or fall.
- Young population: a skeletally immature fracture, frequently occurs as an epiphyseal fracture of the proximal humeral growth plate (referred to as “Little League Shoulder”)
- Following a fracture, muscles in the region can cause a deformed appearance to the shoulder
- Of concern is neurovascular injury of the nearby axillary artery and brachial plexus, which provide blood and nerve innervation to the arm.
- Fracture to the surgical neck is the most common fracture in this region
FOOSH or fall on the lateral aspect of the affected side (most common in individuals 60 years of age or older.) In the young these fractures occur commonly in those who participate in throwing sports.
Medical treatment is most commonly a sling with the arm slightly abducted.
Physical therapy interventions may be necessary because this injury tends to “stiffen” quickly over the first two to three weeks post-injury. Physical therapy will work first to restore good range of motion, and progress to active exercises and strengthening as the fracture heals.
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 fractures are generally caused by a fall on the shoulder, but direct trauma can also result in a clavicular fracture.
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.
Fractures of the Scapula
There are four basic sections of the scapula, the body, neck, acromion and glenoid fossa.
Fracture of the body of the scapula:
- Etiology: fractures of the scapula generally occur from a direct blow, fall or high-energy trauma.
- Of concern is an underlying pulmonary injury due to a possible corresponding rib fracture.
- Treatment: most scapular fractures respond well to conservative treatment by a physical therapist (for more information please see interventions for shoulder fractures). Symptomatic treatment designed to decrease pain and improve function may also be appropriate. Fractures to the body of the scapula are generally stabilized by the surrounding musculature.
Fracture of the neck, glenoid region and coracoid process of the scapula:
- Etiology: direct trauma or fall
- Of concern is damage to the neurovascular structures that pass through this area known as the thoracic outlet.
Fracture of the acromion process of the scapula:
- Etiology: direct trauma or fall
- Treatment: Acromion and coracoids fractures may require pinning or open reduction surgical interventions to stabilize the fracture.
- Caution should be taken with younger adolescents who are still growing because open growth centers may be mistaken for fractures.
- Radiographs should be taken of the opposite shoulder to determine if the ossification center is still developing.
Intra-articular fractures of the glenoid fossa:
- Etiology: direct trauma or fall
- Treatment: This type of fracture may require surgical open reduction if it involves the joint to the degree that stability or mobility of the shoulder is at risk of causing degenerative changes in the joint.
- More extensive physical therapy will be needed because this injury has the potential for severe weakness and hypo-mobility (loss of movement) due to the period of immobilization required post-surgery.
Little Leaguer’s Shoulder
This type of fracture is an injury to the proximal growth plate of the shoulder. Pathology for this injury includes a fatigue fracture from repetitive use. Due to the fact that this injury affects the growth plate, radiographic studies may take up to 4-6 weeks to show evidence of widening in the epiphyseal plate. Signs and symptoms include acute shoulder pain when attempting to throw a ball.
This injury occurs during the “follow through” (throwing) phase and “cocking” (wind up and hold) phase of throwing a ball.
It may be necessary to rest the bone for 8-to-12 months to reossify (harden) and remodel following a growth plate fracture. Physical therapy interventions can help improve: range of motion, strength, coordination, proprioception and endurance.
Prevention of Little Leaguer’s Shoulder
- Discourage athlete from pitching at home during and after the season
- Restrict or eliminate the throwing of curveballs, sliders, and other breaking balls
- Shorten playing season
- Restrict pitchers to two innings per game until growth plate is closed
- Provide three to four rest days between pitching
- Allow for proper conditioning and warm-up
- Instruct throwing athlete in proper throwing mechanics
- Educate coaches and parents of the risk and prevention of this injury
Symptoms of a shoulder 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
Treatment of most shoulder fractures will require a period of immobilization in a sling. More severe shoulder 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 shoulder 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 shoulder 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.
Most fractures 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.
Scapula: The rarest of shoulder fractures, this type of fracture occurs most often due to trauma. Medical treatment may vary from immobilization in a sling for 2-4 weeks, to open surgery especially when the glenoid, acromion, or neck of the scapula are involved because they may effect joint alignment of the shoulder.
Humeral: When occurring in young people these fractures usually just require immobilization for a short period of time. More complicated humeral fractures that occur in the older population may require surgery to restore alignment, especially when they are displaced or affect the humeral head and shoulder joint. Surgical intervention may require the use of plates, screws and wires.
Rate of recovery and the prognosis from a shoulder 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.