Shoulder Fractures/ Injuries

Shoulder injuries most commonly occur in athletes participating in sports such as swimming, tennis, pitching, and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.

Shoulder injuries cause pain, stiffness, restricted movements, difficulty in performing routine activities, and popping sensation.

Some of the common shoulder injuries include sprains and strains, dislocations, tendinitis, bursitis, rotator cuff injury, fractures, and arthritis.

• Sprains and strains: A sprain is stretching or tearing of ligaments (tissues that connect adjacent bones in a joint). It is a common injury and usually occurs when you fall or suddenly twist. A strain is stretching or tearing of muscle or tendon (tissues that connect muscle to bone). It is common in people participating in sports. Strains are usually caused by twisting or pulling of the tendons.
• Dislocations: A shoulder dislocation is an injury that occurs when the ends of the bone are forced out of its position. It is often caused by a fall or direct blow to the joint while playing contact sport.
• Tendinitis: It is an inflammation of a tendon, a tissue that connects muscles to bone. It occurs because of injury or overuse.
• Bursitis: It is an inflammation of fluid filled sac called bursa that protects and cushions your joints. Bursitis can be caused by chronic overuse, injury, arthritis, gout, or infection.
• Rotator cuff injury: The rotator cuff consists of tendons and muscles that hold the bones of the shoulder joint together. Rotator cuff muscles allow you to move your arm up and down. Rotator cuff injuries often cause a decreased range of motion.
• Fractures: A fracture is a break in the bone that commonly occurs because of injury, such as a fall or a direct blow to the shoulder.
• Arthritis: Osteoarthritis is the most common type of shoulder arthritis, characterized by progressive wearing away of the cartilage of the joint.

Early treatment is necessary to prevent serious shoulder injuries. The immediate mode of treatment recommended for shoulder injuries is rest, ice, compression and elevation (RICE). Your doctor may also prescribe anti-inflammatory medications to help reduce the swelling and pain.

Your doctor may recommend a series of exercises to strengthen shoulder muscles and to regain shoulder movement.

Clavicle fracture, also called broken collarbone is a very common sports injury seen in people who are involved in contact sports such as football and martial arts as well as impact sports such as motor racing. A direct blow over the shoulder that may occur during a fall on an outstretched arm or a motor vehicle accident may cause the clavicle bone to break. Broken clavicle may cause difficulty in lifting your arm because of pain, swelling and bruising over the bone.

Broken clavicle bone, usually heals without surgery, but if the bone ends have shifted out of place (displaced) surgery will be recommended. Surgery is performed to align the bone ends and hold them stable during healing. This improves the shoulder strength. Surgery for the fixation of clavicle fractures may be considered in the following circumstances:

• Multiple fractures
• Compound (open) fractures
• Fracture associated with nerve or blood vessel damage and scapula fracture
• Overlapping of the broken ends of bone (shortened clavicle)

Plates and Screws fixation

During this surgical procedure, your surgeon will reposition the broken bone ends into normal position and then uses special screws or metal plates to hold the bone fragments in place. These plates and screws are usually left in the bone. If they cause any irritation, they can be removed after fracture healing is complete.

Pins

Placement of pins may also be considered to hold the fracture in position and the incision required is also smaller. They often cause irritation in the skin at the site of insertion and must be removed once the fracture heals.

Complications

Patients with diabetes, the elderly individuals and people who make use of tobacco products are at a greater risk of developing complications both during and after the surgery. In addition to the risks that occur with any major surgery, certain specific risks of clavicle fracture surgery include difficulty in bone healing, lung injury and irritation caused by hardware.

Percutaneous elastic intramedullary nailing of the clavicle is a newer and less invasive procedure with lesser complications. It is considered as a safe method for fixation of displaced clavicle fractures in adolescents and athletes as it allows rapid healing and faster return to sports. The procedure is performed under fluoroscopic guidance. It involves a small 1 cm skin incision near the sternoclavicular joint, and then a hole is drilled in the anterior cortex after which an elastic nail is inserted into the medullary canal of the clavicle. Then the nail is passed on to reach the fracture site. A second operation to remove the nail will be performed after 2-3 months.

The scapula (shoulder blade) is a flat, triangular bone providing attachment to the muscles of the back, neck, chest and arm. The scapula has a body, neck and spine portion.

Scapular fractures are uncommon but do occur and require a large amount of force to fracture. They are usually the result of intense trauma, such as a high-speed motor vehicle accident or a fall from height onto one's back. They can also occur from a fall on an outstretched arm if the humeral head impacts on the glenoid cavity.

Symptoms of a scapular fracture include the following:

• Pain: Usually severe and immediate following injury to the scapula.
• Swelling: The scapular area quickly swells following the injury.
• Bruising: Bruising occurs soon after injury.
• Impaired Mobility: Decreased range of motion of the joint occurs, often with inability to straighten the arm.
• Numbness: Numbness, tingling, or coldness of the hand and forearm can occur if blood supply is impaired or nerves are injured.
• Popping Sound: A cracking or popping sound, also referred to as crepitus, can often be heard or felt at the time of the fracture.

Scapular fractures should be evaluated by an orthopedic surgeon for proper diagnosis and treatment.

Your surgeon will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include:

• X-rays: A form of electromagnetic radiation that is used to take pictures of bones.
• CT scan: This test creates images from multiple X-rays and shows your physician structures not seen on regular X-ray.
• MRI: Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.

Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, most scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement.

Conservative treatment options include:

• Immobilization: A sling is used for comfort and to support the shoulder to allow healing to take place. This is usually worn about 3-6 weeks depending on the type of fracture and how well you heal.
• Prescription Medications: Pain medications will be prescribed for your comfort during the healing process.
• Physical Therapy: Early progressive range of motion exercises is essential in restoring full shoulder function. Your physician will most likely refer you to a Physical Therapist for instruction on proper exercises and early motion of the shoulder to prevent complications.

Surgical Introduction

Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. will usually require surgical intervention to realign the bones properly and restore a functional, pain free range of motion to the shoulder joint.

Scapular fracture repair surgery has historically been performed through a large, open incision. Newer, minimally invasive techniques have evolved and surgery to repair scapular fractures can now be performed through arthroscopy.

The forearm is made up of 2 bones, namely, the radius and ulna. The primary function of your forearm is rotation i.e., the ability to turn your palm up and down. The fracture of the forearm affects the ability to rotate your arm, as well as bend and straighten the wrist and elbow. The breaking of the radius or ulna in the middle of the bone requires a strong force and it is most commonly seen in adults. In most of the cases, both bones are broken during a forearm fracture.

Cause

The forearm bones can break in several ways. The bones can crack slightly or can break into many pieces. Forearm fractures are generally due to automobile accidents; direct blow on the forearm or fall on an outstretched arm during sports, climbing stairs, etc.

Symptoms

The symptoms of a forearm fracture include intense pain in the arm, bruises and swelling. Your fractured forearm may appear bent and shorter compared to your other arm. You may experience numbness or weakness in the fingers and wrist. You may be unable to rotate your arm. Sometimes, a broken bone sticks out through the skin or the wound penetrates down to the broken bone.

Diagnosis

Your doctor may conduct a physical examination and record your medical history initially. Your doctor may feel your arm thoroughly to determine tenderness. You may be asked to get an X-ray done to determine displaced or broken bones.

Treatment

Usually people with forearm fractures are immediately rushed to the emergency room for treatment. Treatment of forearm fractures aims at putting back the broken bones into position and preventing them from moving out of place until they are completely healed.

Nonsurgical Treatment

In case only one bone is broken and is not out of place, your doctor might treat it with a cast or brace and provide a sling to keep your arm in position. Your doctor will closely monitor the healing of the fracture. If the fracture shifts in position, you may be advised to undergo surgery to fix the bones back together.

Surgical Treatment

When both forearm bones are broken, surgery is usually required. During surgery, the cuts from the injury will be cleaned and the bone fragments are repositioned into their normal alignment. They are held together with screws and metal plates attached to the outer surface of the bone. The incision is sutured firmly and a sling is provided to facilitate healing.

The radius (bone on the thumb side) and ulna (bone on the little-finger side) are the two bones of the forearm. Forearm fractures can occur near the wrist, near the elbow or in the middle of the forearm. Apart from this, the bones in children are prone to a unique injury known as a growth plate fracture. The growth plate, which is made of cartilage (flexible tissue) is present at the ends of the bones in children and helps in the determination of length and shape of the mature bone.

The healing of fractures in children is quicker than that in adults. Thus, if a fracture is suspected in a child, it is necessary to seek immediate medical attention for proper alignment of the bones.

Types of fractures

Forearm bones may break in many ways. Fractures may be “open” where the bone protrudes through the skin, or “closed” where the broken bone does not pierce the skin. The common types of fractures in children include:

• A stable fracture that compresses the bone on one side, forming a buckle on the opposite side of the bone, without breaking the bone (Buckle or torus fracture)
• One side of the bone breaks and bends the bone on the other side (Greenstick fracture)
• Displacement of the radius, and dislocation of the ulna at the wrist where both bones meet (Galeazzi fracture)
• Fracture affecting the upper or lower portion of the bone shaft (Metaphyseal fracture)
• Fractured ulna and dislocated head of the radius (Monteggia fracture)
• Fracture occurring at or across the growth plate (Growth plate fracture)

Causes

Forearm fractures in children are caused due to a fall on an outstretched arm or direct hit on the forearm, which may result in breakage of one or both bones (radius and ulna).

Signs and Symptoms

A fractured forearm causes severe pain and numbness. Other signs and symptoms include:

• Swelling
• Tenderness
• Inability to turn or rotate the forearm
• Deformed forearm, wrist or elbow
• Bruising or discoloration of the skin
• Popping or snapping sound during the injury

Diagnosis

Forearm fractures in children can be diagnosed by analyzing X-ray images of the wrist, elbow or the forearm.

Treatment

The treatment of forearm fractures in children is based on the location, type of fracture, degree of bone displacement and its severity.

Non-surgical therapy

Your child’s doctor will advise you to apply an ice pack over a thin towel on the affected area for 15-20 minutes 3-4 times a day, to relieve pain and swelling. For severe angled fractures, in which the bones have not broken through the skin, your doctor will align the bones properly without the need for surgery (closed reduction). A splint or cast may be required for 3 to 4 weeks for a stable buckle fracture. Immobilization for 6 to 10 weeks is recommended for more serious fractures.

Surgical Treatment

Surgery may be necessary for severe fractures such as fractures of the growth plate or the joint. Other conditions, such as broken skin, bone displacement, unstable fractures, misaligned bones, and bones healing in an improper position may also require surgical repair. Your surgeon will first align the bones through an incision and use fixation devices like pins or a metal implants to hold the bones in place while the wound heals. A cast or a splint may be placed to hold the bones in place.

Conclusion

In the long run, the forearm of your child may have a slightly different or crooked look than before the fracture, which is normal. It may take around 1-2 years for the bones of the forearm to straighten while the bones undergo the process of remodeling (reshaping). For growth plate fractures, your child’s doctor will carefully monitor the hand for many years to ensure that growth occurs normally.

Shoulder injuries in baseball players are usually associated with pitching. While this overhand throwing activity can produce great speed and distance for the ball, when performed repeatedly, it can place a lot of stress on the shoulder.

The shoulder is a shallow ball and socket joint, formed by the bone of the upper arm (humerus), which articulates with the shoulder blade in a cavity called the glenoid fossa. The joint relies a great deal on surrounding soft-tissue structures such as tendons, ligaments and muscles (rotator cuff muscles) to maintain smooth motion and stability. The glenoid cavity is surrounded by a raised ridge of cartilage called the labrum that deepens the cavity and a ligamentous structure called the shoulder capsule centers the humerus in the cavity. The biceps muscle, certain back muscles as well as a group of muscles called the rotator cuff all work together to stabilize the shoulder.

While pitching, the arm is thrown outward and backward to generate speed. This action forces the head of the humerus forward, stressing the surrounding ligaments and tendons. These stresses can lead to injuries, causing pain and inflammation. Common injuries include:

• Tears of the labrum
• Tendonitis (inflammation of the tendons) and tears of the rotator cuff
• Tendonitis and tears of the biceps tendon
• Impingement of the rotator cuff tendons between the humeral head and glenoid
• Partial dislocation of the joint (instability)

Pain and instability of the shoulder can result in reduced throwing velocity and accuracy.

Your therapist will assess your shoulder injury by reviewing your pain and the movements that produces it, and performing a thorough physical examination. Imaging studies such as X-rays and MRIs may be ordered.

Most shoulder injuries involve soft tissue structures which can be treated by a period of rest, ice application, medication and physical therapy to stretch and strengthen the muscles and ligaments, improving and maintaining range of motion. A change in throwing technique may be suggested to reduce stress on the injured shoulder.