Shoulder Fractures

Shoulder fractures involve a break of the bone at the top of the humerus near the joint. They commonly happen after a direct fall on the shoulder. Sometimes, they can occur if you fall onto an outstretched hand. The fractures can involve the rotator cuff tendon attachments or damage the joint itself.

Who gets shoulder fractures?

The short answer is anyone! In younger patients, these typically happen as a result of contact sports, including rugby and football. Cyclists who fall from their bikes may fracture their humerus. However, they can also happen from any innocent fall onto the shoulder. This is typical in older age groups, especially when people have osteoporosis, which is an age-related weakening of their bones. A shoulder fracture in anyone over 60 often triggers a bone health assessment to check whether you have osteoporosis which puts you at risk of other fractures, such as hip and spinal fractures.

Symptoms

01 Bruising and swelling at the top of your arm after a fall

02 Pain that is worst in the first few weeks, often making it helpful to sleep sitting up slightly and avoid lying on the affected side

03 Difficulty using the shoulder until pain subsides

How is a shoulder fracture diagnosed?

A shoulder fracture is often very obvious from the bruising and swelling at the top of your arm after a fall. Most people visit the nearest A&E and are sent for an X-ray which clearly shows the fracture.

There are different types of shoulder fracture. At their simplest, the break is in two parts, with the parts roughly in their normal position. More severe fractures are broken into several pieces and occasionally the shoulder joint is also dislocated.

Treatment options

Non surgical

Sling Treatment

Most people are treated with a sling to help keep the fractured bone ends in line. The first few weeks are the most painful and it is often helpful to sleep sitting up slightly, and avoiding lying on the affected side. You are advised to take regular painkillers and frequently take your arm out of the sling to move your elbow, wrist and hand to prevent stiffness.

The sling is worn for 3-4 weeks, until the pain subsides. As the pain subsides, you are able to use your shoulder more and more. You are often seen in clinic after a week, and then at 6 weeks to check on healing and, if needed, for a new X-ray. After 6 weeks, if all is going well, you are usually referred to physiotherapy to help get your arm moving properly again. Mr. Davies advocates early movement if you have broken your shoulder and allows you to start using your arm as soon as possible. The key is to listen to your body, don't overdo it, and take painkillers.

You can return to work when comfortable. If you work at a desk, this may be after only a week or two. Most people find that they can write and use a computer if they find a comfortable position. Heavier jobs will require more time off work until the fracture has healed. You can return to driving when out of the sling and you feel safe to steer and use the gearstick. This is usually after a minimum of 6 weeks.

If your fracture does not heal after several weeks, your doctor may offer you surgery to try to encourage it to heal. By following your doctor's advice, avoiding smoking and looking after yourself, you can maximise the chance of it healing.

Surgical

Shoulder Fracture Surgery

You may opt for surgery to treat the fracture. Many fractures can be repaired with a metal plate and screws and this may help your shoulder recover better. If the fracture is especially severe, you may instead be offered a reverse shoulder replacement. With surgery, some people are able to get back to normal activities more quickly. However, like all surgery, it carries risks as well as benefits.

Recovery

Most shoulder fractures heal reliably. However, the joint is very sensitive to injury and most adult patients do not have a completely normal shoulder after recovery, although few people have significant pain or difficulty with their normal activities once they have recovered. The main complications to note are:

Shoulder stiffness: As stated above, after full recovery, most adults have minimal or no pain in their shoulder and can adapt to do all of their normal activities. However, few people get back to their full movement. On average, after a year, you might expect to raise your arm just above shoulder height, get your hand to the back of your head and the lower part of your back. Some people have much more movement than this and some have very limited movement and develop a frozen shoulder. If this happens, your doctor may offer you physiotherapy, hydrodilatation and, if all else fails, surgery.

Avascular necrosis: When you break your shoulder, it can damage the blood supply to the joint. If this happens, the bone can collapse over several months, causing this condition. It results in a painful shoulder with very limited movement. It can also lead to arthritis in the shoulder joint. If this happens, you may be offered a shoulder hemiarthroplasty or full shoulder replacement. Mr. Davies specialises in stemless shoulder replacements which work well for this condition.

Failure to heal: The humerus is one of the more predictable bones to heal. Occasionally, however, these fractures do not heal by themselves. We call this a non-union. Several factors including smoking, your age and the severity of the injury can affect the chance of your fracture healing. This is an important aspect to discuss with your doctor when deciding on treatment. If it does not heal, it usually remains painful around the fracture and can affect your ability to move your arm. In this situation, you may be offered surgery to fix the fracture and encourage it to heal.

Malunion: This means that the shoulder heals but in an incorrect position. This can result in pain or difficulty moving your shoulder. There may be an option for your surgeon to do an operation that breaks the bone (a so-called osteotomy) to restore it to normal again. If this is not possible, you may be offered a reverse shoulder replacement.

Nerve injury: Sometimes, nerves that move your arm and supply sensation down your arm can be damaged, causing weakness, paralysis or loss of feeling. This is usually temporary due to a stretch of the nerve but if permanent can lead to long-term disability.

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