Shoulder Fracture Flashcards
What is the most common shoulder fracture?
The most common site of shoulder fracture is the proximal humerus, accounting for around 5% of all fractures.
Briefly describe the pathophysiology of shoulder fractures
The majority of proximal humeral fractures are low energy injuries occurring in elderly patients falling onto an outstretched hand from standing. These injuries occur primarily in the context of an osteoporosis.
They also less commonly occur in younger patients usually the result of a high energy traumatic injury, therefore there are often associated soft tissue or neurovascular injuries.
What are the risk factors for shoudler injuries?
The risk factors for low energy proximal humerus fractures are comparable to other osteoporotic fractures, including female gender, early menopause, prolonged steroid use, recurrent falls, and frailty.
What are the clinical features of shoulder fractures?
The principal features of this injury will be pain around the upper arm and shoulder, with restriction of arm movement and an inability to abduct their arm.
On examination, there is likely to be significant swelling and bruising of the shoulder, which can spread to the chest and down the arm.
Why is a neurovascular examination important following a shoulder fracture?
Due to the close anatomical relationship with the axillary nerve and the circumflex vessels, is important to check the neurovascular status of the arm
Damage to the axillary nerve can result in loss of sensation in the lateral shoulder (“Regimental Badge Area”) and loss of power of the deltoid muscle.
How does damage to the axillary nerve present?
Damage to the axillary nerve can result in loss of sensation in the lateral shoulder (“Regimental Badge Area”) and loss of power of the deltoid muscle.
What investigations should be ordered for a shoulder fracture?
As for any trauma case, urgent bloods, including a coagulation and Group and Save, should be sent.
Plain film radiographs are the required initial imaging modality for suspected shoulder fracture. To appropriately to visualise and classify a proximal humeral fracture, anteroposterior (AP), lateral scapular, and axillary views are all required.
Further imaging with a CT scan can be used for preoperative planning, or if the position of any of the humeral segments is unclear.
Briefly describe what is shown on the x-ray
A comminuted proximal humeral fracture
What classification system is used for shoulder fractures?
Neer classification system is used to characterise proximal humeral fractures based on the relationship between 4 main segments of the proximal humerus.
Briefly describe Neer Classification System
The Neer classification system is used to characterise proximal humeral fractures based on the relationship between 4 main segments of the proximal humerus:
- Greater tuberosity
- Lesser tuberosity
- Articular segment (anatomical neck)
- Humeral shaft (surgical neck)
Briefly describe the conservative management of a shoulder fracture
The majority of proximal humeral fractures can be managed conservatively, especially those minimally displaced without neurovascular compromise.
The patient requires immobilisation initially with early mobilisation including pendular exercises at 2-4 weeks post injury dependent on fracture pattern. The patient must have a correctly applied polysling that allows their arm to hang; the effect of gravity on the arm will aid the reduction of the fragments of most humeral fractures.
Following a shoulder fracture, when is surgical management appropriate?
Surgical fixation is indicated in patients with displaced, open, or neurovascularly compromised fractures, however the type of surgery is dependent on the classification and complexity of the fracture, and patient factors.
Briefly describe the surgical management of shoulder fractures
Patients with multiple segment injuries may be managed with open reduction internal fixation (ORIF) or intermedullary nailing.
Hemiarthroplasty can be performed in a small number patients who experience complex injuries, or injuries that include splitting of the humeral head and are likely to have significant complications if the fracture is treated using ORIF.
Reverse shoulder arthroplasty (RSA) is an option for low demand patients, or patients who require revision after a failed previous procedure.
What is reverse shoulder arthropathy (RSA)?
RSA involves a total shoulder arthroplasty in which the ball and socket portions of the shoulder joint are reversed. Usually conservative management will be attempted before arthroplasty.
Briefly describe the role of physiotherapy following a shoulder fracture
Extensive physiotherapy will be required to regain full function and reduce pain. Rehabilitation time for a proximal humeral fracture is around 1 year and is very dependent on how soon the patient was allowed to mobilise their shoulder.
