Treatment and Surgery of Fractures Around the Shoulder

What Are Fractures Around the Shoulder?

The most common types of fractures around the shoulder are as follows:

1. Clavicle Fractures (Collarbone Fractures):
   
   • They account for approximately 5-10% of all fractures and are quite common.
   • Usually occur as a result of a fall onto the shoulder or an outstretched hand.
   • Most commonly seen in the middle portion of the bone (mid-shaft), but can also fracture at the end near the shoulder joint (distal) or near the breastbone (proximal).
2. Scapula Fractures (Shoulder Blade Fractures):
   
   • Less common and usually result from high-energy trauma (traffic accidents, falls from height).
   • May occur as fractures of the body or neck of the bone, or fractures involving the shoulder socket (glenoid).
   • Frequently accompanied by other serious injuries such as rib fractures and lung injuries.
3. Proximal Humerus Fractures (Upper End of the Arm Bone):
   
   • Very common, and can occur even from simple falls, especially in elderly individuals with osteoporosis (bone loss).
   • The fracture may involve the head of the humerus (joint surface), the bony prominences called tuberosities where the rotator cuff muscles attach (greater and lesser tuberosity), or the area just below the head called the surgical neck.
   • Classified according to the number of fragments (2, 3, or 4 parts) and the degree of displacement (e.g., Neer Classification). This classification influences the choice of treatment.

What Are the Symptoms of Shoulder Fractures?

Symptoms vary depending on the type and severity of the fracture, but generally include the following:

• Severe Shoulder Pain: Pain that increases especially when trying to move the arm.
• Swelling and Bruising: Rapidly developing swelling at and around the fracture site and bruising due to bleeding under the skin.
• Deformity: Especially in clavicle fractures, a visible bump under the skin or the shoulder appearing to droop. Proximal humerus fractures may also cause a change in shoulder shape.
• Restricted Movement: Inability to raise or move the arm due to pain.
• Crepitus: A crackling sound felt or heard with movement as the fracture ends rub against each other.
• Signs of Nerve or Vascular Injury (EMERGENCY!): Symptoms such as numbness, tingling, loss of strength, paleness, or coldness in the arm suggest an accompanying nerve or vascular injury and require immediate medical attention.

How Are Shoulder Fractures Diagnosed?

Accurate diagnosis and detailed assessment of the fracture are essential for the treatment plan. Prof. Dr. Murat Bozkurt follows these steps during the diagnostic process:

• Patient History: Information is gathered on how the injury occurred (mechanism of the fall, direction of the blow, etc.), the patient’s age, general health status, and activity level.
• Physical Examination:
  
  • The shoulder region is carefully inspected (deformity, swelling, skin integrity – is there an open fracture?).
  • Tender areas are palpated.
  • Active and passive shoulder movements are assessed to the extent pain allows.
  • Most importantly, the nerve and vascular status of the arm (neurovascular examination) is carefully assessed. Pulses are checked, and sensation and muscle strength are evaluated.
• Imaging Methods:
  
  • X-ray: The primary method for diagnosing shoulder fractures. X-ray films taken from different angles (usually at least two perpendicular views) are used to assess the fracture’s location, type, degree of comminution, and amount of displacement. AP, lateral (e.g., scapular Y or velpeau), and axillary views may be needed for the proximal humerus; special views may be required for the clavicle and scapula.
  • Computed Tomography (CT): Especially in intra-articular fractures (glenoid, humeral head), highly comminuted proximal humerus fractures, or cases requiring surgical planning, CT is requested to see the fracture fragments, displacement, and bone structure in more detail in three dimensions. It is very useful in determining the surgical strategy.
  • Magnetic Resonance Imaging (MRI): Generally not necessary for the diagnosis of an acute fracture. However, it may be requested if a soft tissue injury such as an accompanying rotator cuff tear is suspected.

Treatment Methods for Shoulder Fractures: Conservative and Surgical

Treatment of fractures around the shoulder is determined based on the fracture type, location, degree of displacement, the fracture’s relationship with the joint, the patient’s age, bone quality, activity level, and general health status. There are two main treatment approaches:

Non-Surgical (Conservative) Treatment:

• Who Is It Used For? Preferred for stable fractures (low risk of shifting) where the fragments are not significantly separated (minimally displaced or non-displaced), or for patients whose general health status is not suitable for surgery.
• Methods:
  
  • Arm Sling or Velpeau Bandage: The most commonly used method. Keeps the arm immobile, allowing the fracture to heal and reducing pain. Used especially in most proximal humerus fractures and some clavicle/scapula fractures. Duration of use varies depending on fracture type and healing speed (usually 3-6 weeks).
  • Figure-of-8 Bandage: Once frequently used for clavicle fractures, this bandage aims to bring the fracture ends closer together by pulling the shoulders back. It is less preferred today due to comfort issues and debated effectiveness.
  • Pain Control: Pain-relieving medications are used.
  • Early Physical Therapy: Very important. Especially in proximal humerus fractures, passive or active-assisted movements such as pendulum exercises are started as early as the physician allows (usually within the first 1-2 weeks) to prevent the shoulder from completely stiffening (frozen shoulder). The exercise program is expanded as healing progresses.
• Follow-up: Regular X-ray checks are used to monitor fracture healing and position.

Surgical Treatment:

• When Is It Needed?
  
  • If there is significant displacement or angulation between the fracture fragments (this increases the risk of nonunion, malunion, or loss of function).
  • If there is an open fracture (where the fracture ends pierce the skin, carrying a high risk of infection).
  • If there is vascular or nerve injury accompanying the fracture.
  • If the fracture involves the joint surface with step-off or displacement in the joint (this needs to be corrected to reduce the future risk of osteoarthritis).
  • Floating Shoulder: Cases where both the clavicle and the scapular neck are fractured together (this disrupts the function of the shoulder suspensory system).
  • If a young, active patient has high functional expectations and the fracture is displaced.
  • Cases where conservative treatment has failed (nonunion, malunion).
• Surgical Techniques (Vary by Fracture Location):
  
  • Clavicle Surgery: Open Reduction and Internal Fixation (ORIF) is most commonly performed. This means the fracture site is surgically opened, the fracture ends are placed in the correct position (reduction), and fixed to the bone with specially designed plates and screws (internal fixation). Rarely, a pin placed inside the bone (intramedullary fixation) may also be used.
  • Scapula Surgery: Surgery is required less often. ORIF (plate-and-screw fixation) may be performed, especially for neck fractures involving the shoulder socket (glenoid) or showing significant angulation.
  • Proximal Humerus (Upper Arm Bone) Surgery: The technique is chosen based on the fracture type, degree of comminution, patient age, and bone quality:
    
    • ORIF (Plate-and-Screw Fixation): The fracture fragments are anatomically repositioned and fixed with special locking plates and screws. Frequently preferred for displaced 2-, 3-, and 4-part fractures, particularly in patients with adequate bone quality.
    • Intramedullary Nailing: A fixation method using a nail placed inside the bone. Particularly an option for surgical neck fractures.
    • Hemiarthroplasty (Partial Replacement): Replacement of only the humeral head with a metal prosthesis when the head (ball) is severely comminuted by the fracture, its blood supply is disrupted, or it cannot be anatomically repaired, particularly in elderly patients.
    • Reverse Total Shoulder Arthroplasty (RTSA): A special type of prosthesis in which both the humeral head and the glenoid socket are replaced (the ball is placed where the socket was, and the socket where the ball was). Increasingly preferred, especially in highly comminuted proximal humerus fractures, elderly patients, cases with very poor bone quality, or where the rotator cuff has also been severely damaged, because it provides better functional outcomes than hemiarthroplasty.

Prof. Dr. Murat Bozkurt determines the most appropriate surgical method (ORIF, replacement, etc.) based on the characteristics of the patient and the fracture, and applies it using modern techniques for shoulder fractures in Ankara.

Risks, Benefits, and the Recovery Process

• Benefits (Surgery): Anatomical correction of the fracture fragments, achieving stable fixation so the bone heals in the correct position, the possibility of starting shoulder movement earlier (reduces stiffness), improved functional outcome, and reduced risk of nonunion or malunion.
• Risks:
  
  • General surgical risks: Infection, bleeding, nerve or vascular injury (especially during surgery), anesthesia complications, blood clotting (DVT – rare in the shoulder).
  • Risks specific to fracture surgery: Nonunion, malunion, loosening, breakage, or displacement of the fixation material (plate, screw, prosthesis), implant causing discomfort under the skin, shoulder stiffness (frozen shoulder), avascular necrosis (AVN – particularly disruption of the blood supply to the humeral head), future development of osteoarthritis, need for repeat surgery.
• Recovery Process:
  
  • Recovery time varies considerably depending on the fracture type, location, severity, and the treatment method applied (conservative or surgical).
  • Use of Arm Sling: Generally, following both conservative and surgical treatment, an arm sling must be worn for a few weeks (usually 2-6 weeks or longer) for the initial healing of the fracture.
  • Physical Therapy and Rehabilitation: ABSOLUTELY ESSENTIAL at every stage of treatment and afterward. Its purpose is to prevent shoulder stiffness, restore joint range of motion, increase muscle strength, and return shoulder function to normal. The timing of starting physical therapy and the content of the program are determined by the physician based on the fracture type and treatment given. It begins with passive movements, gradually progressing to active movement and strengthening.
  • Timeline: Bone healing generally takes 6-12 weeks. However, full recovery of shoulder function can take months (3-6 months or longer). Full recovery after particularly complex proximal humerus fractures can take up to 1 year. The patient’s adherence to the rehabilitation program directly affects outcomes.

Treatment of Fractures Around the Shoulder in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Fractures around the shoulder are conditions frequently encountered in emergency departments and orthopedic clinics in Ankara. Correct and timely treatment of these fractures is of great importance for the patient to regain shoulder function. Prof. Dr. Murat Bozkurt follows these steps in his approach to fractures around the shoulder:

• Fast and Accurate Diagnosis: He quickly determines the fracture’s type, location, and severity through the patient’s history, careful physical examination (especially neurovascular status), and appropriate imaging methods (X-ray, and CT when needed).
• Individualized Treatment Plan: He decides on the most appropriate treatment method (conservative or surgical) by taking into account the characteristics of the fracture (displacement, joint involvement, etc.) and the patient’s individual factors (age, activity level, bone quality, expectations).
• Modern Surgical Techniques: When surgery is needed, he applies the most suitable and up-to-date surgical technique for the fracture type (ORIF with plate and screws, intramedullary nailing, hemiarthroplasty, or reverse shoulder replacement) using modern implants. The goal is to achieve stable fixation and allow for early movement.
• Rehabilitation Focus: Following both conservative and surgical treatment, he emphasizes the importance of early and properly planned rehabilitation to prevent shoulder stiffness and maximize function, and guides his patients through this process.

Fractures around the shoulder generally have good outcomes with accurate diagnosis and timely, appropriate treatment. Whether non-surgical or surgical treatment is applied, it is very important to fully follow your doctor’s recommendations and physical therapy program for a successful recovery. If you experience a shoulder fracture in Ankara, you can consult Prof. Dr. Murat Bozkurt for expert opinion and treatment.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt by phone at 0312 502 70 74.