Humerus and Clavicle Fractures
Proximal Humerus Fractures
Humerus is the upper arm bone and it forms two joints —shoulder joint and elbow joint. The proximal humerus is the upper end of arm bone that forms shoulder joint. Fractures of proximal humerus are common in elderly individuals suffering from osteoporosis. Fractures are caused by traumatic injuries such as a fall on outstretched hand from greater heights or motor vehicle accidents. In younger individuals, a severe trauma can cause these fractures.
Proximal humerus fractures can be categorized into 4 groups:
- Greater tuberosity fractures: Greater tuberosity is the insertion site for attachment of rotator cuff tendons. Greater tuberosity fractures are less common and are seen in cases of shoulder dislocations and in those with osteoporosis. Greater tuberosity fragment is pulled off when cuff muscle contracts or anterior shoulder dislocates. Direct impact to the shoulder causes the tuberosity bone to break into multiple fragments Partial rotator cuff tears often accompany non-displaced fractures and these fractures can be diagnosed using MRI or diagnostic arthroscopy.
- Lesser tuberosity fractures: These fractures often caused by posterior shoulder dislocations or traumatic muscle contractions by electrical shock or convulsions. If left untreated, these fractures cause subscapularis muscle (stabilizer and mobilizer muscle) deficiency and requires a major muscle transfer procedure.
- Surgical neck fractures: Fractures of the surgical neck are most common in patients with osteoporotic bone. These fractures also damage the axillary nerve that carries sensory information from shoulder.
- Humeral head fractures: Humeral head fractures are very often in elderly individuals and chances are more in those with osteoporotic bone. These fractures occur in younger individuals by significant trauma whereas a mild traumatic injury can cause fracture in elderly individuals with osteoporosis.
In addition to above, another type of proximal humerus fractures is two, three, and four part fractures, a fracture cause multiple fragmentation of the proximal humerus.
Patients with proximal humerus fracture experience severe pain, swelling, and restricted motion of the shoulder.
Proximal humerus fracture is diagnosed by physical examination, X-ray of the affected area and/or computerized tomography (CT) scan.
Most proximal humerus fractures are minimally displaced and can be treated with conservative approaches such as use of sling to immobilize and early physical therapy to improve the functional outcome. Surgery may be necessary in displaced fractures. The multiple fragments are fixed with plates, screws, or pins and in severe cases a shoulder replacement surgery is performed.
Clavicle Fracture
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.