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 glenoid is the socket that forms the ball and socket joint of the shoulder. Fractures of the glenoid are rare but can occur due to major trauma or during high-energy sports activities.

Symptoms of a glenoid fracture include shoulder pain, swelling, deformity at the site of the fracture and inability to move the arm. Your doctor will perform a thorough physical examination and order X-ray’s or a CT scan to determine the extent of the fracture and displacement of the joint.

Non-displaced fractures require immobilization in a sling for about six weeks. If the fracture has led to the displacement of the bones, then surgery may be required to correct and fix them with pins, plates or screws. Physical therapy may be recommended to aid recovery, and improve range-of-motion and strength of the arm.

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.