Traumatic Shoulder Injuries

Fractures

Fractures commonly involve the clavicle/collar bone, proximal humerus/top of the upper arm bone, and scapula/shoulder blade.

Clavicle Fractures

Symptoms following a clavicle fracture often include:

Swelling about the middle of the collarbone area. The area may have a “bump,” which is actually the prominent ends of the fracture under the skin. Shoulder range of motion is limited but sometimes possible to perform through a limited range.

Most clavicle fractures can be treated without surgery. Surgery is necessary when there is a compound fracture that has broken through the skin or the bone is severely out of place. Surgery typically involves fixing of the fracture with plates and screws or rods inside the bone.

Proximal Humerus Fractures

Proximal humeral fractures often result in a severely swollen shoulder with very limited movement of the shoulder and severe pain.

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is usually required. Surgery usually involves fixation of the fracture fragments with plates, screws, or pins or it involves shoulder replacement.

Scapula Fractures

Scapular fractures result in localized pain, moderate swelling and severe bruising about the shoulder blade.

Most fractures of the scapula can be treated without surgery. Treatment involves immobilization with a sling or shoulder immobilizer, icing, and pain medications.

Dislocations

Dislocations occur when the bones on opposite sides of a joint do not line up. The most common of these involve the following joints of the shoulder:

  • A dislocation of the acromioclavicular joint (collar bone joint) is called a “separated shoulder.” Dislocations of the acromioclavicular joint can be caused by a fall onto the shoulder or from lifting heavy objects. The term “shoulder separation” is not really correct, because the joint injured is actually not the true shoulder joint.
  • A dislocation of the sternoclavicular joint interrupts the connection between the clavicle and the breastbone (sternum).
  • The glenohumeral joint (the ball and socket joint of the shoulder) can be dislocated toward the front/anteriorly or toward the back/posteriorly. Anterior dislocations of the shoulder are often caused by the arm being forcefully twisted outward when the arm is above the level of the shoulder. These injuries can occur from a fall or a direct blow to the shoulder. Posterior dislocations of the shoulder are much less common than anterior dislocations of the shoulder.

Life after a shoulder fracture, separation, or dislocation can be greatly affected for several weeks or even months. Most shoulder injuries whether treated surgically or nonsurgically require a period of immobilization followed by rehabilitation.

If the injury was not severe, there is fairly rapid improvement and return of function after the first 4 to 6 weeks. Shoulder exercises, usually as part of a supervised physical therapy program, are usually necessary. Exercises decrease stiffness, improve range of motion, and help you regain muscle strength.

Rotator Cuff Tears

Soft-tissue injuries are tears of the ligaments, tendons and muscles of the shoulder. Rotator cuff tears are a common source of shoulder pain.

The rotator cuff of the shoulder joint is comprised of four muscles that surround the humeral head or ball of the shoulder joint. The muscles are referred to as the “SITS” muscles: supraspinatus, infraspinatus, teres minor, and subcapularis. The muscles function to provide rotation, elevate the arm, and give stability to the shoulder joint. These muscles arise from the scapula or shoulder blade and are attached to the ball joint or humeral head of the shoulder.

There are several common factors that cause rotator cuff tears. One factor is tendon blood supply. The blood supply to the rotator cuff diminishes with age and transiently with certain motions and activities. The diminished blood supply may contribute to tendon degeneration and tearing.

Another factor that can cause damage to the rotator cuff is the presence of bone spurs underneath a bony ledge above the head of the humurus (the acromion). The spurs rub on the tendon when the arm is elevated. The rubbing of the tendon on the bone spur can lead to weakening of the tendon.

Traumatic injuries also account for tears of the rotator cuff and often occur when there is a fall upon an outstretched arm or can also occur from trauma associated with impact (football injury).

The decision on how to treat rotator cuff tears is based on the severity of symptoms and functional requirements. Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every person.

Surgical management is indicated for a rotator cuff tear that does not respond to nonsurgical management and is associated with weakness, loss of function, and limited motion

Following rotator cuff surgery, therapy progresses in stages:

4-6 weeks post operatively

Initially, the repair needs to be protected until adequate healing of the tendon to bone occurs. For this reason, most patients use a sling for the first 4 to 6 weeks after surgery and are instructed to limit active use of the arm during this period. Passive range-of-motion exercises are begun with a therapist; may be taught as well.

6-12 weeks

Progressive elbow and wrist and hand, strengthening along with assisted range-of-motion exercises continue during the next 6 to 12 weeks.

8-12 weeks

Progressive strengthening of the shoulder is the focus during this time along with acquisition of full active motion of the shoulder.

Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery.

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