Most of the time, this type of fracture follows a fall. The surgical operation is not systematic. A simple immobilization of the shoulder may suffice while the bone consolidates.
In general, it is falling that we broke our shoulder. The bone breaks as a result of a direct impact (a violent blow to the shoulder) or indirect (typically when a person falls from his height and absorbs the fall with the palms of the hands).
Who can break their shoulder?
This type of accident can happen to anyone and at any age. But two categories of people are more particularly concerned.
- The bikers, the cyclists or even the skiers can fall violently on the shoulder. Most often, the fracture is at the level of the clavicle, this elongated bone, located at the base of the neck and which is flush with the skin.
- The women after menopause are sometimes weakened by osteoporosis, a pathology that causes bone demineralization. The bone being less solid, it breaks at the slightest fall. The osteoporotic fractures lhe most common are in the wrists, hips (neck of the femur), and vertebrae. “The shoulder fracture comes in the fourth position”, estimates Dr. Adrien Jacquot, an orthopedic surgeon at the Louis Pasteur clinic in Essay-lès-Nancy. In the context of osteoporosis, it is the head of the humerus, the long bone of the arm, which breaks.
What are the symptoms of a broken shoulder?
Three signs can give the alert. “None of these signs are characteristic of a fracture, but they put the chip in the ear”, observes Dr. Jacquot.
Visible deformity of the shoulder
There is a clear difference between the traumatized shoulder and the healthy shoulder. This is for example the case when the collarbone is displaced.
The appearance of a large hematoma
After the trauma, an effusion of blood forms, and the shoulder begins to swell. Quickly, it loses volume and turns blue. Without medical intervention, the hematoma may spread to the chest and diffuse up to the elbow. “Some people have an entirely black arm, especially if they are taking blood thinners”, observes Dr. Jacquot.
Pain at the slightest movement
The patient takes a tense and characteristic attitude. As a pain-relieving reflex, he blocks his arm, glued to the body, the elbow bent. In medical language, we speak of “the attitude of the traumatized upper limb”.
What medical examinations to know if his shoulder is broken?
A shoulder x-ray allows the diagnosis of fracture to be made very quickly.
The scanner, which gives a more precise image of the bone, is only used in two circumstances:
- in case of doubt, if the image is not significant on the radio;
- en case of displaced fracture of the shoulder : “In this case, the CT scan allows us to characterize the fracture and decide whether to operate or not. If the decision to operate is made, the images of the scanner help us to choose the best surgical technique, that is to say a conservative treatment with the installation of a plate or a nail; either (but this is rarer) the fitting of a shoulder prosthesis when the fracture is complex “, specifies Dr Jacquot.
In which cases should a fractured shoulder be operated on?
The decision is made on a case-by-case basis, depending on multiple factors.
Depending on the severity of the fracture
A open collarbone fracture always requires surgery, to avoid the risk of infection.
For a displaced fracture, the operation is being considered, but it is not systematic. “Orthopedic treatment, with a simple immobilization of the shoulder, gives very good results, including on a displaced fracture. A study compared patients with a displaced but simple fracture of the head of the humerus. One group was operated on, the other not. A year later, we observe that there is no difference between operation and orthopedic treatment. Orthopedic treatment is no better. He is simply “no less good” and less aggressive. Even when the fracture is displaced, it is sometimes necessary to know how to choose this option ”, remarks Dr. Jacquot.
According to the patient’s age and state of health
In an elderly person in poor health, thesurgery can cause complications and ultimately will not provide more benefit than simply immobilizing the shoulder.
According to the patient’s professional and sporting activities
The decision will not always be the same for a tennis player who needs to perform wide movements, for a mason whose shoulders need to be strong, or for a sedentary retiree. In all cases, it is necessary estimate the expected benefits of the operation and weigh them against the potential risks.
What are the surgical techniques?
When it is necessary to operate a fracture of the shoulder, osteosynthesis material (plate, screws, nails, etc.) is placed so that the bone is properly maintained.
- At the level of the clavicle, “The only option is to install a metal plate held by screws”, explains the surgeon.
- At the level of the head of the humerus, the bone will be repaired thanks to an internal or external “guardian”. The surgeon has two options. Either he poses an external plate, fixed with screws. Either he inserts a “nail”, a large rod, inside the humerus.
“This osteosynthesis material is not systematically removed. It is generally preferred to avoid the risks of a second surgical intervention. It is only removed if it is inconvenient for the patient ”, underlines Dr. Jacquot.
The shoulder prosthesis is only considered for a complex fracture of the head of the humerus (multiple fragments or very displaced), presenting a risk of necrosis, especially when small arteries have been torn during the trauma.
When it is not operated, how to immobilize the shoulder?
Different systems exist:
- After a broken collarbone, the shoulder is held in place by “clavicular rings”, a sort of backpack whose shoulder straps oblige the patient to stand up straight, shoulders back.
- After a fracture of the head of the humerus, the arm is worn as a sling.
To heal well, the shoulder must be protected for six weeks, but a re-education gentle, under the supervision of a physiotherapist, can begin as early as the third week. Very gradually, the patient can raise his arm. A fracture of the head of the humerus can rise above the horizontal, from the start of rehabilitation, if the movement is not painful.
In any case, for the bone to regain its full strength, it takes 6 months to a year.
How to sleep with one arm in a sling?
Above all, you must avoid pressing on the shoulder. For this, Dr. Jacquot advises his patients to sleep in a semi-seated position and to wedge a cushion behind the elbow to prevent it from moving back. This way the shoulder stays in place.
How to re-educate your shoulder after a fracture?
The re-education start slowly from the third week of immobilization. The physiotherapist will mobilize the shoulder passively (without the patient contracting his muscles) in order to maintain the flexibility of the joint.
Then, as soon as the shoulder is sufficiently restored, a muscle strength work is undertaken, using rubber bands and weights. “This work can only start if the shoulder is painless and flexible. In this phase of rehabilitation, the goal is to recover at least 70 to 75% of muscular strength, so as to be able to perform the gestures of everyday life. It lasts the time necessary to achieve this objective ”, specifies the surgeon.
This rehabilitation can be followed by a phase of rmuscle strengthening with a physiotherapist, a sports trainer, or self-rehabilitation exercises at home depending on the patient’s profile.
It takes more than three months of muscular training before considering resuming sport or work requiring the shoulder.
What are the risks of long-term sequelae?
If this rehabilitation is not carried out correctly, the shoulder can retain a certain stiffness, whether it has been operated on or not.
The risk of osteoarthritis is rarer. It only concerns complex fractures of the head of the humerus affecting the joint. “This is also an argument for the installation of a shoulder prosthesis”, remarks the surgeon. Some 20,000 shoulder prostheses are fitted each year in France, most often for problems of osteoarthritis or a complete rupture of the tendons of the rotator cuff. The shoulder fracture is only a small part of it.