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Fracture of shoulder — Clinical Guidelines

Overview

Fractures of the shoulder, particularly those involving the proximal humerus, represent a significant orthopedic challenge due to their potential to disrupt complex joint mechanics and surrounding soft tissues. These injuries often result from high-energy trauma and can lead to substantial morbidity, including pain, loss of function, and decreased quality of life. Commonly affecting older adults and individuals with osteoporosis, shoulder fractures necessitate careful management to restore function and prevent complications such as avascular necrosis, nonunion, and glenohumeral arthritis. Effective treatment strategies are crucial in day-to-day practice to optimize patient outcomes and minimize long-term disability 1 3 5.

Pathophysiology

Shoulder fractures, especially those of the proximal humerus, disrupt the intricate balance of the shoulder girdle, involving the humeral head, glenoid, rotator cuff, and deltoid muscle. The mechanical forces often lead to comminution and displacement, compromising blood supply to the humeral head, particularly in multifragmentary fractures. Avascular necrosis of the humeral head can ensue if the fracture disrupts the nutrient arteries, leading to bone cell death and subsequent collapse 1 3. Additionally, the injury frequently damages the rotator cuff tendons and muscles, contributing to instability and impaired shoulder function. Over time, these structural changes can exacerbate joint incongruity, accelerating the development of post-traumatic osteoarthritis 4 7.

Epidemiology

Proximal humeral fractures are most prevalent among individuals aged 60 years and older, with a bimodal distribution seen in both the elderly and younger populations involved in high-impact activities. The incidence rates vary geographically but generally increase with age, reflecting the higher prevalence of osteoporosis in older adults. Males tend to have a slightly higher incidence due to higher rates of trauma-related injuries, although both sexes are affected. Recent trends indicate a rising incidence, likely attributed to aging populations and increased survival rates of trauma patients 1 3 5.

Clinical Presentation

Patients typically present with acute shoulder pain, swelling, and limited range of motion following trauma. Common symptoms include inability to lift the affected arm, deformity at the shoulder, and bruising. Red-flag features include severe pain disproportionate to the injury, inability to localize the pain, neurological deficits (e.g., weakness in the arm or hand), and signs of systemic compromise (e.g., shock). These features warrant urgent evaluation to rule out more severe injuries such as neurovascular compromise or associated fractures 1 3.

Diagnosis

The diagnostic approach for shoulder fractures involves a combination of clinical assessment and imaging studies. Clinical Criteria:

History and Physical Examination: Detailed history of trauma, pain localization, and functional limitations.

Imaging Studies:

- X-rays: Essential for initial diagnosis, identifying fracture lines, displacement, and involvement of the greater tubercle, lesser tubercle, surgical neck, or humeral head. - CT Scan: Provides detailed images for complex fractures, assessing comminution and intra-articular extension. - MRI: Useful for evaluating soft tissue injuries, including rotator cuff tears, which are common complications 1 3 5.

Specific Tests and Cutoffs:

X-ray Interpretation: Identification of fracture lines and displacement patterns (Neer classification).

CT Scan: Assessment of fracture complexity and joint involvement.

MRI: Detection of rotator cuff tears (e.g., signal changes indicative of tear).

Differential Diagnosis:

Rotator Cuff Tear: Pain and weakness without obvious deformity; MRI confirms tear.

Glenohumeral Arthritis: Chronic pain, stiffness; X-ray shows joint space narrowing and osteophytes.

Bursitis: Localized tenderness over bursae; aspiration may reveal inflammatory fluid 1 3 5.

Management

Nonoperative Management

Immobilization: Sling or shoulder immobilizer for initial stabilization.

Pain Management: NSAIDs or opioids as needed for pain control.

Early Mobilization: Gentle range-of-motion exercises to prevent stiffness, typically initiated after initial healing phase.

Physical Therapy: Gradual strengthening and mobility exercises post-immobilization 1 3.

Operative Management

Closed Reduction and Internal Fixation:

- Locking Plate Osteosynthesis: For displaced fractures, aiming to restore anatomical alignment. - Stemmed Hemiarthroplasty: Indicated for elderly patients or those with poor bone quality, providing pain relief and functional restoration. - Reverse Total Shoulder Arthroplasty (RTSA): Considered for complex fractures with significant rotator cuff deficiency or anticipated poor outcomes with other methods 1 3 5.

Specific Techniques and Considerations:

Plate Selection: Customized to fracture pattern and bone quality.

Implant Choice: Tailored to patient age, bone quality, and functional demands.

Postoperative Care: Early mobilization, physical therapy, and regular follow-up imaging to monitor healing and implant stability 1 3 5.

Complications

Avascular Necrosis: Risk increases with intra-articular fractures; monitored with serial imaging.

Nonunion and Malunion: Common in complex fractures; requires surgical intervention if symptomatic.

Rotator Cuff Injury: Often coexists; MRI essential for diagnosis and management.

Implant-Related Issues: Periprosthetic fractures, loosening, and infection; prompt referral for revision surgery if suspected 1 3 5.

Prognosis & Follow-up

Prognosis varies based on fracture type, patient age, and treatment modality. Key prognostic indicators include initial fracture displacement, bone quality, and presence of associated injuries. Recommended follow-up intervals include:

Immediate Postoperative: Regular clinical assessments and imaging (e.g., X-rays at 6 weeks, 3 months).

Long-term: Annual evaluations to monitor for complications such as arthritis, implant loosening, or functional decline 1 3 5.

Special Populations

Elderly Patients: Higher risk of complications; tailored rehabilitation and conservative approaches often preferred.

Pediatrics: Growth plate injuries require careful management to avoid growth disturbances; orthopedic consultation essential.

Comorbidities: Patients with osteoporosis or other systemic conditions may benefit from specialized fixation techniques and close monitoring 1 3 5.

Key Recommendations

Imaging with X-rays and CT for Complex Fractures: Essential for accurate diagnosis and planning (Evidence: Strong 1 3).

Early Mobilization Post-Fracture: To prevent stiffness and improve functional outcomes (Evidence: Moderate 3).

Consider Reverse Total Shoulder Arthroplasty for Complex Cases: Particularly in elderly patients with significant rotator cuff deficiency (Evidence: Moderate 5).

Regular Follow-Up Imaging: To monitor healing and detect early complications such as nonunion or implant issues (Evidence: Moderate 1 3).

Tailored Treatment Based on Patient Age and Bone Quality: Optimizes outcomes and minimizes complications (Evidence: Expert opinion 5).

Physical Therapy Integration: Essential for restoring range of motion and strength post-treatment (Evidence: Moderate 3).

Close Monitoring for Avascular Necrosis: Serial imaging in high-risk patients (Evidence: Moderate 1).

Referral for Specialist Intervention: For suspected complications like implant loosening or infection (Evidence: Expert opinion 5).

Use of Biomechanicalally Optimized Implants: To enhance stability and reduce revision rates (Evidence: Moderate 7).

Consider Humeral Stem Length in Periprosthetic Fracture Management: To minimize fracture risk around implants (Evidence: Moderate 8).

References

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A survey and biomechanical analysis of the feasibility of the thumb test for determining the cancellous bone quality for stemless shoulder prosthesis. Journal of orthopaedic surgery (Hong Kong) 2023. link 13 Friedman RJ, Boettcher ML, Grey S, Flurin PH, Wright TW, Zuckerman JD et al.. Comparison of long-term clinical and radiological outcomes for cemented keel, cemented peg, and hybrid cage glenoids with anatomical total shoulder arthroplasty using the same humeral component. The bone & joint journal 2023. link 14 Hornung AL, Cohn MR, Mehta N, McCormick JR, Menendez ME, Pourzal R et al.. The Definition of Periprosthetic Osteolysis in Shoulder Arthroplasty: A Systematic Review of Grading Schemes and Criteria. JBJS reviews 2022. link 15 Magosch P, Lichtenberg S, Habermeyer P. Survival of stemless humeral head replacement in anatomic shoulder arthroplasty: a prospective study. Journal of shoulder and elbow surgery 2021. link 16 Quental C, Folgado J, Comenda M, Monteiro J, Sarmento M. Primary stability analysis of stemless shoulder implants. Medical engineering & physics 2020. link 17 Comenda M, Quental C, Folgado J, Sarmento M, Monteiro J. Bone adaptation impact of stemless shoulder implants: a computational analysis. Journal of shoulder and elbow surgery 2019. link 18 Chamseddine M, Breden S, Pietschmann MF, Müller PE, Chevalier Y. Periprosthetic bone quality affects the fixation of anatomic glenoids in total shoulder arthroplasty: in vitro study. Journal of shoulder and elbow surgery 2019. link 19 Kilian CM, Morris BJ, Sochacki KR, Gombera MM, Haigler RE, O'Connor DP et al.. Radiographic comparison of finned, cementless central pegged glenoid component and conventional cemented pegged glenoid component in total shoulder arthroplasty: a prospective randomized study. Journal of shoulder and elbow surgery 2018. link 20 Lazarus MD, Cox RM, Murthi AM, Levy O, Abboud JA. Stemless Prosthesis for Total Shoulder Arthroplasty. 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Fracture of shoulder