Category Archive Fracture of Bone A-Z

Supracondylar fracture of the humerus is one of the most talked about and often encountered injury (only after clavicle and both bone forearm fracture) in pediatric age group with a male predominance accounting for 16% of all pediatric fractures and 60% of all pediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [rx–rx]. In the pediatric age group, the more common age of presentation is 5-7 years (90% cases). Extension type injury is more common than the flexion type [rx]. It is frequently found in the non-dominant extremity. The flexion type is common in elderly children [rx]. Certain studies have reported up to 30% incidence of open fractures in this subset of the patient [rx].

The vast majority are extension type, resulting from a fall onto an outstretched hand, where the elbow is hyperextended, the olecranon is driven into the olecranon fossa and the anterior humeral cortex fails in tension. The pull of triceps tends to displace the distal fragment posteriorly and proximally. Neurovascular complications are reported in 5–19 % of displaced fractures [rx, rx], due to the close proximity of structures such as the brachial artery and the anterior interosseous nerve. However, most nerve injuries are neurapraxia and recover without further intervention [rx].

Anatomy of Supracondylar Fracture

Anatomically, the distal humerus has a triangular shape which is built of two columns and a “tie arch”[rx]. The medial column holds at its distal end the nonarticular medial epicondyle with the insertion of the flexor muscles and the medial part of the humeral trochlea. The lateral column holds at its distal end the capitellum and more proximally the lateral epicondyle with the insertion of the extensor muscles (mobile wad). From a lateral perspective, the articular surface of the trochlea and capitellum is projected anteriorly at an angle of 40° to the axis of the humerus, the trochlear axis being externally rotated at an angle of 3°–8° and compared with the longitudinal axis being in 4° to 8° of valgus [rx, rx, rx].

When a fall on the outstretched hand occurs, the olecranon engages on the olecranon fossa and if elbow extension progresses, the olecranon finally acts as a fulcrum on the fossa. Therefore, the bone begins to break at first anteriorly and the fracture progresses posteriorly. If the energy is high, the posterior cortex disrupts, and finally, complete posterior displacement of the distal fragment occurs with the posterior periosteum acting as a hinge. This is the mechanism of extension-type fractures, which represent 97% to 99% of the total.^[rx]

Both supracondylar ridges, condyles, and epicondyles give rise to attachment of various muscles which are responsible for the displacement and rotation of distal fragment. Neurovascular structures lie in proximity to the supracondylar region. The brachial artery which commonly gets involved in supracondylar fracture of humerus lies along the anteromedial aspect of distal humerus just superficial to the brachialis muscle. Major neurological structures of the upper limb (median, radial, and ulnar nerves) are also in close relation with supracondylar region [rx].

Any fracture in the elbow region or upper arm may lead to Volkmann’s ischemic contracture, but it is especially associated with supracondylar fracture of the humerus. Volkmann’s contracture results from acute ischemia and necrosis of the muscle fibers of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor politics long. The muscles become fibrotic and shortened.

Mechanism of Supracondylar Fracture

Extension type of supracondylar humerus fractures typically results from a fall on to an outstretched hand, usually leading to a forced hyperextension of the elbow. The olecranon acts as a fulcrum which focuses the stress on the distal humerus (supracondylar area), predisposing the distal humerus to fracture. The supracondylar area undergoes remodeling at the age of 6 to 7, making this area thin and prone to fractures. Important arteries and nerves ( median nerve, radial nerve, brachial artery, and ulnar nerve) are located in the supracondylar area and can give rise to complications if these structures are injured. Most vulnerable structure to get damaged is the Median Nerve. ^[rx] Meanwhile, the flexion-type of supracondylar humerus fracture is less common. It occurs by falling on the point of the elbow or falling with the arm twisted behind the back. This causes anterior dislocation of the proximal fragment of the humerus.^[rx]

Types of Supracondylar Fracture

Classification of Fracture Supracondylar Humerus

Fractures of the supracondylar humerus may be classified in a number of ways as per the following:

•  Displaced or undisplaced fractures of the supracondylar humerus
• Open or closed fractures of the supracondylar humerus.
• Uncomplicated or complicated fractures of the supracondylar humerus (with/without neurological and/or vascular involvement).
• Extension type (95%) or flexion type (5%).
• Modified Gartland’s staging system [rx] is based on the lateral radiograph and widely used for extension type supracondylar fractures to classify further as it can help to guide treatment.

Type I fracture –  Undisplaced.

Type II fractures – Displaced with angulation, but maintain with an intact posterior cortex.

II A fracture – Angulation.

II B fracture – Angulation with rotation.

Type III fracture – Completely displaced and lack meaningful cortical contact, but have a periosteal hinge (either medial/ lateral) intact.

III A fracture – Medial periosteal hinge intact. Distal fragment goes posteromedially.

III B fracture – Lateral periosteal hinge intact. Distal fragment goes posterolaterally.

Type IV fracture – Have no periosteal hinge and are unstable both in flexion and extension i.e., they have multidirectional instability.

Gartland’s classification was modified by Wilkins in 1984,^[rx] subdividing type II fractures into IIA or IIB according to the absence (IIA) or presence (IIB) of malrotation. However, this sub-classification of type II fractures does not show a good intro- and inter-observer reliability.^[rx]

• Type I – Non-displaced fractures (< 2 mm). The AHL still crosses through the center of the capitellum. These fractures are stable because of the integrity of the periosteum.

• Type II – Moderately displaced (> 2 mm). The AHL passes anterior to the center of the capitellum; the posterior periosteum is intact but acts as a hinge.

• Type III – Completely displaced. This type of fracture is more unstable, with extensive soft-tissue and periosteal damage and increased incidence of neurovascular injuries.

Causes of Supracondylar Fracture

In correlation to the abovementioned bimodal distribution of age [rx], mainly two fracture mechanisms can be distinguished: low-energy trauma of the elderly with direct impact on the elbow or indirect impact resulting from a fall on the outstretched hand and high energy trauma of the young patient resulting essentially from road traffic or sport accidents [rx].

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken supracondylar fracture.
• Sports injuries – Many supracondylar Fracture occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Supracondylar Fracture

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the supracondylar fracture reason. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]
• Clinical parameters such as the temperature of the limb extremities (warm or cold), capillary refilling time, oxygen saturation of the affected limb, presence of distal pulses (radial and ulnar pulses), assessment of peripheral nerves (radial, median, and ulnar nerves), and any wounds which would indicate open fracture.
• Doppler ultrasonography should be performed to ascertain the blood flow of the affected limb if the distal pulses are not palpable. Anterior interosseous branch of the median nerve most often injured in the postero-lateral displacement of the distal humerus as the proximal fragment is displaced anteromedially.

Comminuted fracture of the elbow. Labelled artwork and corresponding X-ray of extensive comminuted fractures of the distal (elbow) end of the humerus bone in a patient’s left arm. A comminuted fracture is where the bone has broken into several pieces. This is an anterior (frontal) view of the elbow in its extended position, with the fractures being of the lateral and medial condyles. The artwork at right shows the location of the elbow bones in the arm, with the joint in extension. For the surgery carried out, see C021/0785. Screws and metal plates fixed across the condylar fractures held the fragments in place, allowing them to heal in the correct alignment.

Diagnosis of Supracondylar Fracture

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]

• There is pain and swelling about the elbow. Bleeding at the fracture results in a large effusion in the elbow joint.
• Depending on the fracture displacement, there may be a deformity. With severe displacement, there may be an anterior dimple from the proximal bone end trapped within the biceps muscle.
• The skin is usually intact. If there is a laceration that communicates with the fracture site, it is an open fracture, which increases infection risk. For fractures with significant displacement, the one end can be trapped within the biceps muscle with resulting tension producing an indentation to the skin, which is called a “pucker sign”.
• The vascular status must be assessed, including the warmth and perfusion of the hand, the time for a capillary refill, and the presence of a palpable radial pulse. Limb vascular status is categorized as “normal,” “pulseless with a (warm, pink) perfused hand,” or “pulseless–pale (nonperfused)” (see “neurovascular complications” below).
• The neurologic status must be assessed including the sensory and motor function of the radial, ulnar, and median nerves (see “neurovascular complications” below). Neurologic deficits are found in 10-20% of patients.^[rx] The most commonly injured nerve is the median nerve (specifically, the anterior interosseous portion of the median nerve). Injuries to the ulnar and radial nerves are less common.

Anterior X-ray

Carrying angle can be evaluated through an AP view of the elbow by looking at the Baumann’s angle.^[rx] There are two definitions of Bowman’s angle:

• The first definition of Baumann’s angle is an angle between a line parallel to the longitudinal axis of the humeral shaft and a line drawn along the lateral epicondyle. The normal range is 70-75 degrees. Every 5 degrees change in Bowman’s angle can lead to 2 degrees change in carrying angle.^[rx]
• Another definition of Baumann’s angle is also known as the humeral-capitellar angle. It is the angle between the line perpendicular to the long axis of the humerus and the growth plate of the lateral condyle. Reported normal values for Baumann’s angle range between 9 and 26°.^[rx] An angle of more than 10° is regarded as acceptable.^[rx]

Lateral X-ray

• On the lateral view of the elbow, there are five radiological features should be looked for: teardrop sign, anterior humeral line, coronoid line, fish-tail sign, and fat pad sign/sail sign (anterior and posterior).^[rx][rx]

Teardrop sign

• Teardrop sign is seen on a normal radiograph but is disturbed in the supracondylar fracture.^[rx]

Anterior humeral line

• It is a line drawn down along the front of the humerus on the lateral view and it should pass through the middle third of the capitulum of the humerus.^[rx] If it passes through the anterior third of the capitulum, it indicates the posterior displacement of the distal fragment.^[rx]

Fat pad sign/sale sign

• A non-displaced fracture can be difficult to identify and a fracture line may not be visible on the X-rays. However, the presence of a joint effusion is helpful in identifying a non-displaced fracture. Bleeding from the fracture expands the joint capsule and is visualized on the lateral view as a darker area anteriorly and posteriorly, and is known as the sail sign.^[rx]

Coronoid line

• A line drawn along the anterior border of the coronoid process of the ulna should touch the anterior part of the lateral condyle of the humerus. If lateral condyle appears posterior to this line, it indicates the posterior displacement of the lateral condyle.^[rx]

Fish-tail sign

• The distal fragment is rotated away from the proximal fragment, thus the sharp ends of the proximal fragment look like a shape of a fish-tail.^[rx]

Compartment syndrome

• Increased interstitial pressure within a closed fascial compartment can lead to compartment syndrome. This increased pressure can result in compromised circulation to the nerves and muscles in that compartment. Elevated tissue pressure obstructs venous outflow from the compartment, which further contributes to the increased pressure and swelling. Ischemia occurs once the pressure rises above arteriolar circulation. Muscle and nerve tissue becomes damaged as soon as 4–6 h after the onset of abnormal pressures.
• The first sign of compartment syndrome is disproportionate pain requiring increasing doses of pain medication [rx]. Other findings include sensory changes such as paresthesias, loss of active movements in the affected compartment, forearm tenderness, palpable tenseness of the muscles of the forearm (or arm), and pain with passive flexion or extension of the fingers.

Treatment of Supracondylar Fracture

Non-Pharmacological

• Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
• The Range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

Indications of Surgical Intervention to be Considered in the Following Conditions [rx]

• If close manipulation fails to achieve the reduction.

• If after close reduction fracture is unstable i.e., failure to maintain the reduction.

• If neurological involvement occurs during or after the manipulation of fracture.

• If vascular exploration is required.

• In open fractures.

• All Type II and III fractures requiring elbow flexion of more than 90° to maintain the reduction.

• All Type IV fractures supracondylar humerus.

• Polytrauma with multiple ipsilateral fractures requiring surgical intervention.

Surgical approaches to the distal humerus

• Various surgical approaches to the distal humerus have been described over the past decades. Each fracture needs its appropriate exposure and in cases of intra-articular involvement the exposure of the articular surface. Olecranon osteotomy, the triceps-splitting, triceps-sparing, and triceps-lifting approaches being the most frequently performed approaches in the surgical treatment of distal humerus fractures [rx–rx], we will be giving an overview of the established approaches offering selected indications and an evaluation of the related published data.

Surgical Approaches Used for Treatment of Fractures of the Distal Humerus (Canale & Beaty: Campbell’s Operative Orthopaedics, 11^th edition, Mosby (2007)17.

Complications of Supracondylar Fracture of The Humerus

What is The Most Common Site of Fracture in The Humerus/Humeral shaft fractures (HSFs) represent 3% of the fractures of the locomotor apparatus, and the middle third of the shaft is the section most affected? In the majority of cases, it is treated using nonsurgical methods, but surgical indications in HSF cases are increasingly being adopted. The diversity of opinions makes it difficult to reach a consensus regarding the types of osteosynthesis, surgical technique and quantity and quality of synthetic materials that should be used. It would appear that specialists are far from reaching a consensus regarding the best method for surgical treatment of HSFs.

Fracture shaft of humerus includes a group of fracture where the main fracture line lies distal to surgical neck of the humerus and proximal to supracondylar ridge distally. It accounts for nearly 3.5% of all different type of fractures of bone. 5% of injuries were associated with open wound and 63% were of simple fracture pattern.

Anatomy of Humeral Shaft Fractures

The humerus itself is a cylinder proximally, which provides strength and resistance to both torsional and bending forces, and distally it tapers to a triangular shape. It is enveloped in muscle and soft tissue, hence the favorable prognosis for healing in uncomplicated fractures. Muscles originating on the humeral shaft include the brachialis, brachioradialis, and the medial and lateral heads of the triceps brachii. The deltoid, pectoralis major, teres major, latissimus dorsi, and coracobrachialis all insert on the humeral shaft and depending on the location of the fracture, all will have specific deforming forces acting on the fracture fragments. The blood supply to the humeral shaft is provided predominantly by the nutrient artery that should be protected during surgical dissection [rx].

The arm can also be divided into anterior and posterior compartments by thick fibrous bands – the medial and lateral intermuscular septa. The brachial artery, median nerve, and musculocutaneous nerve remain in the anterior compartment for their entire course and are rarely encountered in surgical exposures to the humerus. The median nerve receives contributions from the medial and lateral cords of the brachial plexus and then travels just medial to the brachial artery, adjacent to the coracobrachialis muscle belly and along the anterior surface of the medial intermuscular septum. It provides no innervation to muscles proximal to the elbow.

The ulnar nerve arises from the medial cord of the brachial plexus and begins in the anterior compartment. It travels anterior to the medial intermuscular septum and posterior to the brachial artery. At the arcade of Struthers, approximately 8 cm from the medial epicondyle, it crosses to the posterior compartment to enter the cubital tunnel. It also provides no innervation to muscles proximal to the elbow.

The radial nerve is a terminal branch of the posterior cord of the brachial plexus. It begins in the posterior compartment and then passes through to the anterior compartment. It begins anteromedially and travels along the subscapularis proximally to join with the profound brachii at the triangular interval. About 10–14 cm from the lateral acromion, the nerve and artery travel along the posterior humerus in the spiral groove, separating the medial and lateral heads of the triceps at about the level of the deltoid tuberosity. It enters the anterior compartment through the lateral intermuscular septum approximately 10 cm from the distal articular surface, here it is tightly bound by the septum and therefore susceptible to traction injuries and radial nerve palsies [rx, rx].

Causes of Humeral Shaft Fractures

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fractures, such as osteoporosis, a low bone density, or vitamin B deficiency.^[rx]

• Humeral Shaft Fractures –  most often occur among elderly people with osteoporosis who fall on an outstretched arm.^[rx] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure.^[rx]
• A stress fracture of the proximal – and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

In younger patients, proximal humeral fractures are usually caused by high-energy trauma, such as traffic accidents or sporting accidents. In older patients, the most common cause is a fall onto the outstretched arm from a standing position, which is a type of low-energy trauma [rx, rx]

Symptoms Humeral Shaft Fractures

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]

Diagnosis of Humeral Shaft Fractures

Typically, the patient holds the injured arm in a protective posture close to the chest. Pain, swelling, hematoma, and tenderness of the proximal portion of the humerus may indicate the presence of a fracture. The perfusion and sensorimotor function of the limb should be tested in the periphery. The functioning of the axillary nerve should be tested as well.

• Radiographic examination using anterior and lateral views is sufficient for diagnosing and classifying HSFs.
• Bone scintigraphy, magnetic resonance, and computed tomography are used in special situations, such as for diagnosing and staging pathological fractures.
• Electroneuromyography is only useful for diagnosing neurological lesions from the third week after the trauma. Therefore, adequate clinical examination is essential.

Radiographs

• Recommended views
  • • obtain AP and lateral of humerus and elbow
    • include the entire length of humerus and forearm

Obtain wrist radiographs if elbow injury present or distal tenderness on exam

• Oblique radiographs may assist in surgical planning
• Traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice

CT

• Often obtained for surgical planning
• Especially helpful when shear fractures of the capitellum and trochlea are suspected
• 3D CT scan improves the intraobserver and interobserver reliability of several classification systems

MRI

• Usually not indicated in acute injury

Treatment of Humeral Shaft Fractures

Non-Pharmacological

• Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
• The range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Modalities – Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Among the various nonsurgical treatment methods (confectioners’ clamp, hanging plaster cast, thoracic-brachial plaster cast, and Velpeau immobilization), the use of brachial orthoses is the nonsurgical method most used today[rx], [rx].

This enables contraction of the adjacent muscle groups and stimulates consolidation. However, certain aspects of HSFs and patient characteristics make it difficult to carry out treatment using external immobilization. With increasing incidence of HSFs due to multiple trauma, exposed fractures and deviation caused by muscle action[rx], along with other factors such as obesity, which lead to poor results from nonsurgical treatment, many investigators have been seeking new treatment methods, such as the use of pins[rx], intramedullary nails[rx] or screwed plates[rx], [rx]. Thus, although most HSFs can be treated nonsurgically, the fracture characteristics and patient requirements should be fundamental with regard to indicating surgery[rx].

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Types of interventions

We will compare different methods of surgical management for humeral shaft fractures. The comparisons will include the following:

• Plate versus intramedullary nail fixation – this will include the comparison of any plate versus any IMN fixation, as well as specific comparisons of commonly used devices such as dynamic compression plate versus locked intramedullary nailing.
• Different methods of plate fixation – this will include comparisons of dynamic compression plate versus locking compression plate; and MIPO versus conventional ORIF.
• Different methods of intramedullary nailing – this will include retrograde versus antegrade nailing; and locked nailing versus unlocked nailing.

Surgery 

• Closed reduction with percutaneous pinning (CRPP)
• Open reduction with internal fixation (ORIF)
• Intramedullary rod fixation
• Shoulder arthroplasty
• Reverse shoulder arthroplasty

Suture Fixation

• This technique has been described as a method to treat proximal humerus fractures and avoid the complications associated with implant placement and arthroplasty [rx, rx]. Using this method, nonabsorbable sutures are passed through the rotator cuff tissue and/or the bone fragments, in order to obtain and maintain the reduction.
• This technique avoids extensive soft tissue stripping and the risk of symptomatic implants. It also preserves the bone stock of the proximal humerus, which may allow for future procedures.

Plate Fixation

• Operative fixation of the proximal humerus has evolved over the years. Development of locking technology, as well as a site-specific implant, has helped overcome some of the problems initially seen with operative fixation. Locking screws have improved the fixation of the head and soft metaphyseal, and often osteoporotic bone, frequently associated with these patients [rx].
• The number of proximal screw options and trajectories attempts to maximize the fixation in the head of the humerus. Conventional plating may still be used in the case of a young patient with good bone quality, or for the treatment of simple two-part greater tuberosity fractures. Successful treatment with either plating technique relies on bone quality, as well as the accuracy of reduction and humeral head viability [rx, rx, rx, rx].

References

How Long Does it Take to Heal a Fractured Humerus/Humeral shaft fractures (HSFs) represent 3% of the fractures of the locomotor apparatus, and the middle third of the shaft is the section most affected. In the majority of cases, it is treated using nonsurgical methods, but surgical indications in HSF cases are increasingly being adopted. The diversity of opinions makes it difficult to reach a consensus regarding the types of osteosynthesis, surgical technique and quantity and quality of synthetic materials that should be used. It would appear that specialists are far from reaching a consensus regarding the best method for surgical treatment of HSFs.

Fracture shaft of humerus includes a group of fracture where the main fracture line lies distal to surgical neck of the humerus and proximal to supracondylar ridge distally. It accounts for nearly 3.5% of all different type of fractures of bone. 5% of injuries were associated with open wound and 63% were of simple fracture pattern.

Anatomy of Humeral Shaft Fractures

The humerus itself is a cylinder proximally, which provides strength and resistance to both torsional and bending forces, and distally it tapers to a triangular shape. It is enveloped in muscle and soft tissue, hence the favorable prognosis for healing in uncomplicated fractures. Muscles originating on the humeral shaft include the brachialis, brachioradialis, and the medial and lateral heads of the triceps brachii. The deltoid, pectoralis major, teres major, latissimus dorsi, and coracobrachialis all insert on the humeral shaft and depending on the location of the fracture, all will have specific deforming forces acting on the fracture fragments. The blood supply to the humeral shaft is provided predominantly by the nutrient artery that should be protected during surgical dissection [rx].

The arm can also be divided into anterior and posterior compartments by thick fibrous bands – the medial and lateral intermuscular septa. The brachial artery, median nerve, and musculocutaneous nerve remain in the anterior compartment for their entire course and are rarely encountered in surgical exposures to the humerus. The median nerve receives contributions from the medial and lateral cords of the brachial plexus and then travels just medial to the brachial artery, adjacent to the coracobrachialis muscle belly and along the anterior surface of the medial intermuscular septum. It provides no innervation to muscles proximal to the elbow.

The ulnar nerve arises from the medial cord of the brachial plexus and begins in the anterior compartment. It travels anterior to the medial intermuscular septum and posterior to the brachial artery. At the arcade of Struthers, approximately 8 cm from the medial epicondyle, it crosses to the posterior compartment to enter the cubital tunnel. It also provides no innervation to muscles proximal to the elbow.

The radial nerve is a terminal branch of the posterior cord of the brachial plexus. It begins in the posterior compartment and then passes through to the anterior compartment. It begins anteromedially and travels along the subscapularis proximally to join with the profound brachii at the triangular interval. About 10–14 cm from the lateral acromion, the nerve and artery travel along the posterior humerus in the spiral groove, separating the medial and lateral heads of the triceps at about the level of the deltoid tuberosity. It enters the anterior compartment through the lateral intermuscular septum approximately 10 cm from the distal articular surface, here it is tightly bound by the septum and therefore susceptible to traction injuries and radial nerve palsies [rx, rx].

Causes of Humeral Shaft Fractures

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fractures, such as osteoporosis, a low bone density, or vitamin B deficiency.^[rx]

• Humeral Shaft Fractures –  most often occur among elderly people with osteoporosis who fall on an outstretched arm.^[rx] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure.^[rx]
• A stress fracture of the proximal – and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

In younger patients, proximal humeral fractures are usually caused by high-energy trauma, such as traffic accidents or sporting accidents. In older patients, the most common cause is a fall onto the outstretched arm from a standing position, which is a type of low-energy trauma [rx, rx]

Symptoms Humeral Shaft Fractures

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]

Diagnosis of Humeral Shaft Fractures

Typically, the patient holds the injured arm in a protective posture close to the chest. Pain, swelling, hematoma, and tenderness of the proximal portion of the humerus may indicate the presence of a fracture. The perfusion and sensorimotor function of the limb should be tested in the periphery. The functioning of the axillary nerve should be tested as well.

• Radiographic examination using anterior and lateral views is sufficient for diagnosing and classifying HSFs.
• Bone scintigraphy, magnetic resonance, and computed tomography are used in special situations, such as for diagnosing and staging pathological fractures.
• Electroneuromyography is only useful for diagnosing neurological lesions from the third week after the trauma. Therefore, adequate clinical examination is essential.

Radiographs

• Recommended views
  • • obtain AP and lateral of humerus and elbow
    • include the entire length of humerus and forearm

Obtain wrist radiographs if elbow injury present or distal tenderness on exam

• Oblique radiographs may assist in surgical planning
• Traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice

CT

• Often obtained for surgical planning
• Especially helpful when shear fractures of the capitellum and trochlea are suspected
• 3D CT scan improves the intraobserver and interobserver reliability of several classification systems

MRI

• Usually not indicated in acute injury

Treatment of Humeral Shaft Fractures

Non-Pharmacological

• Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
• The range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Modalities – Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Among the various nonsurgical treatment methods (confectioners’ clamp, hanging plaster cast, thoracic-brachial plaster cast, and Velpeau immobilization), the use of brachial orthoses is the nonsurgical method most used today[rx], [rx].

This enables contraction of the adjacent muscle groups and stimulates consolidation. However, certain aspects of HSFs and patient characteristics make it difficult to carry out treatment using external immobilization. With increasing incidence of HSFs due to multiple trauma, exposed fractures and deviation caused by muscle action[rx], along with other factors such as obesity, which lead to poor results from nonsurgical treatment, many investigators have been seeking new treatment methods, such as the use of pins[rx], intramedullary nails[rx] or screwed plates[rx], [rx]. Thus, although most HSFs can be treated nonsurgically, the fracture characteristics and patient requirements should be fundamental with regard to indicating surgery[rx].

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Types of interventions

We will compare different methods of surgical management for humeral shaft fractures. The comparisons will include the following:

• Plate versus intramedullary nail fixation – this will include the comparison of any plate versus any IMN fixation, as well as specific comparisons of commonly used devices such as dynamic compression plate versus locked intramedullary nailing.
• Different methods of plate fixation – this will include comparisons of dynamic compression plate versus locking compression plate; and MIPO versus conventional ORIF.
• Different methods of intramedullary nailing – this will include retrograde versus antegrade nailing; and locked nailing versus unlocked nailing.

Surgery 

• Closed reduction with percutaneous pinning (CRPP)
• Open reduction with internal fixation (ORIF)
• Intramedullary rod fixation
• Shoulder arthroplasty
• Reverse shoulder arthroplasty

Suture Fixation

• This technique has been described as a method to treat proximal humerus fractures and avoid the complications associated with implant placement and arthroplasty [rx, rx]. Using this method, nonabsorbable sutures are passed through the rotator cuff tissue and/or the bone fragments, in order to obtain and maintain the reduction.
• This technique avoids extensive soft tissue stripping and the risk of symptomatic implants. It also preserves the bone stock of the proximal humerus, which may allow for future procedures.

Plate Fixation

• Operative fixation of the proximal humerus has evolved over the years. Development of locking technology, as well as a site-specific implant, has helped overcome some of the problems initially seen with operative fixation. Locking screws have improved the fixation of the head and soft metaphyseal, and often osteoporotic bone, frequently associated with these patients [rx].
• The number of proximal screw options and trajectories attempts to maximize the fixation in the head of the humerus. Conventional plating may still be used in the case of a young patient with good bone quality, or for the treatment of simple two-part greater tuberosity fractures. Successful treatment with either plating technique relies on bone quality, as well as the accuracy of reduction and humeral head viability [rx, rx, rx, rx].

References

What is The Treatment For a Fractured Humerus/Humeral shaft fractures (HSFs) represent 3% of the fractures of the locomotor apparatus, and the middle third of the shaft is the section most affected. In the majority of cases, it is treated using nonsurgical methods, but surgical indications in HSF cases are increasingly being adopted. The diversity of opinions makes it difficult to reach a consensus regarding the types of osteosynthesis, surgical technique and quantity and quality of synthetic materials that should be used. It would appear that specialists are far from reaching a consensus regarding the best method for surgical treatment of HSFs.

Fracture shaft of humerus includes a group of fracture where the main fracture line lies distal to surgical neck of the humerus and proximal to supracondylar ridge distally. It accounts for nearly 3.5% of all different type of fractures of bone. 5% of injuries were associated with open wound and 63% were of simple fracture pattern.

Anatomy of Humeral Shaft Fractures

The humerus itself is a cylinder proximally, which provides strength and resistance to both torsional and bending forces, and distally it tapers to a triangular shape. It is enveloped in muscle and soft tissue, hence the favorable prognosis for healing in uncomplicated fractures. Muscles originating on the humeral shaft include the brachialis, brachioradialis, and the medial and lateral heads of the triceps brachii. The deltoid, pectoralis major, teres major, latissimus dorsi, and coracobrachialis all insert on the humeral shaft and depending on the location of the fracture, all will have specific deforming forces acting on the fracture fragments. The blood supply to the humeral shaft is provided predominantly by the nutrient artery that should be protected during surgical dissection [rx].

The arm can also be divided into anterior and posterior compartments by thick fibrous bands – the medial and lateral intermuscular septa. The brachial artery, median nerve, and musculocutaneous nerve remain in the anterior compartment for their entire course and are rarely encountered in surgical exposures to the humerus. The median nerve receives contributions from the medial and lateral cords of the brachial plexus and then travels just medial to the brachial artery, adjacent to the coracobrachialis muscle belly and along the anterior surface of the medial intermuscular septum. It provides no innervation to muscles proximal to the elbow.

The ulnar nerve arises from the medial cord of the brachial plexus and begins in the anterior compartment. It travels anterior to the medial intermuscular septum and posterior to the brachial artery. At the arcade of Struthers, approximately 8 cm from the medial epicondyle, it crosses to the posterior compartment to enter the cubital tunnel. It also provides no innervation to muscles proximal to the elbow.

The radial nerve is a terminal branch of the posterior cord of the brachial plexus. It begins in the posterior compartment and then passes through to the anterior compartment. It begins anteromedially and travels along the subscapularis proximally to join with the profound brachii at the triangular interval. About 10–14 cm from the lateral acromion, the nerve and artery travel along the posterior humerus in the spiral groove, separating the medial and lateral heads of the triceps at about the level of the deltoid tuberosity. It enters the anterior compartment through the lateral intermuscular septum approximately 10 cm from the distal articular surface, here it is tightly bound by the septum and therefore susceptible to traction injuries and radial nerve palsies [rx, rx].

Causes of Humeral Shaft Fractures

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fractures, such as osteoporosis, a low bone density, or vitamin B deficiency.^[rx]

• Humeral Shaft Fractures –  most often occur among elderly people with osteoporosis who fall on an outstretched arm.^[rx] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure.^[rx]
• A stress fracture of the proximal – and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

In younger patients, proximal humeral fractures are usually caused by high-energy trauma, such as traffic accidents or sporting accidents. In older patients, the most common cause is a fall onto the outstretched arm from a standing position, which is a type of low-energy trauma [rx, rx]

Symptoms Humeral Shaft Fractures

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.^[rx]

Diagnosis of Humeral Shaft Fractures

Typically, the patient holds the injured arm in a protective posture close to the chest. Pain, swelling, hematoma, and tenderness of the proximal portion of the humerus may indicate the presence of a fracture. The perfusion and sensorimotor function of the limb should be tested in the periphery. The functioning of the axillary nerve should be tested as well.

• Radiographic examination using anterior and lateral views is sufficient for diagnosing and classifying HSFs.
• Bone scintigraphy, magnetic resonance, and computed tomography are used in special situations, such as for diagnosing and staging pathological fractures.
• Electroneuromyography is only useful for diagnosing neurological lesions from the third week after the trauma. Therefore, adequate clinical examination is essential.

Radiographs

• Recommended views
  • • obtain AP and lateral of humerus and elbow
    • include the entire length of humerus and forearm

Obtain wrist radiographs if elbow injury present or distal tenderness on exam

• Oblique radiographs may assist in surgical planning
• Traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice

CT

• Often obtained for surgical planning
• Especially helpful when shear fractures of the capitellum and trochlea are suspected
• 3D CT scan improves the intraobserver and interobserver reliability of several classification systems

MRI

• Usually not indicated in acute injury

Treatment of Humeral Shaft Fractures

Non-Pharmacological

• Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
• The range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Modalities – Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.

Among the various nonsurgical treatment methods (confectioners’ clamp, hanging plaster cast, thoracic-brachial plaster cast, and Velpeau immobilization), the use of brachial orthoses is the nonsurgical method most used today[rx], [rx].

This enables contraction of the adjacent muscle groups and stimulates consolidation. However, certain aspects of HSFs and patient characteristics make it difficult to carry out treatment using external immobilization. With increasing incidence of HSFs due to multiple trauma, exposed fractures and deviation caused by muscle action[rx], along with other factors such as obesity, which lead to poor results from nonsurgical treatment, many investigators have been seeking new treatment methods, such as the use of pins[rx], intramedullary nails[rx] or screwed plates[rx], [rx]. Thus, although most HSFs can be treated nonsurgically, the fracture characteristics and patient requirements should be fundamental with regard to indicating surgery[rx].

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Types of interventions

We will compare different methods of surgical management for humeral shaft fractures. The comparisons will include the following:

• Plate versus intramedullary nail fixation – this will include the comparison of any plate versus any IMN fixation, as well as specific comparisons of commonly used devices such as dynamic compression plate versus locked intramedullary nailing.
• Different methods of plate fixation – this will include comparisons of dynamic compression plate versus locking compression plate; and MIPO versus conventional ORIF.
• Different methods of intramedullary nailing – this will include retrograde versus antegrade nailing; and locked nailing versus unlocked nailing.

Surgery 

• Closed reduction with percutaneous pinning (CRPP)
• Open reduction with internal fixation (ORIF)
• Intramedullary rod fixation
• Shoulder arthroplasty
• Reverse shoulder arthroplasty

Suture Fixation

• This technique has been described as a method to treat proximal humerus fractures and avoid the complications associated with implant placement and arthroplasty [rx, rx]. Using this method, nonabsorbable sutures are passed through the rotator cuff tissue and/or the bone fragments, in order to obtain and maintain the reduction.
• This technique avoids extensive soft tissue stripping and the risk of symptomatic implants. It also preserves the bone stock of the proximal humerus, which may allow for future procedures.

Plate Fixation

• Operative fixation of the proximal humerus has evolved over the years. Development of locking technology, as well as a site-specific implant, has helped overcome some of the problems initially seen with operative fixation. Locking screws have improved the fixation of the head and soft metaphyseal, and often osteoporotic bone, frequently associated with these patients [rx].
• The number of proximal screw options and trajectories attempts to maximize the fixation in the head of the humerus. Conventional plating may still be used in the case of a young patient with good bone quality, or for the treatment of simple two-part greater tuberosity fractures. Successful treatment with either plating technique relies on bone quality, as well as the accuracy of reduction and humeral head viability [rx, rx, rx, rx].

References

Proximal humeral fractures are common, particularly in the elderly. Along with proximal femoral, distal radial, and vertebral-body fractures, they are a common type of osteoporotic fracture. Women are affected two to three times as often as men [rx]. Proximal humerus and humerus fractures account for 4% to 6% and 1% to 3% of all fractures respectively in both young and elderly patients.

The proximal humerus has two necks. The anatomic neck is the old epiphyseal plate, and the surgical neck is the metaphyseal area below the humeral head. The blood supply is the anterior and posterior humeral circumflex artery with the axillary nerve as the major nerve of this region. The humeral shaft is a cylindrical bone that gradually becomes triangular distally. This bone serves as an insertion site for the pectoralis major, deltoid, and coracobrachialis and is the site of origin for the brachialis, triceps, and brachioradialis. The radial nerve is the major nerve of the humerus shaft which is seen in the spiral groove and is approximately 14 cm from the lateral epicondyle and 20 cm from the medial epicondyle. The major nerves of the distal humerus are the ulnar nerve and radial nerve. Distal humerus fractures comprise the supracondylar fractures, single condyle fractures, bi-column fractures, and coronal shear fractures. Treatment options include open reduction and internal fixation, closed reduction and percutaneous pinning, and intramedullary nailing or bracing.[rx][rx][rx]

Anatomy of Proximal Humeral Fractures

The proximal humerus includes the humeral head, greater tuberosity, lesser tuberosity, and the humeral shaft. In the sagittal plane, the humeral head is retroverted an average of 30 degrees relative to the humeral shaft [rx]. In the coronal plane, it is angled 130 to 150 degrees cephalad relative to the diaphysis. Fractures through the anatomic neck can result in significant vascular compromise to humeral head leading to avascular necrosis [rx].

In neutral rotation, the greater tuberosity forms the lateral border of the proximal humerus. The lesser tuberosity, which sits directly anterior in this position, becomes profiled medially when the humerus is internally rotated—this creates a rounded silhouette “lightbulb sign” on radiograph. The long head of the biceps passes between the two tuberosities in the intertubercular groove, approximately 1 cm lateral to the midline of the humerus, and its relationship is an important landmark during fracture reduction [rx].

The supraspinatus muscle, innervated by the suprascapular nerve, attaches to the superior facet of the greater tuberosity with a force vector that pulls predominantly in a medial direction. The infraspinatus muscle, also innervated by the suprascapular nerve, inserts on the middle facet of the greater tuberosity. The teres minor muscle, innervated by the axillary nerve, attaches to the inferior facet. Together, these three externally rotate and yield a posteromedially directed deforming force. Therefore, if the greater tuberosity is fractured, it is displaced posteromedially. If it remains intact, and there is a surgical neck fracture, the resulting deformity is typically varus and external rotation. Anteriorly, the subscapularis, innervated by the upper and lower subscapular nerves, attaches to the lesser tuberosity, resulting in anteromedial displacement of this osseous fragment if fractured [rx, rx]. The pectoralis major tendon insertion is an important landmark, especially during hemiarthroplasty.

The ulnar nerve arises from the medial cord of the brachial plexus and begins in the anterior compartment. It travels anterior to the medial intermuscular septum and posterior to the brachial artery. At the arcade of Struthers, approximately 8 cm from the medial epicondyle, it crosses to the posterior compartment to enter the cubital tunnel. It also provides no innervation to muscles proximal to the elbow.

The radial nerve is a terminal branch of the posterior cord of the brachial plexus. It begins in the posterior compartment and then passes through to the anterior compartment. It begins anteromedially and travels along the subscapularis proximally to join with the profunda brachii at the triangular interval. About 10–14 cm from the lateral acromion, the nerve and artery travel along the posterior humerus in the spiral groove, separating the medial and lateral heads of the triceps at about the level of the deltoid tuberosity. It enters the anterior compartment though the lateral intermuscular septum approximately 10 cm from the distal articular surface, here it is tightly bound by the septum and therefore susceptible to traction injuries and radial nerve palsies [rx, rx].

Types of Humeral Fractures

AO/OTA Classification of Distal Humerus Fractures

The AO classification divides proximal humeral fractures into three groups, A, B and C, each with subgroups, and places more emphasis on the blood supply to the articular surface. The assumption is that if either the lesser or greater tuberosity remains attached to the particular segment, then blood supply is probably adequate to avoid avascular necrosis.

Type A: extra-articular unifocal (either tuberosity +/- surgical neck of the humerus)

• A1: extra-articular unifocal fracture
• A2: extra-articular unifocal fracture with an impacted metaphyseal fracture
• A3: extra-articular unifocal fracture with a non-impacted metaphyseal fracture

Type B: extra-articular bifocal (both tuberosities +/- surgical neck of the humerus or glenohumeral dislocation)

• B1: extra-articular bifocal fractures with impacted metaphyseal fracture
• B2: extra-articular bifocal fractures with non-impacted metaphyseal fracture
• B3: extra-articular bifocal fractures with glenohumeral joint dislocation

Type C: extra-articular (anatomical neck) but compromise the vascular supply of the particular segment

• C1: anatomical neck fracture, minimally displaced
• C2: anatomical neck fracture, displaced and impacted
• C3: anatomical neck fracture with glenohumeral joint dislocation

The risk of avascular necrosis increases from type A (very low) to type C (high risk) and thus determines treatment.

Milch Classification of Single Column Condyle Fractures

Jupiter Classification of Two-Column Distal Humerus Fractures

The classification has been variably adapted by multiple authors. What is presented below is what will probably be understood by most surgeons and radiologists and consists of four major groupings, based on the number of displaced parts?

One-part fracture

No fragments meet the criteria for displacement; a fracture with no fragments considered displaced is defined as a one-part fracture regardless of the actual number of fracture lines or their location.

• fracture lines involve 1-4 parts
• none of the parts are displaced (i.e <1cm and <45 degrees)

These undisplaced/minimally displaced fractures account for ~70-80% of all proximal humeral fractures and are almost always treated conservatively.

Two-part fracture

One segment is displaced, which may be the greater tuberosity, lesser tuberosity, or articular segment at the level of the anatomic neck or surgical neck.

• fracture lines involve 2-4 parts
• one part is displaced (i.e >1cm or >45 degrees)

Four possible types of two-part fractures exist (one for each part):

• surgical neck: most common
• greater tuberosity
  • frequently seen in the setting of anterior shoulder dislocation
  • a lower threshold of displacement (> 5mm) has been proposed
• anatomical neck
• lesser tuberosity: uncommon

These fractures account for approximately 20% of proximal humeral fractures.

Three-part fracture

With a three-part fracture, one tuberosity is displaced and the surgical neck fracture is displaced. The remaining tuberosity is attached, which produces a rotational deformity.

• fracture lines involve 3-4 parts
• two parts are displaced (i.e >1cm or >45 degrees)

Two three-part fracture patterns are encountered:

• greater tuberosity and shaft are displaced with respect to the lesser tuberosity and articular surface which remain together
  • most common three-part pattern
• lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together

These fractures account for approximately 5% of proximal humeral fractures.

Four-part fracture

All four segments (both tuberosities, the articular surface, and the shaft) meet criteria for displacement. The articular segment typically is laterally displaced and out of contact with the glenoid [rx]. This is a severe injury and carries a high risk of avascular necrosis.

• fracture lines involve more than 4 parts
• three parts are displaced (i.e., >1 cm or >45 degrees) with respect to the 4^th

These fractures are uncommon (<1% of proximal humeral fractures).

This pattern has poor non-operative results, and as the articular surface is no longer attached to any parts of the humerus which are attached to soft tissues, it has a high incidence of osteonecrosis.

Valgus-Impacted Four-Part Fractures

Neer added this pattern [rx] as a separate category in 2002 [rx]. In this situation, the head is rotated into a valgus posture and driven down between the tuberosities, which splay out to accommodate the head. Unlike in the classic four-part fracture, the articular surface maintains contact with the glenoid, and is not laterally displaced. This four-part fracture warranted its own category because the prognosis and treatment for this injury are different than those for the classic four-part fracture [rx, rx].

Causes of Proximal Humeral Fractures

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fracture, such as osteoporosis, a low bone density, or vitamin B deficiency.^[rx]

• Proximal humerus fractures –  most often occur among elderly people with osteoporosis who fall on an outstretched arm.^[rx] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure.^[rx]
• A stress fracture of the proximal – and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

In younger patients, proximal humeral fractures are usually caused by high-energy trauma, such as traffic accidents or sporting accidents. In older patients, the most common cause is a fall onto the outstretched arm from a standing position, which is a type of low-energy trauma [rx, rx]

Symptoms Proximal Humeral Fractures

• Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, musculature may cause absence of deformity on inspection.^[rx]
• Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.^[rx]
• Symptoms from poor blood circulation in the arm is uncommon due to collateral circulation in the arm.^[rx]

Diagnosis of Proximal Humeral Fractures

Typically, the patient holds the injured arm in a protective posture close to the chest. Pain, swelling, hematoma, and tenderness of the proximal portion of the humerus may indicate the presence of a fracture. The perfusion and sensorimotor function of the limb should be tested in the periphery. The functioning of the axillary nerve should be tested as well.

Radiographs

• Recommended views
  • • obtain AP and lateral of humerus and elbow
    • include entire length of humerus and forearm

Obtain wrist radiographs if elbow injury present or distal tenderness on exam

• oblique radiographs may assist in surgical planning
• traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice

CT

• often obtained for surgical planning
• especially helpful when shear fractures of the capitellum and trochlea are suspected
• 3D CT scan improves the intraobserver and interobserver reliability of several classification systems

MRI

• usually not indicated in acute injury

Treatment of Proximal Humeral Fractures

Non Pharmacological

•  Immobilization –  in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, closed reduction may improve the deformity and the amount of bony contact.
• In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to outcome.
• Range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
• Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder, so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Modalities – Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
• Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of, and maintain, a pain-free shoulder.
• Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for range of motion without placing a weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with overhead range of motion.

Medications

Medication can be prescribed to ease the pain.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement – to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery 

• Closed reduction with percutaneous pinning (CRPP)
• Open reduction with internal fixation (ORIF)
• Intramedullary rod fixation
• Shoulder arthroplasty
• Reverse shoulder arthroplasty

Suture Fixation

• This technique has been described as a method to treat proximal humerus fractures and avoid the complications associated with implant placement and arthroplasty [rx, rx]. Using this method, nonabsorbable sutures are passed through the rotator cuff tissue and/or the bone fragments, in order to obtain and maintain the reduction.
• This technique avoids extensive soft tissue stripping and the risk of symptomatic implants. It also preserves the bone stock of the proximal humerus, which may allow for future procedures.

Plate Fixation

• Operative fixation of the proximal humerus has evolved over the years. Development of locking technology, as well as site-specific implant, has helped overcome some of the problems initially seen with operative fixation. Locking screws have improved the fixation of the head and soft metaphyseal, and often osteoporotic bone, frequently associated with these patients [rx].
• The number of proximal screw options and trajectories attempt to maximize the fixation in the head of the humerus. Conventional plating may still be used in the case of a young patient with good bone quality, or for the treatment of simple two-part greater tuberosity fractures. Successful treatment with either plating technique relies on bone quality, as well as the accuracy of reduction and humeral head viability [rx, rx, rx, rx].

References

How Do I Treat an Injured Scapula/Scapula fracture is rare and historically have been treated effectively with nonsurgical methods. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.

Fractures of the scapula are rare, comprising 1% of all skeletal injuries and 3%–5% of injuries of the shoulder girdle [rx]. As a rule they are sustained as a result of high-velocity trauma, although rarely they can occur due to low impact injuries [rx]. We report the case of a patient who sustained a low-velocity indirect fracture of his scapula following a simple mechanical fall, in which the diagnosis was initially missed.

Mechanism of Scapula Fracture

The mechanism of scapular fractures is always a high-energy trauma. Concomitant injuries occur in up to 90% of the patients with the majority being thoracic injuries followed by injuries of the ipsilateral extremity [rx–rx]. Thus, complex shoulder injuries often involve fractures of the ipsilateral clavicle, the acromion or the coracoid process as well as ligamentous and osseoligamentous structures as the acromioclavicular joint, the coracoclavicular ligaments and the coracoacromial ligament. However, the classification of scapula fractures described by Euler and Ruedi [rx], as well as the Ideberg classification of glenoid fractures, do not systematically include concomitant injuries of the shoulder girdle. Goss and co-workers introduced the concept of the Superior Shoulder Suspensory Complex (SSSC) and expanded the definition of a floating shoulder to a double disruption of this bone and soft tissue ring [rx, rx]. In contrast to previous definitions of a floating shoulder being a combined fracture of the scapular neck and the ipsilateral clavicle [rx, rx–rx], only a double-disruption of the SSSC causes an unstable anatomical situation and therefore a true floating shoulder [rx]. Biomechanical cadaver studies performed by Williams and colleagues emphasized that a fracture of the scapular neck and the ipsilateral clavicle can only produce an unstable, floating shoulder when combined with a disruption of the coracoacromial and acromioclavicular capsular ligaments [rx]. However, this assertion of stability has recently been doubted [rx] indicating that there are still controversial criteria of stability and little agreement on classifications and indications.

Types of Scapula Fracture

Neck fractures

Coracoid process fractures

Acromion fractures

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

Classification

Fractures of the scapula are relatively uncommon and may be classified according to the following anatomic locations.^1,2

• The body and spine
• The acromion
• The neck
• The glenoid rim and supraglenoid tuberosity

Associated injuries include

• Rib fractures
• Hips lateral lung injuries
• Injuries to the shoulder girdle complex
• Neurovascular injuries
• Suprascapular nerve injuries
• Vertebral compression fractures

Scapula Fracture Causes

• Fractures of the scapula typically result from a high-energy blunt-force mechanism [rx–rx]. Direct force may cause fractures in all regions of the scapula, while indirect force via impaction of the humeral head into the glenoid fossa can cause both glenoid and scapular neck fractures. Motor vehicle collisions account for the majority of scapular fractures with 50% occurring in occupants of motor vehicles and 20% in pedestrians struck by motor vehicles [rx, rx].
• Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.^[rx] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions.^[rx]
• About three-quarters of cases are caused by high-speed car and motorcycle collisions.^[rx] Falls and blows to the shoulder area can also cause the injury.^[rx]Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, boxing or skiing) can also fracture the scapula.^[rx]
• Scapular the fracture – can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Scapula Fracture

How Do You Treat a Fractured Scapula/Scapula fracture is rare and historically have been treated effectively with nonsurgical methods. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.

Fractures of the scapula are rare, comprising 1% of all skeletal injuries and 3%–5% of injuries of the shoulder girdle [rx]. As a rule they are sustained as a result of high-velocity trauma, although rarely they can occur due to low impact injuries [rx]. We report the case of a patient who sustained a low-velocity indirect fracture of his scapula following a simple mechanical fall, in which the diagnosis was initially missed.

Mechanism of Scapula Fracture

The mechanism of scapular fractures is always a high-energy trauma. Concomitant injuries occur in up to 90% of the patients with the majority being thoracic injuries followed by injuries of the ipsilateral extremity [rx–rx]. Thus, complex shoulder injuries often involve fractures of the ipsilateral clavicle, the acromion or the coracoid process as well as ligamentous and osseoligamentous structures as the acromioclavicular joint, the coracoclavicular ligaments and the coracoacromial ligament. However, the classification of scapula fractures described by Euler and Ruedi [rx], as well as the Ideberg classification of glenoid fractures, do not systematically include concomitant injuries of the shoulder girdle. Goss and co-workers introduced the concept of the Superior Shoulder Suspensory Complex (SSSC) and expanded the definition of a floating shoulder to a double disruption of this bone and soft tissue ring [rx, rx]. In contrast to previous definitions of a floating shoulder being a combined fracture of the scapular neck and the ipsilateral clavicle [rx, rx–rx], only a double-disruption of the SSSC causes an unstable anatomical situation and therefore a true floating shoulder [rx]. Biomechanical cadaver studies performed by Williams and colleagues emphasized that a fracture of the scapular neck and the ipsilateral clavicle can only produce an unstable, floating shoulder when combined with a disruption of the coracoacromial and acromioclavicular capsular ligaments [rx]. However, this assertion of stability has recently been doubted [rx] indicating that there are still controversial criteria of stability and little agreement on classifications and indications.

Types of Scapula Fracture

Neck fractures

Coracoid process fractures

Acromion fractures

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

Classification

Fractures of the scapula are relatively uncommon and may be classified according to the following anatomic locations.^1,2

• The body and spine
• The acromion
• The neck
• The glenoid rim and supraglenoid tuberosity

Associated injuries include

• Rib fractures
• Hips lateral lung injuries
• Injuries to the shoulder girdle complex
• Neurovascular injuries
• Suprascapular nerve injuries
• Vertebral compression fractures

Scapula Fracture Causes

• Fractures of the scapula typically result from a high-energy blunt-force mechanism [rx–rx]. Direct force may cause fractures in all regions of the scapula, while indirect force via impaction of the humeral head into the glenoid fossa can cause both glenoid and scapular neck fractures. Motor vehicle collisions account for the majority of scapular fractures with 50% occurring in occupants of motor vehicles and 20% in pedestrians struck by motor vehicles [rx, rx].
• Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.^[rx] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions.^[rx]
• About three-quarters of cases are caused by high-speed car and motorcycle collisions.^[rx] Falls and blows to the shoulder area can also cause the injury.^[rx]Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, boxing or skiing) can also fracture the scapula.^[rx]
• Scapular the fracture – can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Scapula Fracture

How Long Does it Take For a Scapular Fracture to Heal/It can take 6 to 12 months to completely restore shoulder motion. Scapular body fractures are typically treated nonsurgically with good results. However, fractures of the scapular neck or glenoid may require surgical intervention.

Scapula fracture is rare and historically have been treated effectively with nonsurgical methods. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.

Fractures of the scapula are rare, comprising 1% of all skeletal injuries and 3%–5% of injuries of the shoulder girdle [rx]. As a rule they are sustained as a result of high-velocity trauma, although rarely they can occur due to low impact injuries [rx]. We report the case of a patient who sustained a low-velocity indirect fracture of his scapula following a simple mechanical fall, in which the diagnosis was initially missed.

Mechanism of Scapula Fracture

The mechanism of scapular fractures is always a high-energy trauma. Concomitant injuries occur in up to 90% of the patients with the majority being thoracic injuries followed by injuries of the ipsilateral extremity [rx–rx]. Thus, complex shoulder injuries often involve fractures of the ipsilateral clavicle, the acromion or the coracoid process as well as ligamentous and osseoligamentous structures as the acromioclavicular joint, the coracoclavicular ligaments and the coracoacromial ligament. However, the classification of scapula fractures described by Euler and Ruedi [rx], as well as the Ideberg classification of glenoid fractures, do not systematically include concomitant injuries of the shoulder girdle. Goss and co-workers introduced the concept of the Superior Shoulder Suspensory Complex (SSSC) and expanded the definition of a floating shoulder to a double disruption of this bone and soft tissue ring [rx, rx]. In contrast to previous definitions of a floating shoulder being a combined fracture of the scapular neck and the ipsilateral clavicle [rx, rx–rx], only a double-disruption of the SSSC causes an unstable anatomical situation and therefore a true floating shoulder [rx]. Biomechanical cadaver studies performed by Williams and colleagues emphasized that a fracture of the scapular neck and the ipsilateral clavicle can only produce an unstable, floating shoulder when combined with a disruption of the coracoacromial and acromioclavicular capsular ligaments [rx]. However, this assertion of stability has recently been doubted [rx] indicating that there are still controversial criteria of stability and little agreement on classifications and indications.

Types of Scapula Fracture

Neck fractures

Coracoid process fractures

Acromion fractures

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

Classification

Fractures of the scapula are relatively uncommon and may be classified according to the following anatomic locations.^1,2

• The body and spine
• The acromion
• The neck
• The glenoid rim and supraglenoid tuberosity

Associated injuries include

• Rib fractures
• Hips lateral lung injuries
• Injuries to the shoulder girdle complex
• Neurovascular injuries
• Suprascapular nerve injuries
• Vertebral compression fractures

Causes of Scapula Fracture

• Fractures of the scapula typically result from a high-energy blunt-force mechanism [rx–rx]. Direct force may cause fractures in all regions of the scapula, while indirect force via impaction of the humeral head into the glenoid fossa can cause both glenoid and scapular neck fractures. Motor vehicle collisions account for the majority of scapular fractures with 50% occurring in occupants of motor vehicles and 20% in pedestrians struck by motor vehicles [rx, rx].
• Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.^[rx] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions.^[rx]
• About three-quarters of cases are caused by high-speed car and motorcycle collisions.^[rx] Falls and blows to the shoulder area can also cause the injury.^[rx]Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, boxing or skiing) can also fracture the scapula.^[rx]
• Scapular the fracture – can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Scapula Fracture

Scapula fracture are rare and historically have been treated effectively with nonsurgical methods. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.

Fractures of the scapula are rare, comprising 1% of all skeletal injuries and 3%–5% of injuries of the shoulder girdle [rx]. As a rule they are sustained as a result of high-velocity trauma, although rarely they can occur due to low impact injuries [rx]. We report the case of a patient who sustained a low-velocity indirect fracture of his scapula following a simple mechanical fall, in which the diagnosis was initially missed.

Mechanism of Scapula Fracture

The mechanism of scapular fractures is always a high-energy trauma. Concomitant injuries occur in up to 90% of the patients with the majority being thoracic injuries followed by injuries of the ipsilateral extremity [rx–rx]. Thus, complex shoulder injuries often involve fractures of the ipsilateral clavicle, the acromion or the coracoid process as well as ligamentous and osseoligamentous structures as the acromioclavicular joint, the coracoclavicular ligaments and the coracoacromial ligament. However, the classification of scapula fractures described by Euler and Ruedi [rx], as well as the Ideberg classification of glenoid fractures, do not systematically include concomitant injuries of the shoulder girdle. Goss and co-workers introduced the concept of the Superior Shoulder Suspensory Complex (SSSC) and expanded the definition of a floating shoulder to a double disruption of this bone and soft tissue ring [rx, rx]. In contrast to previous definitions of a floating shoulder being a combined fracture of the scapular neck and the ipsilateral clavicle [rx, rx–rx], only a double-disruption of the SSSC causes an unstable anatomical situation and therefore a true floating shoulder [rx]. Biomechanical cadaver studies performed by Williams and colleagues emphasized that a fracture of the scapular neck and the ipsilateral clavicle can only produce an unstable, floating shoulder when combined with a disruption of the coracoacromial and acromioclavicular capsular ligaments [rx]. However, this assertion of stability has recently been doubted [rx] indicating that there are still controversial criteria of stability and little agreement on classifications and indications.

Types of Scapula Fracture

Neck fractures

Coracoid process fractures

Acromion fractures

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

Classification

Fractures of the scapula are relatively uncommon and may be classified according to the following anatomic locations.^1,2

• The body and spine
• The acromion
• The neck
• The glenoid rim and supraglenoid tuberosity

Associated injuries include

• Rib fractures
• Hips lateral lung injuries
• Injuries to the shoulder girdle complex
• Neurovascular injuries
• Suprascapular nerve injuries
• Vertebral compression fractures

Causes of Scapula Fracture

• Fractures of the scapula typically result from a high-energy blunt-force mechanism [rx–rx]. Direct force may cause fractures in all regions of the scapula, while indirect force via impaction of the humeral head into the glenoid fossa can cause both glenoid and scapular neck fractures. Motor vehicle collisions account for the majority of scapular fractures with 50% occurring in occupants of motor vehicles and 20% in pedestrians struck by motor vehicles [rx, rx].
• Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.^[rx] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions.^[rx]
• About three-quarters of cases are caused by high-speed car and motorcycle collisions.^[rx] Falls and blows to the shoulder area can also cause the injury.^[rx]Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, boxing or skiing) can also fracture the scapula.^[rx]
• Scapular the fracture – can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time.^[rx]
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf

Symptoms of Scapula Fracture

Clavicle Fracture Treatment/Clavicle fracture is one of the most common injuries around the shoulder girdle [rx]. It has been reported that fractures of the clavicle account for approximately 2.6% of all fractures [rx]. Incidence in males is usually highest in the second and third decade which decreases thereafter as per age [rx]. In females, it is usually bimodal, with a peak incidence in young and elderly [rx]. Allman classified clavicle fractures into three groups based on their location along the bone. The middle-third fractures are most common and account for approximately 80–85% all clavicular fractures [rx].

Fractures of the clavicle are common injuries accounting for between 2.6 and 4% of adult fractures and 35% of injuries to the shoulder girdle [rx–rx]. Early reports of clavicle fractures date back to Hippocrates [rx], who noted that “when a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage”.

Anatomy

The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years [rx].

Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concaves laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. The cross-sectional geometry also changes along its course. It progresses from more tubular medially to flat laterally. This change of contour, which is most acute at the junction of the middle and outer thirds, may explain the frequency of fractures seen in this area [rx].

The lateral clavicle is anchored to the coracoid process by the coracoclavicular ligament, composed of the lateral trapezoid and medial conoid parts. The static joint stabilizers are the AC ligaments, controlling the horizontal stabilizer
“?

 The CC ligament controlling the vertical stability. The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migration of the distal clavicle after disruption of the AC and CC ligaments alone [rx].

The deltoid, trapezius and pectoralis major muscles have important attachments to the clavicle. The deltoid muscle inserts onto the anterior surface of the lateral third of the clavicle, and the trapezius muscle onto the posterior aspect. The pectoralis major muscle inserts onto the anterior surface of the medial two thirds.

Mechanism of Injury of Clavicle Fracture

With the exception of the rare pathologic fracture due to metastatic or metabolic disease, clavicle fractures are typically due to trauma [rx]. Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall [rx]. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from the force applied directly to the shoulder. In a study of 122 consecutive patients, 87% clavicle injuries resulted from a fall onto the shoulder, 7% resulted from a direct blow, and 6% resulted from a fall onto an outstretched hand [rx].

Types of Beauty Bone Fracture

Classification

GROUP I – Middle third fractures (80%)

GROUP II – Distal third fractures (15%)

• Type I – Minimally displaced / inter ligamentous
• Type II – Displaced fractures, fracture medial to the coracoclavicular ligaments
  • IIA – Both ligaments (conoid and trapezoid) attached to the distal fragment
  • IIB – Conoid tore, trapezoid attached to the distal fragment
• Type III – Fractures involving articular surface
• Type IV – intact coracoclavicular ligaments attached to periosteal sleeve plus proximal fragment displaced
• Type V – Comminuted

GROUP III – Fracture of the proximal third (5%)

• Type I – Minimally displacement
• Type II – Displaced
• Type III – Intra-articular
• Type IV – Epiphyseal separation
• Type V – Comminuted

Classification by Robinson (Edinburgh classification)

ED managementthirdFollow-upMiddle

Causes of Clavicle Fracture

• Clavicle fractures  – are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Clavicle Fracture

• Pain – particularly with arm movement or on the front part of the upper chest
• Often – after the swelling has subsided, the fracture can be felt through the skin.
• Sharp pain – when any movement is made
• Referred pain – dull to extreme ache in and around clavicle area, including surrounding muscles
• Possible nausea – dizziness, and/or spotty vision due to extreme pain
• Bruising –  swelling, or bulging over your collarbone
• Decreased feeling – or a tingling feeling in your arm or fingers
• Swelling – ecchymosis, and tenderness may be noted over the clavicle
• Abrasion – over the clavicle may be noted, suggesting that the fracture was from a direct mechanism
• Crepitus from – the fracture ends rubbing against each other may be noted with gentle manipulation
• Difficulty breathing – or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax
• Palpation of the scapula – and ribs may reveal a concomitant injury
• Tenting and blanching of the skin – at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization
• The shoulder may appear shortened – relative to the opposite side and may droop
• Non-use – of the arm on the affected side is a neonatal presentation
• Associated distal nerve dysfunction indicates a brachial plexus injury
• Decreased pulses may indicate a subclavian artery injury
• Venous stasis discoloration and swelling indicate a subclavian venous injury.
• Pain where the broken bone is
• Having a hard time moving your shoulder or arm, and pain when you do move them
• A shoulder that seems to be sagging
• A cracking or grinding noise when you raise your arm
• The bone that is pushing against or through the skin
• The patient may cradle the injured extremity with the uninjured arm

Diagnosis of Clavicle Fracture

Physical Examination

• In a clavicle fracture, there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
• During the physical examination, a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
• The basic method to check for a clavicle fracture is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.^[rx]

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Clavicle Fracture Treatment

Treatment available can be broadly

Medications

Medication can be prescribed to ease the pain. 

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.^[10]

Surgery is considered when one or more of the following conditions present.

• Comminution with separation (bone is broken into multiple pieces)
• Significant foreshortening of the clavicle (indicated by shoulder forward)
• Skin penetration (open fracture)
• Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
• Nonunion after several months (3–6 months, typically)
• Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

• Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
• Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
  Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
• Precontoured locking plates
• Hook plate
• Distal radius plates
• Coracoclavicular screws
• Flexible coracoclavicular fixation
• Arthroscopic treatment
• Intra-medullary fixation
• Tension band fixation

Complications

There are risks associated with any type of surgery. These include:

• Nonunion (1-5%)
• Infection (~4.8%)
• Pneumothorax
• Adhesive capsulitis
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• The difficulty with bone healing
• Lung injury
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Thoracic outlet syndrome
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration
• Subclavian thrombosis

Rehabilitation of Beauty Bone Fracture

• A rehabilitation protocol was started after removal of the bandage in group 1 and immediately after plate fixation in group 2. Gentle pendulum exercises of the shoulder in the sling/arm pouch were allowed as per pain tolerance immediately after surgery in the surgically treated group and after 3 weeks in the conservative group.
• At 3 weeks, gentle active range of motion of the shoulder was allowed with abduction limiting to 90°. Subsequently, the active range of motion exercises that are to be performed at home is advised. At four to 6 weeks, active to an active assisted range of motion in all planes were allowed.
• When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to 12 weeks, isometric and isotonic exercises were prescribed to the shoulder girdle muscles with a return to full activities (including sports) at 3 months.
• Regular follow-up was done every fortnight for the initial 6 weeks, then at 06 weeks, 03 and 06 months using the patient’s subjective evaluation, functional outcome, and radiographic assessment. Patients’ subjective evaluation was investigated by direct interview at the follow-up visits. Functional outcome was graded on the standardized clinical evaluation and completion of the Constant and Murley score [rx].

References

Beauty Bone Fracture/Clavicle fracture is one of the most common injuries around the shoulder girdle [rx]. It has been reported that fractures of the clavicle account for approximately 2.6% of all fractures [rx]. Incidence in males is usually highest in the second and third decade which decreases thereafter as per age [rx]. In females, it is usually bimodal, with a peak incidence in young and elderly [rx]. Allman classified clavicle fractures into three groups based on their location along the bone. The middle-third fractures are most common and account for approximately 80–85% all clavicular fractures [rx].

Fractures of the clavicle are common injuries accounting for between 2.6 and 4% of adult fractures and 35% of injuries to the shoulder girdle [rx–rx]. Early reports of clavicle fractures date back to Hippocrates [rx], who noted that “when a fractured clavicle is fairly broken across it is more easily treated, but when broken obliquely it is more difficult to manage”.

Anatomy

The clavicle is the first bone in the human body to begin intramembranous ossification directly from mesenchyme during the fifth week of fetal life. Similar to all long bones, the clavicle has both a medial and lateral epiphysis. The growth plates of the medial and lateral clavicular epiphyses do not fuse until the age of 25 years [rx].

Peculiar among long bones is the clavicle’s S-shaped double curve, which is convex medially and concaves laterally. This contouring allows the clavicle to serve as a strut for the upper extremity, while also protecting and allowing the passage of the axillary vessels and brachial plexus medially. The cross-sectional geometry also changes along its course. It progresses from more tubular medially to flat laterally. This change of contour, which is most acute at the junction of the middle and outer thirds, may explain the frequency of fractures seen in this area [rx].

The lateral clavicle is anchored to the coracoid process by the coracoclavicular ligament, composed of the lateral trapezoid and medial conoid parts. The static joint stabilizers are the AC ligaments, controlling the horizontal stability, and the CC ligament controlling the vertical stability. The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migration of the distal clavicle after disruption of the AC and CC ligaments alone [rx].

The deltoid, trapezius and pectoralis major muscles have important attachments to the clavicle. The deltoid muscle inserts onto the anterior surface of the lateral third of the clavicle, and the trapezius muscle onto the posterior aspect. The pectoralis major muscle inserts onto the anterior surface of the medial two thirds.

Mechanism of Injury of Clavicle Fracture

With the exception of the rare pathologic fracture due to metastatic or metabolic disease, clavicle fractures are typically due to trauma [rx]. Younger individuals often sustain these injuries by way of moderate to high-energy mechanisms such as motor vehicle accidents or sports injuries, whereas elderly individuals are more likely to sustain injuries because of the sequela of a low-energy fall [rx]. Although a fall onto an outstretched hand was traditionally considered the common mechanism, it has been found that the clavicle most often fails in direct compression from the force applied directly to the shoulder. In a study of 122 consecutive patients, 87% clavicle injuries resulted from a fall onto the shoulder, 7% resulted from a direct blow, and 6% resulted from a fall onto an outstretched hand [rx].

Types of Beauty Bone Fracture

Classification

GROUP I – Middle third fractures (80%)

GROUP II – Distal third fractures (15%)

• Type I – Minimally displaced / inter ligamentous
• Type II – Displaced fractures, fracture medial to the coracoclavicular ligaments
  • IIA – Both ligaments (conoid and trapezoid) attached to the distal fragment
  • IIB – Conoid tore, trapezoid attached to the distal fragment
• Type III – Fractures involving articular surface
• Type IV – intact coracoclavicular ligaments attached to periosteal sleeve plus proximal fragment displaced
• Type V – Comminuted

GROUP III – Fracture of the proximal third (5%)

• Type I – Minimally displacement
• Type II – Displaced
• Type III – Intra-articular
• Type IV – Epiphyseal separation
• Type V – Comminuted

Classification by Robinson (Edinburgh classification)

ED managementthirdFollow-upMiddle

Causes of Clavicle Fracture

• Clavicle fractures  – are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
• Sports injuries – Many wrist fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis – a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate – intake of calcium or vitamin D
• Football or soccer – especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Clavicle Fracture

• Pain – particularly with arm movement or on the front part of the upper chest
• Often – after the swelling has subsided, the fracture can be felt through the skin.
• Sharp pain – when any movement is made
• Referred pain – dull to extreme ache in and around clavicle area, including surrounding muscles
• Possible nausea – dizziness, and/or spotty vision due to extreme pain
• Bruising –  swelling, or bulging over your collarbone
• Decreased feeling – or a tingling feeling in your arm or fingers
• Swelling – ecchymosis, and tenderness may be noted over the clavicle
• Abrasion – over the clavicle may be noted, suggesting that the fracture was from a direct mechanism
• Crepitus from – the fracture ends rubbing against each other may be noted with gentle manipulation
• Difficulty breathing – or diminished breath sounds on the affected side may indicate a pulmonary injury, such as a pneumothorax
• Palpation of the scapula – and ribs may reveal a concomitant injury
• Tenting and blanching of the skin – at the fracture site may indicate an impending open fracture, which most often requires surgical stabilization
• The shoulder may appear shortened – relative to the opposite side and may droop
• Non-use – of the arm on the affected side is a neonatal presentation
• Associated distal nerve dysfunction indicates a brachial plexus injury
• Decreased pulses may indicate a subclavian artery injury
• Venous stasis discoloration and swelling indicate a subclavian venous injury.
• Pain where the broken bone is
• Having a hard time moving your shoulder or arm, and pain when you do move them
• A shoulder that seems to be sagging
• A cracking or grinding noise when you raise your arm
• The bone that is pushing against or through the skin
• The patient may cradle the injured extremity with the uninjured arm

Diagnosis of Clavicle Fracture

Physical Examination

• In a clavicle fracture, there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
• During the physical examination, a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
• The basic method to check for a clavicle fracture is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.^[rx]

Differential Diagnosis/ Associated Injuries

• Scapholunate ligament tear
• Median nerve injury
• TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
• Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
• Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
• Compartment syndrome
• DRUJ (Distal Radial Ulnar Joint) Instability
• Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures^[rx]

Plain radiographs

• Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
• The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

• CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
• CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

• Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
• MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment of Clavicle Fracture

Treatment available can be broadly

Medications

Medication can be prescribed to ease the pain. 

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.^[rx]
• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.
• Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.

Surgery

The evidence for different types of surgery for breaks of the middle part of the clavicle is poor as of 2015.^[10]

Surgery is considered when one or more of the following conditions present.

• Comminution with separation (bone is broken into multiple pieces)
• Significant foreshortening of the clavicle (indicated by shoulder forward)
• Skin penetration (open fracture)
• Associated nervous and vascular trauma (brachial plexus or supraclavicular nerves)
• Nonunion after several months (3–6 months, typically)
• Displaced distal third fractures (high risk of nonunion)

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

• Plates and screws – After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone. After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
• Pins or screws –  Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
  Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
• Precontoured locking plates
• Hook plate
• Distal radius plates
• Coracoclavicular screws
• Flexible coracoclavicular fixation
• Arthroscopic treatment
• Intra-medullary fixation
• Tension band fixation

Complications

There are risks associated with any type of surgery. These include:

• Nonunion (1-5%)
• Infection (~4.8%)
• Pneumothorax
• Adhesive capsulitis
• 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
• Bleeding
• Problems with wound healing
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia
• Hardware prominence
• Malunion with cosmetic deformity
• Restriction of ROM
• The difficulty with bone healing
• Lung injury
• Hardware irritation
• Fracture comminution (Z deformity)
• Fracture displacement
• Increased fatigue with overhead activities
• Thoracic outlet syndrome
• Dissatisfaction with appearance
• The difficulty with shoulder straps, backpacks and the like
• ~30% of patient request plate removal
• Superior plates associated with increased irritation
• Superior plates associated with increased risk of subclavian artery or vein penetration
• Subclavian thrombosis

Rehabilitation of Beauty Bone Fracture

• A rehabilitation protocol was started after removal of the bandage in group 1 and immediately after plate fixation in group 2. Gentle pendulum exercises of the shoulder in the sling/arm pouch were allowed as per pain tolerance immediately after surgery in the surgically treated group and after 3 weeks in the conservative group.
• At 3 weeks, gentle active range of motion of the shoulder was allowed with abduction limiting to 90°. Subsequently, the active range of motion exercises that are to be performed at home is advised. At four to 6 weeks, active to an active assisted range of motion in all planes were allowed.
• When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to 12 weeks, isometric and isotonic exercises were prescribed to the shoulder girdle muscles with a return to full activities (including sports) at 3 months.
• Regular follow-up was done every fortnight for the initial 6 weeks, then at 06 weeks, 03 and 06 months using the patient’s subjective evaluation, functional outcome, and radiographic assessment. Patients’ subjective evaluation was investigated by direct interview at the follow-up visits. Functional outcome was graded on the standardized clinical evaluation and completion of the Constant and Murley score [rx].

References