The guidelines developed by the New York State Workers Compensation Board are designed to support healthcare providers in administering suitable treatment for shoulder fractures.
Created with medical professionals in mind, these Workers Compensation Board guidelines aid in determining the appropriate level of care for individuals with shoulder fractures.
It’s essential to highlight that these guidelines do not replace clinical judgment or professional experience. The ultimate decision on care should be a collaborative one, involving the patient and their healthcare provider in consultation.
There are five prevalent types of shoulder fractures, and each type will be discussed individually, presented in the sequence of their most frequent occurrence
Clavicular Fracture
Patient history and initial diagnostic procedures.
The mechanism of injury for shoulder fractures can stem from direct blows or axial loads applied to the upper limb. Commonly associated injuries include rib fractures, long-bone fractures of the same side limb, and scapulothoracic dislocations.
Physical Findings
Physical findings associated with shoulder fractures may involve pain in the clavicle, visible abrasions on the chest wall, clavicle, and shoulder, observable deformities in the aforementioned regions, and pain during palpation and motion at the shoulder joint area.
Laboratory Tests
Generally, shoulder fractures do not warrant routine imaging. However, imaging is recommended in select patients where a systemic illness or disease is suspected
X-Ray
Imaging is recommended in select patients as clinically indicated. Indications typically involve routine chest x-rays. If these x-rays do not provide adequate information, a 20° caudal cranial anteroposterior (AP) view centered on the area of concern may be necessary.
Non-Operative Treatment Procedures
The majority of shoulder fractures can be effectively managed with closed techniques and do not necessitate surgical intervention. Following reduction, the arm is immobilized using either a sling or a figure-8 bandage. Shoulder rehabilitation typically commences with pendulum exercises around ten to 14 days after the injury. Following pain control, the therapy program can be advanced using non-operative therapeutic approaches.
Medications, including analgesics and nonsteroidal anti-inflammatories, may be indicated for pain management. In rare instances, narcotics may be necessary acutely for fractures.
Operative Procedures
Recommended – in specific patients based on clinical indications. Indications for operative procedures include open fractures, vascular or neural injuries requiring repair, bilateral fractures, ipsilateral scapular or glenoid neck fractures, scapulothoracic dislocations, flail chest, and nonunion displaced-closed fractures that exhibit no evidence of union after four to six months. Additionally, a Type II fracture/dislocation at the AC joint, where the distal clavicular fragment remains with the acromion and the coracoid, and the large proximal fragment is displaced upwards.
Post-Operative Procedures
Post-Operative procedures would involve an individualized rehabilitation program established through communication among the physician, surgeon, and therapist. This program would commence with two to three weeks of rest using a shoulder immobilizer while promoting isometric deltoid strengthening. Subsequently, pendulum exercises with progression to assisted forward flexion and external rotation would follow, and strengthening exercises should be initiated at ten to 12 weeks.
Proximal Humeral Fracture
History Mechanism of Injury
Mechanism of Injury: A fall onto an abducted arm or high-energy (velocity or crush) trauma with an abducted or non-abducted arm can cause proximal humeral fractures. Common associated injuries include glenohumeral dislocation, stretch injuries to the axillary, musculocutaneous, and radial nerves, as well as axillary artery injuries in high-energy accidents.
Physical Findings
Physical Findings may encompass pain in the upper arm, swelling and bruising in the upper arm, shoulder, and chest wall, abrasions about the shoulder, and/or pain with any attempted passive or active shoulder motion.
Laboratory Tests
Generally not indicated. Recommended – in specific patients where a systemic illness or disease is suspected.
Testing Procedures
X-Ray
Recommended – in specific patients based on clinical indications. Indications include a trauma series (three views) with a scapular Y view, axillary view, and a lateral view in the plane of the scapula. Note: The latter two views are necessary to determine if there is a glenohumeral dislocation. Note: Classification is by the Neer Method, where there can be four fragments – the humeral shaft, humeral head, greater tuberosity, and the lesser tuberosity. The fragments are not considered true fragments unless they are separated by 1 cm or angulated 45 degrees or more.
Vascular Studies
Recommended – in specific patients based on clinical indications. Indications include obtaining vascular studies emergently if radial and brachial pulses are absent.
Therapeutic Procedures: Non-Operative
Recommended: in specific patients based on clinical indications. Indications include managing impacted fractures of the humeral neck or greater tuberosity non-operatively. Isolated and minimally displaced fractures (less than 1 cm) are treated non-operatively. Anterior or posterior dislocation associated with minimally displaced fractures can usually be reduced by closed means, but general anesthesia is needed.
May Include:
- Medications, such as analgesics and nonsteroidal anti-inflammatories, would be prescribed. Narcotics may be indicated acutely for fractures and should be prescribed as indicated in Section E. 1.
- Immobilization is provided with a sling, supporting the elbow, or with an abduction immobilizer if a non-impacted greater tuberosity fragment is present.
- Immobilization is continued for four to six weeks.
- Shoulder rehabilitation begins with pendulum exercises ten to 14 days after injury. Subsequently, with pain control, the therapy program can progress with therapeutic approaches noted in Section E, Therapeutic Procedures: Non-Operative.
Operative Procedures
Recommended – in specific patients based on clinical indications. Indications include unstable surgical neck fractures (no contact between the fracture fragments) and partially unstable fractures (only partial contact) with associated upper extremity injuries. Note: Displaced 3- and 4-part fractures may be managed by prosthetic hemiarthroplasty and reattachment of the tuberosities.
Post-Operative Procedures
Recommended – in specific patients based on clinical indications. Post-Operative Procedures would involve an individualized rehabilitation program established through communication among the physician, surgeon, and therapist.
Humeral Shaft Fracture
History and Initial Diagnostic Procedures (Humeral Shaft Fracture)
Mechanism of Injury: A direct blow can cause a fracture at the junction of the middle and distal thirds of the humeral shaft; twisting injuries lead to a spiral humeral shaft fracture; high-energy (velocity or crush) incidents result in a comminuted humeral shaft fracture.
Physical Findings
Physical Findings may include:
- Deformity of the arm;
- Bruising and swelling;
- Possible sensory and/or motor dysfunction of the radial nerve.
Laboratory Tests
Generally not indicated. Recommended – in select patients where a systemic illness or disease is suspected.
Testing Procedures
- Plain x-rays, including AP view and lateral of the entire humeral shaft.
- Vascular studies if the radial pulse is absent.
- Compartment pressure measurements if the surrounding muscles are swollen, tense, and painful, particularly if the fracture resulted from a crush injury.
Non-Operative Treatment Procedures
- Most isolated humeral shaft fractures can be managed non-operatively.
- Medications, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics may be indicated acutely for a fracture and should be prescribed as indicated in Section E.1.d.
- A coaptation splint may be applied. The splint starts in the axilla, extends around the elbow, and is brought up to the level of the acromion. It is held in place with large elastic bandages.
- At two to three weeks after injury, a humeral fracture orthosis may be used to allow for full elbow motion.
Operative Procedures
Recommended – in select patients as clinically indicated. Indications include open fractures, associated forearm or elbow fractures (i.e., the floating elbow injury), burned upper extremity, associated paraplegia, multiple injuries (polytrauma), a radial nerve palsy that occurred after closed reduction, and/or a pathologic fracture related to an occupational injury. Accepted methods of internal fixation include:
- A broad plate and screws; and/or
- Intramedullary rodding with or without cross-locking screws.
Post-Operative Procedures
Post-Operative Procedures would involve an individualized rehabilitation program based on communication among the physician, the surgeon, and the therapist. Following rigid internal fixation, therapy may start to obtain passive and later active shoulder motion using appropriate therapeutic approaches as seen in Section Non-Operative Treatment Procedures, Humeral Shaft Fracture. Active elbow and wrist motion may start immediately.
Scapular Fracture
History and Mechanism of Injury (Scapular Fracture)
Mechanism of Injury: Scapular fractures, which are the least common shoulder fractures, encompass acromial, glenoid, glenoid neck, and scapular body fractures. Except for anterior glenoid lip fractures resulting from an anterior shoulder dislocation, all other scapular fractures are attributed to high-energy injuries.
Physical Findings (Scapular Fracture)
Physical Findings may include:
- Pain around the shoulder and thorax;
- Bruising and abrasions;
- Possibility of associated humeral or rib fractures; and/or
- Vascular problems (pulse evaluation and Doppler examination).
Laboratory Tests
Recommended – in select patients as clinically indicated. Indications: Due to the association with high-energy trauma, this may involve a complete blood count, urinalysis, and chest x-ray.
Testing Procedures
Recommended – in select patients as clinically indicated.
- X-Ray X-ray trauma series (three views) are needed: AP view, axillary view, and a lateral view in the plane of the scapula.
- Arteriography if a vascular injury is suspected.
- Electromyographic exam (EMG) if nerve injuries are noted.
Non-Operative Treatment Procedures
Non-displaced acromial, coracoid, glenoid, glenoid neck, and scapular body fractures can all be treated with a shoulder immobilizer. Medication, such as analgesics and nonsteroidal anti-inflammatories, would be indicated. Narcotics may be indicated acutely for a fracture and should be prescribed as indicated in Section E.1.d. Pendulum exercises may be started within the first week. Progress to assisted range of motion exercises at three to four weeks using appropriate therapeutic procedures.
Operative Treatment
Recommended – in select patients as clinically indicated.
- Acromial fractures that are displaced should be internally fixed to prevent a nonunion. These fractures may be fixed with lagged screws and a superiorly placed plate to neutralize the muscular forces.
- Glenoid fractures that are displaced greater than two to three mm should be fixed internally. The approach is determined by studying the results of a CT scan.
- Scapular body fractures require internal fixation if the lateral or medial borders are displaced to such a degree as to interfere with scapulothoracic motion.
- Displaced fractures of the scapular neck and the ipsilateral clavicle require internal fixation of the clavicle to reduce the scapular neck fracture.
Post-Operative Procedures
Post-Operative Procedures would include an individualized rehabilitation program based upon communication among the physician, the surgeon, and the therapist. A shoulder immobilizer is utilized, pendulum exercises at one week, deltoid isometric exercises are started early, and, at four to six weeks, active range of motion is commenced.
Sternoclavicular Dislocation/Fracture
History and Mechanism of Injury
Mechanism of Injury: Established with sudden trauma to the shoulder/anterior chest wall; anterior dislocations of the sternoclavicular joint usually do not require active treatment; however, symptomatic posterior dislocations will require reduction.
Physical Findings
Physical Findings may include:
- Pain at the sternoclavicular area;
- Abrasions on the chest wall, clavicle, and shoulder can be seen;
- Deformities can be seen in the above regions; and/or
- Pain with palpation and motion at the sternoclavicular joint area.
Laboratory Tests
Are generally not indicated. Recommended – in select patients where a systemic illness or disease is suspected.
Testing Procedures X-Ray- Vascular Studies
Recommended – in select patients as clinically indicated. Indications: Plain x-rays of the sternoclavicular joint are routinely done. When indicated, comparative views of the contralateral limb may be necessary. X-rays of other shoulder areas and chest wall may be done if clinically indicated. Indications: Vascular studies should be considered if the history and clinical examination indicate extensive injury.
Therapeutic Procedures: Non-Operative
Symptomatic posterior dislocations should be reduced in the operating room under general anesthesia.
- Immobilize with a sling for 3-4 weeks. Subsequently, further rehabilitation may be utilized using procedures set forth in Section E, Therapeutic Procedures: NonOperative.
- Medications, such as analgesics and nonsteroidal anti-inflammatories, may be indicated; narcotics may be indicated acutely for a fracture and should be prescribed as indicated for limited periods.
- Manipulation (for Sternoclavicular Dislocation): Manipulative treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance. Time to produce effect for shoulder treatment: one to six treatments.
Operative Procedures
Not Recommended.
