Shoulder and humerus

Clavicle

Diagnosis

In adults, the clinical diagnosis of a fractured clavicle is usually obvious. Deformity, swelling, and tenderness are evident at the site of
injury, and the affected shoulder tends to sag. A radiograph is not essential for isolated fractures of the clavicle (Fig. 14.1A). If a
pneumothorax is suspected, take a chest radiograph showing both clavicles and both shoulder joints.

Equipment

See equipment forApplication of plaster,Annex 1 and add a crepe bandage and a triangular sling.

Treatment

Classical treatment is the application of a well-padded gure-of-eight bandage, but this may be uncomfortable, especially in the axillae, if
not properly applied. For some patients a triangular sling is more suitable.

A gure-of-eight bandage is applied to alleviate pain, but is not essential to healing. First ensure that the shoulders are braced back (Fig.
14.1.B). Use a broad stockinet as a bandage, secured by a few turns of plaster, and pad the axillae well with cotton wool. The patient
should sit, hands on hips, as the bandage is applied (Fig. 14.1C, D). Anaesthesia is unnecessary.

A triangular sling can also give satisfactory results, and may be more acceptable to the patient (Fig. 14.1E - G).

Fig. 14.1. Fracture of the clavicle. Fracture (A); applying a gure-of-eight bandage (B - D); applying a triangular sling (E - G).

After-care

After-care consists of frequent, active elevation and retraction of the shoulder, as well as exercises for the elbow and hand. Check the
bandage or sling frequently and remove it after 3 weeks for children or 6 weeks for adults.

Complications

Complications of this injury are rare, but can include non-union, malunion, and temporary stiffness of the shoulder.

Scapula

Scapular fractures are usually associated with rib fractures; look for such associated injuries.

Diagnosis
Conrm the diagnosis by taking a chest radiograph.

Equipment

A triangular sling.

Treatment

Reduction of the fracture is impossible and unnecessary, even if it is communicated. Hold the upper limb in a triangular sling on the
same side as the fractured scapula. The patient should wear the sling for 5 - 4 weeks and perform graduated pendulum exercises daily
(Fig. 14.2A, B), so that full activity is restored by the fourth week.

Fig. 14.2. Pendulum exercises for fracture of the scapula (A, B).

Proximal humerus

Diagnosis

Suspect a fracture of the proximal humerus if there is a history of shoulder pain following trauma and a tender swelling of the shoulder
with loss of, or restricted, function. Conrm the injury by obtaining a radiograph of the humerus.

The sites that may be fractured are the greater and lesser tuberosities and the surgical neck, with or without anterior dislocation.

Equipment

A crpe bandage and a triangular sling.

Treatment

Treat isolated fractures of the greater or lesser tuberosity or undisplaced fractures of the surgical neck of the humerus (i.e., fractures
without a complete transverse fracture-line across the full width of the humeral shaft) by holding in a triangular sling, with early
mobilization of the shoulder joint (Fig. 14.3A - C). Treat displaced fractures (having a complete transverse line across the bone) and
fractures associated with dislocation by reduction to the best possible position with the patient under anaesthesia, followed by application
of an axillary pad and an arm-to-chest bandage (Fig. 14.3D - F). In cases of fracture dislocation, try to reduce the dislocation as
described for uncomplicated dislocation. If closed reduction fails or if there is any evidence of neurovascular injury, refer the patient.
Fig. 14.3. Fractures of the proximal humerus. Fracture of greater tuberosity (A); incomplete fracture of the surgical neck of the
humerus (B); triangular sling (C) applied to treat (A) or (B); complete fracture of the surgical neck of the humerus (D); fracture
dislocation of the shoulder joint (E); arm-to-chest bandage (F) applied after reduction of (D) or (E).

As soon as the pain subsides, usually in 10 - 15 days, initiate pendulum exercises in a sling and graduated activity, aiming at full activity
within 8 - 12 weeks after the injury.

Complications

Possible complications include delayed union, malunion, non-union, and joint stiffness.

Humeral diaphysis

Diagnosis

The diagnosis is made from a history of injury followed by pain and weakness in the arm. There is usually obvious deformity and
abnormal mobility at the site of injury. Take a radiograph to conrm the diagnosis (Fig. 14.4A, B). Check for radial nerve palsy by testing
dorsiexion of the wrist (Fig. 14.4G - I).

Equipment

See equipment forApplication of plaster,Annex 1 and add a triangular sling and a crepe bandage.

Treatment

Treat the patient conservatively by closed reduction (with appropriate anesthesia) and immobilization. Perfect bony apposition is not
essential. Minimal overriding is acceptable (Fig. 14.4A), but distraction of the humeral fragments is not (Fig. 14.4B). Immobilize the
fractured humerus for 4 - 6 weeks in an arm-to-chest bandage (sling and swathe) or in a U-shaped plaster slab (Fig. 14.4C - F) with a
triangular sling. The patient should begin daily shoulder exercises, continuing until the fracture is consolidated.

If the fracture shows no evidence of union after 8 weeks, or if there is distraction of the bone ends, refer the patient.

Complications

The commonest complication of humeral shaft fracture is radial nerve palsy. Protect the affected wrist with a cock-up splint (Fig. 14.4J,
K) or in a POP bandage. Vascular damage at the diaphyseal level is rare unless there is an open fracture, for example as a result of a
shooting injury. Refer patients with either of these complications.
 Fig. 14.4. Humeral diaphyseal fractures. Fractures (A, B); determining the required length of plaster bandage for making a U-
slab (C); applying a padded U-slab, which is then secured with a wet cotton bandage (D, E); nal position of the arm in plaster
(F); relationship of the radial nerve to the shaft of the humerus (G); testing for radial nerve palsy (H - I); splint for wrist drop
caused by radial nerve palsy (J, K).