Clavicle fractures
Assessment
Examine:
- skin tenting or open injury
- brachial plexus and distal pulses
- chest for associated rib injury/pneumothorax
- shoulder girdle for scapular injury
Most midshaft fractures can be treated non-operatively. Surgery is considered for selected patients with marked displacement/shortening, open fracture, threatened skin, neurovascular injury or specific functional demands.
Distal clavicle fractures are assessed for coracoclavicular ligament integrity because unstable patterns have a higher nonunion risk.
Most clavicle fractures involve the middle third. Assess:
- skin tenting/open injury
- neurovascular status
- shortening and displacement
- comminution
- associated chest or shoulder-girdle injury
Many heal successfully without surgery, but operative fixation may be considered with selected markedly displaced fractures, open injury, skin compromise, neurovascular issues or specific high-demand circumstances.
Complications include:
- non-union
- symptomatic malunion
- hardware irritation
- infection
- neurovascular injury
Proximal humerus fractures
Decision-making is based on:
- age and physiological reserve
- fracture pattern and displacement
- head viability
- bone quality
- pre-injury shoulder function
- rotator-cuff status
Options:
- non-operative rehabilitation
- fixation
- hemiarthroplasty in selected fracture patterns
- reverse shoulder arthroplasty, particularly in selected older patients with complex reconstructability issues
Humeral shaft fractures
Many closed fractures heal successfully in a functional brace.
Indications for surgery include selected:
- open fractures
- vascular injury
- polytrauma
- segmental or pathological fractures
- unacceptable alignment or failed non-operative treatment
Radial nerve palsy is common. In a closed fracture with primary palsy, observation is often appropriate initially unless there is another indication for exploration. New palsy after manipulation or surgery requires careful reassessment.
Many closed shaft fractures can heal with functional bracing.
Indications for surgery may include:
- open fracture
- vascular injury
- polytrauma
- unacceptable alignment
- floating elbow or associated injuries
- failure of non-operative management
- selected radial nerve scenarios
Distal clavicle fractures
Distal fractures behave differently because stability depends on the relationship between fracture line and coracoclavicular ligaments. Unstable patterns have a greater non-union risk and may require fixation or ligament-supporting strategies.
Proximal humeral fractures
Assessment should consider:
- patient physiological age
- bone quality
- fracture pattern
- tuberosity displacement
- head vascularity
- rotator cuff
- pre-injury function
Most minimally displaced fractures are managed non-operatively with early guided motion.
Operative choices for proximal humerus
Depending on pattern and patient:
- percutaneous or screw fixation
- locking plate
- intramedullary nail
- hemiarthroplasty
- reverse shoulder arthroplasty
The decision depends on reconstructibility, tuberosity biology, bone quality and expected cuff function.
Radial nerve palsy
Primary radial nerve palsy with a closed humeral-shaft fracture often recovers spontaneously. The mechanism, fracture type and timing of palsy matter when deciding on observation versus exploration.
A new palsy after manipulation or fixation requires a different level of concern.
FRCS synthesis
Separate fractures by anatomical region and biology. The correct management of a displaced proximal humerus fracture in an elderly osteoporotic patient is not the same as management of a humeral-shaft fracture in a young adult.