Shoulder Fracture

"Shoulder fracture" is shorthand for breaks in any of four bones around the shoulder, and they're treated very differently from each other. The shoulder is built from four parts. The clavicle is the collarbone. The scapula is the shoulder blade. The proximal humerus is the top of the arm bone, with the round ball that sits in the socket. The sternoclavicular joint is where the collarbone meets the breastbone. Each bone breaks under different forces, in different groups of patients, and asks for different treatment. Sorting out which one is yours is the first step.

The clavicle is the most commonly broken bone in the shoulder, and one of the most commonly broken bones in the body. Kids fall onto it. Cyclists fall over the bars onto it. Contact-sport athletes get hit on it. Most clavicle fractures heal reliably in a sling. A smaller group needs surgery: badly displaced breaks, shortened breaks where the two ends ride past each other, breaks that have tented the skin, or breaks in multiple pieces. Those get a plate, and you typically regain function faster than with a sling. Over the past two decades, surgeons have gradually leaned toward fixing more of these in young, high-demand patients than we used to.

The proximal humerus is the most commonly broken shoulder bone in older adults. The usual story is a low-energy fall onto an outstretched hand or onto the side of the shoulder, in someone whose bone is weakened by osteoporosis. Surgeons grade these breaks by how many of the bone's four parts have split apart and shifted. The number of displaced parts drives the decision. Most one-part and many two-part fractures heal in a sling. Three- and four-part fractures, and those with significant displacement of the head, are the operative ones. In older patients with very fragmented patterns, the operation is often a reverse shoulder replacement rather than fixation.

The scapula is the hardest shoulder bone to break: it sits buried in muscle and takes a lot of force to fracture. When it does break, the cause is almost always a high-energy injury, such as a car crash or a fall from height. There are often other injuries that take priority. Most scapula fractures are treated without surgery, because the muscles around the bone act as an internal splint. Only specific patterns need fixing: badly displaced fractures of the socket (the glenoid), neck fractures that leave the shoulder unstable, and breaks through the joint surface.

The sternoclavicular joint sits at the inner end of the collarbone where it meets the breastbone. Injuries there are uncommon but serious. Dislocations toward the front are unstable and uncomfortable but rarely dangerous. Dislocations toward the back (posterior dislocations) sit behind the breastbone and can press on the large blood vessels of the chest. Those are emergencies. They are put back in place urgently, often in the operating room with a chest surgeon on standby. The site has its own dedicated sternoclavicular injury page.

Each of these has its own page with mechanism, diagnosis, and treatment specific to that bone:

• Clavicle fractureMost common shoulder fracture, falls onto the shoulder, cyclists, contact sport
• Humeral shaft fractureThe middle of the upper arm bone, often heals in a functional brace

Most shoulder fractures announce themselves with sharp pain and an inability to lift or rotate the arm. The location of the pain narrows the bone. Pain and visible deformity at the collarbone points to the clavicle. Pain at the front of the shoulder, with bruising spreading down the upper arm, points to the proximal humerus. Deep tenderness over the back of the shoulder blade after a high-energy injury points to the scapula. Pain at the inner end of the collarbone, where it meets the breastbone, points to the sternoclavicular joint.

Two warning signs change the urgency. The first is the broken end of a clavicle tenting the skin: you can see and feel the bone end pushing on the skin from the inside. That is a same-day operative problem, because the skin will eventually break down over it. The second is numbness or weakness anywhere in the arm or hand after a shoulder fracture. That means a nerve has been stretched, and it needs evaluation today, not next week. Cool, pulseless, or pale skin in the hand or arm raises the same urgency for the artery instead of the nerve. And as with any fracture, a break that's come through the skin (open fracture) is an immediate trip to the OR.

Your provider examines the whole shoulder region: the collarbone from end to end, the shoulder blade, and the top of the arm bone. They then check that the nerves and circulation in your arm are intact. Standard X-rays for a shoulder injury include three views: a front view, a side view through the shoulder blade, and a view looking up into the armpit. A specific collarbone series is added when that bone is suspect. An extra view angled up toward the breastbone is added for inner-collarbone injuries. CT is the go-to for planning surgery on the upper arm bone. It is also used for injuries at the inner end of the collarbone, where major blood vessels sit close by and plain X-rays don't show enough detail.

Most shoulder fractures heal without an operation. The plan depends on which bone is broken and how far the pieces have moved, but the backbone is the same. Protect the bone while it knits. Get the shoulder moving before it stiffens. Watch the position with repeat X-rays. Here is what that looks like in order.

1. Sling Immobilization

   Most clavicle fractures and most proximal humerus fractures heal in a sling while the bone forms callus; your surgeon will tell you how long to wear it. The sling is for comfort more than alignment. These fractures hold their position because the surrounding muscle splints them.

2. Early Protected Motion

   Stiffness is the enemy of the shoulder. Gentle pendulum exercises and supported range-of-motion are started early, on a timeline your surgeon sets. The exact timing depends on which bone is involved and which way the pieces are leaning. The goal is bone that heals without a frozen shoulder waiting for you on the other side.

3. Serial Imaging

   Out-of-sling X-rays at intervals your surgeon chooses confirm the position is holding. Any late shift changes the plan toward surgery. That is most common with clavicle fractures that shorten or tilt over time.

Surgery is offered when the bone won't heal reliably in alignment you can function with. That includes significantly displaced or shortened clavicle fractures, especially in younger or high-demand patients. It includes proximal humerus fractures with three or four displaced parts, with the head split, or with the head losing its blood supply. It includes scapular fractures with significant displacement of the socket or with shoulder instability. And it includes posterior sternoclavicular dislocations.

The operations match the bone. Clavicle Fracture Fixation is plate-and-screw fixation of the broken clavicle. Shoulder-end upper-arm fracture fixation is plate-and-screw fixation of the broken proximal humerus, with stitches through the rotator cuff to help hold the pieces. Sometimes the head is too fragmented, or the bone too weakened by osteoporosis, to support fixation reliably. In older patients, a reverse shoulder replacement is then increasingly the right answer. Its design doesn't depend on the broken bone or the rotator cuff to function. Scapula Fracture Fixation is reserved for the specific patterns that benefit from it.

If non-operative care is not enough, these procedures are offered by the OSI team for this condition:

• Clavicle fracture fixationShoulder
• Proximal humerus fracture fixationShoulder
• Reverse shoulder replacementShoulder

Providers Who Treat Shoulder Fracture

Michael S. Vrana, M.D.

David B. Templin, M.D.

Trent Twitero, M.D.

External patient-education references and related OSI pages for additional background:

• AAOS OrthoInfo, patient education library
• OSI glossary, orthopedic terminology in plain language