Shoulder Pain & Fractures

Episode 42 - Shoulder Pain & Fractures

Dr. Chehab: [00:00:00] Welcome to IBJI's OrthoInform where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic conditions that we see every day. Today, it is my pleasure to welcome Dr.

John Ross, who will be speaking about fractures about the shoulder John you grew up in the Barrington area? 

Dr. Ross: I did, yes. 

Dr. Chehab: Okay. Tell us a little bit more about your background, your education, your training. 

Dr. Ross: Yeah, yeah. So, um, grew up in the northwest suburbs, went to Barrington High School played golf there, , and then ended up, uh, going to Emory University to, to play golf in college as well as study neuroscience and, uh, do pre-med.

Went there ultimately decided, med school was what I wanted to do. I wanted to be a surgeon. Ended up going to Rush University for medical school then went to UConn around Hartford for, uh, my residency, and then did a, uh, shoulder and elbow fellowship in Tampa at FOI. 

Dr. Chehab: Um, FOI...

Dr. Ross: Florida Orthopaedic Institute. Yeah Sorry. 

Dr. Chehab: And just for the [00:01:00] listeners, both UConn and Florida Orthopaedic Institute have some pretty well-known shoulder specialists. They do. 

Dr. Ross: Yeah. 

Dr. Chehab: And you've chosen to specialize in the shoulder in your practice? 

Dr. Ross: Correct. Yeah. 

Dr. Chehab: And what does your practice focus on?

Dr. Ross: Uh, it's mostly complex, uh, open shoulder cases, so, treating arthritis with replacements, be it anatomic replacements or reverse replacements treating complex fractures of the shoulder, uh, with either fixation or, uh, sometimes you replace, uh, the joint in certain cases. And then also, um, other open procedures, uh, about the arm, clavicle fractures, humerus fractures elbow trauma.

And then I do have some kinda just bread-and-butter general orthopedic practice, which makes up a part of my practice as well. 

Dr. Chehab: Yeah. And, um, and you were Alpha Omega Alpha. For the listener, that's a very prestigious, Oh, thank you ... society, um, the top 5, 10% of the class- Yeah ... maybe. I wish I were one of those.

And, uh so, um, again, welcome to OrthoInform. Thank you. Thanks for being here. Yeah. Um, we're gonna talk about fractures about the shoulder, and we can take a little [00:02:00] bit of a tour of the shoulder, Sure ... anatomically. And, um, l- let's start with the clavicle. Mm-hmm. Um, there are clavicle fractures, but then there are clavicle fractures divided by where they occur.

Dr. Ross: Yes. 

Dr. Chehab: And the most common location of a clavicle fracture is the midshaft of the clavicle. Correct. Yeah. So take us through how those typically happen, how patients present what you see on exam, and then what your thought process is, is in terms of how you wanna treat, um- yeah ... those patients.

Dr. Ross: Um, so about 80% of clavicle fractures I would say are, are midshaft clavicle fractures. There's varying, forms of fractures. You can have an, a nondisplaced fracture, which is generally treated non-operatively in a sling. You could have a displaced fracture, uh, in just a couple parts. You could have a displaced fracture in many parts, you know.

There's treated, uh, ones that are in as many as eight pieces. So 80% I would say are those midshaft ones. Um, and then you'll see or- small amount of ones that are closer to the breastbone or medial. Um, and then I would say maybe around 20, 15%, uh, that are, are, uh, distal [00:03:00] clavicle fractures or, or lateral end of the clavicle fractures.

And so I think, uh, in terms of treating, uh, clavicle fractures, we can just start with kind of the midshaft ones. The pendulum, I think, in the literature and, and what, uh, orthopedists are doing in general tends to sway in terms of how to ideally treat clavicle fractures. I think you can find an ample amount of evidence, uh, that strongly supports, uh, treating those non-operatively and an ample amount that would support treating them surgically.

So I've kind of found that there are, uh, several things that come into play when making those decisions. Before-- But before we even get to that you had asked about just kind of how do these happen, how do patients present. Commonly the ways I've seen them is a hard fall onto the arm.

Sometimes it's, going over the front of a bike snowboarding, um, but various, uh, kind of higher energy trauma- Mm-hmm ... uh, to the shoulder, to the front of the, uh, chest are what are causing these. Patients present, guarding their arm. In some cases, there's obvious deformity. In some cases, there's actual skin tenting or, um, the appearance of the bone [00:04:00] kind of right under the skin, almost ready to break out.

Dr. Chehab: Yep. 

Dr. Ross: And, um, yeah, so they're, they're painful. They have a lot of swelling kind of around the area, um, and their shoulder motion's usually, uh, pretty limited. So and then in terms of, trying to counsel patients one way or the other, you know, is surgical treatment best for you? Is, is maybe non-operative treatment.

I think it's... You have to take the whole picture into account. 

Dr. Chehab: Yeah. 

Dr. Ross: The patient's age and the fracture morphology I think are probably the two most important things. What does that patient wanna do? Are they a, 18-year-old contact athlete versus a 92-year-old elderly woman who lives in a retirement home?

Generally the same fracture in those two patients is treated, you know, vastly differently. And so, and then getting into kind of the fracture morphology or the appearance of the fracture the more displaced or shortened the fracture, the more typical, uh, you are to recommend, uh, surgery for that or, uh, if it's in more pieces or again, if, if the, the demands of the patient are, are a little bit higher than, say, relative to someone else.

Dr. Chehab: So what are the rates... let's take a simple [00:05:00] midshaft non-comminuted, meaning just two pieces of the clavicle, one, a clean break. Um, what are the rates of healing with non-operative treatment in a young adult? 

Dr. Ross: In a young adult, uh, I mean, I would say they're the non-union rate or the not healing rate, uh, could be up to 5 to 10%, but it's rather high.

I mean, these generally go on to heal. 

Dr. Chehab: So the healing rate's very, very high. 

Dr. Ross: Correct. 

Dr. Chehab: The rate of not healing is low, and then there's a percentage of those that don't heal that aren't particularly symptomatic either. 

Dr. Ross: Correct. You also have fibrous non, painless fibrous non-unions, which make up a percentage as well.

Yeah. 

Dr. Chehab: So they can be offered non-operative treatment and expect a good result. But they can also be offered operative treatment, For reasons which would be such, you 

Dr. Ross: know- Yeah, I think, um, with the majority of, of clavicle fractures, uh, I think the selling point to, to consider surgery is more reliability of outcome.

So if you're someone that, knows that they really wanna have the best possible function they can have of the arm and you wanna get back as quickly as you can, and have that process be as reliable as possible I think surgery offers that. I think your [00:06:00] non-healing rate, uh, you know, approaches, uh, 0% or it's around 1% if you're fixing these and fixing them well.

And then I think it's also just in terms of being able to counsel the patient, okay, so, you know, you'll be in a sling for one to two weeks until your follow-up, then you're gonna be moving your arm right away, then at six weeks I'm gonna let you start, you know, lifting about 5 to 10 pounds, and then by three months, generally unrestricted activity.

So you can kind of, have an idea of exactly how the process is gonna go- Yeah ... um, more often than if you're treating something non-operatively where requires a lot more follow-ups, a lot more watchful waiting a little bit more unknowns, uh, potentially. So 

Dr. Chehab: it's a little bit more predictable with the procedure.

Dr. Ross: Correct. 

Dr. Chehab: Yeah. It's, um, uh, you can get people doing things earlier with the procedure. Correct. And there's very little risk of it not healing. What are some of the downsides, though, of the procedure? What are some of the potential complications that- Yeah ... patients could face with doing a procedure?

Dr. Ross: Um, I mean, the kind of the first and most obvious, I guess, would be, failure of it, it not healing or the if that process happens, um, the hardware sometimes migrating or coming out of the wound. [00:07:00] Um, you can have kinda simple stuff that you see every day like, uh, slight infections that may need just oral antibiotics, or you ha- may have more serious infections where you have to take the patient back to the OR.

I think that's closer to, around 1%. Sure. But the non-union or malunion rate, uh, which mean either if the fracture doesn't heal or heals in a bad position, you basically bring that rate down to, to- Zero ... to zero if you're, if you're doing surgery. Right. Right. And then the other things, I mean, fixing clavicle fractures, uh, I do like to be up- upfront with patients about all the risks.

I mean, it is somewhat of a, a dangerous area. You have the brachial plexus and the, you know, the main artery to the arm right underneath that area. So you're gonna wanna go to somebody if you're gonna have surgery for a clavicle fracture that, you know, does a, a good amount of them and is comfortable operating in that area because although, you know, a serious injury like that would be exceedingly rare, that they do happen.

Dr. Chehab: Yeah. Yeah. And, and right at the beginning of this, you discussed the pendulum. Yeah. That, that the way we treat things, the pendulum is swung. And when I was in training in the early 2000s, there was, the pendulum was swinging towards [00:08:00] operating on the majority of clavicle fractures because the outcomes were superior.

And then over time, the pendulum started swinging back, that the outcomes weren't- that different after a year between the two treatments, and so there started becoming a little bit less enthusiasm for the surgical treatments. But there's certainly circumstances where the surgery absolutely gave better outcomes.

So can you talk about some of those circumstances? 

Dr. Ross: Yeah, I mean, I would say those are the cases where you walk in the room or you look at the X-ray and you kinda know right away, like, "Oh, I'm gonna recommend surgery." I mean, ones where the clavicle is shortened two, three, four centimeters even, and those, the, you know, the fracture fragments are in multiple pieces, uh, or they're widely displaced where, you know, those two ends of the bone for new bone to form between those without going in there and actually placing them together and, you know, using hardware to kind of compress them together, uh, becomes a lot higher.

So, you can't instantly, uh, know a percentage and tell a patient, "Oh, this is a 25% chance this one's not gonna heal." But you just have a general gestalt where you, you kinda know, [00:09:00] uh, when you see it, like, "Hmm, this is one that clearly- It's gonna be harder to heal ... I think, I think you should, you should address with surgery.

Dr. Chehab: Yeah. Yeah. Looking at all comers, young, active patients with simple clavicle fractures can be treated operatively or non-operatively. But if they desire a more predictable, fast recovery, they, surgery would be a good option for them. If they're willing to have a more prolonged recovery little more variability in terms of the outcome but generally expecting a good result non-operative treatment would be an option for them.

Dr. Ross: Correct. 

Dr. Chehab: It's not risk-free not to do surgery. There is the risk of it not healing appropriately, of it healing short, of it healing crooked, and some of those can affect shoulder function. Correct? 

Dr. Ross: Correct. 

Dr. Chehab: Yeah. And, and so, you know- It is a bit of a dealer's choice with some of these clavicle fractures about treatment approach.

Dr. Ross: Correct, yeah. 

Dr. Chehab: Okay. And then if we're gonna move to a different part of the shoulder let's talk about the proximal humerus, so basically the shoulder on the ball [00:10:00] side as opposed to the socket side. And can you describe what proximal humerus fractures are? Again, it's a bit of an anatomy lesson probably.

Dr. Ross: Yeah. So, uh, basically, your humerus is the upper arm bone. The top end, um, is shaped like a ball, uh, almost like a, a ball sitting on a golf tee. The golf tee would be the socket side or your glenoid, which is from the scapula bone. 

Dr. Chehab: Yeah. 

Dr. Ross: Um, and so proximal humerus fractures would basically be fractures of pretty much the upper third of that humerus bone that are about the articulating area.

Dr. Chehab: And there's certain patterns that we talk about with proximal humerus fractures. Can you describe those? 

Dr. Ross: Yeah. Um, commonly we, we break them up into parts. So you have your articular piece. You have the piece that connects to the, uh, rotator cuff muscle in the front called the subscapularis. That's the lesser tuberosity piece.

You have your greater tuberosity piece, which I, I think that's really the main piece, uh, that you're thinking about, uh, in these fractures. That's, uh, a little bit more back, uh, in the shoulder, and that, uh, connects to the supraspinatus and infraspinatus, uh, which are your primary rotator cuff muscles that go over the top of the [00:11:00] shoulder.

And then you have your constant fragment or your shaft piece. Yeah. Yeah. 

Dr. Chehab: And so, um, the pattern of fracture really makes a difference in terms of the treatment. So let's, let's kind of walk through the sort of... We talk about two-part, three-part, four-part fractures. Mm-hmm. Um, let's start with a simple two-part fracture.

What's the most common one? 

Dr. Ross: Yeah, so I would say at the at the surgical neck- 

Dr. Chehab: Yeah ... 

Dr. Ross: um, of the humerus, so basically right below where the, the circular part, uh, that's articulating meets the, uh, cylindrical shaft. 

Dr. Chehab: Okay. And so, uh, a patient presents with a surgical neck fracture. How do you evaluate that, and what are some of the treatment options that, um, a patient has?

Dr. Ross: Yeah, so, um, you're getting x-rays, uh, in the clinic, uh, generally three views, sometimes four if the patients can tolerate it, uh, basically 90-degree, uh, orthogonal views on every angle to, uh, really get a 3D picture of, of what's going on. Generally, the patients, uh, present with, uh, really no ability to use their shoulder whatsoever.

Right. They generally do still have, function at the elbow and [00:12:00] beyond, but oftentimes really don't even wanna move their elbow at all. You'll see sometimes, uh, swelling in the, in the front of the shoulder that generally follows gravity and goes down the arm. You'll see kind of bruising into the biceps region.

And, uh, you know, generally these patients are, are pretty miserable. Yeah. They're pretty painful. 

Dr. Chehab: Yeah. And then, um, you take the X-rays, and w- what do you see on the X-ray that might have you decide one way or the other in terms of treatment? 

Dr. Ross: Yeah, so not too dissimilar from what we talked about with clavicle fractures.

I mean, I guess this applies to fractures in general. You're looking at, you know, how many pieces is the fracture in- Right ... and how moved are those pieces from their normal locations. Yeah. And generally the farther apart they are from their typical location and the more pieces you have, the