New York State Medical Treatment Guidelines for
Shoulder Fractures in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Shoulder Fractures.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Shoulder Fractures of Shoulder Injury

Shoulder fractures come in five different categories. Each type will be discussed individually and in the order of greatest frequency.

Clavicular Fracture of Shoulder Fractures

Background and Initial Diagnostic Techniques (Clavicular Fracture)
Mechanism of Injury: Injuries to the upper limb can be caused by blows to the body directly or by applying axial loads; often resulting injuries include rib fractures, long-bone fractures in the ipsilateral limb, and scapulothoracic dislocations.

Physical Findings (Clavicular Fracture) of Shoulder Fractures

Physical Findings may include:

• Discomfort in the clavicle
• There are visible abrasions on the shoulder, collarbone, and chest wall;
• In the aforementioned areas, deformities can be detected; or
• During mobility and palpation, there is pain near the shoulder joint.

Testing Procedures of Clavicular Fracture X-Ray are recommended – When a systemic illness or disease is suspected in a subset of patients.

Indications: Would ordinarily consist of chest x-rays. A 20° caudal cranial AP view centred on both clavicles can be used if they do not provide enough details.

Non-Operative Treatment Procedures

• The majority don’t need surgery because closed approaches can control them properly. The arm is immobilised in a sling or figure-8 bandage after reduction. Pendulum exercises are used to start shoulder rehabilitation 10 to 14 days following the injury. Following the management of the pain, the therapeutic programme can be advanced using non-operative therapeutic techniques.
• Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) would be recommended; opioids might occasionally be used acutely for fractures.

Operative Procedures of Clavicular Fracture

Operative Procedures of Clavicular Fracture are recommended clinically appropriate in a subset of patients.

Indications: Open fractures, vascular or neural injuries that need to be repaired, bilateral fractures, ipsilateral scapular or glenoid neck fractures, scapulothoracic dislocations, flail chest, and nonunion displaced-closed fractures that show no evidence of union after four to six months would all be indications for surgical procedures.

There is also a Type II fracture/dislocation at the AC joint, where the massive proximal fragment is moved upward while the distal clavicular fragment remains attached to the acromion and the coracoid.

Post-Operative Procedures of Clavicular Fracture

An individual rehabilitation programme built on communication between the doctor, the surgeon, and the therapist would be part of post-operative procedures. Pendulum exercises with progression to assisted forward flexion and external rotation would come next.

Strengthening exercises should be started at ten to twelve weeks. This programme would start with two to three weeks of rest with a shoulder immobiliser while encouraging isometric deltoid strengthening.

Proximal Humeral Fracture of Shoulder Fractures

History Mechanism of Injury of Proximal Humeral Fracture

Mechanism of Injury: High-energy (velocity or crush) trauma with an abducted or non-abducted arm as well as a fall onto an abducted arm may also result in injury; Axillary artery injuries with high energy accidents and accompanying injuries such glenohumeral dislocation and strain injuries to the axillary, musculocutaneous, and radial nerves are frequent.

Physical Findings of Proximal Humeral Fracture

Physical Findings may include

• Pain in the upper arm;
• Bruising and swelling of the chest wall, shoulder, and upper arm;
• Bruising near the shoulder; or
• Any attempt at passive or aggressive shoulder mobility causes pain.

Laboratory Tests of Proximal Humeral Fracture

Testing Procedures of Proximal Humeral Fracture X-Ray are recommended clinically appropriate in a subset of patients.

Indications: Trauma series (three views) are required; a lateral view in the plane of the scapula, an axillary view, and a view.

Note: In order to evaluate whether a glenohumeral dislocation exists, the latter two views are required.

Note: The humeral shaft, humeral head, larger tuberosity, and lesser tuberosity can all be classified using the Neer Method. Unless the fragments are separated by 1 cm or are angulated by 45 degrees or more, they are not actually considered to be fragments.

Vascular Studies of Proximal Humeral Fracture

Vascular Studies of Proximal Humeral Fracture are recommended clinically appropriate in a subset of patients.

Indications: Are quickly acquired in the absence of the brachial and radial pulses.

Therapeutic Procedures: Non-Operative

Therapeutic Procedures: Non-Operative are recommended clinically appropriate in a subset of patients.

Indications: Impacted fractures of the greater tuberosity of humeral neck are treated nonoperatively.

Non-operative treatment is used for isolated and lightly displaced (less than 1 cm) fractures.

A general anaesthesia is required, however anterior or posterior dislocation associated with minimally displaced fractures can typically be controlled by closed methods.

May Include:

It would be advised to take medications, such as analgesics and nonsteroidal anti-inflammatories. Drugs should be prescribed as described in Section E if they are acutely indicated for fracture.

If a non-impacted greater tuberosity fragment is present, an abduction immobiliser may be used instead of a sling to support the elbow.

Continual immobilisation lasts for four to six weeks.

Pendulum exercises are used to start shoulder rehabilitation 10 to 14 days following the injury. The therapy programme can then be advanced using the therapeutic techniques listed in Section E, Therapeutic Procedures: Non-Operative, when the pain has been controlled.

Operative Procedures of Proximal Humeral Fracture

Operative Procedures of Proximal Humeral Fracture are recommended clinically appropriate in a subset of patients.

Indications: surgical neck fractures that are unstable (where the fracture pieces are not in touch).

fractures that are partially unstable (only partial contact), along with identical upper extremity injuries.

Note: Reattaching the tuberosities and performing a prosthetic hemiarthroplasty are two treatment options for displaced 3- and 4-part fractures.

Post-Operative Procedures of Proximal Humeral Fracture are recommended – Clinically appropriate in a subset of patients.

A tailored rehabilitation programme built on communication between the doctor, surgeon, and therapist would be included in post-operative procedures.

Humeral Shaft Fracture of Shoulder Fractures

History and Initial Diagnostic Procedures (Humeral Shaft Fracture)
Mechanism of Injury: High energy (velocity or crush) will result in a comminuted humeral shaft fracture; a direct blow can fracture the humeral shaft at the point where its middle and distal thirds meet.

Physical Findings of Humeral Shaft Fracture

Physical Findings may include:

• Condition of the arm
• Swelling and bruising; or
• Possible radial nerve damage on the sensory and/or motor levels

Laboratory Tests of Humeral Shaft Fracture

Are generally not indicated

Testing Procedures of Humeral Shaft Fracture

Testing Procedures of Humeral Shaft Fracture are recommended clinically appropriate in a subset of patients.

• AP and lateral views of the whole humeral shaft on plain x-rays.
• If there is no radial pulse, perform vascular tests.
• If the surrounding muscles are swollen, tense, and painful, and especially if the fracture was caused by a crush injury, compartment pressure measures should be performed.

Non-Operative Treatment Procedures

• The majority of solitary humeral shaft fractures don’t require surgery.
• Analgesics and nonsteroidal anti-inflammatory drugs would be recommended. Drugs like heroin may be urgently needed for a fracture and should be prescribed as per Section E.1.d.
• One option is to use a coaptation splint. Starting in the axilla, the splint is extended around the elbow and raised to the level of the acromion. With the aid of broad elastic bandages, it is secured.
• A humeral fracture orthosis may be utilised to allow for complete elbow motion two to three weeks after the injury.

Operative Procedures of Humeral Shaft Fracture

Operative Procedures of Humeral Shaft Fracture are recommended clinically appropriate in a subset of patients.

Indications: For postoperative treatment, there are:

A floating elbow injury; an open fracture; a forearm or elbow fracture associated with it; upper extremity burns; paraplegia associated with; several wounds (polytrauma); the development of radial nerve palsy following closed reduction; or a pathologic fracture associated with an occupational injury.

Accepted methods of internal fixation include:

• A wide plate with screws; or
• Rodding inside the medullary cavity with or without cross-locking screws.

Post-Operative Procedures of Humeral Shaft Fracture

A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures.

After stiff internal fixation, therapy can be commenced to restore passive and later active shoulder motion using the right therapeutic techniques, as shown in Section D.9.c.v, Non-Operative Treatment Procedures, Humeral Shaft Fracture. You can immediately begin moving your elbow and wrist actively.

Scapular Fracture of Shoulder Fractures

History and Injury Mechanism (Scapular Fracture)

Acromial, glenoid, glenoid neck, and scapular body fractures are among the shoulder fractures with the least frequency of injury. All other scapular fractures are induced by a high energy injury, with the exception of anterior glenoid lip fractures brought on by a dislocated anterior shoulder.

Physical Findings (Scapular Fracture) Physical Findings
may include:

• Pain in the chest and shoulder area;
• Bruises and scrapes;
• Possible rib or humeral fractures in addition; or
• Vascular issues (pulse assessment and Doppler inspection).

Laboratory Tests of Scapular Fracture

Laboratory Tests of Scapular Fracture are recommended clinically appropriate in a subset of patients.

Indications: Due to the connection between high intensity trauma, tests such a full blood count, urine, and chest x-ray may be performed.

Testing Procedures of Scapular Fracture X-Ray

Testing Procedures of Scapular Fracture X-Ray are recommended clinically appropriate in a subset of patients.

Three views of the X-rays are required for a trauma series: the AP view, the axillary view, and the lateral view in the plane of the scapula.

If a vascular injury is suspected, angiography.

If there is any nerve damage, an electromyographic examination (EMG) should be performed.

Non-Operative Treatment Procedures of Scapular Fracture

A shoulder immobiliser may be used to treat nondisplaced acromial, coracoid, glenoid, glenoid neck, and scapular body fractures.

It would be advised to take medication, such as analgesics and nonsteroidal anti-inflammatories.

Drugs should be prescribed as described in Section E.1.d if they are acutely indicated for fracture.

Exercises with a pendulum might begin within the first week.

At three to four weeks, using the proper therapeutic techniques, advance to aided range-of-motion activities.

Operative Treatment of Scapular Fracture

Operative Treatment of Scapular Fracture is recommended clinically appropriate in a subset of patients.

To avoid a nonunion, displaced acromion fractures should be internally repaired. These fractures can be treated with lag screws and a plate that is positioned higher up to counteract the pressures of the muscles.

Glenoid fractures that are more than two to three mm dislocated need to be internally repaired. By looking at the CT scan results, the strategy is chosen.

If the lateral or medial margins of the fractured scapular body are misaligned enough to restrict scapulothoracic motion, internal fixation is necessary.

Internal fixation of the clavicle is necessary to reduce displaced fractures of the scapular neck and the ipsilateral clavicle.

Post-Operative Procedures

A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures. A shoulder immobiliser is used, pendulum exercises are started after one week, deltoid isometric exercises are started right away, and active range of motion is started after four to six weeks.

Sternoclavicular Dislocation/Fracture of Shoulder Fractures

History and Mechanism of Injury of Sternoclavicular Dislocation/Fracture

The sternoclavicular joint can dislocate anteriorly without active treatment, but posterior dislocations that are symptomatic will need to be reduced. The mechanism of injury is abrupt trauma to the shoulder and anterior chest wall.

Physical Findings of Sternoclavicular Dislocation/Fracture

• Discomfort in the sternoclavicular region;
• There are visible abrasions on the shoulder, collarbone, and chest wall;
• In the aforementioned areas, deformities can be detected; or
• At the sternoclavicular joint area, there is pain on palpation and motion.

Laboratory Tests of Sternoclavicular Dislocation/Fracture

Laboratory Tests of Sternoclavicular Dislocation/Fracture are recommended clinically appropriate in a subset of patients.

Testing Procedures of Sternoclavicular Dislocation/Fracture

Testing Procedures of Sternoclavicular Dislocation/Fracture are recommended clinically appropriate in a subset of patients.

X-Ray- Vascular Studies

X-Ray- Vascular Studies are recommended clinically appropriate in a subset of patients.

Indications: The sternoclavicular joint is frequently subjected to plain x-rays. Comparative views of the contralateral limb for the NYS WCB MTG – Shoulder Injury 60 may be required when appropriate.

If clinically necessary, X-rays of the chest wall and other shoulder regions may be taken.

Indications: If the history and clinical examination reveal significant harm, vascular investigations should be taken into account.

Therapeutic Procedures: Non-Operative

• Use a sling to keep you immobile for 3–4 weeks. The techniques outlined in Section E, Therapeutic Procedures: NonOperative, may thereafter be used for additional rehabilitation.
• Narcotics may be suggested initially for fracture and should be provided as indicated for short periods of time. Medications such as analgesics and nonsteroidal anti-inflammatory drugs may also be indicated. Consider Section E.1.
• Manipulation (for Sternoclavicular Dislocation): Manipulative treatment (not therapy) is described as the therapeutic use of manually guided forces by an operator to restore homeostasis that has been disrupted by the accident or occupational disease, and has clinical importance.
• One to six treatments are needed for shoulder therapy to take effect.

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