Shoulder Fractures and Dislocations

Traumatic shoulder injuries seen in urgent care/GP practice — clavicle, AC joint, proximal humerus, and scapula. For rotator cuff tears and impingement, see Rotator Cuff Tendinopathy; for glenohumeral dislocation, see Shoulder Dislocations / Stabilisation.

Always examine the joint above and below the injury, document neurovascular status before and after any splinting, and have a low threshold for a full 3-view series (AP, scapular Y, axillary) — a dedicated clavicle/scapula view if either is specifically suspected. Urgent referral for any open fracture, skin tenting (impending open fracture), or signs of neurovascular compromise.

Clavicle fracture

The most common shoulder-girdle fracture — young males after a fall onto the shoulder/outstretched hand or direct blow, comprising 44–66% of shoulder injuries. Middle third (Allman type 1) accounts for 69–80%; lateral third (type 2) 21–28%; medial third (type 3) only ~2% but carries the highest risk of underlying vascular/lung injury (subclavian vessels, lung apex) — assess lung fields and distal pulses.

Management:

• Most are treated non-operatively in a simple sling (figure-of-eight bracing is no longer preferred — no better union rate, less comfortable).
• Refer for consideration of surgery if: displaced >100% (no cortical contact), >1.5cm shortening, comminuted, or involving the AC joint ligaments.
• Urgent referral if skin tenting is present (impending open fracture).
• Otherwise: sling, analgesia, ortho follow-up within ~1 week. Gentle ROM at 2–4 weeks, strengthening 6–10 weeks, return to sport 8–12 weeks — progress gradually to avoid adhesive capsulitis.

Acromioclavicular (AC) joint injury

Direct blow to the point of the shoulder (fall with the arm adducted) or a FOOSH. Tenderness over the AC joint is the most reliable sign — Type I injuries often have a normal X-ray, so a good exam matters as much as imaging.

Exam: cross-body (horizontal) adduction test and O’Brien’s test — both can also be positive with AC joint OA, so interpret alongside the history.

Rockwood classification (graded on X-ray by coracoclavicular (CC) and AC-joint distance, compared with the uninjured side):

Type	Injury	Management
I	AC ligament sprain, normal X-ray	Sling, analgesia, physio for ROM/strength
II	AC ligament ruptured, CC ligament sprained	Sling, physio
III	Both AC and CC ligaments ruptured, CC distance <2x normal	Usually non-operative (controversial — surgery if high-demand/cosmetic concern); sling + physio, ortho follow-up
IV–VI	Posterior/inferior clavicle displacement or CC distance >2x normal	Refer for surgery — sling in the interim

Proximal humerus fracture

Typically an elderly fall onto an outstretched arm (2:1 female, osteoporosis/ epilepsy/diabetes as risk factors); higher-energy trauma in younger patients.

• Test axillary nerve function (deltoid abduction + “regimental badge” lateral-shoulder sensation) — the nerve most often injured, especially with subcoracoid dislocation of the humeral head.
• Risk of concurrent rotator cuff tear if the fracture involves the greater/lesser tuberosity insertion sites.
• Anatomical neck fractures carry a real avascular necrosis risk (the posterior humeral circumflex artery, the main blood supply to the head, is most vulnerable here).
• ~80–85% are managed non-operatively: sling immobilisation, early pendulum exercises within 2–3 weeks to prevent adhesive capsulitis, then progressive physio.
• Refer urgently for: 4-part fracture, anatomical neck fracture, or fracture-dislocation (Neer classification — displacement >1cm or angulation >45° between fragments defines a ‘part’).

Scapular fracture

Uncommon (~0.5% of all fractures) — the scapula is well protected by muscle, so a scapular fracture implies a significant-energy mechanism; assume concomitant polytrauma, especially chest (rib fractures ~64% co-occur) and spine, until proven otherwise. Most are managed non-operatively (sling, analgesia, physio) — surgery is rare (<1%), reserved for a “floating shoulder” (concomitant clavicle + scapular neck fracture), significant glenohumeral instability, or a displaced glenoid/neck fracture.

Shoulder dislocation (brief)

Anterior dislocation accounts for ~97% of shoulder dislocations; posterior is rare and easily missed on a single AP view (obtain a scapular Y or axillary view — look for loss of external rotation). Full assessment, reduction principles, and post-reduction rehabilitation are covered on Shoulder Dislocations / Stabilisation. A few points worth flagging for urgent care specifically: arterial injury is rare (<1%, most often the axillary artery) but should be reassessed for post-reduction; a neurological deficit (usually neurapraxia, with excellent recovery) is found in ~13.5% of patients after reduction; and traumatic shoulder dislocation is rare in children (<2%) before the humeral physis closes (14–17yo) — a skeletally immature patient with this mechanism is more likely to have sustained a proximal humerus fracture instead.