Fractures & dislocations

Bones are designed to flex a little when force is applied to them, but too much force can cause them to break (fracture). A bone might completely or partially fracture and the fracture may be crosswise or lengthwise, or the bone may break into multiple pieces. If the force applied is not too great the bone may crack rather than break all the way through. Generally, the greater the force, the more severe the fracture. In the most severe impacts, a bone can shatter.

Fractures are normally due to:

• Trauma, for example falling heavily or a major impact such as a vehicle collision.
• Overuse which can result in a stress fractures. These are common sporting injuries.
• Osteoporosis which is a disorder that weakens the bones.

At Thames Shoulder and Elbow we treat all types of arm fracture, from the collar bone down to the wrist. Some of the fractures we see most commonly are:

• Acute fracture – these are broken bones caused by some type of trauma, for example, a heavy impact or fall. In most cases, they can be treated with a sling or a cast to immobilise the broken bone and hold the ends in place while they heal. However, sometimes you may need surgery to reposition the bones and then fix them in place using metal pins, plates or screws. In some cases, we may need to insert a metal rod through the centre of the bone to hold the fragments in place. If the fracture is very severe and located very close to a joint then you may need joint replacement surgery. This entails removing the damaged joint and replacing it with a prosthetic implant (e.g. a full or partial shoulder or elbow replacement).
• Non-union fracture – this is a fracture that has failed to heal. It is different to a delayed union fracture, which is where bones take longer than usual to heal. Non-union fractures are caused by poor stability or a lack of blood flow to the injury site, or both. In this case, we may need to stabilise the bone with surgery and/or use bone grafting to stimulate healing. A bone graft involves either taking bone from another part of the body or using donated bone, and attaching it to the fracture site. This provides a scaffold for new bone to grow onto and also provides fresh bone cells and a supply of chemicals to help the fracture heal.
• Mal-union fracture – this is a fracture that has healed incorrectly, possibly resulting in deformity or reduced function of the limb. This can be the result of removing a cast too early, the bones being improperly aligned when immobilised or failing to get proper medical support following a fracture. The normal approach is to surgically re-break the bone and then re-set it correctly.

A dislocation occurs when the ends of your bones are forced from their normal position in a joint. Shoulders and elbows are often affected. It most commonly affects sports people, particularly those who experience frequent falls such as skiers, and people who participate in contact sports like rugby and football.

Most cases can heal natural after the joint is replaced by emergency doctors, however in many cases there can be persistent problems due to tearing of tendons or ligaments.

If you are aged under 25, a dislocated shoulder is likely to be accompanied by a labral tear, which is a tear to the cartilage around the rim of the shoulder socket that helps to hold the ball of the joint in place. You are also at high risk of future dislocations. We recommend a diagnostic scan so we can see what is going on inside the joint. If it shows you have a labral tear, we normally recommend surgery to repair it, particularly if you regularly participate in contact or racket sports.

If you are aged between 25 and 40, you are less likely to have recurrent dislocations providing you follow the exercises recommended by a physiotherapist. However, it is important to have you shoulder assessed by a specialist a few works after the dislocation to make sure you are not at risk of ongoing problems.

If your shoulder has already dislocated more than once, a diagnostic scan is recommended to assess the condition of your joint.

Keyhole surgery is often required to repair soft tissue damage. Sometimes bone damage has also occurred. If this is very extensive then keyhole surgery might not be enough and a different type of operation called a Latarjet procedure is recommended. This involves detaching a nearby piece of bone and transferring to the defect on your shoulder socket. Although this is a slightly bigger operation, with slightly higher risks, it is very effective in stabilising the shoulder joint.

If you are aged over 40, you are at greater risk of sustaining a rotator cuff tear if you dislocate your shoulder. For this reason, we always recommend a diagnostic scan.

Your acromioclavicular (AC) joint is located at the top of your shoulder between your collarbone and your shoulder blade. The collar bone acts as a strut to keep the shoulder blade in the correct position against the back of your chest. If you fall directly onto the point of your shoulder or receive a blow to your AC joint, the collarbone may separate from the shoulder blade. This is called an AC joint separation.

In many cases an AC injury is not severe enough to need surgery and most people recover full use of their shoulder after a few weeks of physiotherapy. In many other cases people have already developed strong muscles to keep their shoulder blade in place, meaning the AC joint is less important.

However, some AC joint separations do need surgery if control of the shoulder blade has become affected. X-rays aren’t normally sufficient to determine the full extent of an AC separation, only examination by an experienced surgeon. If surgery is required, it is best done within four weeks of the injury occurring.

After this, it may be necessary to reconstruct the AC joint using a synthetic ligament. A sling is recommended for 4 weeks after surgery, followed by gradual rehab. Most sports can be resumed after 3 months, but contact sports need to be avoided for 6 months.

A dislocated elbow occurs when the bones of the forearm move out of place in relation to the upper arm. It is most commonly caused by falling onto an outstretched arm or trauma, such as a heavy impact or collision. An x-ray will be taken before and after the elbow is put back in place by an emergency doctor, to make sure it is sitting correctly and to assess for any associated fractures.

Most elbow dislocations can be treated with a short period of rest followed by physiotherapy. However, it is important that you are assessed by a specialist soon after injury as if there is an associated fracture or suspicion of a severe ligament tear then you may need surgery. Fractures may need to fixed and ligaments repaired to restore your elbow back to normal. The elbow will be kept in a sling for a short period after the procedure, before starting physiotherapy as soon as possible.