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Physician Assistant Exam: Shoulder Fractures

Pretty much everyone knows what it’s like to hurt the shoulder or upper arm, so it’s important to know for the Physician Assistant Exam (PANCE). Doing much of anything can be difficult, especially if the pain or injury affects the dominant arm. You should know about different derangements of the shoulder and upper arm, namely fractures.

Collarbone fractures

Trauma is usually the only way that a clavicular fracture can occur. Either the person suffered a direct strike against the clavicle, or more commonly, the person fell on an outstretched arm or shoulder.

The affected person presents with pain and swelling, although sometimes you don’t see much swelling. On examination, you can palpate the fractured area. Make sure you perform a thorough neurovascular examination as well. A radiograph is a good imaging study for identifying clavicular fractures.

Treatment of a fractured clavicle is generally conservative, consisting of the use of a sling and pain medication. Surgery may be required in a small percentage of cases — when you see multiple fractures on radiograph, when there’s evidence of neurovascular compromise, or when the fracture isn’t healing as it should, despite conservative treatment.

The fractured scapula

A fracture of the scapula is uncommon. This fracture is usually associated with significant trauma to the thoracic area, such as from a high-impact motor vehicle accident.

On examination, as with any trauma, look for other associated injuries, including injuries to the arm, thoracic cage, and so forth. Closely associated injuries include pneumothorax, pulmonary contusion, and fracture of the clavicle.

Radiograph imaging can show a fractured scapula, although it’s sometimes missed; a CT scan provides more detailed imaging. Understand that in many trauma situations, especially a motor vehicle accident, the person is first stabilized and then goes right down to the imaging center for a CT scan to look for traumatic injuries.

The treatment for a fractured scapula is usually conservative, involving a sling and pain medication. Physical therapy reduces the risk of a frozen shoulder.

The fractured humerus

Fractures of the humerus, which are usually caused by trauma to the upper arm (usually related to falls), are most common in the elderly population. Underlying medical conditions that can affect bone health, including osteoporosis and renal osteodystrophy, place people more at risk for this fracture.

As with clavicle fractures, the most common cause of a fracture of the humerus is falling on an outstretched hand. Humerus fractures can also occur in the younger population, usually because of motor vehicle accidents. Sports injuries and auto accidents account for most humeral injuries in younger men.

A fracture can affect three areas of the humerus: the proximal humerus, the distal humerus, and the middle of the humerus (a mid-shaft fracture). On presentation, the person complains of pain in the affected area. He or she also usually has decreased range of motion. With a mid-shaft fracture, the person can complain of numbness of the dorsal aspect of the hand, which indicates damage to the radial nerve.

Most of the time, humerus fractures are treated conservatively without surgical intervention. Many times, the affected person is sent home with an arm sling or arm brace. If the radial nerve is significantly affected (a nerve palsy), then surgery may be indicated.

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