1. FRACTURE CLAVICLE

2. COMMON SITE OF FRACTURE
Fracture Mid shaft of Clavicle
Fracture outer end of Clavicle
Acromio Clavicular seperation
Sternoclavicular seperation

3. Pain--- in fracture site Swelling----in fracture site
CAUSES OF FRACTURE:
Violent force in upward and backward landing on outstretched hand (commonly associated with # of the middle third of the clavicle)
Direct blow
CLINICAL FEATURES:
Pain--- in fracture site
Swelling----in fracture site
Asymmetry of shoulder
Restriction of shoulder movements
Deformity---( Hump in Shoulder )

4. Classification of fracture
Fractures can be classified as
Displaced
Un Displaced
Articular or Nonarticular.
Open Fracture
In displaced fracture: The proximal fragment is elevated due to contraction of Strenocleidomastoid, the distal fragment is depressed due to weight of limb and rotated medially by Pectoralis Muscles.
Open fracture: Clavicle pierce outside the skin.

5. Classification of fracture
*Allman classified clavicular fractures into three groups on the basis of their location
Group I: Fractures of the middle third (80%)
Group II: Fractures of the distal third (12–15%)
Group III: Fractures of the proximal third (5–6%)
Group II subtypes: Neer subclassified Group II fractures further on the basis of the location of the coracoclavicular ligament to the fracture fragment

6. Classification of fracture
Type I: The fracture occurs between the coracoclavicular & acromioclavicular ligaments (stable).
Type II: Fracture medial to the coracoclavicular ligament (unstable).
Type IIA: Both ligaments (conoid and trapezoid) attached to the distal fragment.
Type IIB: Conoid is torn but trapezoid ligament attached to the distal fragment.
Type III: The fracture involves the acromioclavicular joint without coracoclavicular ligament injury.

8. Fracture mid shaft of clavicle

9. Fracture lateral end of clavicle, displaced fracture

10. Treatment of fracture of clavicle
Medical management:
Radiographic confirmation of diagnosis is done with an anteroposterior view of the shoulder including the whole clavicle.
Analgesics: ( To minimize pain) e.g.Paracetomol
Anti inflammatory Drugs: ( To control Inflammation) e.g.NSAID( Non steroidal anti-inflammatory drugs)
Antibiotics: For open Fractures e.g. Amoxycillin
Calcium/Vitamin D supplement.

11. Treatment of fracture of clavicle
Conservative management:
Undisplaced # are treated conservatively with Sling,
A Sling to support the weight of limb.
A Figure of eight bandage helps to relieve pain. It only supports the # but will not reduce the #.
Surgical management:
Displaced # ---- (ORIF)--Plates and Screws are used.
Severe displacement resulting in tenting of the skin
Associated neurovascular injury requiring operative intervention
Open fracture requiring debridement
Non-union (failure of conservative treatment)

12. Physical therapy management
Impairments that physical therapist may assess and treat include: 1. Pain 2. Range of motion 3. Strength training 4. Scar tissue mobilization

13. Physical therapy management
The overall goals of physical therapy after a clavicle fracture are:
To decrease pain
To improve functional mobility in shoulder and arm.
Normal mobility and strength should be achieved six to eight weeks after injury.

14. Physical therapy management
Physical therapy treatment can be started once the patient is refered by the surgeon.
Early Mobilization Exercises gives a good Rehabilitation.
Various treatments or modalities to help control pain. These may include heat, ice, or TENS
After Immobilization Period, Pendular Exercises are started
Range of Motion Exercises: (ROM) may be limited in shoulder after the immobilization period in a clavicle fracture. physical therapist will prescribe exercises to help improve the ROM of shoulder to ensure that patient is able to perform tasks like reaching overhead or out to the side.
Retraction Movements are avoided

15. Physical therapy management
*Isometric strengthening exercises to Upper limb Muscles.
After a clavicle fracture, the muscles around shoulder may become weak. This is due to immobilization and disuse that occurs as the fracture is healing.
Strengthening exercises for shoulder and arm may be prescribed to help improve the function of your arm. 
Wolff's law states that bone grows and remodels in response to the stress that is placed upon it, so progressive exercise is important after fracture to ensure that maximum healing takes place.

16. If surgery is done to reduce fractured collar bone, a surgical scar will be present over the fracture site. Physical therapist may perform scar mobilization and massage techniques to help improve the mobility of surgical scar.
It may also be instructed , self-massage to perform on own to improve the mobility of surgical scar tissue.

17. Complications
Malunion: Although common, it rarely causes any functional impairment.
Non-union: Rare.
Neurovascular involvement: Subclavian vessels and brachial plexus are at risk especially if a clavicular fracture is caused by a high velocity trauma.
Degenerative arthritis of the acromioclavicular or sternoclavicular joint.

18. Points to remember in children
Most common fracture in children.
Fractures of the clavicle encountered in infants frequently occur as a result of birth trauma (e.g. traction during a breech delivery). Such injuries usually heal within a week and immobilization is usually not necessary.
Fractures affecting the medial or lateral third of the clavicle may involve the growth plate.
Most fractures unite rapidly following immobilization in a collar and cuff sling.

19. Fracture of humerus

20. Common site of fracture
Fracture proximal humerus
Fracture surgical neck of humerus
Fracture shaft of humerus
Fracture condyles of humerus

21. Fracture proximal humerus
* Proximal humerus (the humeral head, anatomical and surgical neck and the greater and lesser tuberosities)
*Neer classification:
GROUP-1: minimal displacement
Group-2:anatomical neck # with less than 1cm displacement
Group-3:displacement or angulated surgical neck
Group-4:displaced # of greater tuberosity
GROUP-5:# of lesser tuberosity
GROUP-6: # with dislocations

22. Fracture Upper End Of Humerus
Avulsion Of Greater Tuberosity:
Supraspinatus Tendon is attached.
Common in fall of Older people
Treatment:
Support, till pain settles, followed by Physical Therapy after 3-4 weeks.
If fragment is jammed between, operation is needed.

23. Fracture Greater Tuberosity

24. FRACTURE SURGICAL NECK OF HUMERUS
It is common in adults
Causes: Due to fall on out stretched hand.
Common types of Fracture occurring:
Displaced
Impacted (more common)
Stable
Unstable
Clinical Features:
Pain, Swelling, Loss of movement, asymmetry in shoulder levels
The Extensive bleeding is common

25. TREATMENT Conservative Treatment:
Support to limb in SLING or Collar for 4-6 weeks.
Impacted fracture can be mobilized after 2 weeks.
Surgical Management:
Surgery is avoided due to following reasons:
Surgery is generally avoided in Elderly
Alignment does not affect Union
Early movement is important to avoid stiffness.
Physical therapy Exercises should be started as early as the patient is referred by the Surgeon.

26. Fracture Shaft of Humerus
Causes:
Indirect Trauma
Direct Trauma
Common site of #
Middle third of the shaft
Common types of #
Direct Trauma will cause Transverse or Oblique #, sometimes as Communited #
Indirect Trauma will cause a rotational force resulting in Spiral Fracture.
Displacement is due to muscle pull. If the fragment is below the Deltoid insertion then upper fragments are abducted .

27. Fracture Shaft of Humerus

28. Communited Fracture

29. MANAGEMENT Conservative Management: It is followed in Stable #
Sling Support “Posterior Slab”
(It extends from Shoulder to wrist with elbow at 90 degree). This allows weight of the arm to maintain reduction.

30. MANAGEMENT Surgical Management Intramedullary Nailing:(IM Nailing)
It is commonly used to position the fracture
Plates and screws are also used.

31. Complications Radial Nerve Injury:
As the fracture is common in shaft of Humerus, near Spiral groove --Radial nerve may be affected.
Wrist Drop:
Radial Nerve Injury causes weakness of Forearm and wrist Extensors muscles leading to Wrist drop.
Delayed Union
Non-Union

32. Fracture Condyle of Humerus
Common in Children
Supracondylar # is most common
Causes:
Fall with pointing elbow
Fall with outstretched hand
Clinical Features:
Pain, Swelling, Loss of Function, instability of elbow

33. MANAGEMENT Conservative Management:
In children conservative management is usually followed and arm is immobilized in one of following methods
A cuff and collar
Posterior Slab + Cuff and collar
Plaster with elbow at approximately 90 degree or little more and extending from below Shoulder down to wrist or hand (plaster should be cut at wrist so that it is possible to feel Radial pulse)

34. Complications 1. Damage to Brachial Artery:
It is caused due to its close proximity near Fracture site.
It affects the circulation and it is a Medical emergency.
2. It may lead to Volkman’s Ischaemic contracture.
Flexor muscles of forearm are replaced by Fibrous tissue which produce flexion of Wrist and Fingers.

35. Complications

36. Complications 3. Myositis Ossificans:
The Periosteum may be torn from bone resulting in bleeding and formation of a Haematoma, osteoblasts in blood forms new bone on the muscle when forceful extension is done.
Pain and Loss of movement
4.Cubitus Valgus
5. Stiff Elbow

37. Cubitus Valgus