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.

What our office can do if you have workers compensation injuries

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

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Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
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Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
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19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
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03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
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14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
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18:17 17 Nov 20
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17:26 17 Nov 20
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Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
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Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

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