Proximal Humerus Fractures
Shoulder surgery performed by an Adelaide-based orthopaedic specialist
The proximal humerus is the upper part of the arm bone near the shoulder joint. The proximal humerus is where the rotator cuff muscles attach to the arm. Fractures often involve the attachment sites of these muscles, making them complex injuries.
These types of fractures are common in older adults, especially women with osteoporosis, and can also occur as a result of trauma, such as a fall or car accident. They are the fourth most common fracture in the elderly (>65 years old), with a 2:1 female-to-male ratio.
Fractures of the proximal humerus can make normal activities extremely difficult, as all movement at the shoulder is usually very painful.
Causes and symptoms of proximal humerus fractures
Most proximal humerus fractures are a result of a simple fall in an elderly individual. Patients usually describe tripping over something and falling directly onto the shoulder. Other causes include high-energy trauma in younger patients, like car accidents or falling off a bicycle.
We also see patients with proximal humerus fractures or shoulder dislocations after seizures.
Symptoms of proximal humerus fractures include:
- Pain and tenderness
- Swelling and bruising
- Inability to move the shoulder
- Severe discomfort when trying to sleep or lay down
- Numbness of shoulder or hand in severe cases
Types of proximal humerus fractures
There are 4 main types of proximal humerus fractures, based on the amount of fragments and if there was a dislocation.
Two part fracture
These fractures represent the ball of the shoulder breaking off in a simple pattern leaving only 2 parts to the injury. Depending on how displaced (distance between the parts) the fracture is helps decide the management and whether surgery is recommended.
Three or four part fracture
These fractures represent a multi-fragment fracture that also involves the rotator cuff muscle insertion points. There are attachment points at the front and side of the humeral head where the rotator cuff muscles attach, they are called the lesser and greater tuberosities. In 3- or 4-part fractures, 1 or both of these tuberosities also fracture, making the rotator cuff muscle deficient.
Fracture dislocation
This is a complex pattern whereby the humeral head has dislocated out of the socket but also suffered a fracture. This can also be in 2, 3 or 4 parts, and can be very complex. If the humeral head is stuck dislocated, this will always need surgery to put the shoulder back in the joint.
Treatment for Proximal Humerus Fractures
Non-surgical treatment
Proximal humerus fractures can be difficult to manage, as the shoulder is difficult to fully immobilise. Unlike the wrist, which can be put into a plaster or splint, the shoulder can only be supported in a sling which can still allow movement and be uncomfortable.
Typical non-surgical treatment will include:
- Initially supportive shoulder sling, either a broad arm sling or a collar and cuff
- Analgesia is typically required during the first 3 weeks as the fracture fragments are still mobile.
- Monitoring with regular X-rays
- Physical therapy by a local physiotherapist to start gentle range of motion exercises followed by a gentle strengthening program once sufficient healing has occurred.
Shoulder surgery
For more severe fractures or to allow an earlier range of motion, surgery may be beneficial. Fractures that often require surgery include:
- Fracture dislocations
- Locked dislocations
- Open or "compound" type fractures
- Fractures causing nerve damage - patients experiencing numbness or tingling
- Fractures where bone fragments are misaligned and cannot be corrected by a sling
Surgery on proximal humerus fractures can be complex, and most often, Dr Oscar Brumby-Rendell will organise a CT scan to use 3D planning. The 3D CT allows accurate visualisation of all the fragments and if the fracture is repairable. In some cases, particularly in more elderly proximal humerus fractures (>65yrs old), a joint replacement can be the best treatment option.
Dr Brumby-Rendell uses an incision at the front of the shoulder (anterior approach) and goes between 2 major muscles - the deltoid and pectoralis major. He will then use a specific plate system for the shoulder to reconstruct the fracture and put the fragments back in the right spot. This is called open reduction and internal fixation. If the damage is too severe, then he may need to conduct a joint replacement.
After the operation, the patients are treated with a shoulder sling and start a customised rehabilitation plan specific to their injury and surgery type. Most often, rehabilitation starts with gentle pendulum exercises and progresses to allow full active motion over the course of 6 weeks.
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