Shoulder: Fractures of the proximal humerus

Treatment of the proximal humerus fractures depends on many factors, starting from patient preferences, the pattern of the fracture, to the experience and bias of the surgeon.

Basic anatomy of the shoulder

Three bones meet at the shoulder joint:

  1. Scapula (the shoulder blade)
  2. Clavicle (collarbone)
  3. Humerus, which is the long bone that starts at the shoulder and ends above the elbow.

The proper shoulder joint is the glenohumeral joint, where the glenoid part of the scapula meets the head of the humerus.

The proximal humerus is commonly fractured after falls. Patients usually refer to these fractures simply as "shoulder fractures." However, shoulder fractures technically include the fractures of the clavicle and the fractures of the shoulder blade as well.

In this page I will briefly discuss proximal humerus fractures.

Proximal humerus fractures

Not all fractures of the proximal humerus are the same. Some fractures are minimally displaced, some are widely displaced.

For minimally displaced fractures of the proximal humerus, early physical therapy is usually the optimal treatment.

For displaced fractures, surgery comes in 2 different flavors

  1. Open reduction internal fixation (ORIF) with plate and screws
  2. When the quality of the bone is poor, a replacement operation is appropriate. Nowadays it would usually be a reverse replacement.

The proximal humerus cannot be casted effectively due to its location. A hanging arm cast may be appropriate for certain fracture patterns however.

Risks of surgery

  1. Surgery is done under general anesthesia. General anesthesia risks apply, which include death, stroke, heart attack, etc.
  2. As with other surgery, there is always a risk of infection.
  3. The injury or the surgery may cause nerves to strech, with symptoms such as paresthesias, numbness, or paralysis.
  4. As with other fracture surgery, there is a risk of nonunion, malunion, loss of fixation, breakage of hardware, etc.

Case 1

This is the case of a piano teacher in her 40's. The injury occurred after a fall on ice.

The xray above shows a fully displaced and angulated proximal humerus fracture. There is a certain amount of metaphyseal comminution.

As is always the case, a large amount of pain and swelling was present when I saw the patient in the ER.

Surgery was done the day after the injury. If the pain had been more tolerable, surgery could have been postponed up to 2 weeks.

Bridge fixation of the fracture is carried out.

Physical therapy starts right after surgery. Immediate passive and active assisted range of motion is appropriate.

For the first 6 weeks of physical therapy, active shoulder elevation increases the stresses at the fracture site and should not be done.

This patient regained full range of motion and strength. She was followed up for 2 years to monitor for development of osteonecrosis.

She had no complaints other than an occasional painless click that I attributed to scar and sutures at the rotator cuff level.

Xray above shows fully healed fracture.

Case 2: proximal humerus fracture treated with RSA

This is the case of a a female in her 70's who fractured her right shoulder after a fall on ice. Xrays and CT show a "Neer 3 part fracture" of the right shoulder.

Treatment options were presented to the patient as follows:

  1. No surgical intervention. A sling is used for comfort. The patient is willing to accept a large amount of shoulder stiffness. Pain will decrease somewhat with time, moderate pain is likely to continue on a permanent basis. This was the initial recommended treatment for this patient.
  2. Surgical open reduction, internal fixation, with plate and screws. In this patient, with a diagnosis of osteoporosis, treatment with plate+screws would most likely have resulted in loss of fixation due to poor bone quality. Another surgery would have been necessary.
  3. Hemiarthroplasty used to be an alternative treatment, but it is inferior to reverse replacement in this situation, due to unpredictable healing of humeral tuberosities.
  4. Reverse shoulder replacement has become the preferred surgical option for orthopedists who treat these fractures. .

The patient initially elected to not have surgery. Approximately 3 weeks later she reevaluated her situation and sought surgical treatment due to continued severe pain. The reverse shoulder replacement was done 1 month after the injury.

Reverse shoulder replacement resulted in quick improvement.

Range of motion after reverse replacement is expected to be less than the full natural range of motion of the shoulder joint. This patient was able to raise the arm above the shoulder level. She became able to wash her face, comb her hair, and feed herself within 1 month. She was able to drive 6 weeks after surgery.

This is the xray appearance approximately 2 years later.

Reverse shoulder replacement is not without risks. It is no longer an experimental procedure, but it does not have the track record of, say, hip replacement or knee replacement prostheses. It is an operation that is best reserved for elderly patients, or for extreme cases.

Here is a list of risks of reverse shoulder replacement:

  1. All the risks of regular shoulder replacement surgery:
    1. Death
    2. Infection
    3. Periprosthetic fracture
    4. Loosening of prosthetic components
    5. Nerve damage.
  2. Glenoid loosening, notching, and fracture are risks of this surgery as well.
  3. Dislocation of the artificial joint is a possibility as well.
  4. Delayed acromion fracture is a problem that sometimes occurs after a reverse shoulder replacement. The acromion is where the deltoid muscle attaches, and after a reverse replacement, the deltoid is the only muscle raising the arm up and can sometimes stress the acromion too much.