Shoulder: ORIF for fractures of the proximal humerus

Treatment of the proximal humerus fractures depends on fracture pattern, patient preferences, as well as the experience and bias of the surgeon.

Fracture pattern

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.

When facing this type of surgery, patients often ask for a cast. The proximal humerus cannot be casted effectively due to its location. A hanging arm cast may be appropriate for certain fracture patterns however.

How is this surgery done?

The deltopectoral approach is used to reach the fracture. Fluoroscopy xrays are used during surgery to check the position of the fracture fragments. Once appropriate alignment is achieved, a metal plate is placed adjacent to the fracture, and screws are then inserted above and below the break. The wound layers then are closed.

What is the recovery like?

  1. As a patient, one must always remember that the surgery is the beginning, not the end of the healing. In addition, metal and screws can fatigue, break, loosen. In theory, it is always a race between the bone healing on one side, and the hardware failing on the other.
  2. It is therefore necessary to follow up regularly with xrays as advised.
  3. The fracture takes about 6 months to heal.
  4. Physical therapy is necessary to prevent stiffness in the first 6 weeks, and to regain strength thereafter.

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 study

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.