Proximal Humeral Fractures

proximal-humeral-fractures1Fractures of the proximal humerus are complex problems that often portend a less than excellent outcome. These injuries should only be treated by a well-trained fracture surgeon with experience in repairing these fractures. We treat approximately 30 cases per year with plate fixation and they represent one of our particula clinical interests. Dr. Solberg has published several papers in peer reviewed journals and made numerous presentations at national and international meetings on surgical repair of proximal humerus fractures. We approach all proximal humerus fractures in a systematic way by analyzing the fracture pattern, bone quality, available implants and then formulate a plan to achieve the best clinical results.

Most of these injuries are low energy fractures, especially in older individuals with softer bone, that do not require surgical intervention and can be treated with conservative means. Some fractures are unstable and do not do well without surgery to re-align the fractured bone. The surgical treatment depends on many factors. The two methods for surgical treatment of these fractures are hemiarthroplasty and open reduction and internal fixation (ORIF).

proximal-humeral-fractures2We recommend ORIF for most patients who need surgery for their proximal humerus fractures. This procedure involves making an incision over the front of the shoulder joint, aligning the bone fragments under direct vision and holding the lined up fragments with a plate and screws. We use specially designed plates that are manufactured for repairing proximal humerus fractures. The screws lock into the plate and form a fixed angle device. This creates a very stable construct that helps maintain the correct alignment while the bone heals. Most patients stay overnight in the hospital for pain control. The clinical data has indicated that repair of the fracture with a locking plate yields better outcomes that patients who undergo hemi-arthroplasty.

Additional imaging studies are usually helpful in planning for surgical fixation. 3-D CT reconstructions of the fracture help to determine the best place for placement of the implants. The CT is also helpful to pick up additional details that are often difficult to discern on plain x-rays. This cuts down on the time it takes to do the surgery and in turn minimizes the risk of other complications like infection and loss of reduction.

Recovery from ORIF is fairly slow but consistent and shoulder function improves in a fairly linear fashion over a 10-12 month period of time. It is important for patients to participate in their own therapy to maximize the outcome over time. Physical therapy and a structured home exercise program and essential to achieve good outcomes. Good and excellent results can be expected in about 75-80% of patients treated with locking plate fixation as opposed to roughly 40-50% good outcomes for hemiarthroplasty.

In some cases, the fracture involves the joint surface and is not amenable to repair with plate and screws and in these cases a hemiarthroplasty is indicated. Hemiarthroplasty is a surgical procedure in which the upper portion of the humerus is reconstructed with an artificial ball. The surgery uses the same incision and approach as ORIF. Most patients stay overnight in the hospital for pain control and go home the day after surgery. The clinical outcomes of hemiarthroplasty are fairly consistent with good relief of pain, but limited range of motion and power. Because of these relatively mediocre outcomes, hemiarthroplasty is reserved for fractures that are un-reconstructible or in which the risk of failure with plate fixation is very high.

Regardless of whether you undergo ORIF or hemiarthroplasty, after discharge from the hospital you will begin rehabilitation almost immediately. This instruction sheet answers the most commonly asked questions and serves as a reference for what to expect after surgery and what things you can do to help speed healing. Post-operative physical therapy is a critical part of the recovery process and most patients continue to improve clinically for up to 18 months.

Post op Shoulder Fracture Instructions

Dr. Solberg has performed roughly 200 ORIF procedures over the last 10 years with a fixed angle plate and has evaluated his outcomes data and published the results as part of an ongoing project. This has given him a large amount of experience and expertise in repairing these types of fractures.

Publications:

Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4- part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome.
– J Orthop Trauma,
2009 Feb, 23 (2), 113-9

Solberg BD, Moon CN, Franco DP, Paiement DP. Surgical Treatment of Three and Four Part Proximal Humerus Fractures.
– J Bone Joint Surg,
2009 Jul, 91-A (7), 1689-1697