Displaced Proximal Humerus fracture

 

 

Proximal humerus fractures

 

Fractures of the proximal humerus are complex problems and are often difficult to achieve good results for patients who have them.  These injuries should only be treated by a well-trained fracture surgeon with experience in repairing these fractures.  I treat approximately 30 cases per year with plate fixation and they represent one of my particular areas of clinical interest.  I have published several papers in peer reviewed journals and made numerous presentations at national and international meetings on surgical repair of proximal humerus fractures.  I approach all proximal humerus fractures in a systematic way by analyzing the fracture pattern, bone quality, available implants and then formulating a plan to achieve the best clinical results for my patients. 

 

Proximal humerus fracture after plate fixation

 

 

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, but in summary there are two methods for surgical treatment of these fractures:  Hemiarthroplasty and Open Reduction and Internal Fixation (ORIF).

 

 

Photograph of a locking plate with several screws anchored in the plate

 

I 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 (reduction) with a plate and screws.  I use a specially designed plate that is manufactured for repairing proximal humerus fractures and have included the surgical technique guide below as a separate link. The screws "lock" into the plate and form a "fixed angle device" in which the position of the screws is locked in place and the screws don't toggle in the screw holes.  This creates a very stable contract that helps maintain the correct alignment while the bone heals. The surgery takes 1-2 hours and 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.

 

 

Link to: Axsos Proximal Humerus Plating System

 

 

In preparation for surgery I will usually get additional imaging studies to help me to plan the surgery pre-operatively.  I will often ask of 3-D CT scans, which are 3 dimensional reconstructions of the fracture to help me to determine the best place for placement of the implants including screw direction.  The CT is also helpful to pick up additional details that are often difficult to discern on plain x-rays. By evaluating the fracture thoroughly on x-ray and CT scan, I am able to plan the surgery ahead of time and this cuts down on the time it takes to do the surgery. This in turn minimizes the risk of other complications like infection and loss of reduction.

 

 

 

3-D CT scan of a Proximal Humerus Fracture

 

 

 

 

 

 In some cases, the fracture involves the joint surface and is not amenable to repair with plate and screws and in these cases I repair the shoulder using a hemiarthroplasty. Hemiarthroplasty is a surgical procedure in which the upper portion of the humerus is reconstructed with an artificial ball, which acts as a partial shoulder replacement.  The surgery uses the same incision and approach as ORIF and takes roughly 1-2 hours to perform.  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, I reserve hemiarthroplasty for the fractures which are un-reconstructible or in which failure with plate fixation is very high. The implant that I generally use allows more flexibility in positioning the artificial joint surface relative to the native humerus bone and gives me more options to repair the rotator cuff to the implant.

 

 

Proximal Humerus Fracture after hemiarthroplasty

 

 

Link to: EPOCA surgical technique

 

 

A well performed ORIF is a very technically demanding procedure and I employ the most advanced locking implants to hold the fracture fragments in a good position.  Most patients stay overnight in the hospital and are discharged the next day.  Recovery 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.  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. Physical therapy and a structured home exercise program and essential to achieve good outcomes.  

 

After discharge from the hospital you will begin rehabilitation almost immediately. I have included my post-op instruction sheet below as a separate link. This instruction sheet answers the most commonly asked questions and serves a 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.

 

Link to Post op Shoulder Fracture Instructions

 

 

I have included a few of the recent publication I have written about the outcomes of repair of proximal humerus fractures. I have performed roughly 200 ORIF procedures over the last 8 years with a fixed angle plate and have evaluated my outcomes data and published the results as part of an ongoing project. This has given me 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