Proximal humerus fractures (Broken shoulder)

What is proximal humerus fractures?

The shoulder joint comprises three bones, scapula (shoulder blade), clavicle (collar bone) and humerus (upper arm bone) in a socket named as the glenoid cavity. The ball-shaped head of the humerus (upper arm) fits in the glenoid cavity in such a manner, it moves freely in the socket. Proximal humerus fractures are also given the name broken shoulder. It is caused due to direct blow onto the shoulder or fall on an outstretched hand. It has a bimodal distribution and could be caused by a low energy injury (fall) in older patients with weak bone or from a high energy injury (road traffic accidents) in younger patients. .

Its incidence is 4-6% of all fractures and is the third commonest fracture after hip fracture and wrist fracture. Women are more affected by this fracture than men and almost 80% of these fractures could be treated without surgery.

 

What are the symptoms of proximal humerus fractures?

The symptoms of these fractures include swelling of the affected shoulder, bruising, pain and loss of function after the trauma. The pain is severe in the first three days and could take upto 3 weeks to settle down. Weakness and numbness on the outside of the upper arm with a visible deformity are also common.

 

How is it diagnosed?

These fractures are diagnosed after assessment of complete medical history, physical examination and X-ray. In some cases, your surgeon can advise you for CT or MRI scan to detect the extent of the damage of the affected area.

 

How is it treated?

Fractures in the proximal humerus can be treated conservatively or surgically. It depends upon the personality of the fracture, associated injuries, age, healing and remodelling potential of an individual. Conservative treatments give good results in almost 80-85% of these fractures.

Surgery is indicated in

Absolute indications

  • Open fracture
  • Vascular injury
  • Floating shoulder (associated fracture of clavicle/shoulder blade)
  • Intra-articular fracture
  • Nerve injury
  • Non-union
  • Fracture gap with interposition of soft tissues
  • Complete displacement of tuberosities

Relative indications

  • Pathologic fracture
  • Polytrauma
  • Symptomatic malunion
  • Delayed union
  • Inadequate reduction
  • Bilateral humeral fractures.

 

What are the non-operative treatments?

It is done by immobilization, rest, medications and physiotherapy.

  • Immobilization– the patient is immobilized with a cuff and collar and in selected cases polysling for 4-6 weeks. With the cuff and collar the elbow weight acts on the shoulder to align the fracture closer to the anatomical position.
  • Rest– the patient is advised to take proper rest and avoid any further injury to the affected area.
  • Medicines– Painkillers like codeine and paracetamol are prescribed to relieve the pain during healing. Anti-inflammatory drugs such as aspirin and ibuprofen are prescribed to control swelling. However, using anti-inflammatory medications longer could lead to delayed bone healing.
  • Physical therapy – Pendulum exercises are started as early as possible and progressed to gentle range of motion (ROM) exercises 3-4 weeks. Besides, the elbow, wrist and hand are kept mobile to prevent their stiffness and weakness. Strenuous exercises are gradually introduced by your physiotherapists after radiological union around 6 weeks.
  • Most of these fractures could be treated without surgery in children.

 

What does the operation involve?

The main aim of the surgery is to achieve realignment of the fractured bone and to restore the normal mobility of the arm.

  • Surgery is done as a day case under general anaesthetic to obtain the desired alignment. The skin over the affected area is incised and the bone fragments are realigned to their normal position.
  • Plates and screws are used to fix the bone internally in its normal position during healing. In patients with complex fractures, bone substitutes are used to accelerate healing and to bridge the gap.
  • The skin is stitched using absorbable sutures and a sling is applied. The surgical time is usually 1-2hrs and a majority of the patients go home the same day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and pendulum exercises for the shoulder. This is necessary to prevent stiffness and to maintain the strength of the muscles near your shoulder after healing.
  • The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
  • The patient is reviewed at 2 weeks and referred for physiotherapy.
  • The fracture union is confirmed by x-rays at regular intervals, usually 6 weeks, 12 weeks and 6 months. However, in selected cases x-rays are taken in first few weeks to assess displacement/union.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
  • The sling could be removed around 4-6 weeks
  • The physiotherapy begins with gentle exercises and is progressed to strengthening exercises around 8 weeks. This depends on the X-ray reports and clinical union of fracture as guided by your surgeon.

 

Are there any risks?

  • Infection
  • Delayed union
  • Non-union
  • Mal-union
  • Nerve injury
  • Vascular injury
  • Frozen shoulder
  • Myositis ossificans
  • Hypertrophic scar
  • Frozen shoulder
  • Anaesthetic complications

 

What are the results of the operation?

The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the injury, associated injuries, treatment involved and adherence to physiotherapy. However, is more predictable in the author’s experience.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury.  You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

Proximal humerus fractures

  1. Proximal humerus fracture
  2. ORIF with plates and screws

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