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Treatment For Severe Fractures of the Upper Arm
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Posted on: 11/30/1999
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Older age and brittle bones make a bad combination when a family member takes a fall and breaks a bone. Hip fractures are the most familiar injuries in our older adult population. But shoulder fractures are on the rise. In particular, the topic of this article: fractures of the proximal humerus are receiving more attention these days.
The humerus is the upper arm bone and a break in the proximal portion refers to the top of the long shaft of the bone. This is where it intersects with the round (humeral) head that fits into the shoulder socket. A sudden fall even from a standing position can generate enough force to break the humeral shaft away from the humeral head. Sometimes the humeral head splits into multiple parts at the same time.
Treatment depends on many patient-related factors. Age, condition of the bones, presence of other injuries, mental status, and fracture pattern are just a few of the considerations the surgeon takes into account when forming the plan of care. X-rays and CT scans help show the extent of damage.
Surgeons often use one of two well-known systems to classify fractures. The Neer classification looks at the number of broken pieces of bone that have shifted away by more than one centimeter or that angle more than 45 degrees from their normal location. The AO-ASIF classification looks at how much of the shoulder joint surface is involved.
Both systems help predict the risk of osteonecrosis (bone death) from lack of blood supply. If the risk is too great, then surgery to replace the bone is done instead of trying to save it. Shoulder replacement may be complete (both sides of the joint removed and replaced) or a hemiarthroplasty (just one side is replaced).
The decision to replace part or all of the shoulder isn't easy. The patient must have good enough bone to support the implant. They must be strong enough to have major surgery and then go through rehab.
There are several factors that might prevent a patient from having this type of shoulder surgery after a fracture. The first is medical instability -- the patient's health is too compromised to survive anesthesia and major surgery.
Infection, nerve damage, or young age are additional risk factors. With younger patients who have fractured the proximal humerus as a result of a traumatic accident, it may be possible to repair the damage with wires and screws and without replacing the joint.
The authors provide detailed specifics of the various surgical techniques used to repair or replace severely fractured proximal humeral bones. Photos taken during surgery, drawings, and carefully worded descriptions provide the reader with an inside view of what is done in surgery.
Equally important is the after-care. Preventing post-operative complications and supporting rehabilitation efforts can go a long way in speeding recovery. Pain relief, good motion, and strength needed for a return to full function are the goals. When those goals are met, patients are more likely to be satisfied with the results.
More recently, the use of a reverse arthroplasty has been the implant of choice for inactive patients aged 70 or older with severe osteoporosis and now a severe fracture. In this type of implant, the ball portion of the shoulder is put where the socket used to be and the socket now goes where the ball or humeral head was located.
Patients with fracture and poor muscle function (often caused by an old unrepaired rotator cuff tear) are also good candidates for the reverse arthroplasty. The design of the reverse arthroplasty creates a much more stable shoulder joint that can function without a rotator cuff.
In summary, the aging of America has been accompanied by an increased number of proximal humeral fractures. These are not simple, straightforward injuries. Complex fracture patterns along with challenging health problems in older adults make successful treatment difficult. In the future, we can expect to see more and more studies comparing treatment approaches to find out what works best.
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References:
James E. Voos, MD, et al. Arthroplasty for Fractures of the Proximal Part of the Humerus. In The Journal of Bone & Joint Surgery. June 2010. Vol. 92-A. No. 6. Pp. 1560-1567.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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