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Orthopedic Services
Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA 91206
Ph: (818) 409-8000

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Oh boy. Dad was lifting some boxes in the garage and snapped the upper part of his arm into four pieces (the round ball at the top of the shoulder). They've got him in surgery now. What should we expect in terms of recovery?

Severe fractures of the humeral head (round ball at the top of the upper arm) often affects older adults with fragile bones from osteoporosis. Fragmented fractures like your father's from low-energy trauma (e.g., raising the arm, lifting a cup of coffee) are typical. As you have discovered, surgical treatment is usually needed for displaced three- and four-part proximal humeral fractures. A displaced fracture means the broken pieces have separated apart and shifted. Displaced fractures with so many pieces of bone often means tendons attached to each bone fragment will also shift position. A change in the pull of force of tendon and muscle contracting can cause further deformity. Sometimes a tendon will become trapped between bone fragments. Such cases are complex and present unique challenges to the surgeon. Damage or disruption of the blood vessels to the humeral head can further complicate treatment. Without enough blood to the area, the bone can die, a process called osteonecrosis. Preserving or restoring blood supply becomes a critical goal of treatment. Most of the time, a patient with three-or four-part fractures of the humeral bone will need surgery to either repair the damage or remove and replace the humeral head. In the case of repair, one effective technique is with a piece of hardware called locked plates. Open incision surgery is required to realign the bone fragments and then screw them together and hold them in place. That's where the locked plates come into play to hold and support the bone until healing takes place. Complications from this procedure are common and can include osteonecrosis, loss of fixation, infection, and nonunion of the bone. The screws holding the plate in place can also back out or puncture through the femoral head. When it is not possible to save the humeral head, the surgeon can remove and replace just the head (called hemiarthroplasty). Patients who are medically stable are the best candidates for hemiarthroplasty. It is useful when the fracture cannot be reduced and/or when the shoulder cannot be lined up properly. Poor bone quality may also prevent the use of locking plates thus making replacement the only reasonable choice. Older patients (70 years old or older) with poor bone quality are most likely to be treated with a reverse total shoulder arthroplasty (RTSA). Their inability to participate in a rehab program makes the more stable RTSA necessary. No matter what treatment is applied, results depend on getting the bones lined up properly for good healing. Malpositioning is the number one risk factor for failed healing and poor overall results. Surgical technique in getting the right suture tension and compression is important, too. Patients who can participate in rehab from day one can expect recovery within nine to 12 months. Full motion and strength are not always regained but function in daily activities is usually achieved. It's likely your father will need some assistance at home in the early days to weeks. If he still drives, he will be restricted from driving for the first two months and need transportation to his medical and physical therapy appointments.


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