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

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My wife is in a nursing home. Last night she fell and broke her upper arm into four pieces. The nursing staff and doctors are trying to decide the best way to treat this problem. She's 81-years-old, has dementia, and can't follow directions. She also has severe osteoporosis, which I've been told compounds the problem. What are some of the treatment options?

When it comes to fractures of the humerus (upper arm) in older adults, there are many things to keep in mind. The age of the person matters because people over age 70 often have low bone mass and slow healing. The way in which the bone has fractured, the anatomy of the underlying structures, and risk of ischemia (loss of blood supply to the bone) are additional variables to consider. The chances of developing osteonecrosis (death of the bone) increase with each one of these factors. A very well-known surgeon (Dr. Charles Neer) introduced the idea of replacing the shoulder instead of trying to repair it. That was back in 1970. Since then, surgeons have tried full joint replacement and hemiarthroplasty (replacing only one side of the joint). These methods have proven to work but not always smoothly. Ischemia and osteonecrosis are still major concerns. Pain relief and improvement in function and recovery aren't always guaranteed. So, experts have gone back to the drawing board to rethink surgical treatment for these fractures. They asked themselves if the results could be improved with better surgical technique. They have tried developing implants specifically designed for the type of fracture involved. They have studied the anatomy of the joint very carefully trying to mimic it in every way with reconstructive surgery. Achieving optimal anatomical structures involves the structure, shape, angle, length, and orientation of bone, muscle, tendons, ligaments, even fat deposits. Given all of the factors you have described, your wife might be a good candidate for a reverse shoulder arthroplasty. That's a shoulder replacement (implant) that is the opposite of the usual prosthesis. The reverse shoulder prosthesis is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula. In the "normal" artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic. The humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder. In the reverse shoulder replacement, the ball and the socket are reversed. The humeral component is combination of a metal stem that fits into the marrow cavity of the upper humerus and, on top of the metal stem, a plastic socket. This plastic socket fits onto the humeral component to create a ball and socket type bearing. The glenoid component is usually made of two parts. A metal tray (base plate) attaches directly to the bone. The glenoid base plate is inserted into a small peg hole drilled into the bone and is secured with special screws through the base plate into the bone. Attached to that metal tray, a metal ball is attached that will fit into the plastic socket attached to the humeral component. The plastic is very tough and very slick, much like the articular cartilage it is replacing. This is only one idea but it seems to match your wife's needs for a stable joint in a patient who won't be able to undergo typical postoperative rehab. This type of implant makes it possible for older adults with fragile bones or damaged rotator cuff tendons to regain movement and function for their everyday activities.


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