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Surgery for Severe Fractures of the Humeral Head
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Posted on: 02/23/2012
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Severe fractures of the humeral head (round ball at the top of the upper arm) can affect young and old alike. Younger patients are more likely to have three- or four-part humeral head fractures as a result of high energy trauma. Older adults with fragile bones from osteoporosis can suffer similar fragmented fractures from low-energy trauma (e.g., raising the arm, lifting a cup of coffee).
In this article, orthopedic surgeons from Columbia University Medical Center (New York City) review the surgical treatment of 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.
The surgeon may need to use a bone graft and realign the rotator cuff to prevent loss of motion. Choosing the right implant design and placing the implant at the correct angle and height are additional key factors in a good outcome and patient satisfaction.
The authors offer other surgeons their own insights and thoughts on each of these areas. The role of postop rehab and complications on results are also discussed. 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.
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References:
Edwin R. Cadet, MD, and Christopher S. Ahmad, MD. Hemiarthroplasty for Three- and Four-Part Proximal Humerus Fractures. In Journal of the American Academy of Orthopaedic Surgeons. January 2012. Vol. 20. No. 1. Pp. 17-27.
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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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