WHAT IS A PROXIMAL HUMERUS FRACTURE?
Osteoporosis is a bone disease characterized by deterioration in bone mass, and as a consequence, compromised bone strength. It is identified as the basic reason why the elderly are considered to be the prime ‘‘suspects’’ of proximal humerus fractures – epidemiological research indicates that a proximal humerus fracture is the third most common type of bone fracture in individuals over the age of 65. It is usually attributed to injuries sustained by a fall, even in cases of falls from a small height, whereas in younger individuals, it is the result of a forceful collision, for example a car crash.
The humerus is the single bone that structures the human arm. The humeral head, which is hemispherical in shape and ‘‘clinks together’’ with the glenoid cavity of the scapula to form the glenohumeral joint, is the proximal extremity of the humerus. The clinical presentation of a proximal humerus fracture is pain, deformity around the site of the injury, as well as ecchymosis (bruising) of the injured shoulder. In cases of injury of the axillary nerve, the patient additionally experiences numbness. It is typical for the patient to hold the injured arm with the contralateral hand.
HOW IS A PROXIMAL HUMERUS FRACTURE TREATED?
The appropriate treatment is selected based on an elaborate ‘‘classification’’ algorithm that evaluates the severity of each proximal humerus fracture. Two basic criteria are taken into consideration: the number of broken ‘‘bone pieces’’ in the fractured humeral head (two, three or four), as well as the degree of displacement between bone fragments (dislocation) – which is normally greater than 1 cm of displacement or 45 degrees of angulation.
Conventional treatment is usually recommended in cases of stable and non-displaced fractures and consists of mobilization of the shoulder with the help of a sling, application of ice, medication to relieve pain, as well as physiotherapy. Orthopedists advise the patient to remain ‘‘immobile’’, considering the most substantial complication that occurs after shoulder fractures is extended and severe joint stiffness: the shoulder ‘‘locks up’’ and necessary daily movements become challenging. In the course of the patient’s treatment period, shoulder X-rays are utilized in order to monitor the positioning of the humeral head. The sling is normally removed after 6 weeks.
In cases of unstable and displaced proximal humerus fractures, surgical treatment is considered to be the patient’s only option. In fact, proximal humerus fractures are particularly demanding and an experienced surgeon with extensive knowledge of the anatomy of the shoulder is deemed necessary in order to choose and perform the optimal surgical technique. Elements of the assessed fracture include bone quality, orientation of the fracture pattern, as well as concurrent soft tissue injuries. Furthermore, a vital aspect of proximal humerus fractures is determined by the individual: the patient’s age, level of physical activities, possible pre-existing medical conditions, as well as whether the patient is right-handed or left-handed, are all taken into consideration.
The surgeon performs internal fixation of the proximal humerus fracture, ideally preserving the joint’s bone structure in the event of a shoulder arthroplasty being required in the future. Depending on the case, wires, percutaneous pins, plates and screws are used. In cases of comminuted fractures –which are very rare and correspond to 1% of total proximal humerus fractures– the humeral head is replaced by a metallic implant, since there is a high risk of necrosis.
Postoperatively, the patient must follow a personalized rehabilitation program that corresponds to the severity of the fracture as well as the type of the performed surgical technique. Rehabilitation is estimated to last up to 6 to 9 months.