Proximal Humerus Fracture: Surgery or No Surgery?

I'm Dr. Patrick Denard. I'm a shoulder specialist at the Oregon Shoulder Institute where I do 100% shoulder in my practice. My passion is trying to help people get back to their life. I try to do that by giving them good information and also researching shoulders so that I can help people not only in my practice, but all across the country and all across the world. So I want to talk about proximal humeral fractures or shoulder fractures. Now, proximal humeral fracture refers to the ball portion of the ball and socket joint or the glenohumeral joint Proximal means near. So when we say proximal, we're talking about the top part of the shoulder. These fractures occur in about 5% of people. Most commonly, these are going to be from— let me just redo that. The most common mechanism is a fall onto the arm. You can also see these occur from high-energy injuries such as a car accident. And there's really two broad sort of groups of people who get proximal humerus fractures. The first and most common is older population where bone density is a concern. The second is the younger population where it's typically gonna be a high-energy injury such as a fall from height or a fall off a bike or the motor vehicle accident. When we talk about a fracture, that is a broken bone, with a proximal humerus, we talk about four parts. There's the ball part, there's the neck below the ball, and then there's the tuberosities, the lesser tuberosity and the greater tuberosity. So we use classification systems to talk about proximal humerus fractures that really essentially talk about those four parts. And the another thing that we do with this is we think about proximal humerus fractures in terms of the blood supply to the bone. So what we know is that if there is extension from the ball, because the blood supply comes up in a retrograde manner, meaning it comes from distal to proximal, comes up and inserts into the ball far away rather than coming from the ball down, you can damage the blood supply to the ball when you have a proximal humerus fracture. If you have extension of the bone, meaning you don't just break right off at the ball, the break occurs a little bit lower, the blood supply is typically preserved. If it occurs right at the ball, the blood supply is more likely to be compromised. So what happens there is if the blood supply is compromised, somebody has a greater likelihood of developing what's called avascular necrosis. So avascular meaning without blood. In other words, if the blood supply is compromised over time, that ball can break down and lead to arthritis of the shoulder. Essentially, it can wither away. Leading to a lot of pain, a loss of range of motion. Now we of course want to avoid this complication after an injury, but sometimes we cannot avoid this. This is just something that relates to the fracture pattern. So what we try to do is identify people at risk for getting that avascular necrosis. And if somebody is at a higher risk of avascular necrosis because of their fracture pattern, we know that we are more likely to go on to doing a shoulder replacement as opposed to trying to fix the fracture if we're looking at a surgical treatment. Now, in terms of the anatomy, the tuberosity pieces are really important because the tuberosity are little outcroppings in the bone on the top and in the front. These are important because this is where the rotator cuff inserts. So the subscapularis inserts into the lesser tuberosity, and the supraspinatus and infraspinatus and teres minor insert into the greater tuberosity. So one of the things that we look at in terms of treatment is the displacement of those tuberosities. We look at that and the relationship of the ball to the shaft of the bone. As a general guideline, I look for the amount of displacement and somebody who has more than 5 to 10 millimeters of displacement of a tuberosity segment is more likely to benefit from surgery. The reason for that is that even if it heals, but it heals in an abnormal position, then you're not gonna have good long-term function of the shoulder because the rotator cuff functions under a normal length-tendon relationship. In other words, it has to be out to length. If it shortens because it pulls back and it's displaced off and it heals in that position, somebody ends up with poor function. In terms of the ball relationship to the shaft, I typically look for less than 50% displacement as a general guideline. Perhaps a lower threshold if somebody is on the younger side. Now, fortunately, when it comes to treatment, most people can be managed conservatively with proximal humerus fractures. Something like 70 to 80% of these are gonna be managed conservatively because most of these occur with relatively little displacement. The important thing there is that if you have a minimally displaced, that is a not a very displaced proximal humerus fracture, meaning the parts are relatively well aligned, is that somebody gets into early range of motion. And data shows that the earlier you move with a stable fracture, the better you do long-term. What do I mean by that? You typically want somebody moving within a couple of weeks, that is 2 to 3 weeks. That's beginning with what are called pendulum exercises and then table slides across, uh, a table in front of them and doing some rotation out to the side. So check out my rehab exercises. On my rehab playlist where you can see table slides and passive external rotation stick exercises demonstrated. Those are good early things to do in the setting of a stable fracture. Now, if somebody has displacement of the fracture, especially that tuberosity malalignment and shaft malalignment that we talked about earlier, there's really two broad categories of treatment. The first, uh, if they need surgery, the first is to do a plate. That's where you make an incision in the front of the shoulder. You put a plate on the side of the bone and align the segments with screws. You also want to make sure that the rotator cuff is reinforced with sutures because we need to bring that rotator cuff back in around the ball. I'll pass sutures through the tendon and into the plate itself to help stabilize everything. And in some cases do some grafting procedures. This is reserved typically for younger people. So as a general guideline, somebody who's under the age of 60. When I talk about shoulder, and also for some segments of fractures in older individuals where there's relative preservation of the ball or head. In other words, we believe there's a low risk that they A, are not going to heal, or B, are going to go on to avascular necrosis as I talked about earlier. The second main category of treatment is reverse shoulder replacement. This is most commonly used in people who broke their shoulder, who are elderly, who have a lot of displacement of the fracture. So what we do here is again, make an incision in front of the shoulder, put a ball on the socket side and the stem of the cup on the arm bone side. We do this in cases where the chance of healing is very low based on the fracture pattern, or if there's a very high risk that the ball is going to go on to avascular necrosis. The reason to do a reverse shoulder replacement is that it has been found that the outcomes with that procedure are better than those of just doing a partial shoulder replacement. And that's because the tuberosity healing is higher in that case. And even if the tuberosities do not heal, you can still have very good function because the reverse helps restore the stability to drive function of the shoulder. So what do those look like? If you undergo a plate fixation or surgical fixation, that's typically a procedure that takes 45 minutes to 1 hour. It's done on an outpatient basis. Somebody's in the sling for typically 4 weeks afterwards. I have them doing some early range of motion and they're working their way up. With a reverse shoulder replacement, it's very similar. It's about an hour. Again, 4 weeks in the sling, but they're doing early range of motion. Now, recovery timeline. When you have, when you break your shoulder, one of the things that is frustrating for people about this is they go from essentially feeling normal to all of a sudden having a significant injury. And I typically tell people, whether you're treated conservatively or if you're treated with surgery, this is typically a 6-month process. And that surprises people. Secondly, if you undergo surgery, that means the injury is quite severe. And it's very common that you do not get back normal function. If you have it plated, it may be in the, in a particular fracture pattern that you can get back normal function. But if you undergo a reverse shoulder replacement for this condition, a good result is not that somebody goes straight up and down. A good result is typically that somebody can get above shoulder level, which is better than they would've been without surgery. But it's sometimes hard for people to understand that distinction because prior to the injury, they were normal. So it's really important to understand, again, it's a long recovery. And depending on the fracture type and how it has to be treated based on that fracture type, you may not end up with function like you were the day before injury. So in terms of the rehab around shoulder fractures, especially in the conservative rehab, but this also ties into rehab around those that are treated surgically, I really think about this in 4 phases. The first phase is rest. So if you break your shoulder and we treat it conservatively, you want to just let it calm down for a couple of weeks. Second phase is working on early motions. You want to start that within a couple of weeks for the reasons I outlined. Particularly, it's been shown that those who move earlier do better. They're less likely to get stiffness. As you progressively increase your range of motion, somebody's going to wean from a sling. So for instance, somebody may be in a sling for 4 weeks after they break their shoulder, but they're moving early and they're progressively weaning out. And then the fourth phase is moving into strengthening. That's typically going to occur anywhere around 2 to 3 months after the injury or after surgery if that's required. But then you got to go back and regain your function, which is really that longer period between 3 and 6 months where you're working on getting back your normal life, getting back into your normal activities. One of the things that I like to tell people if they break their shoulder, if in particular if they're over the age of 65, is really think about bone density. So if somebody has not had a DEXA scan and they had a simple fall and they break their shoulder, not a high-energy fall with a, you know, a significant fall down height, but if they simply just fell over and broke their shoulder, if they have not had a DEXA scan, that is a bone density scan, within the last couple years, that should absolutely be done. I would also recommend considering getting a vitamin D level because that relates to bone health. There are some people in fact who say that if you break your shoulder from a low energy injury, regardless of your DEXA scan, you should potentially be considered at risk and be put on a medication for osteoporosis. So I will order DEXA scans for my patients, but I will also recommend that somebody go see their primary care physician to consider, should I be on treatment long-term, because what you don't want to do is break your shoulder, have that go untreated, and then the next fall is you fall and break your hip. So you want to make sure your bone density is addressed. In addition, another really good thing to do is to make sure you're working on balance. If this occurred from an isolated random event, that's one thing, but if somebody is, is becoming more likely to fall, you really want to learn— work on balance and strength because falling for elderly people is a serious thing where it can really impact their health, especially if they sustain a hip fracture. So I think about it as an overall condition that I wanna help try to see people see their overall picture and perhaps prevent other problems down the line. Last thing I wanna talk about is treatment in terms of medication. So how do you address this? So proximal humerus fractures can be very painful out of the gate. Oftentimes you're gonna get a lot of swelling and bruising. So typically we're gonna focus on managing pain with ice. I really like using a compressive machine that is a pack that goes over the shoulder that supplies continuous cold therapy along with compression that helps reduce swelling. Ice is just a really good pain reliever. The other, uh, medication that can be considered is Tylenol. Uh, Tylenol's just over the counter. You can take 1,000 milligrams every 8 hours. That's the max dose that somebody can take per day. I'll typically tell somebody to schedule that right out of the gate. You can consider use of anti-inflammatories like Motrin or Advil. One of the downsides though is those tend to cause some bleeding, so sometimes they can cause a little bit of swelling. And theoretically, Motrin or Advil, Aleve, all these inhibit fracture healing. So you can use 'em for a short period of time in the first few days if you're very, very painful. But I wouldn't take these for months. Because you can potentially inhibit fracture healing because anti-inflammatories, as the name suggests, inhibit the same sort of mediators, that is inflammatory mediators that are used to encourage fracture healing or healing of a broken bone. The last thing that can be used as well is narcotics or things like oxycodone or Vicodin, and those are used on a very short-term basis, like a few days. Whether that's around the injury or around the surgery. So hopefully this information helps you understand shoulder fractures a little bit better. Again, the key things is really understanding the pattern so you know what treatment is right for you. The majority of these can be managed conservatively and doing early motion, especially with stable fractures, so that you avoid the risk of stiffness.