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Proximal humerus fractures are very common and in most cases can be managed without surgery. When surgery is indicated, it requires careful planning using 3D CT scans, meticulous surgical fracture fixation and close follow up with guided rehabilitation. Patients stay in hospital overnight and wear a sling for 6 weeks; strengthening is commenced at 3 months postoperatively. Surgery is able to produce a more reliable outcome for younger patients and those with higher demands in function and sport.
The decision to proceed with surgery is unique to each individual and based on a number of factors, such as fracture pattern, occupation, sporting demands, social situation and overall expectations.
The goal of proximal humerus (shoulder) fracture surgery are to obtain anatomical reduction and stable fixation to allow early range of motion and return to full function in a timely manner.
There are many parts to a proximal humerus (shoulder) fracture that need to be accounted for – indeed proximal humerus fracture surgery is complex and quite intricate. The different factors to consider are:
Humeral head (ball) fracture
Humeral shaft (arm bone) fracture
Tuberosities (rotator cuff insertion points)
Biceps tendon
Bone loss
Blood supply
Most patients report a sense of “relief” after their proximal humerus fracture is fixed and can commence light activity with the operated arm (such as self care, feeding, and using a mobile phone) immediately.
There are three essential components to a good outcome from surgery:
Post-operative physiotherapy
Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.
The JPL pathway allows for self-directed, early passive shoulder range of movement:
Either a “standard” or an “abduction” sling is required for the first 6 weeks after your surgery. A “standard” sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery). The type of sling is selected specific to you and your shoulder surgery.
Therapy overview
After the surgery you will be in a sling and protect your shoulder to allow the shoulder fracture repair to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.
The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the fracture begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder and rotator cuff strengthening exercises are commenced at 12 weeks after shoulder fracture surgery. Dr Pant will discuss when it is safe to return to your chosen sports. Generally, collision sports and overhead contact athletes need more time to allow for healing.
Driving after proximal humerus fracture surgery
Showering and getting dressed
Sleeping after Shoulder Surgery
Elbow and hand movement
Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications.
The risk of complications after clavicle fracture surgery is less than 1% in the Sydney Shoulder Unit experience. General risks include:
Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone/tendon healing. Most healthy patients, however, cope well with shoulder fracture surgery and are unlikely to have complications.
The outcome after proximal humerus fracture surgery is good to excellent; however, it is not possible to restore the shoulder back to “normal”. During shoulder fracture surgery, your own damaged tissues are repaired in an attempt to restore your anatomy; often we can get this very close to normal/anatomical but the shoulder will unlikely return to its pre-injury state.
Most patients report a feeling of the shoulder being secure/stable immediately after surgery, and by two weeks they are back to basic things around the house. Therapy using the JPL protocol commences at two weeks post-surgery. At the final follow up visit at 3 months the fracture has usually healed and strengthening can commence. The chance of hardware complication in the Sydney Shoulder Unit experience is less than 5%.
Dr Pant has extensive experience treating proximal humerus fractures and is highly skilled in the surgical repair of all shoulder fractures. As the lead shoulder trauma surgeon at St Vincent’s Hospital for many years, he has experience with a vast array of shoulder fractures and is well versed in guiding you to full recovery.
Dr Sushil Pant is a leading Australian trained orthopaedic shoulder surgeon. He is the founder and medical director of the Sydney Shoulder Unit; and is a Shoulder Surgeon at Sydney Sports Medicine Centre at Sydney Olympic Park.
This is the case of a 50 year old man who sustained a torsional (twisting) injury to his right arm. He presented to hospital with pain and deformity to his right arm. Plain x-rays demonstrate a 3 part shaft fracture with comminution (multiple fragments). The CT scan 3D reconstructions show the extent of the fracture. The treatment advice was to proceed with surgery.
On this occasion, the fracture was reduced and fixed with a intramedullary nail (inside the bone) with locking screws on either end to stabilise the construct. The fracture line is now barely visible and he went on to unite his fracture and return to his previous level of function.
This 54 year old lady fell in her garden at home. She presented to the hospital with shoulder pain and swelling. She underwent immediate imaging with an x-ray and a CT scan with 3D reconstructions.
The fracture of the left shoulder was complex and shaft extension. This type of fracture is very difficult to fix as there is no medial hinge (due to the fractured shaft on the inside of the arm). She underwent an ORIF (Open Reduction and Internal Fixation) + bone graft + rotator cuff repair. The surgery was complex and needed a few tricks to get things looking perfect. Eventually, we achieved anatomical reduction and stable fixation to allow her early range of motion.
She commenced JPL rehabilitation at 2 weeks and united her fracture at 4 months post-surgery. She is back to gardening with new-found enthusiasm.
This 28 year old student had a scooter accident, sustaining this complex injury: a fracture with posterior dislocation and humeral head impaction resulting in articular cartilage injury.
He underwent an ORIF with humeral head elevation, iliac crest (pelvic bone) bone grafting and rotator cuff repair. The x-rays show the anatomical restoration of the humeral head articular surface with stable fixation. He was delighted with his eventual outcome given the complexity of his injury.
This 45 year old gentleman fell off a ladder at home sustaining this injury. The 3D reconstructions of the CT scan show a displaced proximal humerus (shoulder joint) fracture. This was fixed carefully using plates and screws to achieve anatomical realignment and stable fixation. He underwent JPL rehabilitation and then physiotherapy for strengthening, regaining normal, symmetrical range of motion and full function.
This lovely 63 year old lady fell at home, sustaining a very complex head split type of proximal humerus fracture. This case was borderline unreconstructable and an immediate shoulder replacement may be another option. After discussion with the patient, we elected to repair the shoulder fracture to allow her the best chance at keeping her own shoulder joint.
She underwent an ORIF (Open Reduction and Internal Fixation) and cuff repair. The pictures demonstrate the complexity of her fracture pattern. We achieved anatomical reduction and stable fixation: the fracture lines are barely visible on her post-surgical scans. After a period of therapy she went on to do very well regaining close to full function.
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Alternatively, if you have any further questions or would like a consultation with Dr Pant get in touch:
Dr Sushil Pant is a leading Australian trained Orthopaedic Shoulder Surgeon. He is the founder and medical director of the Sydney Shoulder Unit; and is a Shoulder Surgeon at Sydney Sports Medicine Centre at Sydney Olympic Park.
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