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Proximal Humerus Fracture Fixation

Surgery for a proximal humerus fracture can include: suture anchor fixation, plate and screw fixation, intramedullary nail or joint replacement.

Plate and screw fixation is used for most proximal humerus fixations. This is performed through a 12cm incision over the front of your shoulder (fig. opposite - intra-operative x-ray of a specific proximal humerus plate)

Suture repair and the use of bone anchors may be indicated in certain fracture types, generally where only a part of the humerus (greater tuberosity) has been pulled off by the rotator cuff tendons.  This is performed through a small (5cm) incision over the side of your shoulder.

Intramedullary nail devices are sometimes used, rather than a plate.  This is normally done through a small (3cm) incision over the side of your shoulder. For some patients and fracture patterns this represents the best way of fixing the fracture.

Shoulder replacement is sometimes required to reconstruct a very damaged shoulder, or a complex fracture in a patient with weak bone and poor soft tissue quality.  Like many joint replacements, it is generally avoided in patients under 65 years of age. A reverse shoulder prosthesis normally provides more reliable outcomes than a half-shoulder replacement (hemiarthroplasty) in trauma. 

Shoulder fracture surgery is performed under general anaesthesia +/- regional nerve block. You will need to stay in overnight after your operation.  You will wake up with a sling and your arm may be numb from the nerve block.  

What are the risks of proximal humerus fracture surgery?

Although major complications are rare, proximal humeral fracture surgery can be challenging. 

Bleeding – major bleeding is very rare but occasionally you might need a top-up transfusion after surgery

Nerve injury – several nerves pass close to your shoulder and proximal humerus. It is rare for these to get injured during your  operation, but if they do get injured, it is normally through stretching, rather than being cut, and they therefore normally recover 

Infection – as for all surgery, there is a small chance of infection (approx. 2-3%), which sometimes requires further surgery and antibiotic therapy

Failure of bony healing, or fixation failure -  if the bone quality is very poor and the fracture collapses before uniting, or the blood supply has been damaged by the injury, this may be very likely.  Non union can affect up to 20% of cases. Sometimes patients require revision surgery.  If you've had a replacement, best function relies on healing of the tuberosities (lumps of bone that sere as attachments for your rotator cuff tendons).  This is unpredictable in hemiarthroplasty but succeeds in 80% of reverse shoulder replacements after trauma. 

Collapse and arthritis of the humeral head.  The overall rate of this is about 10%, but certain fracture patterns disrupt the blood supply to the humeral head and make this more likely. 

Prominent metalwork – if your fracture collapses down around your screws, they may end up perforating the bone of the humeral head and rub in your shoulder joint.  Care is taken  during surgery to avoid this, but it can still occur in about 10% of cases and may require implant removal

What is my recovery after surgery?

Please take your painkillers regularly and begin them before your nerve block wears off.  You will normally go home the day after your surgery. 

You can start to move your shoulder very gently (your physio will guide you as to what you can do and what to avoid)

Please leave your dressing on until your clinic appointment at 2 weeks

Patients vary in their recovery, but you can expect to return to:

Office Work  3-4 weeks (in a sling)

Light manual work 12 weeks

Heavy manual work 18-26 weeks

Driving is allowed once you are confident and competent to control your vehicle for routine and emergency manoeuvres.  This usually takes 8-12 weeks.

It can take over 12 months to achieve your full rehabilitation potential after proximal humerus fracture surgery.