Fractured shoulders are unique. Because of the complexity of the joint being surrounded by muscles/ tendons, in the past they have had an uncertain prognosis, with the general consensus being that these fractures never recovered that well. This has changed since the release of the reverse shoulder replacement as an option for treating fractured shoulders. Consequently, fractures of a shoulder can now do very well. In general, fractures take longer than the average person would expect to get the best result ( refer to the life cycle of any musculoskeletal injury), but nowadays we aim to achieve the best possible functional outcome.
What sort of fractures are there and how are they treated differently?
A fracture or break of the shoulder (the proximal humerus) can involve any or all of:
- The stem (shaft)
- The humeral head (ball joint surface)
- The tuberosities (insertion of the tendons around the shoulder)
All three elements are vitally important for function of the shoulder.
The one that causes the least issue is an isolated fracture of the shaft. This is where displacement or angulation can still lead to very good function and these fractures tend to heal very well in the vast majority of patients.
Fractures that involve the joint surface (humeral head) run the risk of either the bone dying with time (avascular necrosis) and subsequent development of collapse, and then arthritis. If there is disturbance of the smoothness of the joint surface (incongruity) this can lead to early arthritis. This leads to pain and stiffness.
Fractures of the tuberosities effectively lead to loss of control of the movement around the shoulder, as the tendons are no longer attached to the shoulder and this leads to weakness and lack of function.
In general, fractures of the shaft need restoration of the alignment of the shoulder into an acceptable position so that the bone will heal. Alone, the main reason to operate is if there is no bone contact. If the bones are aligned and touching, then all that is required is a sling.
On the other hand, fractures of the joint surface need to have restoration of the smoothness of the ball, if there is a step in the joint smoothness. If there is also significant displacement from where the ball normally sits, there is a higher risk of the blood supply being damaged and risk of avascular necrosis. In this case, a replacement of the ball with an artificial component may be required.
For fractures of the tuberosities, it is vital to repair these back to the shaft such that the tendons then connect and move the shaft. If there is a higher chance that these fragments of bone will not heal back, as occurs in an older patient where the bone is weak, or if there is disturbance of the joint surface or a high risk of the blood supply being damaged in the joint surface, then component replacement is undertaken in the form of either half a shoulder replacement (hemniarthroplasty) or a full shoulder replacement in the form of a reverse shoulder replacement.
Reverse total shoulder replacement
Consequently an important aspect of treating a shoulder fracture is assessing the individual areas that are broken and considering whether they can be repaired or need to be replaced.
- In a fracture involving the shaft where there is bone continuity and alignment is reasonable, the treatment is the use of a sling to allow the bones to heal. In a scenario where the bones have lost continuity or are particularly badly angled, the fracture may need to be reduced and aligned better and held with a metal plate.
- If the fracture involves the ball, such that there is disturbance of the joint surface, if this joint surface can be reduced perfectly it is undertaken and held with a metal plate. However in the vast majority of situations this may not be possible, particularly in an older patient, and it needs to be replaced. If the fracture only involves the ball, this could involve half a shoulder replacement but often it involves the tuberosities.
- If the fracture involves only the tuberosities or in the case of a younger person, an attempted repair of these tuberosities to the shaft is undertaken, being aware that they could still pull away. In an older patient where the bone is soft, the healing potential is less and the option of a shoulder replacement is more appropriate, and a reverse total shoulder replacement is undertaken.
One can see that it is important to have the ability to treat all these aspects of a shoulder fracture with the knowledge and experience of being able to open a shoulder, repairing the bones with a metal plate or repairing the tuberosities with screws and sutures or the ability undertake a shoulder replacement if necessary. We believe that as a surgeon, that it is important to regularly undertake surgical exposures around the shoulder and be comfortable undertaking all aspect of shoulder care, both tendon, bone and replacements.
Dr Nimon is head of shoulder surgery at The Queen Elizabeth Hospital, and is the go-to surgeon for complex shoulder fractures. Therefore, at Glenelg Orthopaedics you can be reassured that he will do his best to achieve the best possible outcome for such injuries.
Glenelg Orthopaedics, Providing Quality Orthopaedic Care