Proximal Humerus Fractures - What You Need to Know
Welcome to the JonBarlowMD.com blog. I consider it an incredible privilege to be able to share some of my thoughts and opinions with you. My hope is to shed some light on controversial and challenging aspects of orthopedic surgery, and particularly, shoulder and elbow fracture care. While my opinions have been educated by my training at the Mayo Clinic, and Rothman Institute, they remain my own opinions, and not those of the Mayo Clinic.
When I was hired at the Mayo Clinic in the fall of 2017, it was in order to advance the science of taking care of proximal humerus fractures (breaks of the upper part of the arm bone - in or near the shoulder). Although surprising, there are many problems in orthopedic surgery that don't have complete solutions. Proximal humerus fractures (PHFs) are a perfect example. I will break down my thoughts on the injury, and management. I hope that this information will help you make decisions about how to handle your (or your family members) fracture, or (for the physicians in the crowd) how to manage them in your patients.
Proximal humerus fractures can occur due to high energy injuries (car accidents, etc). However, the vast majority of injuries are the result of low energy falls in patients with weak bone (osteopenia or osteoporosis). Therefore, a critical component of any evaluation of a PHF is an assessment by your primary care physician of your bone health. This is typically completed with a "Dexa" scan to look at the bone in your spine or hip. The frequency of these fractures seems to be rising, and it already is the 3rd most common cause of fractures in the elderly (behind hip and wrist, PMID: 16394745).
The challenge in management of these fractures is the complex nature of the shoulder joint. The areas of the bone that are broken involve the attachments of the rotator cuff muscles - muscles that are critical to shoulder function. Small amounts of movement of these attachments can cause noticeable changes in motion, and in some cases, persistent pain. Furthermore, because these fractures are most common in elderly patients, there are substantial social implications to these fractures. Many older adults lose their independence as a result of these injuries.
Evaluation and Treatment
The initial evaluation of PHFs is nearly always the same - getting x-rays of the shoulder. X-rays provide us an excellent view of the fracture lines, and can guide early management of fractures. In some cases, we obtain CT scans (which allow us a more 3-dimensional view of the fracture) to help make decisions about how to treat the fracture. This is sometimes done at the initial evaluation, but can be completed later as well.
Most often, we will start with a simple sling for management of these fractures. Barring other medical issues, the patient can return home, and come back to clinic for evaluation. This will allow the soft tissues to heal, and in some cases, the fracture can align in a better position. In rare cases, for pain control or medical problems, the patient can be brought into the hospital overnight.
The main factor that determines the next steps (continue with the sling, or consider surgery), is the alignment of the fracture. Look at the two x-rays below.
While these examples are dramatic - they illustrate an important point. The fracture on the left can be treated without surgery. The fracture on the right will likely benefit from surgery to improve outcomes (although this is still surprisingly controversial!). In general, the vast majority of PHFs can be treated without surgery (over 90%)
I hope that this gives you some insight into the complex world of proximal humerus fractures. There will be much more to come, as this is really the tip of the iceberg. I look forward to hearing your thoughts, questions, and controversies about this topic!
Jon Barlow, MD