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Dr Jonas Fernandez is an Orthopaedic Surgeon at Putrajaya Hospital. He is also a member of the Malaysian Arthroscopy Society( MAS).
" As surgical techniques continue to improve, treatment for these common shoulder fractures is becoming safer and more effective."
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Afracture of the proximal humerus, the upper part of the arm bone near the shoulder, is one of the most common fractures seen in older adults, especially after a fall. In fact, it is the third most common fracture in older people after hip and wrist fractures. These injuries can be challenging because several muscles around the shoulder pull on the broken bone fragments in different directions. This makes the fracture unstable and increases the risk of poor healing if not treated properly.
Doctors classify these fractures based on how many pieces the bone breaks into and how far the pieces have moved. Some fractures can heal well with a sling and physiotherapy, while others require surgery.
Today, surgeons generally consider three main approaches when surgery is needed: reconstructing the bone with plates and screws, reinforcing the repair with a fibular graft, or replacing the shoulder joint entirely.
LOCKING PLATE FIXATION
One of the most common surgical methods is fixing the fracture with a specially designed metal plate and screws. These“ locking plates” help hold the broken pieces together while the bone heals.
This option is often suitable for younger patients or those with good bone quality and fractures that can still be rebuilt.
However, complications can occur. The repaired bone may collapse into a poor position, screws can penetrate the joint, or the blood supply to the humeral head can be damaged, leading to bone death( avascular necrosis).
The good news is that results have improved significantly over the years. Better surgical techniques, improved implants, and careful patient selection have significantly reduced complication rates.
FIBULAR STRUT GRAFT AUGMENTATION
In patients with weak or osteoporotic bone, plates and screws alone may not provide enough support. To strengthen the repair, surgeons sometimes insert a fibular strut
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graft, a piece of donor bone placed inside the arm bone like an internal support beam.
This technique is especially helpful in fractures where the inner side of the bone has collapsed or where there is a high risk of the fracture falling into a“ varus” position, meaning the bone tilts inward during healing.
Studies have shown that adding a fibular graft can: improve stability, reduce the risk of collapse, lower the chance of needing another surgery, and improve overall shoulder function.
Biomechanical studies also show that combining a plate with a fibular graft creates a stronger construct than plates alone.
While this method can help preserve the patient’ s natural shoulder, it may make future shoulder replacement surgery more technically challenging if needed later.
REVERSE SHOULDER REPLACEMENT
For older patients with severe fractures, poor bone quality, or a high risk of complications, replacing the shoulder joint may provide the best outcome.
The most commonly used procedure today is reverse total shoulder arthroplasty( RTSA), also known as reverse shoulder replacement. Unlike a traditional shoulder replacement, the ball-and-socket design is reversed, allowing the larger shoulder muscles to compensate for damaged tendons and fractured bone.
Reverse shoulder replacement has become increasingly popular because it often provides: reliable pain relief, better shoulder function, faster recovery, and lower revision rates in elderly patients with complex fractures.
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It is especially useful in three- or fourpart fractures where rebuilding the bone is unlikely to succeed. Choosing the Right Treatment There is no“ one-size-fits-all” treatment for proximal humerus fractures. The best option depends on several factors, including: the patient’ s age, bone quality, activity level, fracture pattern, and overall health.
In younger patients, preserving the natural bone with plates and screws is often preferred. In weaker or more complex fractures, adding a fibular graft can improve stability. For elderly patients with severely shattered fractures, reverse shoulder replacement may provide the most predictable results.
As surgical techniques continue to improve, treatment for these common shoulder fractures is becoming safer and more effective, helping patients return to their daily lives with less pain and better function.- The HEALTH
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