Proximal humerus is the term given to the upper end of the arm bone. The upper end of the arm bone along with the dish like cup in the shoulder blade bone forms the shoulder joint. If there is a fracture in this part of bone it is called as Proximal humerus fracture or sometimes called as Neck of humerus fracture.
Proximal humerus takes part in forming the shoulder joint and also gives attachment to the important muscle of the shoulder called rotator cuff muscles. The rotator cuff muscles are important in elevating and rotating the arm. Hence a complex fracture occurring in this region can severely affect the function of the shoulder joint.
Fracture occurs after an injury. This can be as a result of fall or a road traffic accident.
Fracture leads on to severe pain, swelling and deformity of the shoulder joint. It is difficult to move the shoulder due to pain.
A clinical assessment and doing investigation such as X ray will confirm the diagnosis. Sometimes a CT scan of the shoulder will be needed to exactly delineate the complexity of the fracture and also to plan on the appropriate treatment.
Initial treatment is to give adequate pain relief by giving painkiller medicines. Resting the arm in a sling will give some comfort. Majority of the fractures occurring in the proximal humerus are simple fractures. If the broken fragments of a fracture are in continuity and the alignment of the upper arm is in acceptable condition, then the treatment for these fracture will be resting on sling until the fracture starts healing. This will be usually a period of 6 – 8 weeks. Then the sling can be taken off and further mobilization can be encouraged.
If the shoulder joint is worn leading on to severe pain, an artificial joint can be implanted and this is called Total shoulder replacement. A satisfying function and good pain relief can be achieved after performing total shoulder replacement. If no complications occur, more than 95% of the time a shoulder replacement can last for more than 10-15 years.
The procedure is done for those suffering from advanced arthritis of the shoulder joint. Total shoulder replacements are also performed for fractures of the upper end of arm bone. In fractures, usually it is such a situation that the fixation is not possible as the fracture is complex
The choice of procedure depends on number of factors. A severely destroyed humeral head and glenoid surface with well working rotator cuff muscles would require a Anatomic Total Shoulder Replacement. If the rotator cuff muscles are not functioning and a person has got severely damaged shoulder joint, then Reverse polarity Total Shoulder Replacement will be the correct option. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder blade bone and a plastic socket is attached to the upper arm bone. This gives a biomechanical advantage by changing the centre of the rotation of the shoulder joint and also tensions the arm muscle called deltoid. These factors allow using the deltoid muscle instead of the torn rotator cuff to lift the arm thus facilitating to regain the lost movement.
If the destruction of the humeral head is not severe and hence if adequate bone stock is available, then Resurfacing arthroplasty of the shoulder joint will be the option. The above description gives a general outline. Shoulder replacement surgery is highly technical. Each case is individual. The situation will be carefully evaluated before making any decisions. The correct nature of procedure will be determined after physical examination and performing radiological investigations such as X ray and CT Scan.
You will be anaesthetized for the surgery. Hence you would have some blood tests and routine check up by an anesthetist for the surgery. The intensity of the pain in first 24 hours is high. Hence during the surgery you will also have an injection to block the nerve supply of the arm. This block helps to get the whole arm numb and you feel a very little pain after the surgery. A physiotherapist will see you before the surgery and teach you on the exercises that you will have to carry on after the surgery.
An inpatient stay in the ward for 2-3 days may be essential to optimize pain and train for getting range of motion before discharge. An adequate pain relief will be provided, wound will be checked, and an X ray of the shoulder joint will be taken. A physiotherapist will teach the exercises that need to be carried on to get satisfactory function. When discharged, a plan of home exercise programme will be taught.
The success of the surgery is very high. It is in the order of 90-95%. Most of the patients are satisfied with pain relief and gain of mobility.
The complications after the surgery are minimal. Infection, Nerve injury, Dislocation and Fracture are the important complications to think about, but fortunately the incidence of these problems is low.
A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. A sling will be given for comfort during the first four weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery.
Here are some “do’s and don’ts” for when you return home:
Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.
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