Shoulder fracture - Proximal Humerus fractures

Proximal Humerus fractures are the third most common fractures in the elderly population. Fortunately 80% of the fractures are non-displaced or minimally displaced and can be managed non-operatively. The remaining 20% of the fractures require some sort of operative management. The fractures that require surgery are the ones that are significantly displaced and will not yield a good outcome if left as such in the displaced position. 

Proximal humerus fractures are divided into 3 major types- two part, three part or four / five part fractures depending on weather the Greater tuberosity or lesser tuberosity is fractured from the shaft of the humerus bone. The two part fractures are simple to treat operatively if displaced. They can be fixed with a interlock nail of locking plate.  The three part and four part can be managed non-operatively if they not significantly displaced. The recent published data shows that the three part fractures that are significantly displaced in the older age group tend to have similar outcomes whether managed non-operatively or if fixed internally with a locking plate. However it will be wise to anatomically reduce and fix a significantly displaced fracture in the younger age group to restore active movements the shoulder.

Often in the elderly age group when the fracture is 4-5 part and the bone is very osteoporotic, internal fixation is not a good option and in this scenario, the head of humerus needs to be replaced. Hemi-replacement of the shoulder has been practiced since a long time with average to fair results. Off late reverse shoulder replacement for comminuted proximal humerus fractures has been increasingly used in the western countries.

Reverse shoulder replacement yields superior outcomes than hemi replacement in the elderly in very comminuted fractures, especially when the greater tuberosity is also broken into many pieces. Experience with reverse shoulder has grown in recent years and while there are reportedly more complications with this prosthesis, it also yields far superior results if properly done.

In short the recommendation is for non-operative management in both young and old for minimal displaced or non-displaced fractures. In the significantly displaced 3-4 part fractures, internal fixation by locking plate is best in the younger age group and some older people, though most elderly will require either they being left alone or replaced with hemi replacement or reverse shoulder replacement

Arthroscopic Repair

Shoulder arthroscopy involves a tiny camera called an arthroscope to examine or repair the tissues inside or around the shoulder joint. The arthroscope is inserted through a small incision (cut) in the skin.

The word arthroscopy is derived from two Greek words, “arthro” (joint) and skopein" (to look). Therefore, the term literally means "to look within the joint.“ During the procedure, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. 

Due to the thin structure of the arthroscope and surgical instruments, the surgeon uses very small incisions, rather than the larger incision needed for standard, open surgery. This results in less pain for patients and shortens the recovery time.

Causes

Injury, overuse, and age-related wear and tear are common reasons behind most shoulder problems.

Arthroscopic shoulder surgery

may relieve painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage, and other soft tissues surrounding the joint.

Common arthroscopic procedures include:

·         Rotator cuff surgery

·         Bone spur removal

·         Removal or repair of the labrum

·         Repair of ligaments

·         Removal of inflamed tissue or loose cartilage

·         Repair for recurrent shoulder dislocation

Less common procedures such as nerve release, fracture repair, and cyst excision can also be performed using an arthroscope. 

The procedure

Shoulder arthroscopy is most commonly performed using regional nerve blocks which numb the shoulder and arm. This numbing medicine is injected in the base of the neck or high on the shoulder. This is where the nerves that control feeling in the shoulder and arm are located. In addition to its use as an anesthetic during surgery, a nerve block will help control pain for a few hours after the surgery is completed. Many surgeons combine nerve blocks with sedation or a light general anesthetic because patients can become uncomfortable staying in one position for the length of time needed to complete the surgery.

Most arthroscopic procedures take less than an hour; however, the length of the surgery depends on what repairs are required.

During the surgery, the surgeon will first inject fluid into the shoulder to inflate the joint. This makes it easier to see all the structures of the shoulder through the arthroscope. The surgeon then proceeds to make a small puncture in the shoulder (about the size of a buttonhole) for the arthroscope. Fluid flows through the arthroscope to keep the view clear and control any bleeding. Images from the arthroscope are projected on the video screen showing the surgeon the inside of the shoulder and any damage.

The surgeon may close the incisions with stitches or steri-strips (small Band-Aids) and cover them with a large, soft bandage.

Recovery

Although recovery from arthroscopy is often faster than recovery from open surgery, it may still take weeks for the shoulder joint to completely recover.

Some pain and discomfort can be expected for at least a week after surgery. In cases involving extensive surgery, it may take several weeks before the pain subsides. Ice and painkillers aid in the treatment for shoulder pain that follows the surgery.

Also, rehabilitation plays an important role in the recovery process. An exercise program helps regain shoulder strength and motion.

Frozen shoulder or adhesive capsulitis

“Frozen Shoulder” term is a big misnomer.

There is nothing frozen inside or outside the shoulder. In fact it may just be the opposite. The tissues may be inflamed to some extent for some time period.

Codman coined the term “frozen shoulder” in 1934.  However, now it is loosely applied to any misunderstood painful condition of the shoulder.

Scientifically speaking, frozen shoulder, also known, as adhesive capsulitis is a global restriction of movements of the shoulder, which is diagnosed clinically and with a plain X Ray without the aid of any complex investigation like MRI or CT scan

The most important role in diagnosing this condition is that of the clinician, since this can only be diagnosed clinically.

The big question is, however, how to best treat it? Surgery? Rest? Exercise? Physiotherapy?

There are equal numbers of patients disappointed by each of the above treatment modalities.

The best way forward is very clear in my mind, after having treated several of frozen shoulders. Exercises done at home with a corticosteroid injection in the shoulder is the best way to treat it. The key point is to never opt for surgery and to remember that the patient has to work hard at the exercises by himself at home without relying on physiotherapy.

Injection of a corticosteroid is one of the key steps in the management of this condition, since the pain in shoulder does not let the patient do a whole lot of exercises. An injection in the shoulder eases the pain and in some cases the pain disappears entirely within 3-4 weeks. The site of injection, however, varies as per the preferences of the treating physician. The latest advancement in the field of pain management is to inject corticosteroid in the area of the Suprascapular Nerve, which eases the pain considerably.

This is followed by a set of stretching exercises done at home regularly, which slowly increases the range of motion of the patient’s shoulder.

The onlything to remember here is that these are stretching exercises and NOT theraband or strengthening exercises. 

Shoulder Replacement Surgery

Shoulder replacement surgery involves replacing the shoulder joint if it has been damaged or worn away, usually by arthritis or injury. The primary goal of shoulder replacement surgery is pain relief, with a secondary benefit of restoring motion, strength, function, and assisting with returning patients to an activity level as near to normal as possible. 

Causes

Shoulder replacement surgery is usually done when there is severe pain in the shoulder area, which limits the ability to move the arm. Common reasons behind shoulder pain are:

·         Osteoarthritis

·         Poor result from a previous shoulder surgery

·         Rheumatoid arthritis

·         Badly broken bone in the arm near the shoulder

·         Badly damaged or torn tissues in the shoulder

.         Tumor in or around the shoulder

Procedure

Before surgery

The patient is asked about any medications that they have been taking. This includes medicines, supplements, or herbs bought without a prescription. Medicines which make blood clotting harder to occur shall be refrained from consumption before surgery. Consumption of cigarettes or alcohol would be prohibited before the surgery as these factors slow down the recovery process. The patient will likely be asked not to drink or eat anything for 6 to 12 hours before the procedure.

During surgery

There are various types of shoulder replacement surgeries. For total shoulder replacement, the round end of the arm bone will be replaced with an artificial stem that has a rounded metal head. The socket part (glenoid) of the shoulder blade will be replaced with a smooth plastic shell (lining) that will be held in place with special cement. If only 1 of these 2 bones needs to be replaced, the surgery is called a partial shoulder replacement, or a hemiarthroplasty.

For shoulder joint replacement, the surgeon will make an incision (cut) over the shoulder joint to open up the area. Then the surgeon will:

·         Remove the head (top) of the upper arm bone (humerus)

·         Cement the new metal head and stem into place

·         Smooth the surface of the old socket and cement the new one in place

·         Close the incision with staples or sutures

·         Place a dressing (bandage) over the wound.

The surgeon may place a tube in this area to drain fluid that may build up in the joint. The drain will be removed when the patient no longer needs it. Usually, the surgery takes about 1 to 3 hours. The patient would be expected to stay in the hospital for 2 to 3 days post surgery. Painkiller may be prescribed as treatment for shoulder pain to lessen any discomfort when the anesthetic wears off.

Recovery

It usually takes at least three months to make a full recovery from a shoulder replacement surgery. However, this varies between individuals, so it’s important to follow the surgeon’s advice.

The amount of time the dissolvable stitches take to wane off depends on the type of stitches used. For this procedure, they should usually disappear in about six weeks. The patient may need to keep their arm in a sling for several weeks after the operation.

 They should be able to look after themselves and eat and dress within a few weeks after surgery. The patient should refrain from placing their arm in any extreme positions (such as straight out to their side or behind their back) for six weeks after the operation.

The surgeon may recommend avoiding any heavy lifting for up to six weeks after the operation. It’s best not to do any repetitive heavy lifting at all after the operation as this will help the new joint last longer.