Proximal Humerus ORIF or Reverse Replacement
Download this patient information sheet (PDF)
What’s the Problem?
The proximal humerus – or the ball from the shoulder’s ball and socket joint – is commonly injured after falls and traumatic accidents. In some instances, non surgical treatment is reasonable. However, depending on overall health, activity and fracture pattern, some fractures do better with surgery – either surgical fixation or replacement.
How can you treat it?
In some instances, non-surgical treatment is appropriate. This includes:
- Taking pain relief
- Wearing a sling for 6 weeks
- Physio to mobilise the shoulder and arm once the fracture has healed
Ultimately, surgery is only reserved for patients whose injury is severe enough that they would have symptoms of severe shoulder pain, stiffness and immobility without it.
The Operation
Traditionally, fixation of proximal humeral fractures using plates and screws has been performed, with good results. This involves an incision over the front of the shoulder. The broken fragments of bone are manoeuvred back into position, and then a plate and screws used to permanently hold them in place. Afterwards, the arm is placed in a sling for around six weeks and gentle rehabilitation commenced.
An alternative to fixation is shoulder replacement surgery, which has now been shown to give better outcomes in certain patient demographics. This operation involves a similar incision along the front of the shoulder. The fractured fragments of bone are removed, and then a shoulder replacement inserted. The shoulder is a “ball and socket” joint, and in this instance, to allow for movement, this configuration is reversed – to a “socket and ball”. After surgery, the arm is placed in a sling for around six weeks and shoulder rehabilitation commenced
The Anaesthetic
You will be asleep for the duration of the operation (ie a general anaesthetic).
The anaesthetist may talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. Alternatively, Mr Lau can put local anaesthetic into the wound whilst you are asleep, which can also help reduce pain.
What are the Risks of this Operation?
- Infection:
Usually only a superficial wound infection to the top-most layer of the skin. In rarer cases a deep infection can develop and this is a serious complication that may require further surgery and exchange of the implants. Rare but serious, <1%. - Stiffness and ongoing pain:
It is common to have shoulder stiffness for a few months after the operation. This is because your shoulder need to be immobilised in a sling to allow the bone to heal or the prosthesis to settle. Physio after surgery will help with improving movement, but some shoulder rehabilitation will be required. Occasionally, the stiffness may be secondary to the metal plate, and a second operation may be required to remove it. - Damage to the nerves and blood vessels around the shoulder.
Rare but serious, <1% - Metalware Removal:
Ideally, the metal plates and screws stay inside your shoulder for life. In some cases, however, the metalware may become irritable to you with movement. If this occurs, the plates and screws can be removed once the fracture has healed – usually at least 12 months after the first operation. This is a day procedure and no rehabilitation is required. - Clots – Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE).
These are very rare in upper limb surgery, and much lower when compared to lower limb cases like hip and knee replacements. Rare and affects <1% - Loosening of the Implants:
This is not likely to happen for many years after the surgery. The implants used by Mr Lau have an excellent track record in the AOA National Joint Registry
Benefits
If Mr Lau recommends surgery on your proximal humeral fracture, it is because he feels you will have a better outcome with surgery. In particular, your shoulder will be more pain free, have a greater range of motion and have greater functional improvements.
What can I expect?
You will wake up with your arm in a sling after your surgery. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio will see you to go through some exercises you can do to mobilise the fingers, wrist and elbow to prevent excessive stiffness in these joints. These exercises will change over the next few weeks to months but you should try to do them regularly to maximise your rehabilitation.
Most patients spend 1-2 days in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks. Another appointment with Mr Lau will be at 6 weeks with repeat XRs
What should I avoid doing?
- In the first 2 weeks: keep your wound dry. Try to mobilise your fingers and elbow as much as possible but generally remain in the sling except for exercising and hygiene
- Between 2 and 6 weeks: gradually use the sling less and less. You will have no restrictions in moving your shoulder but should limit lifting to lighter objects like a phone or cup.
If you have had a shoulder replacement, there are two additional restrictions that your physio will help you with, which are no external rotation beyond neutral and no extension beyond neutral. - Between 6 and 12 weeks: full range of motion, but no heavy lifting till after 12 weeks
Return to…?
- Work: Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6 weeks before you can use both arms freely whilst seated.
For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months - Drive: In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively.
- Sports/Hobbies:
- Gentle swimming (breaststroke, not freestyle): after 6 weeks for fixation, 12 weeks for replacement
- Gardening (light tasks only): 8-12 weeks
- Bowls: after 3 months
- Golf, tennis, badminton, squash: after 4-6 months
- Weights: commence after 3 months
Concerns or questions?
If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au
If you need urgent medical help, call 000 or go to your nearest emergency department.
Rehabilitation protocols
These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.