Upper arm and shoulder fractures are treated surgically when nearby joint fractures, open fractures or comminuted fractures exist. Depending on the fracture, different procedures with screws, plates, intramedullary nails or prostheses are used.
An upper arm fracture, also known as a humerus fracture, generally occurs as a result of massive force when a person falls on their arm. In the case of older people with reduced bone density (osteoporosis), a mild fall where they support their weight on their arm can sometimes be sufficient to cause such a fracture. Uncomplicated fractures can be treated conservatively. This means when there are no injuries to the soft tissues, no displacements and no bone fragments. On the other hand, complicated comminuted fractures, i.e. open fractures or fractures of the head of the humerus near the shoulder joint (shoulder fracture) should be treated surgically. Depending on the type and location of the fracture, different osteosynthesis procedures are used.
What preparations are carried out before the procedure?
The exact progression of the break is displayed with an x-ray, including an MRI examination.
Furthermore, all the usual pre-operative assessments are required before an operation, such as a blood test, blood pressure measurement and an ECG. The patient should stop taking blood-thinning medication and should have an empty stomach for the procedure.
How is the operation performed?
An operation for an upper arm fracture is usually performed on an outpatient basis and it is generally carried out under regional anaesthesia (interscalene block). Patients also receive a sedative. In the case of fractures near the shoulder joint or in the shoulder joint, a shoulder arthroscopy is sometimes carried out at the beginning of the operation. During the operation, the patient sits in a beach chair position.
The surgical procedure used is determined by the location and type the upper arm fracture.
Percutaneous screw fixation
Percutaneous screw fixation involves affixing the bone pieces directly with a screw. Firstly, the fracture is straightened via small incisions in the skin and under fluoroscopic imaging. In the process, a guidewire (Kirschner wire) is also bored into the desired position in the bone fracture. Finally, a bone screw is screwed in via the guidewire, and the wire is removed once more. An average of 2 to 3 screws are required for stable fixation of a fracture.
Intramedullary pinning is used primarily in the case of fractures under the shoulder joint. This method involves fixing the fracture internally by inserting a pin into the bone marrow space. The intramedullary pin connects the bone over the fracture line and is fixed with crossway bolts so that it cannot displace itself.
Metal plates are used to fix comminuted fractures (those with multiple fragments). Firstly, the fragments are brought into the correct position with a wire. Then a titanium plate is laid over the shoulder bone and screwed onto the stable parts of the bone and onto the bone pieces. Afterwards, the wires can be removed once more. A wound drain is usually inserted before closing the operation wound.
In the case of complex fractures with multiple fracture pieces, a shoulder prosthesis is sometimes required. This procedure is covered in the chapter entitled Shoulder prosthesis.
What is the success rate of this procedure?
The healing process depends on various factors. These include the general condition of the patient, the type of fracture and the condition of the bone. In general, upper arm fractures heal well after surgical treatment and more quickly than with conservative treatment. It is important for the healing process to start targeted physiotherapy exercises early.
What are the possible complications and risks of this procedure?
Operations on upper arm fractures usually proceed without major complications. As with all surgery, in exceptional cases the operation may lead to infections, nerve damage, post-operative haemorrhaging or blood clots. In rare cases, this can result in the death of bone parts (humerus head necrosis). If this occurs, an artificial should joint must be inserted in a subsequent operation.
What happens after the operation?
Initial passive exercises of the upper arm are carried out while the patient is still in hospital; a stay of approx. five days is usually required. The patient can perform simple tasks such as eating, washing or writing again within a week. The upper arm is rested in a shoulder sling for several weeks. The fracture usually takes between 6 and 12 weeks to heal fully. The physiotherapy exercises must be carried out on a regular basis to reduce stiffness in the shoulder joint.
After percutaneous screw fixation, the metal must be removed after 3 to 4 months. Titanium plates can be left in the body as long as they do not cause complaints.
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