Shoulder fractures occur after a trauma. Depending on the quality of the bone, the fracture may result from minor or major trauma. We want to say that in osteoporotic patients a minor trauma such as a fall at home can lead to a fracture.
The most frequent fractures are clavicle fractures. These can be classified according to their location in the collarbone and also according to the type of fracture “trace”. The decision on the best type of treatment takes into account in addition to these features the fact that the fragments originate in the skin, there is compression of some of the nerves that go to the arm and also the fact that there is a superior shortening (overlapping of the fragments). at 2cm. All your doctor needs to make a decision is clinical observation and a radiographic examination that may or may not be performed with the immobilization device.
If you choose non-surgical (conservative) treatment, the most common immobilization is what is called a “posterior crossover” which should be used about 3 to 4 weeks. In fractures of the external 1/3 of the collarbone, the immobilization to be used should stabilize the shoulder and support the arm, so that “Gerdy” type devices are better indicated. After the immobilization period, bone callus may not be visible on the radiograph because at this stage only a fibrous callus is formed and therefore not visible on the radiographs.
Here the pain the patient has is a good indicator of fracture focus stability so the smaller the fracture focus, the more likely the consolidation is taking place. For 4 weeks the immobilization devices can be progressively removed and the healing process will be completed by 12 weeks. If there is no consolidation there may be a need for surgical intervention at this stage, justified by the maintenance of pain and crackles in the fracture focus. In these situations, it is sometimes necessary to use a bone graft taken from the iliac (pelvic bone) to ensure the best biological conditions for consolidation.
In patients in which the operative decision is made in the initial phase by the assumptions already mentioned, our treatment of choice is fixation with plate and screws of the fragments. This option gives a high percentage of consolidations and allows early mobilization of the affected shoulder. Its main disadvantage is that there is sometimes a need to remove the plate after a consolidated fracture because as the collarbone is practically under the skin the plate and screws may disturb. Operated patients use an armrest for comfort for the first 2 weeks but can perform simple daily tasks such as washing, dressing, feeding and using the computer. Driving should be limited to 3 weeks.
The fractures of the proximal humerus
They are more common in middle-aged women with osteoporotic bone. However, they are also common in younger individuals and especially associated with certain activities such as mountain biking, skiing and motorcycling. These fractures may or may not be associated with shoulder dislocation, nerve damage, or even arterial injury. To make a correct diagnosis we do radiographic examinations in various orientations generally with radioscopy control. Other imaging techniques such as CT and MRI are very rare. Radiography is sufficient in most cases to characterize the fracture according to the number of fragments, their separation and their angulation. Another essential factor to take into account is the viability of the humeral head.
According to the radiographic exams, bone quality, time since fracture, age, disease and risk of humeral head necrosis our group decides which treatment is best for your condition. When we decide on a non-surgical treatment it may not mean that the fragments are all in an ideal position and that no small changes in function are expected, but that the benefits they would have with a surgical intervention do not justify it in view of the inherent risks. to all surgeries.
If conservative treatment is the option you will be immobilized for about 3 to 4 weeks with a Gerdy type device and can remove it for hygiene. At the end of this period begins a physical therapy program that can be extended to 3 months.
If surgical treatment is required.You are likely to be hospitalized for 2 or 3 days. In the vast majority of cases surgical treatment consists of fixing the fracture fragments in their original correct position and with a device (plate and screws) that, for their stability, allows for early mobilization and use. This decreases the post-surgical stiffness and allows soft tissue (muscle) recovery at the same time as the fracture consolidates. In some cases, fracture characteristics and / or the risk of humeral head necrosis make reconstruction and fixation impossible. In these cases the best results are obtained by placing a shoulder prosthesis, which replaces the head and around which the other bone fragments are fixed.
The results of treating proximal humerus fractures depend on the patient’s own factors such as age, concomitant disease and bone quality, but also on factors inherent in the characteristics of the fracture itself, as has been said. In most patients the regained function allows daily activity adjusted to the various age groups without limitations.
The humerusfractures come from violent injuries such as traffic accidents or motor sports, but can occur in older people with minor injuries. They are characterized by angular and rotational defects of the arm and may be associated with paralysis of the radial nerve which has a path very close to the humerus. This complication translates into the inability to pull the wrist back and extend the thumb on the affected side. It should be noted that the vast majority (> 90%) of these paralysis are transient, fully recovering, but the recovery period may extend to 6 months. Whether the paralysis is pretreatment or after surgical treatment, no electromyographic examination is required before 3 weeks. This confirms the diagnosis we have already made clinically and serves as a comparative standard for subsequent examinations but in the initial phase does not change our attitude towards the large percentage of spontaneous recoveries translates into vigilance and attitudes that prevent the development of stiffness and positions. vicious fist. During the period of paralysis it is necessary to use a splint and to perform physical therapy.
The treatment of humeral fractures can be conservative (non-surgical) or surgical. The decision is made taking into account the type of fracture trace, the number of fragments and the anatomical location of the fracture. In conservative treatment the immobilization can be done with a plaster or with a Gerdy, again according to the characteristics of the fracture and usually lasts at least up to six weeks.
The surgical treatment once again aims at the correct positioning of the bone fragments and a fixation that allows an early mobilization. Two different systems can be used. The plates, which is rarer or the dowels. These are approximately humeral length metal rods that ensure alignment and length and are complemented with transverse screws to ensure correct rotation.
The elbow fractures
The elbow fractures are of various types and may or may not be associated with dislocation of the elbow.
The simplest fractures are olecranon fractures and radial tacicle fractures. The first, unless there is complete coaptation (the bone is only cracked), have surgical indication. In most cases a voltage band device is used which enables early mobilization. Radial tactical fractures if they have separate fragments or with a certain angle may have surgical indication. Depending on the type of fracture, we can only remove the fragment, remove the entire tacicle, assemble and fix the fracture using a plate and screws, or replace it with a prosthesis. Consistently treating these fractures has a good functional outcome.
More complex is the association of these fractures with elbow dislocation. In this case, ligament injuries are associated that need to be evaluated and sometimes repaired.
Also complex are fractures of the distal end of the humerus due to the number and size of the fragments that constitute the fracture. These are fractures that in most cases have surgical treatment and require a complex surgical technique that aims at the correct fixation of the fragments using plates and screws. This technique allows early mobilization to avoid significant decreases in mobility.
The fractures of the forearm bones
The fractures of the forearm bones can occur with only a fractured bone or associated fractures of both bones. These work together and it is therefore essential that the anatomical relationships be maintained between them. For this reason, these fractures almost always require surgical intervention. Except in children the treatment is done with plates and screws since it is essential that with a direct approach the anatomy is restored.