Operation of an upper arm fracture

The operation of an upper arm fracture can be performed in different ways depending on the severity of the fracture.

Less invasive techniques for an upper arm fracture

Closed reposition and percutaneous osteosynthesis reduce soft tissue trauma and the risk of avascular necrosis of the humerus.

However, studies have shown that, unlike the conventional method with plates and intramedullary nails, the percutaneous procedure ensures less stability, even if it allows blood circulation to be maintained.

Intramedullary nails for an upper arm fracture

The intramedullary nails used in proximal fractures cause minor trauma to the tissue, but give a lot of stability.
In these operations, access is directly laterally through the deltoid muscle with an incision along the supraspinatus tendon.
This approach is considered less invasive than access via the anterior deltoid muscle, but the disadvantages due to the incision of the supraspinatus tendon have not yet been determined.
Stable osteosynthesis is advantageous because it makes it possible to start functional therapy at an early postoperative stage and avoid restrictions in shoulder movement.
In addition, it is assumed that a detachment of the fragments is less likely in this procedure.

Biomechanical studies have shown that intramedullary nails on the proximal humerus are more beneficial than a plate for the following reasons:

• stiffness of the implant,
• deformation resistance,
• Surgical success.

In addition, the development of anterior nails enables greater stability in osteoporotic bones and enables early mobilization.

Stable angle plates for an upper arm fracture

This open reposition procedure allows for more accurate reposition and high stability with the osteosynthesis plate. However, this is offset by a higher risk of necrosis of the humeral head compared to other surgical procedures.
In addition, there are studies that indicate the possibility of developing complications, such as the leakage of the screws or a subacromial impingement syndrome due to the bulky plates.
The functional results with conventional procedures of proximal humeral fractures are different.
The goal of fixation of the proximal humeral fracture is anatomical reposition to maintain mechanical stability and restore range of motion without damaging the blood vessels of the humeral head.

The angle-stable fixing plates were introduced as a potential cure for this problem.
As with other fixing plates, the stability of this structure is created by the plate-screw union, which eliminates the need to loosen large areas of the periosteum and thus reduces damage to the blood vessels.

This structure creates a fixture with a fixed angle and is achieved by inserting screws into a plate with holes.
The mechanical blockage consists of the outer plate, which is connected to the bone and fixed with some screws. The screws are fasteners that connect the plate to the bone.
This structure creates an internal fixation that ensures mechanical stability and healing of the fracture. This technique is a good solution for osteoporotic bones.

Hemiarthroplasty for an upper arm fracture

In this surgical procedure, only one implant is inserted into the humerus, while the socket of the shoulder blade (the other part of the joint) remains intact.

The main indications for primary hemiarthroplasty are:

• displaced fractures with four parts,
• fractures with dislocation and impaired blood flow to the head of the humerus,
• Fractures of the head of the humerus, affecting more than 40% of the joint surface.

Summary

The preoperative classification of proximal humeral fractures and comprehensive knowledge of bone and vascular anatomy are fundamental prerequisites for successful treatment and for the choice of procedure.

If reposition and fixation are necessary, aggressive reposition procedures can affect blood flow to the humeral head, which can lead to necrosis regardless of the type of implant.
Modern implants, such as intramedullary nails for proximal humeral fractures and anatomically shaped stable angle plates, also offer high stability in osteoporotic bones and enable the preservation of the blood supply to the humeral head.
These implants allow functional exercises to be performed and have led to good results in most patients, with a tolerable complication rate.

Alternatively, non-surgical treatment of displaced fractures with two or three parts is considered due to the increased surgical risks in elderly patients with severe morbidity.
Elderly patients with displaced fractures of four parts, fractures with dislocation and injuries to the head of the humeral should consider hemiarthroplasty, as it significantly relieves pain despite the functional limitation.

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