Humeral head fracture or humeral head fracture is a common fracture (broken bone), especially in older people. It is noticeable by severe pain and limited mobility of the affected arm and is usually caused by falls on the outstretched arm that have been caught with the hand, forcing the shaft of the humerus bone upward through the head. Alternatively, the fracture may result from falls directly on the shoulder, usually breaking off only portions of the head.
What is a humeral head fracture?
By definition, a humeral head fracture is a fracture of the head of the humerus, which is above the neck. The neck of the humerus is not easily demarcated, so it is generally referred to as a humeral head fracture when the humerus is broken above the shaft. It must be differentiated from a humeral shaft fracture or a distal humerus fracture, which is a humerus fracture at the elbow joint. A so-called subcapital humerus fracture occurs when the shaft breaks at its junction with the humeral head and the shaft is only slightly pushed into the humeral head.
Causes
The main causes of humeral head fractures are falls in which patients try to catch themselves with the outstretched arm or falls directly on the shoulder. Predominantly affected are older people who already suffer from osteoporosis. In cases of severe osteoporosis, a strong blow to the shoulder is also sufficient and the humeral head fractures. This blow can come either from the side or from above. The shoulder joint is the most unstable joint in the whole body, the ratio between the head of the joint and the glenoid cavity is 4:1. Only the muscular rotator cuff (several muscles release fibers that almost completely surround the joint) stabilizes the joint. However, the rotator cuff cannot protect against fractures, so both dislocations (“dislocated” joint) and fractures are common here. However, fracture can also occur in young people after major trauma, such as skiing accidents or falls from a great height onto the shoulder.
Symptoms,, complaints and signs
A humeral head fracture typically presents with a painful restriction of motion in the shoulder area. Swelling develops in the area of the humeral head and above, which is painful to the touch. This pressure pain is usually accompanied by sensory disturbances or paralysis. A bruise may appear in the axillary region and may extend to the inside of the arm and to the side of the chest. Affected individuals often move the arm in a protective position due to the pain and support it with the other arm. If the humeral head fracture is associated with dislocation of the humeral head from the glenoid cavity, it can be clearly palpated under the skin. A simple humeral head fracture cannot be seen externally. However, the symptoms can usually be traced to a specific cause. Assuming early treatment, the complaints subside after four to six weeks. Movement restrictions may persist for up to two months. Permanent restrictions may remain. Chronic pain may develop, or mobility may be permanently reduced as a result of a humeral head that has not grown together optimally. If the humeral head is broken into many fragments, the symptoms mentioned can be very intense. Bone fragments may detach and cause tissue injury.
Diagnosis and progression
The diagnosis is relatively simple to make. The patient comes to the doctor with pain in the shoulder, and the first step after a physical examination is an X-ray, on which the fracture is usually already visible. Computer tomography is then used to determine even more precisely how the individual fragments of the bone are positioned. The course of a humeral head fracture is usually good because therapy, especially if a prosthesis is used, can restore full mobility to the arm.
Complications
As a humeral head fracture progresses, complications may occur. It is not uncommon for various injuries or impairments of the nerves or vessels located in the shoulder region to appear as a direct sequela. As a result, the affected persons suffer from paralysis or circulatory disorders.In some cases, partial stiffening of the shoulder joint occurs with both conservative and surgical therapy. This complication can usually be treated by arthroscopic capsular release combined with anesthesia mobilization and regular physical therapy. In some patients, the humeral head fracture does not heal properly. As a result, there is a risk of developing a so-called pseudarthrosis, also known as a false joint. Pseudarthrosis is the term used when the fractured bone fragments do not grow back together correctly to form a joint. Other conceivable complications are a renewed malposition of the fracture, death of the humeral head, which particularly affects older patients, a labrum lesion, which is an injury to the joint lip, and a rotator cuff rupture. The rotator cuff is a four-headed muscle group that plays an important role in shoulder movements. If there is a severe humeral head fracture, there is a risk of injury to the axillary artery or axillary nerves. After surgery for humeral head fracture, it is also possible for infections to occur in the surgical area. This complication is particularly feared by medical professionals because it significantly complicates further treatment.
When should you see a doctor?
Elderly people who experience severe pain in the shoulder after an accident or fall should consult their primary care physician. A humeral head fracture is usually easily treatable but requires prompt evaluation by a medical professional. Therefore, if you experience any unusual discomfort in the shoulder area, you should see a doctor quickly. This is especially true if the symptoms rapidly increase in intensity. If bruising, swelling or increasing movement restrictions occur, a doctor must be consulted on the same day. In the event of signs of paralysis or circulatory problems, it is best to go immediately to the doctor’s office or the nearest hospital. People suffering from severe osteoporosis are particularly at risk. The fracture occurs predominantly in older people who have already suffered a fracture of the shoulder bones once. Those who belong to these risk groups should talk to their family doctor or an orthopedist if they experience sudden pain. If signs of pseudoarthrosis develop after treatment of a humeral head fracture, the appropriate medical professional must be informed.
Treatment and Theraie
Surgery is then planned, some involving screws and wires and some involving replacement of the entire humeral head (especially in patients with osteoporosis and osteoarthritis) and the use of what is called a total endoprosthesis (TEP). There are many surgical options for fracture treatment, the choice of which depends on which parts of the humeral head are fractured and how stable or unstable the patient’s bone substance basically is. Surgery is always performed for humeral head fractures because, unlike rib fractures, this fracture does not grow back together properly on its own. In addition, the shoulder is simply too important a joint to leave proper healing to chance. After surgery, the patient is usually given a special bandage that fixes the arm in a certain position: Angled at right angles in the elbow joint, approximately 30 degrees anteverted, i.e. rotated forward. If the arm is fixed against the body, as was the case in the past, there is a risk that a nerve will be pinched. This can lead to chronic complaints – which is why there are now special prefabricated positioning pillows that are given to patients as standard during such operations. It is important that the patient leaves the arm alone, but does not work with it too little; physiotherapy is usually prescribed. Physical therapists then ensure that the patient moves the arm through at least every two days in a way that does not compromise healing.
Outlook and prognosis
The prognosis of humeral head fracture is tied to the severity of the damage as well as the age of the patient. With increasing age, complete recovery usually does not occur. The bones become more unstable in the course of life and can no longer be sufficiently regenerated by the organism in the event of damage. In a large number of cases, older patients experience a permanent impairment of their mobility and a decrease in their general resilience.Young patients receive a significantly better prognosis in most cases. In them, complete healing is often documented. At the same time, in addition to age, the number of fragments is decisive for the prognosis. The fewer the fragments, the better the chance of recovery. The best results are achieved with early diagnosis and immediate treatment. The treatment plan for all patients includes surgery. This is always associated with possible complications and risks. Patients with a weakened immune system show a delay in the healing process. If other underlying diseases of the skeletal system are present, the prognosis is further worsened. Nevertheless, a humeral head fracture does not pose a risk to the patient’s life. At worst, mobility is restricted, which triggers a restructuring of daily routines. In individual cases, this can lead to psychological sequelae.
Prevention
It is difficult to avoid a humeral head fracture, because no one voluntarily falls on the shoulder. However, the elderly in particular can prevent osteoporosis and the resulting higher brittleness of bones by getting plenty of exercise and making sure their calcium intake is adequate. Calcium is particularly abundant in milk and dairy products.
Aftercare
Follow-up care depends on whether treatment was by surgery or, as in most cases, by immobilization of the fracture fragments by orthosis. Postoperative follow-up visits for wound control must be followed, during which the physician will develop an individualized treatment plan to achieve normal range of motion. If the patient has been fitted with an orthosis, he or she may and should use his or her hand and fingers, but should not lift any objects that weigh more than a full cup or a telephone receiver. To prevent stiffening of the elbow joint, the orthosis must also be removed several times a day and the elbow moved carefully. After three to six weeks, careful arm movements may be started. If the patient is unsure about this, he can seek support from a physiotherapist. A control examination after about six weeks decides whether the orthosis must still be worn or whether it can be removed. In children, with their faster wound healing, this examination can already be performed after 4 weeks. After 3 months, the muscle strength has recovered. Nevertheless, sports activities should not be started until four to six months after the start of therapy. Pain and swelling can still occur at any time during the first year and are not a cause for concern.
Here’s what you can do yourself
After receiving medical therapy for a humeral head fracture, the patient first immobilizes the affected arm and avoids putting any stress on the injured shoulder if possible. In this way, he or she prevents possible complications and promotes the healing process of the fracture, as well as wound healing in the case of surgery. During the initial healing phase, all physical strain should be avoided. Sports should be avoided for the time being, as the risk of injury is too high and overexertion of the shoulder is likely. For difficult but necessary movements, it is advisable to have the support of another person. In the further course of healing, physiotherapeutic exercises promote the restoration of the load-bearing capacity and mobility of the affected shoulder. The patient first practices physiotherapy with a physiotherapist and then performs it regularly at home to quickly rebuild the muscles. Later, in consultation with the doctor, the external application of pain-relieving ointments to the shoulder area is possible, for example, also with a cooling or warming effect. If a scar is present, the patient relieves unpleasant symptoms such as pain or pulling in the scar area by means of adequate scar care. Gradually, the patient increases his or her physical activity again under medical supervision and guidance, which has a positive effect on the general quality of life.
