Open reduction and internal fixation, cosmetic suturing, and biological tissue sealing for complex proximal humerus fractures in the elderly

Recently, I encountered a 68-year-old female patient who presented with severe pain in the right shoulder and a near-total loss of arm mobility following a fall approximately 2 weeks prior. Through clinical examination combined with imaging evaluation, the patient was diagnosed with a complex proximal right humeral fracture (Figure 1).

Figure 1. Complex fracture of the proximal right humerus

This is a rather complex fracture pattern in orthopedics and traumatology, especially when it occurs in the elderly due to concurrent osteoporosis. A simple fall onto an outstretched hand can create a comminuted fracture pattern. Due to osteoporosis, the cancellous bone in the humeral region has a weak structure, leading to subsidence of the entire humeral head.

To visualize this easily, the cancellous bone structure of the proximal humerus can be likened to a load-bearing scaffolding system. When the bone foundation is weakened by osteoporosis, the entire underlying support becomes unstable, making the joint structure prone to collapse following trauma.

In cases without excessive displacement, conservative treatment can still yield good outcomes. However, for complex proximal humeral fractures, open reduction and internal fixation is indicated to restore the anatomical structure of the proximal humerus. The surgical indication is not only based on the fracture classification (NEER) but also depends on various factors such as age, the patient's functional demand, and comorbidities.

For a 68-year-old, healthy, right-handed patient, I advised surgical fixation to help restore early mobility while avoiding complications such as muscle atrophy and joint stiffness.

The surgical choice was plate and screw fixation under intraoperative C-arm fluoroscopy control. The subsided cancellous bone will be augmented with synthetic bone graft underneath to create a "scaffolding" layer for the humeral head above (Figure 2). Typically, after placing the plate and screws, the fracture site is hemostatic, and the thick deltoid muscle in the shoulder covers the surrounding dead space, preventing bleeding, so a drain will not be placed. The incision is closed with aesthetic suturing and sealed with surgical skin glue. The patient will not need dressing changes or suture removal. (Figure 3)

Figure 2. Postoperative radiograph

Figure 3. Surgical scar after peeling off the skin glue

At the 2-week follow-up, the patient's incision was well-healed and dry, the scar was small and aesthetically pleasing, with no signs of infection. The control X-ray also showed that the bone had been anatomically reduced, with the bone graft stable internally.

In cases of complex proximal humeral fractures with good postoperative stability, patients can begin an early rehabilitation program to improve shoulder range of motion, reduce the risk of joint stiffness, and optimize the recovery of upper extremity function.

Over the next 6 weeks, the patient will continue to be monitored for bone healing and shoulder mobility recovery during subsequent follow-up visits. Let's look forward to the recovery results with the doctor!