Shoulder Arthroplasty for Acute Proximal Humerus Fracture Info

Q: Why replace the joint instead of fixing it with a plate?

Plate fixation works well in younger patients with reconstructable fracture patterns and healthy bone. In older patients with osteoporotic bone, comminuted four-part fractures, or compromised blood supply to the head fragment, plate fixation has high rates of fixation failure, avascular necrosis of the head, and need for revision surgery. Replacing the joint at the index operation, rather than after a failed fixation, generally produces a more predictable outcome with less time spent in a sling and a more reliable return to function. The decision is individual and considers the fracture pattern, bone quality, patient age, activity level, and cuff status.

Q: Why a reverse replacement and not a hemiarthroplasty?

Hemiarthroplasty (replacing only the ball, not the socket) was the historical operation for these fractures but produced unreliable outcomes — function depended heavily on whether the tuberosities and their rotator-cuff attachments healed, and a substantial proportion of patients had ongoing pain and weakness. Reverse total shoulder arthroplasty bypasses the rotator cuff entirely — the deltoid muscle drives elevation through the prosthetic geometry — and is more forgiving of tuberosity nonunion. The current evidence consistently favours reverse over hemiarthroplasty for complex fractures in older patients.

Q: How long does the implant last?

Modern reverse shoulder implants have excellent survivorship — published series report 90 to 95 per cent survival at ten years, with most failures relating to glenoid loosening rather than wear. For an older fracture patient, this typically means the implant will outlast the patient's need for it. Revision is possible if loosening or infection occurs, though it is technically more complex than the index operation.

Q: Will I be able to lift my arm overhead?

Most patients regain forward elevation to around 130 to 150 degrees — enough to reach a top shelf, comb their hair and dress comfortably. External rotation is typically more limited and depends on whether the tuberosity fragments heal back to the prosthesis. The functional gain over the pre-operative fracture state is substantial, and most patients describe their replaced shoulder as pain-free even when the range is not full.

Q: How much does shoulder replacement cost? What does Medicare cover?

Shoulder replacement involves separate fees for the surgeon, anaesthetist, hospital and the prosthesis. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent.

Illustration of a person resting with the arm supported in a sling. — Treatment of a complex shoulder fracture with a replacement. Kieran Hirpara 4.0

What you're feeling

You likely have deep pain in the top of your shoulder where the bone broke. This pain often feels worse when you try to move your arm or lift anything heavy. You might notice the pain flares up at night, making it hard to fall asleep or stay asleep. Many patients find they cannot lie on the injured side at all. Even simple movements like reaching for a cup on a high shelf can trigger a sharp ache.

Daily tasks that used to be easy now feel difficult or impossible. You may struggle to reach behind your back to fasten a bra or tuck in your shirt. Washing your hair or combing your hair becomes a challenge because you cannot lift your arm high enough. If you try to carry groceries or push a door open, the pain in your shoulder will likely increase quickly. Your surgeon may tell you that while pain relief is often good, how well your shoulder moves again is less predictable.

The way your shoulder feels depends on how the bones heal. In older patients, if the bone fragments heal in the right position, you will likely feel better and move more easily. However, if the bones do not heal well, you might continue to feel weak or have limited motion. Some patients who do not have surgery find their shoulder function remains poor for a long time. You should expect that recovery takes time, and your surgeon will guide you through the process to help you get back to your normal life.

What's actually happening

Your shoulder is a ball-and-socket joint wrapped in a sleeve called the joint capsule. The bone ends are covered in smooth cartilage, which acts like a shock absorber so the bones glide easily. When you break the top of your arm bone, this smooth surface is often damaged. The broken pieces can shift out of place, changing how the joint moves. Even a small shift of 15 degrees can alter how your shoulder works.

The broken bone pieces are held together by strong ropes of tendon called tuberosities. These ropes attach to the shoulder muscles that lift and rotate your arm. If these ropes do not heal in the correct spot, your surgeon cannot restore normal movement. Your shoulder may still feel pain-free, but lifting your arm or turning it outward will be difficult. The broken bone fragments can also push upward against the socket, causing friction and pain.

For older patients, this injury is often severe. The bone is fragile, and the tissues are weak. Without surgery, the shoulder may not heal well, leading to more pain and less movement. A joint replacement can provide long-term pain relief. However, the ability to move your shoulder fully is less predictable than the pain relief you will get. The goal is to rebuild the joint so you can use your arm again, even if the movement is not perfect.

What we can do about it

Most people with a broken shoulder bone start with non-surgical care. You will rest the arm and use a sling for a short or long period, as both give similar results. Your physiotherapist will guide you through gentle movements to restore motion. While many elderly patients recover well this way, some experience poor function or pain after one year. If you have a bruise on the front of your shoulder, it may signal a hidden fracture that needs an MRI scan to find.

Your surgeon may prescribe pain medication and anti-inflammatories to help you sleep and move comfortably. For some, an injection of cortisone or hyaluronic acid can reduce swelling and pain for a few months. Platelet-rich plasma injections are also an option to support healing. If you have a hidden fracture that was missed, surgery to realign the bone can still work even if the injury happened over a year ago. These medical steps aim to manage pain while your body heals the broken bone, which usually joins back together successfully in more than 90% of cases treated without surgery.

Surgery is considered when non-surgical care fails or if the fracture is too complex to heal on its own. Your surgeon may recommend a shoulder replacement or a plate and nail system to stabilize the bone. This is often chosen for older patients with severe fractures to improve long-term function and reduce the risk of complications compared to waiting. The goal is to restore your shoulder to pre-injury levels so you can return to daily activities.

When to see someone

See your GP if you have persistent pain that does not improve with rest, or if you feel weakness and instability in your shoulder. Ask for a specialist review if your shoulder locks, gives way, or if symptoms interfere with your sleep or work. Contact your surgeon immediately if you notice a sudden worsening of symptoms. While most elderly patients can be treated without surgery, those with complex fractures may need joint replacement to avoid poor long-term results. Be aware that the risk of death is higher for one year after this injury compared to the general population, so report any new medical issues promptly.