Postoperative Treatment of the Shoulder
The rehabilitation of the shoulder joint both after conservative treatment and post-surgery is very demanding. However, usually passive motion can be started after the first day following surgery or even after reconstruction or prosthetic replacement depending on the pain tolerance of the patient. The rehabilitation program should be according to the patient’s capability, the stability of the repair. In osteoporotic bone, poor purchase of screws accounts for soft-tissue healing like tendons or ligaments. Other conditions like percutaneous cannulated cancellous screws fixation without tension-absorbing sutures may cause a delay in commencing passive motion, usually performed with the help of a physiotherapist.
To achieve full strength and function, the exercise program should be started with a protected activity and further should have proceeded to self-assisted exercises. Then stretching and strengthening steps should be followed.
Postoperative physiotherapy needs careful supervision. Though, mild pain and some movement restrictions of the shoulder joint should not interfere with routine activities. The stiffness may tend to remain if the fracture is severe and the patient is older. Progression in physiotherapy and callous formation needs regular monitoring. Closed mobilization of the joint, even under general anesthesia, can be indicated If required. Although, the risk of additional loosening, or of fractures later on, particularly in elderly patients, should be taken into account. Arthroscopy, open release, and manipulation may be considered in certain conditions particularly in younger patients.
Issues and Complications
- Positioning of Implants
In osteoporotic bone, inappropriate placement of the implant, displacement of fragments, and implants may occur. Screws in the metaphyseal shaft area are likely to lose and to migrate. Moreover, screws in the head required to be of optimal length. Muscular activity and passive external forces, working on a long lever arm, are often assessed wrongly. So careful and regular examination of optimal bone and implant position intraoperatively using image intensifier is necessary. A larger size screw of larger size or bone cement should be applied prophylactically If they hold in subchondral bone or cortex is not found adequate.
Post-operatively, prior to allowing the motion range, it has to be determined intraoperatively under direct view and using an image intensifier. The stability of the bone-implant construct should be established together with the absence of any resistance to the directions and range in which passive movement is to be allowed
- Mal-union and Non-union
Though, mal-union and non-union are rarely seen. If it occurs and causes notable symptoms like severe discomfort and the loss of function, then internal fixation and open correction can prove reliable and useful for patients with acceptable bone quality and soft tissues.
Percutaneous K-wires may give rise to infection and irritation across their tracks. If a deep infection occurs, it should be managed aggressively. Washing out and debriding of soft tissues and sometimes of necrotic fragments is necessary. Usually, only after a second or third look, the whole head fragment has to be removed. There may be the possibility of prosthetic replacement indication after the settlement of the infection.
- Avascular necrosis
However, avascular necrosis is not a clinical problem but it may result in the partial or total collapse of the humeral head with in-congruency. This may cause malfunction and pain. Though the x-ray view often does not correlate with the clinical picture.
Avascular necrosis of the humeral head is frequent in B fractures and particularly in C fractures. It is because of the specific arrangement of its blood supply. After understanding it, a surgeon should aim at preserving as many vessels and soft-tissue attachments as possible. The use of plates and excessive numbers of sutures and tension-absorbing bands should be avoided where possible accordingly.
Primary prosthetic replacement, if done as a primary procedure, seems to have a better prognosis in C2 fractures and C3 fractures and will avoid the requirement of a second operation in elderly patients who has not more than 10–20 years’ life expectancy.
- Nerve lesions
During the accident or iatrogenically by closed manipulation and percutaneous fixation, the axillary nerve may be damaged. In soft-tissue retraction using Hohmann retractor or hooks in course of open reduction, this danger occurs. Similarly, the musculocutaneous nerve can be damaged particularly if an osteotomy of the coracoid process is carried out which is generally unnecessary.
The adjacent brachial plexus may also be jeopardized in dislocations and fracture-dislocations. So while positioning the patient, extra caution must be taken into account prior to and during the operation so the plexus does not stretch or harm its blood supply by indirect or direct manipulations.
Knee and shoulder arthroscopy implants have made the treatment much faster and easier than ever before. Hand Plating System is also useful for large fragments and small fragments as well and specifically designed for the contour of the bones.