Should Surgery Be Urgent for a Humerus Fracture in Elderly Patients?

Is surgery urgently needed for a humeral fracture?

Hello, Doctor: My mother is 64 years old and has Parkinson's disease.
She underwent surgery on her left elbow due to an injury from a fall two years ago, but because of an infection, she had to undergo a debridement surgery.
Then, in July of last year, she had a total elbow arthroplasty, which means she has already had three surgeries! Unfortunately, four days ago, she fell again and landed on her left arm.
We rushed her to the emergency room for an X-ray, which revealed that the artificial joint was not dislocated, but the upper arm (humerus) near the elbow was fractured.
The fracture line runs from the upper right to the lower left, exactly where the artificial joint was anchored in the bone.

Since my mother has already undergone multiple surgeries, she is quite fearful of more procedures.
Her bottom line is that she just wants to avoid pain! The orthopedic surgeon on call in the emergency department believes that surgery is not necessary and that a cast will suffice, suggesting that over time, the pain should subside.
He also mentioned that the surgical outcome may not necessarily be better, as he considers the situation too complex and noted that my mother has some osteoporosis, making it difficult to manage in one operation.
The next day, I consulted the attending physician who previously operated on my mother.
Upon seeing the X-ray, he immediately stated that surgery is essential! He believes that without surgery, healing is impossible (due to the use of bone cement), and pain is likely to persist, potentially worsening the condition.
He suggested that a single surgery could resolve the issue, involving first bonding the fracture surfaces, then reinforcing the outer layer with donor bone, and finally stabilizing it with plates and screws.
Since the artificial joint is not dislocated, it does not require intervention, and once the humerus heals, the elbow should regain its current function.
Now, both my mother and I are very hesitant because the opinions of the two doctors are so contradictory.
When I heard the emergency orthopedic surgeon refer to the attending physician as "teacher" during a phone call, I felt uncomfortable relaying the emergency physician's perspective to the attending physician.
Therefore, I would like to seek your opinion! Additionally, if surgery is indeed the better option, is it preferable to have it sooner rather than later? My mother is quite superstitious and believes that this Thursday, according to the lunar calendar, is an inauspicious day for any activities, and she feels anxious about proceeding.
She wants to wait until next Thursday for the surgery, which would mean two weeks after the injury.
Should I insist on having the surgery sooner, or should I respect her feelings to avoid psychological distress that could affect the safety of the procedure?

spot, 30~39 year old female. Ask Date: 2012/03/19

Dr. Shi Guozheng reply Orthopedics

Because there are no visible changes in the imaging, it is difficult to make a judgment.
However, after receiving a joint replacement, if the fracture is unstable, surgery is usually required.
If it is a stable fracture, conservative treatment may be an option.
You may consider consulting a third physician for a second opinion.
If immobilization with a cast can achieve healing, then surgery may not be necessary.
Bones that have undergone multiple surgeries often have osteoporosis, making them more susceptible to fractures.

Reply Date: 2012/03/19

More Info

When it comes to managing a humerus fracture in elderly patients, especially those with complex medical histories like your mother, the decision to proceed with surgery can be quite nuanced. Given your mother's age of 64 and her history of Parkinson's disease, previous surgeries, and the recent fall resulting in a fracture near her elbow, there are several factors to consider.

Surgical Necessity
1. Fracture Type and Location: The nature of the fracture is crucial. If the fracture is non-displaced and stable, conservative treatment with immobilization might be sufficient. However, if the fracture is displaced or involves the area where the artificial joint is anchored, surgical intervention is often necessary to ensure proper healing and to alleviate pain.

2. Bone Quality: You mentioned that your mother has some degree of osteoporosis. This condition can complicate both the healing process and the surgical procedure. Osteoporotic bones may not hold screws or plates as effectively, which can lead to complications post-surgery.

3. Pain Management: Your mother’s primary concern is to avoid pain. If the fracture is not treated surgically, there is a significant risk that she will continue to experience pain and may not regain full function of her arm. Surgery, while it carries risks, often provides a more definitive solution to pain and functional limitations.

Timing of Surgery
1. Urgency: Generally, the sooner a fracture is stabilized, the better the outcome. Delaying surgery can lead to complications such as malunion (healing in an incorrect position) or nonunion (failure to heal), particularly in the context of an elderly patient with existing health issues.

2. Psychological Factors: Your mother’s belief in waiting for a more auspicious time based on superstition can complicate matters. While respecting her feelings is important, it is also crucial to communicate the potential risks of delaying surgery. Prolonged waiting could lead to increased pain and complications.

3. Consultation with Specialists: Since you have conflicting opinions from different orthopedic surgeons, it may be beneficial to seek a third opinion or to have a detailed discussion with the surgeon who has previously treated your mother. This can help clarify the necessity of surgery and the risks involved.

Recommendations
- Communicate Openly: Encourage an open dialogue between your mother and her healthcare providers. It’s essential that she feels comfortable expressing her fears and concerns. This can help in making a more informed decision regarding her treatment.

- Consider a Multidisciplinary Approach: Given her complex medical history, involving a geriatrician or a pain management specialist could provide additional insights into her overall health and the best course of action.

- Evaluate Risks vs. Benefits: Discuss the potential risks of surgery versus the risks of non-surgical management. If surgery is deemed necessary, emphasize that it may significantly improve her quality of life and reduce pain.

- Timing: If surgery is recommended, it is generally advisable to proceed sooner rather than later. If your mother insists on waiting, try to negotiate a shorter timeframe that still allows for her psychological comfort while minimizing the risk of complications.

In conclusion, while the decision to operate on a humerus fracture in an elderly patient is complex, it is often necessary to ensure proper healing and pain management. Open communication with healthcare providers, understanding the risks involved, and addressing psychological concerns are all critical in making the best decision for your mother’s health.

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