Management of displaced proximal humeral fractures
Introduction:
Proximal humeral fractures with a dual age distribution occurs
either in young people following high energy trauma or in those older
than 50 years with low velocity injuries like simple fall [1,2]. Three
fourths of the fractures occur in older individuals with an occurrence
three times more often in women than in men [1, 3]. Most of the
proximal humeral fractures are non displaced or minimally displaced
and stable. These can be treated non operatively successfully with early
rehabilitation. But severely displaced and comminuted fractures
warrant surgical management for optimum shoulder function. Surgeons
should be familiar with the different treatment options available.
Treatment of this complicated fracture is guided by bone
quality, fracture pattern, degree of comminution as well as patient
factors such as age and activity level. Ultimate goal should be minimum
shoulder pain and maximum range of motion. Surgical options include
closed reduction and percutaneus pinning (CRPP), transosseous suture
fixation(TOSF), open reduction and internal fixation with either
conventional or locking plate and hemiarthroplasty. Fracture must be
evaluated on individual basis and treatment tailored accordingly.
Anatomy:
The dynamics of this highly mobile joint are the consequence of
its particular bony anatomy and of its soft tissue envelope. The skeletal
anatomy of the glenohumeral joint comprises two retroverted nonconstrained articular surfaces. Mallon et al [4] have made
measurements of the glenoid and found a mean transverse diameter of
24 ± 3.3 mm, a mean superoinferior diameter of 35 ± 4.1 mm, a mean
posterior version of 2.0 ± 4.2° (-7 to -12) and a mean radius of curvature
of 36.6 ± 7.4 mm (24 to 50). The proximal humerus has a cartilaginous
surface which is tilted 45° upwards and about 20° posteriorly with
reference to the distal intercondylar line [5]. Using radiological
techniques, Cyprien et al [6] and Debevoise, Hyatt and Townsend [7]
measured humeral retroversion. The former found a mean value of
26.9 ± 12.22° on the right and 21.2 ± 11.02° on the left. The latter group
determined a mean value of 61.6° (47 to 65) on the right and 60.8° (47
to 85) on the left. The partly spherical surface of the humeral head
occupies approximately one-third of a sphere with an angular value
ranging between 120° and 150°. The radius of curvature in the axial
plane is 22 ± 1.7 mm and the radius of curvature in the coronal plane is
24 ± 2.6 mm [8].
The vascular anatomy of the humeral head plays a major role in
the outcome of trauma. A devascularised head will collapse and
become incongruent, with the development of secondary arthritis. The
arteria arcuata circulates within the humeral head and receives its
blood supply from four major sources: the metaphyseal artery, the
branch of the anterior circumflex artery in the bicipital groove, arteries
from the rotator cuff and the medial branch of the posterior circumflex
artery [9, 10, 11]. Because of this arterial pattern a fracture through
the anatomical neck will lead to complete devascularisation of the
fragment of the head which carries the articular surface.
The power link between the scapula and the humerus is ensured
by the glenohumeral muscle groups which directly cross the joint,
namely the teres major, the deltoid with its three functionally
independent anterior, middle and posterior segments, and the rotator
cuff. The last consists of the musculo tendinous units of subscapularis,
supraspinatus, infraspinatus, and teres minor [12]. The biceps and its
tendinous long head may also be considered as part of the rotator cuff.
The biceps tendon is a valuable surgical landmark separating the lesser
from the greater tuberosity and therefore is of help in identifying the
various fragments with their attached cuff tendons when dealing with a
displaced fracture of the proximal humerus. The structures medial to
the biceps tendon are subscapularis and the lesser tuberosity while
those lateral to it are part of the greater tuberosity and attached
tendons of supraspinatus and infraspinatus [13]. The axillary nerve is at
risk in these fractures [14]. It supplies the deltoid and teres minor
muscles and should be tested for motor and sensory function on the
lateral aspect of the shoulder before any attempt at manipulation for
fracture of the humeral head. At operation it should be visualised or at
least palpated, since it lies anterior to subscapularis before plunging
beneath the tendon of subscapularis and the glenohumeral capsule into
the quadrilateral space on its way to the deltoid and to teres minor. The
integrity of the musculocutaneous nerve should also be checked
clinically, including its motor innervation of biceps and the sensory
supply to the medial forearm. It is usually not necessary to visualise the
nerve at operation but it must be borne in mind that it enters the
biceps approximately 5 to 8 cm below the tip of coracoid although this
distance has been shown to be very variable [15]. Vascular lesions are
infrequently associated with fractures of the proximal humerus [16].
Classification:
The Neer classification [17] and the AO/ ASIF classification [18]
are the most widely used systems to evaluate and determine treatment
of proximal humeral fractures. The Neer classification is based on the
number of fracture parts (displacement >1 cm, angulation >45°),
direction of dislocation, and involvement of the articular surface. The
AO/ASIF classification system for proximal humerus fractures broadly
groups fractures based on the degree of articular involvement and
likelihood of vascular injury. Observer reliability and reproducibility for
both the Neer and the AO/ASIF classification is fair to poor.
Pre operative assessment:
For a successful diagnosis of a fracture of the proximal humerus
it is imperative to have two views perpendicular to each other. The
glenohumeral joint line should be completely open with no overlap of
the head upon the glenoid. The most common standard projections are
the true AP view of the glenohumeral joint perpendicular to the plane
of the scapula and the axillary view parallel to this plane and
perpendicular to the acromion. The axillary view necessitates only a
few degrees of abduction or, if the arm is held in internal rotation by a
bandage, a Velpeau view can be made in which the patient leans
backwards with the x-ray beam directed superoinferiorly from the top
of the shoulder on to a cassette located at the patient’s elbow. AP
internal and external rotation views may be helpful but are difficult to
obtain in cases of acute injury. Scapular Y views are sometimes of use
but are notoriously difficult to interpret and, unless perfectly
performed, should not be used to exclude, for example, posterior
fracture-dislocations [13]. CT is a useful adjunct and three-dimensional
reconstructions can show features not readily recognisable on plain
films [19, 20, 21]. MRI may accurately delineate suspected soft tissue
injury.
Management protocol:
Although the management of displaced proximal humerus fractures
has evolved toward humeral head preservation, treatment should be
guided by careful assessment of vascular status, bone quality, fracture
pattern, and degree of comminution, as well as patient factors, such as
age and activity level. Patients who are either medically unstable or
inactive are poor candidates for surgery and instead may be treated
with sling immobilization until the fracture heals. The ultimate goal is
maximum shoulder function and minimal shoulder pain.
The likelihood of humeral head osteonecrosis is implicit in the
AO/ASIF classification; thus, determining the AO/ASIF fracture type is
the initial step in determining the probability of humeral head
preservation. Type A is a unifocal, extra-articular fracture with an intact
vascular supply. Type B is a bifocal, extra-articular fracture with possible
injury to the vascular supply. Type C is an articular fracture involving
the anatomic neck with a high likelihood of osteonecrosis. Cortical
thickness of the humeral diaphysis is a more reliable and reproducible
predictor of both bone mineral density and the potential for success of
internal fixation than is age [22]. After adjusting for magnification,
medial and lateral cortical thickness is measured from the
anteroposterior view of the proximal humerus [22]. The first level, the
most proximal aspect of the humeral diaphysis, occurs at the level in
which the endosteal borders of the medial and lateral cortices are
parallel. The second level is 20 mm distal to the first level. The
combined cortical thickness is the average of the medial and lateral
cortical thickness at the two levels [22]. Nonsurgical treatment, suture
fixation, and hemiarthroplasty may be the best options for the patient
with combined cortical thickness <4 mm. Cortical thickness ≥4mm is
considered necessary for adequate screw purchase with standard
internal fixation [22].
Nonoperative treatment:
Nonsurgical management traditionally has been recommended for
nondisplaced and minimally displaced proximal humerus fractures.
Sling immobilization with or without closed reduction also has a role in
the management of displaced proximal humerus fractures. Court-
Brown and colleagues [23, 24] recommend 2 weeks of sling
immobilization followed by physical therapy for patients with two-part
surgical neck fractures [24] and valgus-impacted fractures [23]. Twopart proximal humerus fractures with >66% translation were treated
with either a sling or with internal fixation with flexible intramedullary
nailing and tensionband wires [23, 24]. No statistical difference was
reported between the groups in terms of Neer score, [17, 25] return to
activities of daily living, and fracture union [23, 24]. The data
demonstrate that the raw Constant score deteriorates with advancing
age and degree of displacement. However, when calculated based on
age-adjusted Constant score, the older patients actually had better
scores than did the younger patients [23, 24, 26, 27]. Therefore, sling
immobilization is an appropriate treatment option for patients older
than age 60 years with valgus-impacted, two-part surgical neck or twopart tuberosity fractures.
Surgical approaches:
Deltopectoral approach: In displaced fractures of the proximal
humerus, the most common surgical approach is the deltopectoral with
the patient in the ‘beach-chair’ or semi-sitting position. General
anaesthesia is used and sometimes a scalene block may be performed
before intubation. This allows for lighter anaesthesia and the absence
of pain on awakening will prevent uncontrolled movement by the
patient and therefore protect the osteosynthesis. An oblique incision
15 cm long is made starting from below the clavicle and passing over
the coracoid. After appropriate haemostasis of the subcutaneous
tissue, the deltopectoral interval and the cephalic vein are identified. If
there is difficulty in finding the interval because of swelling the search
should be made more proximally near the clavicular insertion of the
deltoid and pectoralis major muscles where, usually, the interval
widens. The cephalic vein is left either with the deltoid muscle or with
the pectoralis muscle, it may be ligated. The conjoined tendons are
then retracted and a curved blunt retractor is placed under the deltoid
muscle around the fragments of the humeral head in the subacromial
space after blood clot and bursal tissue have been removed. The
axillary nerve is identified and palpated by sliding the index finger
under the conjoined tendons on to the anterior aspect of subscapularis.
It is then important to locate the biceps tendon and to use it as a
landmark to help to identify the fragments of the greater and lesser
tuberosities with their attached tendons. With two-part fractures
involving the surgical neck, the alignment of biceps may reflect the
adequacy of the reduction. In a fracture in which the lesser tuberosity is
not detached but where the surgeon wishes to inspect the articular
surface, a small incision through the interval can be made and the
articular surface observed. All the tendinous structures should then be
identified with stay sutures. Reduction may be accomplished by various
techniques from the use of plates and screws in particularly strong
bone to obtain a ‘rigid’ fixation, to relying on osteosutures or wires to
obtain a tension-band construct. This last technique may be particularly
indicated in the presence of osteoporosis. A control radiograph should
always be obtained before closure. In order to obtain a satisfactory
view the x-ray tube should be placed on the contralateral side of the
patient and the cassette applied to the body of the scapula. This will
give a view perpendicular to the plane of the scapula allowing
interpretation of the quality of the reduction and of the position of the
tuberosities.
Deltoid splitting approach: In cases of isolated fractures of the
tuberosity or if an intramedullary device is employed, it is sometimes
sufficient to use a transdeltoid split approach. The patient is in a semisitting position and the skin incision may follow the direction of the
muscle fibres along the upper deltoid at the junction of the anterior
and middle thirds or as a vertical ‘sabre-cut’. The deltoid is split along
its fibres no more than 5 cm from the acromion in order to avoid injury
to the axillary nerve. The cuff is then identified and the haemorrhagic
subacromial bursa partially removed. The fragments of the fracture are
then identified and reduced. Fixation may be by means of isolated
screws, wiring or heavy sutures. If proximal intramedullary nailing is
chosen the same approach can be used. The tendon of supraspinatus is
split to allow the introduction of the nail into the tuberosity. The
proximal part should be buried under the level of the articular cartilage.
Image intensifier control is essential to ensure a satisfactory outcome.
OPERATIVE TREATMENT
Despite general agreement that displaced or more complex
fractures should be treated operatively, there is no consensus on the
type of surgical fixation that should be used. Various methods, such as
closed reduction and percutaneous pinning (CRPP), tension band
wiring, intramedullary nailing, plate fixation, and hemiarthroplasty have
all demonstrated mixed results. Fracture pattern, fracture
displacement, bone quality, preexisting rotator cuff disease or
arthrosis, and patient function are important factors to consider in
developing a treatment plan. The primary goal should be a construct
sufficiently stable to begin early range of motion of the shoulder [2834].
Displaced 2-part and some 3-part proximal humerus fractures may
be managed with CRPP in selected cases. Alternatively, intramedullary
nails (IM) designed specifically for proximal humerus fixation may be
advantageous in some of these fractures. Open reduction and internal
fixation (ORIF) has also been widely used in 2-part, 3-part, and 4-part
fractures. Valgus-impacted 4-part fractures are less likely to have
disruption to the humeral head blood supply and develop
osteonecrosis; thus, ORIF is generally recommended for these injuries
[35-39]. In contrast, displaced 3-part and 4-part fractures are associated
with higher rates of osteonecrosis and other complications [25, 26, 35,
40-42]. Open reduction and internal fixation is advocated for patients
who are young and active, but patients who are elderly may be better
treated with hemiarthroplasty, depending on their bone quality and
physiologic age [43-46]. Recent advances in internal fixation, with
locked plate-screw constructs, have extended our ability to retain the
humeral head in some of these patients [47]. The results and outcomes
of internal fixation versus hemiarthroplasty in this group of patients
have not been compared. The following discussion will review various
surgical treatment options.
Percutaneous Pinning:
First described by Jaberg, this technique is demanding, but it can
be very effective for unstable 2-part surgical neck fractures and even
some 3-part or 4-part fractures in patients with good bone quality [4850]. Closed reduction, with or without percutaneous assistance, is
performed, and 2.5-mm terminally threaded Schanz pins are used to
stabilize the fracture. Knowledge of the anatomy of the axillary and
musculocutaneous nerves is essential in avoiding injury to these
structures [42, 51, 52].Pins should be placed in a divergent fashion to
optimize stability. Three to 4 pins are directed proximally across the
surgical neck fracture, and 1 or 2 pins are placed through the greater
tuberosity into the medial cortex. These augment the fixation of the
surgical neck fracture and will also stabilize a greater tuberosity
fragment. Multiple, tangential fluoroscopic views should be obtained to
avoid penetration of the articular cartilage. Passive range of motion is
initiated postoperatively. Pins placed through the greater tuberosity
will limit abduction until they are removed after 3–4 weeks. The other
pins are removed after 6–8 weeks.
Surgical trauma to the soft tissues and fracture fragments is
minimized with percutaneous pinning. This results in less blood loss and
scar tissue and better preservation of fracture biology compared with
other techniques. One recent study reviewed 71 patients treated with
percutaneous pinning, versus a cohort of patients matched for age and
fracture pattern treated with ORIF. These authors noted that the
incidence of osteonecrosis was higher after ORIF, potentially secondary
to surgical trauma [50]. Percutaneous pinning is a viable option,
particularly in young patients with suitable bone quality. It is speculated
that earlier return of mobility and better final range of motion may also
be possible with this method. However, complications include pin
infections, loss of reduction, and pin migration. Careful patient
selection will minimize these problems. This method is best suited to
patients who have good bone quality and who can comply with
postoperative activity instructions. It is not appropriate for anatomic
neck fractures, fractures with humeral head comminution, or severely
impacted fractures with valgus angulation. Rather, it works well for 2part fractures and for 3-part fractures with minimal greater tuberosity
displacement.
Jaberg reported 95% fracture union after 6–8 weeks with CRPP but
had 4 cases (7%) of pin tract infection [48]. Fenichel et al
retrospectively reviewed 50 patients with unstable 2-part and 3-part
proximal humerus fractures treated with this method [53]. They had no
pin infections, osteonecrosis, or neurovascular problems. However, 7
patients experienced a loss of reduction, 3 of whom underwent revision
fixation. They recommended careful patient selection and close followup in the first 4 weeks after surgery to minimize loss of reduction and
fixation. Better functional outcomes were noted in patients who did not
have an associated fracture of the greater tuberosity, which is
consistent with the experience of other authors [42, 48, 49].
Intramedullary Nails:
Intramedullary nails are effective in stabilizing some proximal
humerus fractures [29, 54, 59]. Preservation of blood supply through
indirect reduction is an advantage of this technique. A greater
propensity for maintenance of reduction is likely in 2-part surgical neck
fractures as opposed to those with associated fractures of the
tuberosities. Several manufacturers offer nails specifically designed for
proximal humerus fractures, with multiplanar locking, blade fixation for
the proximal fragment, or both. These implants may be particularly
useful for proximal humerus fractures in combination with humeral
shaft injuries [54, 56]. Disadvantages include potential damage to the
rotator cuff and chronic shoulder pain.
An anterior acromial approach is recommended for antegrade
humeral nailing. This minimizes surgical trauma to the rotator cuff,
versus a lateral acromial approach, which can injure the insertions of
teres minor and infraspinatus muscles. Care should be taken to protect
the axillary nerve. Blunt dissection and visualization to bone can protect
the axillary nerve from damage when proximal interlocking bolts are
directed from lateral to medial [60]. A lateral starting point or failure to
achieve reduction of the proximal fragment will result in varus
malalignment [56]. Meticulous technique and understanding of the
associated anatomy and radiographic landmarks will prevent this
problem. Displaced 2-part fractures are most amenable to nailing. If 3part fractures are treated with this method, the greater tuberosity
should be reduced and provisionally stabilized with Kirschner wires
before the starting point for the nail is developed.
Agel et al reported the results of 20 patients with proximal humerus
fractures that were treated with a Polarus nail [55]. This implant has
options for proximal interlocking in several directions. Although only 11
of 20 patients healed without any complications, this implant can be
effective for certain fracture patterns. The authors cautioned against
using a nail when the lateral metaphysis is comminuted or if the
starting point extends into the greater tuberosity. In such cases fracture
displacement, fixation failure, or both are more likely [55, 61]. Similarly,
Rajasekhar et al also demonstrated success with this implant, in both
young and elderly patients [57]. Their population of 30 patients
included primarily 2-part fractures and had 80% satisfactory to
excellent results. Other intramedullary implants more recently
developed for use in proximal humerus fractures include proximal
blade fixation or multiplanar locking options, some with threaded
screws to stabilize greater tuberosity and lesser tuberosity fragments
[29, 56]. The early results of these implants appear promising, even in
elderly patients [29].
Open Reduction and Internal Fixation:
Open reduction and internal fixation is an effective method of
treatment for proximal humerus fractures. It is frequently used for
displaced 3-part and 4-part fractures and valgus-impacted 4-part
humerus fractures to promote early motion of the shoulder [35, 37, 38,
42, 62]. Multiple fixation options have been described, ranging from
tension band fixation [25, 33, 63] to conventional large fragment and
small fragment plates and screws [38, 46, 64-70] to new locked plate
and screw constructs [47, 71-81]. No comparative clinical studies to
date have been done to determine clear indications and limitations of
these methods.
Conventional Plates:
A deltopectoral approach or deltoid-splitting approach may be
performed, depending on the fracture pattern and surgeon experience
[38, 39]. Care should be taken to preserve rotator cuff attachments and
the humeral head blood supply in all cases [39, 46, 50, 67, 82-85].
Articular fractures should be anatomically reduced, and relationships of
the tuberosities and their associated rotator cuff insertions should be
restored. Shortening of the humerus, through impaction of a
comminuted surgical neck fracture, may be desirable. This improves the
stability of the construct by increasing the surface area of bony contact
and providing an intact medial buttress [74]. Careful attention to safe
implant placement is essential. Plates should not impinge on the
acromion, the biceps tendon, or rotator cuff insertions. Screw
trajectories should be strategic and divergent to optimize purchase in
the humeral head. Central and inferior placement, with some screws in
the medial cortex, may be beneficial [74, 86].The fixation should ideally
be rigid enough to promote early rehabilitation.
Initial reports of ORIF reviewed experiences with the AO large
fragment T-plate [46, 66, 68, 87]. By Neer’s criteria, Kristiansen et al
reported only 45% satisfactory results for 3-part fractures [66]. Fixation
failures and some of the poor results could be attributed to deficient
bone quality in elderly patients. Placing the T-plate more inferiorly on
the greater tuberosity avoids impingement on the acromion and
increases the number of good results, particularly in 3-part fractures
[48]. However, both of these early studies had high rates of
intraarticular screw placement. Precise attention to surgical technique
to ensure accuracy of screw placement will prevent this complication.
In a group of younger patients (20–40 years old), 83% satisfactory
results were obtained with careful placement of a T-plate or
semitubular blade plate [87]. However, poor results were seen in
patients with underlying rotator cuff damage. In an attempt to reduce
complications associated with the use of the T-plate, Esser advocated a
cloverleaf plate [64]. This is a small fragment implant with more options
for proximal fixation. It can be modified by removing the arm on the
end of the plate to reduce the potential for prominence on the humeral
head. In 26 patients with a mean age of 55 years who had 3-part and 4part fractures, 92% good results were obtained with no nonunions and
no osteonecrosis [64]. Other authors have reported success with this
method [38, 42, 46, 62] and by applying principles of indirect reduction
and fixation with meticulous attention to the surrounding soft tissues.
Semitubular plates may be fashioned into a blade plate for
displaced 2-part and 3-part fractures. This technique may provide
improved fixation of the humeral head, depending on the length of the
blade and the quality of the bone [88, 89]. Several reports have
described good results with few hardware complications [69, 70, 87].
Similarly, 3.5- or 4.5-mm blade plates may be created by bending
standard limited contact dynamic compression plates. These are useful
for treating acute fractures or nonunions [90-92]. More recently, 3.5and 4.5-mm blade plates have been developed by various
manufacturers. Moderately good outcomes have been demonstrated,
even in elderly patients [65, 93] as a result of more rigid fixation of the
humeral head. This method is effective for displaced 2-part fractures
and can be used in 3-part fractures after reduction and fixation of the
greater tuberosity. Some prefabricated blade plates designed for the
proximal humerus have a cannulated system to facilitate accurate blade
placement. Meier et al reviewed 42 consecutive patients treated with a
customized, cannulated, 110-degree blade plate [67]. They described
indirect reduction of the humeral head fragment and restoration of the
head neck angle, while minimizing implant prominence and proximity
of the plate with respect to the acromion. This fixation was sufficiently
stable to permit early rehabilitation. However, 8 patients in their series
(19%) had perforations of the humeral head by the blade because the
fractures collapsed during the healing process. The authors speculated
that the valgus angle of their implant, versus 90-degree blade plates in
other reports, permitted protrusion of the blade. To prevent this
complication, 90-degree blade plates are recommended.
Collectively, these reports suggest that open reduction to restore
relationships of the shoulder joint, along with rigid internal fixation to
initiate early range of motion, will optimize functionality [31, 62, 67]. It
appears that alignment is less important than achieving a stable
construct to permit early range of motion of the shoulder [28, 32-34,
94]. No conclusive information exists from randomized controlled trials
comparing ORIF with nonoperative management [32, 33, 95, 96].
Furthermore, none of the clinical studies to date have compared
different types of fixation; thus, large randomized trials are necessary
to determine the optimal type of treatment for various proximal
humerus fractures.
Locking Plates:
Several new locked plate-screw devices have been developed
over the past few years. Research suggests plates with attached
(locked) screws may provide improved fracture stability and healing.
When a screw is locked to the plate, a fixed point of contact is created,
which may be advantageous in the cancellous bone of the proximal
humerus, especially in elderly patients with osteoporosis [97-100].
Locking plates specifically designed for the proximal humerus have
favorable shapes and screw configurations, which may enhance
maintenance of reduction and reduce hardware complications.
Biomechanical data suggest some advantages to locking plates
[101, 102]. One early study of an experimental precursor to locking
plates reported greater stiffness and increased energy to failure when
compared with an AO T-plate [103]. In osteoporotic bone, torsional
stiffness was improved when locking plates were compared with
cannulated 90-degree blade plates in a cadaver surgical neck fracture
model [100]. However, no difference was seen with bending loads in
the same model. Conflicting information has been published regarding
the performance of intramedullary nails in the proximal humerus
compared with locking plates. In a surgical neck, gap osteotomy,
cadaver model the nail has demonstrated superior stiffness with axial
loading [104] as well as torsional and bending loads [104, 105].
However, Edwards et al found more stiffness in torsion and bending
and less displacement of a locked proximal humerus plate compared
with a nail in a similar model [106]. They concluded that locking plates
may be particularly advantageous in osteoporotic bone.
Some 3-part and 4-part fractures and head-split fractures are not
amenable to nailing, so the clinical applicability of such biomechanical
information is limited. Individualized decision making is essential when
choosing among these implants in the clinical setting, with
consideration to fracture pattern and underlying patient factors
including bone quality, rotator cuff pathology, or associated injuries.
Early clinical results of locking proximal humerus plates have been
promising, although no comparisons with other techniques have been
published [47, 71, 73, 75-80]. Despite the paucity of literature to date
and increased implant costs, surgeons have begun to use locked plating
for both simple and complex proximal humerus fractures based on the
theoretical benefit of improved fracture stability [75, 77].
As with other methods of ORIF, a deltopectoral or deltoid-splitting
approach may be used, depending on the fracture pattern and surgeon
experience [39, 107]. It is important to reduce the fracture fragments
prior to locking screws to the plate. The plate may be used to aid the
reduction. Nonlocked screws can compress the plate to the bone, and
nonlocked screws may also be used to achieve interfragmentary
compression. This should be done prior to placing locked screws. The
locked screws will then serve to protect the reduction [102]. Care
should be taken to maintain the appropriate angle when seating screws
into the plate. This will prevent cross-threading and may minimize
screw disengagement from the plate over time [72, 73, 76, 108]. The
presence of medial column support will improve the stability of the
construct and minimize early loss of reduction [74]. Gardner et al
defined medial column support as an anatomic or slightly impacted
reduction, along with a superior directed oblique locked screw in the
inferomedial region of the proximal fragment [74].
The largest series of locked plating in the proximal humerus was
recently reported by Kettler et al [76]. These authors reviewed 176
patients treated with the PHILOS plate. Technical errors included 11%
with screw perforations into the glenohumeral joint. Another 11% had
secondary displacement of the implant from the humeral head or shaft,
and 14% had malunions [76]. Strict attention to fracture alignment and
implant placement may prevent some of these complications.
Bjorkenheim et al [71] described 72 patients with a mean age of 67
years with isolated proximal humerus fractures treated with the LCP
proximal humerus plate. Half achieved a good or excellent constant
score after 1 year follow-up. Elderly patients and those with C-type
fractures (displaced articular and/or anatomic neck fractures) [108] had
worse functional scores. Only 3 cases of osteonecrosis and 2 nonunions
were identified, but 19 fractures (26%) settled into varus position.
Initial varus malreduction has been noted to increase the risk of
fracture fixation failure [71]. Fankhauser et al noted loss of proximal
screw fixation and varus malalignment in 3 of their 29 patients treated
with locked plating [73]. They recommended augmenting the proximal
fixation with sutures placed through the rotator cuff and attached to
the LCP plate. They also had 2 patients with osteonecrosis and 1 with
plate failure. Constant scores averaged 75 for all patients, and worse
scores noted were again associated with C-type fractures.
Other recent reports have focused on limiting surgical trauma
while reducing and stabilizing the proximal humerus fracture with a
locking plate. A minimally invasive deltoid splitting technique can be
used without damage to the axillary nerve if screws are limited to
superior and inferior holes [109]. Gallo et al advocate 2 incisions with a
delto pectoral exposure for the shaft and head and a lateral approach
to the greater tuberosity [107]. The plate can then be directed through
the lateral wound and used to stabilize the fracture. Surgical trauma to
the deltoid is minimized, and maintenance of the reduction and
accurate implant placement may be facilitated with this method. It may
be particularly effective in patients who are obese or those with large
shoulder muscle mass. Irrespective of the type of plate used,
meticulous surgical technique will maintain the biology around the
fracture to promote healing and diminish the occurrence of
osteonecrosis. This will also minimize scar tissue and soft-tissue
damage, which can impair mobility and function.
Early rehabilitation and restoration of functional mobility of the
shoulder is the key to success after nonoperative management of these
injuries [28-33, 94]. Similarly, the success of surgical treatment depends
on maintaining the reduction to promote early rehabilitation [31, 33,
110]. Perhaps the best indication for surgical treatment is to maintain
an adequate, stable fracture reduction to initiate early range of motion.
It is possible that locking plates used for unstable proximal humerus
fractures permit more aggressive postoperative rehabilitation and
thereby facilitate more rapid return to productive function. It appears
that the benefit of locked plating is in those cases where adequate
fixation via other methods is not possible. Locking technology is not
necessary for many types of proximal humerus fractures, and its use
generates substantial implant expense. The specific indications,
limitations, and cost effectiveness of the locked plating in the proximal
humerus warrant further study.
Hemiarthroplasty:
Hemiarthroplasty remains a useful option for older patients with
anatomic neck and head-split fractures [36, 44, 45, 110-117] It is
controversial whether to treat functional elderly patients with 3-part
and 4-part fractures with hemiarthroplasty versus ORIF [47, 118].
Displaced 4-part fractures are associated with osteonecrosis in 21% to
75% of cases, compared to 8% to 26% of valgus-impacted 4-part
fractures [40-42, 46, 102]. This has been 1 argument favoring
hemiarthroplasty in elderly patients with displaced comminuted
proximal humerus fractures. However, in some cases the presence of
osteonecrosis may not be painful. It is interesting that osteonecrosis
may be present in only a portion of the humeral head and may not
result in collapse in all patients [46, 53, 67, 83, 85]. Thus, the age of the
patient, the quality of the bone, the fracture pattern, and amount of
comminution are all important considerations in developing a
treatment plan. The advent of locking plates has improved our ability to
stabilize some fractures and has likely reduced the frequency of
hemiarthroplasty in the acute setting for proximal humerus fractures.
In some cases it may be impossible to achieve adequate stability with a
plate and screws, and a decision to perform hemiarthroplasty is made
intraoperatively [46, 75]. It is prudent to prepare for this ahead of time
and to discuss both options with patients. It is unknown whether
patients function better over time after ORIF versus hemiarthroplasty.
However, early treatment of displaced fractures, versus delayed
hemiarthroplasty, results in fewer complications and better functional
results [45, 119-121]. This is likely the result of extensive scar tissue,
distortion of the anatomy, and chronic disuse of the shoulder when
these fractures are treated with late arthroplasty.
A recent analysis of literature to date on 4-part proximal humerus
fractures concluded that insufficient evidence exists to define the
optimal treatment for these injuries [95]. Little comparative
information also exists when determining the outcomes of ORIF versus
hemiarthroplasty. Only 1 randomized controlled trial has been
undertaken to date. Tension band wiring was compared to
hemiarthroplasty in a total of 30 elderly patients [122]. A potential 91%
reduction in risk of reoperation was seen with hemiarthroplasty.
Extrapolation of these findings to a younger population cannot be
done. Furthermore, no comparative information exists regarding the
complications and functionality of hemiarthroplasty compared with
more modern methods of internal fixation, including standard plates
and screws or locking plates. Because current literature is insufficient to
promote clinical decision-making, larger trials and randomized studies
are needed [95, 96].
Patients who undergo hemiarthroplasty acutely for proximal
humerus fractures frequently experience loss of function, with residual
stiffness and weakness compared with the contralateral shoulder, [103]
although pain relief may be satisfactory [43, 45, 110, 112-117]. This is
likely magnified by the fact that a large portion of this patient
population could be more active and functional at baseline than
patients who receive shoulder arthroplasty for degenerative arthritis.
On the other end of the spectrum, elderly patients who sustain
proximal humerus fractures in falls may be less functional overall, thus
less capable of participating in aggressive rehabilitation, leading to poor
functional results after hemiarthropalsty [110, 112, 119, 123, 124].
Technical considerations when performing hemiarthroplasty
include component position and tuberosity reconstruction [125, 126].
These issues are problematic when faced with metaphyseal
comminution or bone loss and either very large or comminuted greater
tuberosity fragments. Prostheses specifically designed for fracture
treatment can address these concerns. These have multiple options for
suture attachment and can accommodate a large greater tuberosity
fragment without causing impingement. Application of autogenous
bone graft from the humeral head to the area between the greater and
lesser tuberosities may improve healing of the tuberosities. Care should
be taken to keep cement out of this region because it would interfere
with bone healing.
One recent study reviewed 71 patients treated acutely with
hemiarthroplasty for proximal humerus fractures [125]. Their mean age
was 66 years, and indications for surgery included displaced 4-part and
3-part fractures, head-split fractures, and anatomic neck fractures. Of
the patients, 93% reported no or slight pain and were satisfied.
Malreduction of the greater tuberosity was the most common
complication, occurring in 22% of cases. Overall, patient function was
most affected by the quality of the reconstruction of the greater
tuberosity [125]. This is consistent with other studies [43, 110, 116,
124, 127, 128]. Additional patient factors that contribute to FIGURE 1. a
successful outcome include younger age, strong functional status at
baseline, and no associated neurologic deficits [43]. Careful attention to
component position and tuberosity reconstruction during surgery will
reduce complications [126]. By coupling this with an appropriately
aggressive rehabilitation plan, patient satisfaction and function will be
maximized [43, 45, 111, 125, 127].
Summary:
Proximal humerus fracture management is constantly evolving,
particularly in light of improved understanding of proximal humerus
fracture characteristics and innovations in surgical technique and
technology. The orthopaedic surgeon should approach proximal
humerus fractures on a case-by-case basis and tailor treatment
according to patient and fracture characteristics. Treatment decisionmaking should include assessing the vascular status of the humeral
head, determining the optimal fixation constructs, and implementing
local adjuvants as needed to enhance anatomic fracture healing. The
likelihood of humeral head ischemia is established using the AO/ASIF
classification and Hertel’s radiographic criteria. Fractures with AO/ASIF
type C pattern, metaphyseal extension <8 mm, or medial hinge
displacement >2 mm are associated with high probability of
osteonecrosis and probably are best treated with hemiarthroplasty.
When fixation is required, fracture pattern and cortical thickness should
guide the treatment approach and fixation technique. AO/ASIF type A
fractures are typically treated with sling immobilization. Proximal
humerus fractures with surgical neck translation >66% or tuberosity
displacement >5mmmay be treated with transosseous suture fixation
(cortex <4 mm) or closed reduction and percutaneous fixation (cortex
>4 mm). For multifragment fractures, locked compression plating
creates a stable construct with preservation of the periosteal blood
supply. Calcium phosphate cement, demineralized bone matrix, and
allografts are important local adjuvants that may improve rates of
osseous union and minimize malunion. So, humeral head preservation
and
osteosynthesis
are
being
increasingly
favoured.
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