Review Article
Management of Acute Proximal
Humeral Fractures
Abstract
Vamsi Krishna Kancherla, MD
Anshuman Singh, MD
Oke A. Anakwenze, MD
Proximal humeral fractures, which typically occur in elderly persons,
are among the most common fractures. A myriad of nonsurgical and
surgical treatment options exist for these injuries, including short-term
immobilization and early physical therapy, percutaneous fixation,
plate osteosynthesis, intramedullary nailing, hemiarthroplasty, and
reverse shoulder arthroplasty. The choice of treatment depends on
the fracture type and severity, surgeon expertise, patient age, and
patient health status.
P
From the Department of Orthopaedic
Surgery, St. Luke’s University Health
Network, Bethlehem, PA
(Dr. Kancherla) and the Department of
Orthopaedics, Kaiser Permanente,
San Diego, CA (Dr. Singh and
Dr. Anakwenze).
None of the following authors or any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Kancherla,
Dr. Singh, and Dr. Anakwenze.
J Am Acad Orthop Surg 2017;25:
42-52
DOI: 10.5435/JAAOS-D-15-00240
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
42
roximal humeral fractures are
the third most common fractures, following hip and distal
radius fractures. They account for
approximately 5% of all fractures,
and they are increasing in frequency.1 The elderly population
has a higher incidence of proximal
humeral fractures and typically
sustains more complex fracture
patterns than those sustained by a
younger patient population.1 Given
the likelihood of poor bone quality
in this population, the surgeon
should maintain a high level of
suspicion for fragility fracture
associated with relatively minimal
trauma.
Anatomy
The proximal humerus is divided
into four parts: the greater and lesser
tuberosities, the head, and the
diaphyseal region. Its articulation
with the scapula produces a very
mobile glenohumeral joint, which is
supported by muscle groups about
the shoulder girdle. The rotator cuff
muscle complex is made of four
muscles that attach to the tuberosities. The supraspinatus, infraspinatus, and teres minor tendons
insert onto the greater tuberosity,
and the large subscapularis tendon
attaches to the lesser tuberosity.
Innervation to the supraspinatus
and infraspinatus muscles occurs
through the suprascapular nerve,
whereas innervation to the subscapularis and teres minor muscles
occurs through the subscapular and
axillary nerves, respectively. These
muscles are not only responsible for
coronal and axial motion but also
serve as dynamic stabilizers of the
glenohumeral joint. The deltoid
muscle is a large muscle innervated
by the axillary nerve that originates
from the lateral clavicle, acromion,
and scapular spine and inserts on the
deltoid tuberosity of the humerus. It
is composed of three heads separated
by intramuscular raphae: the anterior deltoid (responsible for forward
flexion and internal rotation), the
middle deltoid (responsible for
abduction), and the posterior deltoid
(responsible for extension and
external rotation).
On average, the humeral head-neck
angle is 135!, and the humeral head
angle is 19! to 22! and is retroverted
in relation to the humeral shaft,
although some evidence would suggest a variability ranging from 26!
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Vamsi Krishna Kancherla, MD, et al
to 47!.2-5 The bicipital groove is
between the greater and lesser
tuberosities. Immediately lateral to
this groove is the insertion of the
pectoralis major, which is innervated
by the lateral and medial pectoral
nerves and provides an internal
rotation and adduction force to the
proximal humerus. When these
muscles work together, they provide
wide degrees of motion in multiple
planes simultaneously. However, in
the setting of a proximal humeral
fracture, the muscles become deforming forces, translating the bony
attachments in the direction of the
respective muscle force vectors.
Historically, the ascending branch
of the anterior humeral circumflex
artery has been described as the
primary source of the vascular supply
to the humeral head.6 The high rate
of injury to this vessel and lower
rates of osteonecrosis associated
with proximal humeral fractures
emphasize the importance of the
vascular anastomoses about the
humeral head. A cadaver study
found that the posterior humeral
circumflex artery supplied blood to
64% of the humeral head, which
may explain the low rate of osteonecrosis after proximal humeral
fractures.7
Figure 1
Fracture Classification
The Neer classification is the most
widely used system for classification
of proximal humeral fractures.
Building on the 1934 Codman classification, which divided the proximal
humerus into the lesser tuberosity, the
greater tuberosity, the head, and the
shaft, Neer expanded the classification to include the concept of fracture
displacement and angulation.8 A
fracture was considered displaced in
the setting of “an angulation of .45!
or a separation of .1 cm”8 (Figure
1). Despite poor interobserver reliability (a mean kappa coefficient of
Diagram showing the Neer classification of proximal humeral fractures.
(Reproduced from Jones CB: Proximal humeral fractures, in Boyer MI, ed: AAOS
Comprehensive Orthopaedic Review 2. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2014, pp 293-302).
0.52),9 this system commonly is used
to classify proximal humeral fractures. The addition of advanced
imaging, such as CT, helps to
improve intraobserver and interobserver reliability, although not substantially.9 These fractures also may
be classified according to the AO/
Orthopaedic Trauma Association
classification system (Figure 2). In
this classification, type A fractures are
unifocal and extra-articular, involving
one of the tuberosities without metaphyseal comminution. Type B fractures are bifocal and extra-articular,
with metaphyseal and tuberosity
involvement. Type C fractures are
intra-articular and include fracturedislocations or head-split fractures. As
in the Neer classification, proximal
January 2017, Vol 25, No 1
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43
Management of Acute Proximal Humeral Fractures
suggesting that osteosynthesis with
preservation of the humeral head is
worth considering in the setting of
adequate reduction and stable conditions for revascularization.
Figure 2
Nonsurgical Management
Illustrations depicting the AO/Orthopaedic Trauma Association classification of
proximal humeral fractures. (Reproduced from Cadet ER, Ahmad CS:
Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad
Orthop Surg 2012;20[1]:17–27.)
humeral fractures carry the risk of
osteonecrosis; type C fractures, in
particular, present a substantial risk
of osteonecrosis.
Hertel et al10 noted the importance
of the metaphyseal head extension—
a radiographic measurement of the
articular fragment from the headneck junction to the inferior extent of
the medial cortex—as a predictor of
44
ischemia after proximal humeral
fracture. The study found that metaphyseal head extension of ,8 mm
and medial hinge disruption .2 mm
correlated strongly with humeral
head ischemia. Despite these findings, Bastian and Hertel11 later
found that initial postfracture
humeral head ischemia does not
predict the development of necrosis,
Most proximal humeral fractures are
amenable to nonsurgical management; however, patients must understand the expectations and comply
with the treatment program. In general, excellent results have been
achieved with short-term immobilization (,2 weeks) in a sling and
early physical therapy.12-15 Most of
the literature supports early mobilization, but it is important to ensure
that further fracture displacement
does not occur.
Nonsurgical treatment of two-part
fractures with early rehabilitation has
been found to be at least as efficacious
as surgical treatment in injuries
with minimal displacement.16,17 In
the setting of considerable displacement, a block to range of motion, and
involvement of the anatomic neck,
better outcomes may be achieved
with surgical fixation, although
well-designed comparative studies of
surgical versus nonsurgical management of two-part fractures are lacking (Figure 3). Some authors have
found that greater tuberosity fractures
with .5 mm of displacement may
benefit from surgical fixation to reduce
the risk of subacromial impingement.14,18 Lesser tuberosity fracture
with internal rotation impingement
also has been reported and may benefit
from surgery if nonsurgical management fails.19 In contrast to other parts
of the proximal humerus, the anatomic
neck is devoid of soft-tissue attachments and has a tenuous blood supply,
which may result in an increased risk
of osteonecrosis.
Although three-part and four-part
fractures often require surgical fixation, nonsurgical management can be
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Vamsi Krishna Kancherla, MD, et al
considered for patients with poor
baseline function and/or an inability
to tolerate a surgical intervention. In
select three-part and four-part fractures, particularly valgus-impacted
fractures with ,1 cm of displacement of the tuberosities in relation to
the head fragment, nonsurgical
treatment may yield good to excellent results.20 Although surgical
management of complex fracture
patterns generally is advocated, the
efficacy of surgical versus nonsurgical management remains to be
elucidated fully. In a study of 60
elderly patients with a displaced
three-part fracture of the proximal
humerus, Olerud et al21 found that
surgical management with a locking
plate resulted in better functional
outcomes and health-related quality
of life than did nonsurgical treatment, but at a cost of additional
surgery in 30% of patients. In contrast, a meta-analysis of randomized
controlled trials did not find improved
functional outcomes with open
reduction and internal fixation (ORIF)
compared with nonsurgical treatment
in elderly patients with displaced threepart or four-part proximal humeral
fractures.22 The study concluded that
these results must be considered in the
context of variable patient demographics. A systematic review supported the use of nonsurgical
treatment of proximal humeral fractures and noted a 2% rate of osteonecrosis mainly associated with threepart and four-part fractures, high rates
of radiographic union, and modest
complication rates.23 Ultimately, the
patient’s baseline physiology and
function may help to quantify the
potential advantages of nonsurgical
management, even in the setting of
complex fracture patterns.
Surgical Management
Complex proximal humeral fractures are challenging to manage
Figure 3
Treatment algorithm demonstrating the surgical options for management of
proximal humeral fractures. CRPP = closed reduction and percutaneous pinning,
IMN = intramedullary nailing, ORIF = open reduction and internal fixation,
PHFx = proximal humeral fracture, RSA = reverse shoulder arthroplasty.
and frequently need to be addressed surgically. Internal fixation and arthroplasty are the most
commonly employed strategies
to manage complex fractures of
the proximal humerus. In select
patients, percutaneous fixation
remains a feasible option in the
surgeon’s armamentarium.
Percutaneous Fixation
Closed reduction and percutaneous
pinning (CRPP) of proximal humeral
fractures was initially described by
Bohler in 1962 and, in some reports,
has been purported to be superior to
open techniques, with higher union
rates, lower rates of osteonecrosis,
decreased scar formation, and
improved cosmesis.24 Classic surgical indications have included twopart fractures of the surgical neck,
greater tuberosity, and lesser tuberosity; three-part surgical neck fractures with involvement of the greater
or lesser tuberosity; and valgusimpacted four-part fractures (Figure
4). For CRPP to be successful, stable
and satisfactory closed reduction
must be achieved, adequate bone
stock with minimal comminution
and an intact medial calcar should be
present, and the patient must comply
with postoperative immobilization
and management.24
Biomechanical studies have found
CRPP to be inferior to ORIF,
although stability can be enhanced
with the use of larger diameter pins,
multiple pins, and cortically engaging pins placed in a multiplanar
configuration.24 Historically, clinical studies have found the outcomes
of CRPP to be satisfactory;24,25
however, in a comparative study of
the outcomes of CRPP, ORIF,
hemiarthroplasty (HA), and reverse
shoulder arthroplasty (RSA) for
management of three- and four-part
proximal humeral fractures, Gupta
et al1 found that the complication rate
associated with CRPP was considerably higher than those associated
with ORIF, hemiarthroplasty (HA),
and reverse shoulder arthroplasty
January 2017, Vol 25, No 1
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45
Management of Acute Proximal Humeral Fractures
neurologic injury affecting the axillary and radial nerves laterally and
the musculocutaneous nerve anteriorly, soft-tissue injury to the cephalic
vein and biceps tendon anteriorly,
and osteonecrosis (28%), although
the risk of osteonecrosis can depend
largely on the initial fracture
pattern.1,24,25
Figure 4
Plate Osteosynthesis
AP radiograph (A) and axial (B) and sagittal (C) three-dimensional CT
reconstructions of the proximal humerus demonstrate a two-part surgical neck
fracture.
(RSA). The overall complication rate
was highest for CRPP (28.4%), followed by RSA (18.9%), ORIF
(15%), and HA (11.3%). The revision rate for CRPP, excluding necessary surgery performed for implant
removal, was 1% and involved revision to RSA. Revision rates for ORIF,
RSA, and HA were 12.7%, 5%, and
4.9%, respectively.
CRPP techniques vary but have
some similar principles. Typically,
the humeral head and shaft are fixed
first using terminally threaded 2.5mm Schanz pins placed in a retrograde, lateral-to-medial direction,
accounting for humeral head retroversion in a safe zone proximal to the
deltoid insertion to avoid the radial
nerve and distal to the course of the
axillary nerve, approximately 5 cm
distal to the acromion (Figure 5). The
ideal starting point is typically twice
the distance from the top of the
46
humeral head to the most inferior
margin of the articular cartilage.
Tuberosity fixation can be achieved
with pins or with 3.5-mm, 4.0-mm,
or 4.5-mm cannulated screws inserted anterograde from the tuberosity bicortically into the calcar for
the greater tuberosity or unicortically into the head for the lesser
tuberosity.25 Medial calcar fixation
should be performed at least 2 cm
distal to the articular surface
to minimize injury to the neurovascular bundle, including the axillary nerve and the posterior humeral
circumflex artery. Pins and screws
are buried underneath the skin, the
arm is immobilized for 3 to 4 weeks,
and the pins are removed in 4 to 6
weeks.24,25
Complications associated with
CRPP include malunion (28%), pin
migration or loosening in up to one
third of patients, pin-track infection,
The advent of fixed-angle locking
plates has revolutionized the management of proximal humeral fractures because the locking screw
technology allows more secure fixation in comminuted and/or osteoporotic bone. Plate fixation is an
excellent choice for management of
substantially displaced two-part
fractures that require surgery and
for three-part fractures without
considerable comminution (Figure
6). Four-part fracture fixation may
be attempted with a locking plate
construct but may be more challenging, with less predictable
results. We believe that, in active
patients aged ,65 years with
acceptable bone stock and minimal
comminution,
internal
fixation
should be attempted or should be
considered strongly. Although low
bone mineral density may not be
predictive of mechanical failure,26
fracture collapse into varus is a risk
after plate fixation; this can
be minimized in the setting of a
noncomminuted medial calcar and
good calcar screw fixation. Care
should be taken when plate osteosynthesis is performed; proud plate
fixation may lead to impingement
against the acromion with abduction,
and a plate that is placed too low
risks poor humeral head fixation.
Compared with HA, locked plate
fixation has been shown to provide
better functional outcomes and a
higher rate of patient satisfaction.
Solberg et al27 compared the results
of HA and locked plate fixation for
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Vamsi Krishna Kancherla, MD, et al
Figure 5
AP (A) and axillary (B) fluoroscopic images of a shoulder demonstrating intraoperative closed reduction and percutaneous
pin fixation for a proximal humeral fracture. AP (C) and lateral (D) radiographs of the same shoulder at 1 year
postoperatively.
Figure 6
A, AP radiograph of the shoulder demonstrating a three-part proximal humeral fracture-dislocation. B, Coronal CT showing
the three-part proximal humeral fracture post-reduction. C, Intraoperative AP fluoroscopic image of the shoulder. D,
Postoperative AP radiograph demonstrating the shoulder at 11.5 weeks postoperatively.
management of three-part and fourpart fractures in a consecutive group
of 48 patients treated with HA and
38 patients treated with locked plate
fixation. At a mean follow-up of 36
months, the authors noted higher
Constant scores in the patients who
underwent ORIF. Poorer results
were noted in patients with four-part
fractures than in those with threepart fractures. A loss of fixation was
more common in fractures with initial varus and extension deformities;
patients with these fractures had
worse outcomes than did those with
valgus impaction fractures.
Despite better outcomes, the complication rate can be higher with
fixation than with HA, and the most
common complications are osteonecrosis and screw cutout. Solberg
et al27 also found that initial varus
fracture displacement in a group of
patients treated with plate fixation
was associated with lower Constant
scores, loss of fixation, head perforation, varus malreduction, and
tuberosity displacement .5 mm.
Osteonecrosis of the humeral head
associated with a head metaphyseal
segment of ,2 mm was noted, as
well.27 In a systematic review of
locking plate fixation, Thanasas
et al28 reported a 7.9% rate of osteonecrosis overall; however, in
patients with four-part fractures, the
rate was 14.5%. The revision rate
was 13.7%. Therefore, the surgeon
must be aware of the potential
complications associated with management of these unstable fracture
patterns; the use of longer screws as
well as strut grafting should be
considered in patients with osteoporotic bone who lack a sufficient
medial calcar.29 Hinds et al30 found
that the clinical outcomes of locked
plating with endosteal fibular strut
allograft augmentation in patients
aged .65 years were comparable to
those in younger patients (mean age,
53 years). The authors noted that the
enhanced stability provided by this
fixation construct allowed early
January 2017, Vol 25, No 1
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47
Management of Acute Proximal Humeral Fractures
Figure 7
A, Preoperative AP radiograph showing a proximal humeral fracture.
Postoperative AP (B) and lateral (C) radiographs of the shoulder following
anterograde intramedullary nail fixation.
intensive postoperative therapy and
resulted in excellent outcomes
regardless of patient age. In this
series of 71 adults, osteonecrosis
occurred .3 years postoperatively in
one elderly patient (1%).
Intramedullary Nail Fixation
Although challenging and controversial because of historical reports of
complications, intramedullary (IM)
nail fixation for proximal humeral
fractures has become more popular in
recent years, with some reports of
success. Postoperative problems, such
as nonunion, malunion, rod migration in older patients, shoulder pain
caused by rotator cuff violation, and
nerve injury caused by interlocking
screw insertion, must be balanced
against a small incision, closed
reduction, and excellent nail-bone
purchase in osteoporotic bone.25
More research is needed, but some
recent clinical studies have found
locked rigid IM nail fixation to be
equivalent to locked plate fixation for
two-part, three-part, and even fourpart proximal humeral fractures.31-35
The indications for IM nailing of
proximal humeral fractures include
48
two-part surgical neck fractures,
young age, concomitant humeral
shaft fracture, and impending pathologic fractures (Figure 7). Improvements in nail design and surgical
technique have led to a resurgence in
the use of anterograde rigid IM nail
fixation for select three-part and
four-part fractures.31
Modern humeral nails are straight
instead of curvilinear, allow the use
of multiplanar locking screws, and
can be inserted from a more medial
starting point near the articular
margin such that injury to the rotator
cuff
tendon
attachment
site
is minimized.25,36 Most nail insertion is performed anterograde with a
rigid locked construct; however,
some reports support the use of
retrograde flexible unlocked implants despite their reduced axial
and rotational stability.25
A biomechanical study of two-part
fractures treated with IM nailing
versus locking plates demonstrated
higher failure rates in torsion with IM
nailing than with locking plates,
which suggests that early motion and
osteoporotic bone could predispose
to poor results.37 Yoon et al38
examined stiffness and load to fail-
ure in a study of various fixation
options for two-part proximal
humeral fractures and found that IM
nailing with a fixed angle blade was
superior to IM nailing with locking
screws, a 3.5-mm fixed angle plate,
and a 4.5-mm fixed angle plate.
Modern IM nail fixation of proximal humeral fractures has yielded
favorable results, including high union rates, low complication rates, and
favorable subjective outcomes.25 In a
retrospective review of 48 patients
with two-part surgical neck fractures
treated with an angular, stable,
locked IM nail, Hatzidakis et al32
reported reliable fracture healing, a
mean Constant score of 71, mean
forward flexion of 132!, and little
residual
shoulder
pain
after
12-month follow-up. In studies of
two-part, three-part, and four-part
fractures, other authors found no
marked objective or subjective differences between locking plate and
IM nail fixation.31,33-35 However,
Zhu et al35 studied two-part fractures with a 3-year minimum followup period and reported an overall
complication rate of 4% and 31%
for IM nailing and locking plate
fixation, respectively. The IM nailing
group had a significantly lower
complication rate than did the
locking plate group (P = 0.024).
Despite these findings, we do not use
IM nail fixation for acute nonpathologic proximal humeral fractures at this time.
Hemiarthroplasty
Historically, HA was the treatment of
choice for complex proximal humeral
fractures and has been studied extensively. It is a technically challenging
procedure with mixed results. The
presence of a functioning rotator cuff
and healed, anatomically reduced
tuberosities are essential for satisfactory outcomes. A thorough preoperative history and intraoperative
assessment can alert the surgeon to
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Vamsi Krishna Kancherla, MD, et al
Figure 8
Preoperative AP (A) and axillary (B) radiographs of the shoulder demonstrating a four-part fracture in a 63-year-old man.
Postoperative AP (C) and external rotation (D) radiographs showing the same shoulder after hemiarthroplasty with
tuberosity repair.
rotator cuff pathology. Tuberosity
malalignment has been noted to be a
major source of failure following
humeral replacement for proximal
humeral fractures.39 Other important
parameters include humeral head
height and version. The humeral head
level should re-create that of the
anatomic head. In a cadaver study,
the authors estimated an average
distance of 5.6 cm between the top of
the humeral head and the upper
border of the pectoralis major muscle
insertion.40 This distance also may be
assessed by visually ensuring that
the head sits on the well-reduced
tuberosities. Humeral lengthening
.10 mm causes excessive tension of
the supraspinatus muscle and places
the tuberosities at risk of detachment.39 The natural humeral head
retroversion ranges from 19! to 22!,
with some variability.2,3,5 The surgeon should be cognizant of this
range and should aim to reproduce
similar version when performing HA.
Failure to do so may put the tuberosity repair under undue tension and
may put the prosthesis at risk for
instability. Adequate fixation of the
tuberosities requires secure fixation
of the tuberosities to each other, to
the prosthesis, and to the humeral
shaft through drill tunnels. Bone graft
may be added to enhance healing and
fill in any defects (Figure 8).
HA for fracture management may
have a high complication rate, with
functional gains that can be less than
satisfactory. In a retrospective review
of 66 patients who underwent shoulder HA for fracture, Boileau et al39
noted that 42% of the patients were
unsatisfied with their final outcome.
At final follow-up, the incidence of
tuberosity malposition was 50%. The
average forward flexion and external
rotation was 101! and 18!, respectively. In a systematic review of 810
HAs performed for treatment of acute
fractures, Kontakis et al41 noted
similarly poor forward flexion
(105.7!). The average postoperative
Constant score in 560 patients was
56.6. A recent randomized study
comparing HA with nonsurgical
treatment of four-part fractures found
no substantial difference in outcomes.42 Such results underscore the
importance of performing HA after
careful preoperative planning and
with meticulous surgical technique.
Reverse Shoulder
Arthroplasty
The initial indications for RSA (as a
salvage option) were rotator cuff
arthropathy and pseudoparalysis.43
The function of the reverse shoulder
prosthesis is based on traditional
Grammont principles of medializing
the glenohumeral center of rotation
and lowering the humerus. This
gives the deltoid muscle a mechanical
advantage by increasing its lever
arm, obviating the need for the
rotator cuff, and providing low shear
forces about the glenoid. The
increased use and popularity of RSA
brought a corresponding rise in the
number of complications, including
scapular notching (44% to 96%),
glenoid loosening (5% to 38%),
instability (2% to 31%), and infection (1% to 15%).44 The longevity
of RSA implants in patients with
arthropathy or fracture has not yet
been elucidated fully. A recent study
noted that 91% of the implants were
viable 10 years after implantation,
but a decline in function was noted at
the 6-year mark.45
The indications for RSA have been
expanded to include acute fractures,
the sequelae of fractures (eg, malunion, nonunion), and revision of
failed fixation or humeral replacement.
RSA is an attractive option for patients
older than 65 years with three-part or
four-part fractures and comminuted
tuberosities, and the procedure may
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49
Management of Acute Proximal Humeral Fractures
Figure 9
A, AP radiograph of the shoulder demonstrating a four-part complex fracture in a 68-year-old man with poor bone quality. B,
Axial CT showing a fracture line through the lesser tuberosity. Postoperative AP (C) and external rotation (D) radiographs of
the shoulder after reverse shoulder arthroplasty.
provide more predictable results than
those provided by standard anatomic
HA in select patients.
The effectiveness of HA versus
RSA has yet to be determined fully.
Young et al46 retrospectively compared the outcomes of 10 patients
who underwent RSA with those of
10 patients who underwent HA for
similar proximal humeral fracture
patterns (two three-part fractures
and eight four-part fractures in each
group). The greater tuberosity was
fixed to the implant in 9 of 10 RSAs.
At an average follow-up of 22 to 44
months, the authors noted similar
forward flexion, external rotation,
American Shoulder and Elbow
Surgeons Shoulder scores, and
Oxford scores in both groups.
Despite similar results, the authors
noted at the last follow-up visit that,
on radiography, the humeral heads
were not centered in five patients
treated with HA. Gallinet et al47
retrospectively compared the results
of 17 patients who underwent HA
with those of 16 patients who
underwent RSA for three- or fourpart proximal humeral fracture. At
a mean short-term follow-up (16.5
months and 12.4 months in the HA
and RSA groups, respectively), the
outcomes were substantially better
in the RSA group than in the HA
group. These patients had better
50
abduction, forward flexion, and
Constant scores. However, the
patients who underwent HA had
better external rotation than did
those who underwent RSA (13.5!
versus 9!).47 The authors claim that
RSA provides more predictable
function; however, the Constant
scores of the RSA group were
comparable to those of the HA
group.48 A blinded, randomized
prospective study substantiated
some of these findings, reporting
better pain and function and a lower
revision rate for RSA than for HA.49
Multiple recent systematic reviews
have reported equivalent clinical
scores and a lower revision rate
associated with RSA, as well as
improved external rotation with
tuberosity repair.50,51 In a systematic
review of 92 studies with a total of
4,500 patients, Gupta et al1 observed
that ORIF led to better clinical outcomes than those of RSA but was
associated with considerably higher
revision rates. HA and RSA were
equivalent with regard to clinical
scores, although tuberosity healing
after HA was noted to be 15.4%.
Uzer et al52 found that tuberosity
union rates following RSA with
autologous grafting improved from
40% (not grafted) to 77.8% (grafted), with associated improvements
in functional outcomes.
Several patient factors and technical factors are necessary for
successful management of complex
proximal humeral fractures with
RSA. Proper function of the deltoid
muscle is required for RSA. Guidelines for surgical management of
these fractures in the setting of axillary nerve palsy are lacking, but RSA
can be performed in the setting of
neurapraxia provided that some deltoid tone is noted on examination. A
complete palsy may allow the use of
only ORIF, HA, and/or arthrodesis,
however. We recommend the use of
CT imaging in addition to radiography when assessing these fractures.
Adequate glenoid bone stock is
required to allow implantation of the
base plate. Bone loss about the
humerus should be noted, and plans
should be made to restore humeral
length with an implant or graft
material to ensure that the deltoid
muscle is tensioned properly. If
proximal bone loss is severe, imaging
of the contralateral humerus may be
performed to replicate the length of
the humerus on the surgical shoulder.
As with HA, tuberosity repair is
recommended to improve rotation,
tension, and stability (Figure 9).
Substantial bone loss and detachment of the tuberosity and soft-tissue
attachments may predispose the
implant to dislocation.44,46,50
Journal of the American Academy of Orthopaedic Surgeons
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Vamsi Krishna Kancherla, MD, et al
We typically perform HA in
active patients aged 40 to 65 years
with complex four-part fractures
or head split patterns that are
likely to have complications with
plate osteosynthesis. A stem that is
convertible to an RSA without
extraction can be advantageous
and should be considered if the
surgeon is familiar and comfortable
with the design.
Summary
Management of proximal humeral
fractures can be challenging, and the
treatment choice is not always obvious. Most of these fractures can be
treated nonsurgically with short-term
immobilization and early physical
therapy. Most complex fractures or
fractures that fail nonsurgical treatment can be managed with a variety
of surgical options. Surgical experience and evidence-based literature
can help to guide the surgeon in the
selection of a surgical option. Complex three-part and four-part fractures may be managed best by
surgeons who have training in
shoulder arthroplasty to allow intraoperative flexibility as needed. RSA is
a relatively new addition to the
treatment algorithm and may provide
more predictable results than those
derived from HA and osteosynthesis
in elderly patients with complex
fracture patterns. However, all
patients must be counseled preoperatively about permanent functional limitations, even in the absence
of pain.
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