DEFINITION

Fractures involving the proximal region of the humerus that provide the supporting framework for the glenohumeral articulation are termed proximal humerus fractures.

These fractures typically occur along the physeal lines as described by Ernest Codman in 1934, most commonly involving the surgical neck and lesser and greater tuberosities.

Proximal humerus fractures remain the second most common fracture of the upper extremity and the third most common fracture in patients older than age 65 years.1

 

 

ANATOMY

 

The proximal humerus is composed of the humeral head, greater tuberosity, lesser tuberosity, and upper humeral shaft. In the normal shoulder, the head is covered with articular cartilage which allows for a smooth articulation with the glenoid. The greater and lesser tuberosities are separated by the intertubercular groove through which the long head of biceps tendon traverses.

 

The superior most point of the humeral head is on average 8 mm cephalad to the greater tuberosity11 and shown to average 30 degrees of retroversion in relation to the shaft.18

 

The upper edge of the pectoralis major tendon is on average 56 mm inferior to the top of the humeral head.15

 

 

 

FIG 1 • A. Anterior view. The anterior circumflex humeral artery branches off the axillary artery, giving rise to the ascending branch, which travels along the bicipital groove to supply the humeral head. (continued)

 

 

The rotator cuff complex (subscapularis, supraspinatus, infraspinatus, teres minor) inserts onto the proximal humerus at the lesser and greater tuberosities. This complex works in concert to not only bring about intricate movements of the arm in space but also to secondarily stabilize the glenohumeral joint.

 

This region consists primarily of metaphyseal bone surrounded by a vascular network of the circumflex humeral vessels.

 

The humeral head receives the majority of its vascular supply from the arcuate artery, a terminal branch of the anterior circumflex humeral artery (FIG 1A). Disruption of this vessel by fracture or iatrogenic causes has the potential to cause avascular necrosis and a poor outcome.

 

The posterior aspect of the greater tuberosity and head are supplied by branches of the posterior circumflex humeral artery9(FIG 1B).

 

The axillary nerve courses around the lateral aspect of the proximal humerus at an average of 61 mm from the midportion of the acromion.4

PATHOGENESIS

 

These injuries are most commonly due to a ground level fall onto the upper extremity in the elderly population with osteopenia.

 

 

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FIG 1 • (continued) B. Posterior view. The posterior circumflex humeral artery sends many branches to supply the posterior head and greater tuberosity.

 

 

 

The majority of fractures are minimally displaced. However, if sufficient energy and diminished bone density exist, displacement can occur, which often follows characteristic fracture patterns as described by Neer.16 The Neer classification is commonly used to describe these injuries and is based on displacement and/or

angulation of the fracture “parts.”16 The use of this classification has led to a better understanding of the

prognostic implications of treatment as well as improved therapeutic interventions.

 

Due to multiple tendon attachments onto the proximal humerus, these parts undergo characteristic patterns of displacement.

 

The greater tuberosity is frequently displaced posterosuperiorly by the strong external rotators of the cuff. The lesser tuberosity is pulled medially by the subscapularis, and the shaft is pulled superiorly and medially by the deltoid and pectoralis major, respectively (FIG 2). The head typically maintains a concentric alignment with the glenoid due to capsular attachments, except for cases of dislocation or valgus collapse.

 

A valgus impacted fracture involves lateral rotation and collapse of the head onto the shaft, with displacement of the tuberosities and impaction of the underlying cancellous bone.

NATURAL HISTORY

 

Significant displacement occurs in less than 15% of all proximal humerus fractures.16

 

Left untreated, displaced three- and four-part fractures are often associated with poor patient outcomes, leading to chronic pain, loss of motion, and impairment with activities of daily living.

 

Significant fracture comminution and displacement can potentially lead to avascular necrosis of the humeral head (FIG 3A-C). Predictors of humeral head ischemia include posteromedial metaphyseal head extension less than 8 mm, loss of the medial hinge, four-fragment fractures, and angular displacement of the head

greater than 45 degrees.10

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

A thorough history should be taken from the patient to include age, mechanism of injury, arm dominance, occupation, prior history of falls, and smoking status.

 

Also critical to consider in the elderly population is functional status, living situation, and medical comorbidities.

 

A detailed physical examination should be performed to assess level of trauma sustained, presence of concomitant injuries, and degree of dysfunction of the injured extremity.

 

The neurovascular status of the extremity should be performed. Distal radial and ulnar pulses should be palpated and compared to the uninjured arm. Distal motor and sensory examinations in the axillary, musculocutaneous, median, radial, and ulnar nerve distribution should be evaluated. This is extremely important in polytrauma patients and those sustaining high-energy trauma.

 

The soft tissue envelope should be evaluated for ecchymoses, open wounds, abrasions, and presence of skin tenting.

 

Ability to perform active arm elevation and assessment of the rotator cuff is difficult secondary to pain and fracture displacement.

 

Of paramount importance is determination of axillary nerve injury, which can be achieved by testing sensation and deltoid motor function.

 

 

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FIG 2 • The greater tuberosity (GT) is frequently displaced posterosuperiorly by the supraspinatus (SS)/infraspinatus (IS)/teres minor (TM). The lesser tuberosity (LT) is displaced medially by the subscapularis (SubS), and the shaft (S) is pulled superiorly and medially by the deltoid (D) and pectoralis major (PM), respectively.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

In fracture cases, patient discomfort often limits radiographic analysis. Typically, a true scapular anteroposterior(AP), scapular Y, and axillary lateral radiographs are obtained to evaluate details of the fracture and whether or not a dislocation is present. A Velpeau view may be helpful in situations where obtaining an axillary lateral is extremely painful (FIG 4A,B).

 

 

 

 

FIG 3 • A. AP view of proximal humerus fracture healed in varus malalignment 8 months after initial injury. B.

At 15 months, a crescent sign is visualized demonstrating avascular necrosis and collapse of the humeral head. C. Arthroscopic view of same patient after débridement of necrotic lesion.

 

 

In certain instances, computed tomography (CT) scan can be obtained to better characterize fracture pattern and aid

 

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in preoperative surgical planning. CT can be very helpful to evaluate head impaction as well as tuberosity fragmentation and displacement (FIG 4C).

 

 

 

 

FIG 4 • A. AP view of a comminuted displaced proximal humerus fracture. B. Velpeau view demonstrating collapse of the humeral head with outward displacement of the tuberosities. C. Axial CT scan showing medial displacement of the lesser tuberosity and extreme external rotation of the humeral head.

 

DIFFERENTIAL DIAGNOSIS

Humeral shaft fracture Rotator cuff tear Scapular fracture Glenohumeral dislocation Brachial plexus injury

 

 

NONOPERATIVE MANAGEMENT

 

Conservative management is the mainstay of treatment for the majority of proximal humerus fractures, as most are minimally displaced. These injuries have a very low nonunion rate.

 

Most patients are able to resume normal activities once fracture healing is achieved. Some loss of motion is typically well tolerated due to the large arc of motion of the shoulder.

 

Patients are placed in a sling or shoulder immobilizer for comfort during the first 10 to 14 days. They are instructed to start elbow/wrist/hand range-of-motion (ROM) exercises immediately after injury to prevent stiffness.

 

Once pain subsides, patients are encouraged to perform daily gentle ROM exercises of the shoulder such as pendulums.

 

When fracture consolidation is evident on follow-up radiographs (typically between 4 and 6 weeks), increased passive and active ROM exercises are added to the therapy regimen.

 

By 3 or 4 months, strengthening is begun and resumption of normal daily activities usually achieved.

 

SURGICAL MANAGEMENT

 

Proximal humerus fractures that have significant comminution and displacement are commonly managed by surgical means. In the young population and in those with good bone quality, every effort should be taken to obtain an anatomic reduction and fixation of the fracture.

 

Frequently used methods include open reduction internal fixation (ORIF), closed reduction percutaneous pinning (CRPP), and intramedullary nail fixation.

 

Prosthetic replacement is considered in three- and four-part fractures, particularly in the elderly with osteoporotic bone and in those with significant head involvement.

 

Hemiarthroplasty has been used most commonly but has been met with mixed results. Postoperative ROM and functional outcomes as well as reduction in pain have proven unpredictable, as hemiarthroplasty relies heavily on correct tuberosity positioning and healing.2,12,17

 

More recently, reverse shoulder arthroplasty (RSA) has been used as primary treatment for these complex injuries. RSA can be an invaluable option in the elderly, osteoporotic patient with a comminuted fracture, where tuberosity reconstruction and healing is felt to be difficult and unpredictable. Inherent in the design of the prosthesis, a good outcome is less dependent on tuberosity quality and healing, allowing for more confidence in reconstruction with varied pathology. 6 The biomechanical advantage of RSA allows the deltoid to take a greater role in arm elevation and abduction.

 

Preoperative Planning

 

Assessment of deltoid function is paramount when deciding whether to perform RSA due to its reliance on deltoid motor function.

 

Plain radiographs of the uninvolved arm can be obtained to assist in preoperative planning and templating.

 

If ORIF is still being considered in the treatment plan, a CT scan can be useful to evaluate tuberosity and head displacement prior to surgery.

 

Positioning

 

The patient is placed in the beach-chair position with all bony prominences padded appropriately. The affected extremity is draped free to allow uninterrupted access.

 

Complete arm extension and adduction should be ensured prior to starting to facilitate glenoid exposure and access to the humeral canal. If a cutout is not present on the bed, then the patient should be moved as far lateral as possible to ensure impingement free ROM.

 

An assistant should be placed behind the shoulder to help with retracting.

 

The surgical arm is allowed to rest on a well-padded Mayo stand throughout the case.

 

C-arm fluoroscopy is positioned at the head of the bed to allow for intraoperative imaging. The C-arm can be pushed toward the contralateral shoulder to allow uninterrupted access to the surgical field when fluoroscopy is not needed (FIG 5).

 

 

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FIG 5 • Prior to beginning the procedure, a fluoroscopic C-arm unit is sterilely draped and brought in from the head of the bed to ensure adequate images can be obtained. The C-arm unit is then pushed over toward the contralateral shoulder to allow the surgeon and assistant to stand beside the patient throughout the procedure.

 

Approach

 

The standard deltopectoral approach is used and allows excellent exposure to the glenohumeral joint through an internervous plane (axillary and pectoral nerves).

 

A low threshold should be maintained to further extend the incision when appropriate visualization is compromised.

 

Bony prominences to include the clavicle, coracoid, and humeral shaft at the deltoid insertion should be

palpated.

TECHNIQUES

• Deltopectoral Approach

A deltopectoral incision is used, starting about 5 cm medial to the acromioclavicular joint and following the anterior edge of the deltoid toward its insertion on the humerus (TECH FIG 1A).

If preserved, the cephalic vein is identified and taken medially with the pectoralis major, cauterizing lateral tributaries from the deltoid.

 

 

 

 

TECH FIG 1 • A. Standard deltopectoral incision following the anterior edge of the deltoid. B. The long head of biceps tendon is identified and tenodesed to the upper edge of the pectoralis major tendon.

 

 

The subdeltoid, subacromial, and subcoracoid spaces are developed and freed of all adhesions. A Browne deltoid retractor is placed into the subdeltoid space, facilitating exposure of the fracture. Any overlying bursa is removed to improve visualization.

 

The long head of biceps tendon is identified and tenodesed to the upper edge of the pectoralis major tendon with a 2-0 nonabsorbable suture (TECH FIG 1B).

• Tuberosity Mobilization in Four-Part Fractures

   

  The biceps tendon is divided above the tenodesis and the rotator interval is opened by following the tendon into the joint. Once exposed, the tendon stump is amputated at its origin on the supraglenoid tubercle.

   

  The lesser tuberosity with attached subscapularis is identified, mobilized, and a tagging suture placed at the tendon-bone interface to aid in mobilization. The greater tuberosity fragment with attached rotator cuff is identified and another tagging suture is placed to facilitate mobilization (TECH FIG 2A). Care is taken to release only adhesions that prevent adequate manipulation of the fragments.

   

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  TECH FIG 2 • A. Tagging sutures are placed around the tuberosities to aid in mobilization. B. The humeral head is removed through the rotator interval with a rongeur. C. Metaphyseal bone can be obtained from the removed humeral head and saved for grafting during tuberosity repair.

   

   

  Through the rotator interval, the humeral head fragment and any free comminuted fragments are

  removed with a rongeur. The metaphyseal bone from the head is saved to be used as bone grafting later in the procedure (TECH FIG 2B,C).

   

  With tuberosities retracted, any remaining capsule attached to the surgical neck is released using electrocautery and facilitated by progressive external rotation and extension of the adducted arm.

• Preparation of the Glenoid

   

  The Browne retractor is removed and the Mayo stand elevated to bring the arm into abduction, relaxing the deltoid and allowing the humerus to retract posteriorly.

   

  Large, sharp Hohmann retractors are placed superiorly and posteriorly to the glenoid, whereas a Cobra retractor is placed anteriorly.

   

  A 360-degree release of the labrum/capsule is performed using electrocautery, with special care taken to protect the axillary nerve while resecting the inferior capsule.

   

  Once excellent exposure is achieved, a 2.5-mm drill bit is used to create a center hole perpendicular to the glenoid face with 10 to 15 degrees of inferior tilt, exiting the anterior scapula (TECH FIG 3A). A depth gauge can be used to ensure that the depth of the drill hole is approximately 30 mm, allowing adequate purchase of the baseplate central screw.

   

  A 6.5-mm tap is inserted into the center hole. The tap should be firmly seated in bone and should not toggle if manually tested (TECH FIG 3B).

   

   

   

  TECH FIG 3 • A. A 2.5-mm drill bit is used to create a pilot hole with the aid of a drill guide. B. A 6.5-mm tap is placed in line with the pilot hole. (continued)

   

   

  Sequential cannulated glenoid reamers are placed over the tap, and the glenoid is reamed until bleeding subchondral bone is evident.

   

  Once the tap is removed, the fixed-angle baseplate with central screw is inserted in line with the central hole. The baseplate should sit flush with the bone and secure fixation is achieved when attempted further advancement of the screw causes the entire scapula to rotate (TECH FIG 3C).

   

  Four 5.0-mm peripheral locking screws are typically placed into the baseplate for additional fixation. An option to use 3.5-mm nonlocking screws is available when inadequate bone stock prevents perpendicular locking screw placement (TECH FIG 3D).

   

  An appropriate-sized glenosphere trial is selected based on size and quality of the glenoid, soft tissue contracture, and anticipated degree of instability. The glenosphere engages the baseplate via a Morse taper (TECH FIG 3E).

   

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  TECH FIG 3 • (continued) C. The glenoid baseplate is screwed into place and appropriate seating is confirmed with rotation of the scapula. D. Locking or nonlocking screws can be placed into the baseplate to enhance stable fixation. E. A trial glenosphere is selected based on gender and size. It engages the baseplate via a Morse taper.

• Humeral Preparation

 

Retractors are removed and the arm is placed into adduction and relative extension. The Browne retractor is placed back underneath the deltoid and a large Hohmann placed medially around the calcar, exposing the humerus.

 

Three no. 5 braided nonabsorbable sutures are placed at the tendon-bone interface of the lesser tuberosity, spaced evenly apart. The needles are removed and suture ends snapped together for later shuttling of the greater tuberosity sutures (TECH FIG 4A).

 

In similar fashion, three no. 5 braided nonabsorbable sutures and two 2-mm FiberTape (Arthrex, Naples, FL) sutures are placed at the tendon-bone interface of the greater tuberosity, evenly spaced apart and in alternating sequence (TECH FIG 4B).

 

 

 

TECH FIG 4 • A. Three no. 5 nonabsorbable sutures (red) are placed medial to the lesser tuberosity at

the enthesis. B. Three no. 5 nonabsorbable sutures and two 2-mm FiberTape sutures (green) are placed medial to the greater tuberosity in alternating sequence. C. The trial glenoid and humeral components have been placed and stability is assessed through a full ROM. D. Proximal humerus fracture with shaft extension and comminution. E. The shaft and medial calcar have been reconstructed which serves as an intraoperative template for prosthesis height assessment. (continued)

 

 

The humeral canal is then sequentially reamed by hand, stopping at the reamer where good cortical chatter is obtained. The real prosthesis is typically undersized by one size to make room for an appropriately thick cement mantle. The appropriate-sized trial is placed down the canal. Alternatively, the real humeral implant can be used to perform the trial reduction with the trial socket insert prior to cementing (TECH FIG 4C).

 

The height of the implant can be approximated by two methods. Commonly, the fracture exits medially at the level of the surgical neck, and if the calcar is intact, the humeral socket can be allowed to sit against it, providing a close estimate of normal

 

 

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height. If the calcar is disrupted, then every attempt should be taken to reconstruct it to serve as a guide in height reconstruction (TECH FIG 4D,E).

 

 

 

TECH FIG 4 • (continued) F. The tuberosities are reapproximated to ensure that they can be reduced around the implant. G. Drill used to make holes for three diaphyseal sutures. H. Lesser tuberosity sutures (red), greater tuberosity sutures (green), and shaft sutures (yellow) are placed appropriately. I. The greater tuberosity sutures (green) have been placed through the medial eyelet of the real humeral implant prior to cementing. J. The real humeral implant is inserted down the cemented canal to the height and version determined during trialing.

 

 

Another method that can be employed when significant comminution and shaft extension is present is to obtain bilateral full-length humeral radiographs with a radiographic ruler to approximate humeral length on the injured side. The uninvolved humeral length is measured from the lateral epicondyle of the distal humerus to the top of the greater tuberosity. Next, the length from the proximal shaft fracture to the lateral epicondyle is measured and this is subtracted from the uninvolved humeral measurement. The difference is the expected length that should be restored to the proximal shaft, giving a good estimate of humeral height reconstruction.

 

Humeral version is obtained using an alignment guide rod, placing the implant into 30 degrees of

retroversion relative to the forearm. The humeral socket liner trial is then chosen from a variety of sizes and constraint.

 

Retractors are removed and a trial reduction is performed, allowing soft tissue tension to dictate prosthesis height relative to the shaft. The tuberosities are brought around the trial implant, approximating their normal configuration (TECH FIG 4F). Ideally, the trial will verify that the tuberosities can be anatomically reduced and repaired.

 

The prosthesis is shucked laterally to assess the tension at the glenohumeral interface. If excessive looseness is encountered, the humeral socket liner trial can be exchanged for a thicker size or the glenosphere can be upsized. Care should be taken when increasing component size, as it may prevent anatomic tuberosity reconstruction. ROM may also be sacrificed in favor of stability; therefore, forward elevation should be checked whenever trial components are changed to ensure that there has not been significant loss of motion.

 

Fluoroscopy is used to ensure that the scapulohumeral arch is restored and that the sphere and socket are well aligned. Once height is deemed appropriate, the humeral stem is marked at the proximal aspect of the fractured shaft to serve as a reference during final stem implantation.

 

Next, the trial components are removed and the real glenosphere is placed onto the baseplate. The glenosphere is locked into place with a central set screw.

 

The humeral canal is irrigated and prepared for cementing. A cement restrictor is inserted 1.5 cm below the estimated tip of the implant.

 

Three drill holes are placed along the anterolateral proximal humeral diaphysis and three no. 5 braided nonabsorbable sutures are passed through the drill holes (TECH FIG 4G,F). These sutures will be used to fix the tuberosities to the shaft once the stem is implanted.

 

The deep ends of the five greater tuberosity sutures are next placed through the medial hole of the final humeral implant and set aside while the cement is prepared.

 

Antibiotic-containing cement is pressurized down the canal with the use of a cement gun until cement is extruding from the proximal portion of the canal. The humeral stem with medial sutures already passed is then introduced into the canal and impacted to the trial determined appropriate depth marked on the prosthesis (TECH FIG 4I). The version guide attached to the stem is used to ensure the implant is in 30 degrees of retroversion relative to the forearm (TECH FIG 4J).

 

Once the cement has appropriately cured, the prosthesis is reduced again with the trial socket liner. Stability and motion are again verified before final insertion of the real humeral socket liner.

• Suture and Tuberosity Management

 

The three no. 5 braided nonabsorbable suture limbs of the greater tuberosity that were passed through the medial hole at the neck of the prosthesis are individually tied to their corresponding deep suture limbs of the lesser tuberosity. The superficial limbs of the lesser tuberosity sutures are pulled to shuttle the greater tuberosity sutures through the subscapularis tendon-bone interface (TECH FIG 5A).

 

Next, the inner limbs of the three no. 5 shaft sutures are passed through the cuff superior to the tuberosities. Typically, the lateral two sutures are passed above the greater tuberosity through the supraspinatus and infraspinatus tendons. The medial suture is placed through the subscapularis tendon superior to the lesser tuberosity (TECH FIG 5B).

 

Next, bone graft taken from the humeral head is packed around the shaft-implant interface. The bone graft provides an optimal environment to promote tuberosity healing once the tuberosities are reduced into place.

 

The two 2-mm FiberTape sutures around the greater tuberosity that were not shuttled around the lesser

tuberosity are tied to reduce the greater tuberosity to the prosthesis (TECH FIG 5C).

 

Once the greater tuberosity has been reduced, the three no. 5 greater tuberosity sutures that were shuttled around the lesser tuberosity are tied sequentially. These sutures reduce the lesser tuberosity and cerclage both tuberosities to the stem, providing strong fixation (TECH FIG 5D,E).

 

The vertical fixation sutures are then tied, securing the tuberosities to the shaft, creating a circumferential cross-hatch construct compressing the fragments to the underlying bone graft and prosthesis (TECH FIG 5F,G).

 

The rotator interval is loosely closed, and final intraoperative motion is assessed.

 

Fluoroscopic imaging is performed to assess component positioning and tuberosity reduction (TECH FIG 5H).

 

The wound is closed in layers, with the subcutaneous tissue being closed with 2-0 absorbable suture. The skin is closed with a running subcuticular 3-0 nonabsorbable monofilament suture.

 

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TECH FIG 5 • A. The no. 5 greater tuberosity sutures (green) are tied to the lesser tuberosity sutures (red)

and shuttled through the subscapularis. B. The no. 5 shaft sutures (yellow) are passed superior to the lesser and greater tuberosities in the rotator cuff. C. The 2-mm FiberTape sutures (green) are tied, attaching the greater tuberosity to the implant. D,E. The no. 5 greater tuberosity sutures (green) are tied, cerclaging the lesser and greater tuberosities to the implant. (continued)

 

 

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TECH FIG 5 • (continued) F,G. Final repair construct demonstrating horizontal cerclage sutures and vertical shaft sutures tied providing secure fixation of the tuberosities to the implant and shaft. H. Intraoperative fluoroscopic image of final repair.

 

 

 

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PEARLS AND PITFALLS

 

	Humeral ▪ Most implant systems provide an alignment guide attached to the humeral stem component to help judge version. The forearm is a convenient guide to assist in correct version placement.     Bone ▪ The cancellous bone of the humeral head can be saved and used as autograft grafting around the implant and tuberosities, providing a more favorable environment for healing.     Soft tissue ▪ If the implant is placed in excessive tightness, ROM will be restricted tensioning postoperatively. The passive ROM that is achieved intraoperatively reflects the maximum amount of active ROM that should be expected postoperatively. If motion is limited secondary to overstuffing, consideration should be given to downsizing the humeral liner.     Implant ▪ Preoperative full-length humeral radiographs of the uninvolved side can be used height as a template to restore implant height in cases of significant comminution and shaft involvement. The use of intraoperative fluoroscopy can be an invaluable aid to reconstruct the tuberosities and achieve appropriate implant height.     Suture ▪ Place all tuberosity sutures prior to cementing and implantation of the humeral management component. It is important to pass the greater tuberosity sutures through the medial eyelet of the implant prior to cementing the stem. The use of large needles helps facilitate suture placement around the tuberosities.

 

 

POSTOPERATIVE CARE

 

Regional anesthesia of the operative extremity is frequently used by the anesthesia team to assist in postoperative pain management.

 

The patient wears a shoulder immobilizer during the first 6 weeks, coming out only for hygiene purposes and to perform gentle pendulum exercises. Elbow, wrist, and hand exercises are encouraged daily.

 

The subcuticular suture is removed in 10 to 14 days at the first postoperative visit.

 

After 6 weeks, the immobilizer is discontinued and a sling is worn in public only. Active-assisted ROM exercises are instituted, which includes supine active-assisted forward elevation. Patients are instructed not to lift anything heavier than a telephone receiver.

 

At 3 months, active ROM is allowed as tolerated. Light strengthening is begun and progressively increased over several weeks.

 

Radiographs of the shoulder are taken at the 2-week, 3-month, 6-month, and 1-year follow-up visits to evaluate tuberosity position and healing.

 

Maximal improvement in function is typically expected about 1 year after surgery.

OUTCOMES

Despite the lack of long-term published studies, RSA is a promising tool in the treatment of these complex

 

 

injuries. RSA has already been used to treat failed hemiarthroplasty for fracture.

Levy et al14 showed that RSA can provide a reliable salvage procedure for failed hemiarthroplasty by improving ROM, functional outcome, and patient satisfaction at short-term follow-up.

RSA appears to reliably restore motion and function when used for acute proximal humerus fractures.13 Importantly, restored forward elevation and abduction can be expected, regardless of tuberosity healing. However, every attempt should be taken to anatomically repair the tuberosities around the prosthesis, as shoulder rotation depends more heavily on tuberosity consolidation.

Gallinet et al7 evaluated their outcomes of RSA in patients in which an anatomic repair of the tuberosities had been performed compared to a group without repair. Their results showed that a consolidated anatomic repair led to significantly better rotation and functional outcome scores compared to nonrepair.

We evaluated our results of RSA for acute proximal humerus fractures in 18 patients with an average follow-up of 27 months and have experienced very promising outcomes with these complicated injuries. At final follow-up, the mean active forward elevation, abduction, external rotation, and internal rotation was found to be 139, 112, 37.5 degrees, and L1, respectively. The mean American Shoulder and Elbow Surgeons (ASES) score was 69.9, whereas the mean Visual Analog Scale (VAS) pain score was 1.7 in this patient cohort.

Recent studies comparing RSA to hemiarthroplasty for these injuries appear to show superior short- to midterm results for those treated with RSA.3,6,8

Although short- and midterm studies appear to be favorable, long-term prospective studies are needed to fully assess the outcomes of RSA in this injury type.

Age and the potential complications unique to RSA should also be factored into the decision making when selecting treatment.5

 

 

COMPLICATIONS

Infection Dislocation Neurapraxia

Complex regional pain syndrome (CRPS) Acromial fracture

Scapular notching with baseplate failure Tuberosity nonunion/malunion