Shoulder and Elbow 2023, Jan, 28 | 12:00 am

Proximal Humeral Fractures

 

Summary

Proximal humeral fractures are the third most common fractures and affect both young and elderly patients. Neer’s classification system is commonly used in determining fracture patterns but has recently been found to have poor reliability and reproduc-ibility. Protecting the posterior humeral circumflex artery during fracture fixation may minimize loss of the blood supply to the humeral head as the anterolateral ascending branch of the anterior circumflex artery supplies the humeral head to a lesser degree than originally believed. Clinically significant difference in patient-reported outcomes and function have not been observed between surgical and nonoperative treatment options for proximal humeral fractures. Open reduction and internal fixation with locked plating has better functional and patient-reported outcomes than hemiarthroplasty. In the past decade, reverse shoulder arthroplasty has become an attractive approach for managing proximal humeral fractures as the prosthesis can compensate for tuberosity complications. Overall, thorough consideration of bone quality, fracture patterns, and the myriad treatment options available is necessary to successfully manage proximal humeral fractures.

Keywords: Proximal humeral fracture, open reduction and internal fixation, reverse total shoulder arthroplasty

 

  1. Background

    1. 5% of all fractures, third most common fracture

    2. Female to male ratio 2–4:1

    3. Increasing incidence with aging population

    4. Associated injuries:

      1. Nerve: Axillary

      2. Vascular: Axillary (5% of four-part fractures)

      3. Other: Rib fracture, pneumothorx.1

    5. Bimodal age distribution:

      1. High-energy injuries in younger patients

      2. Osteoporotic fractures often associated with low-energy trauma in elderly patients.

    6. Fracture patterns are dictated by bone structure and deforming muscle forces.2

       

  2. Neer classification of humeral head fractures

    1. Fracture defined by number of parts

    2. Four parts (▶Fig. 19.1):

      1. Humeral head (HH)

      2. Greater tuberosity (GT)

         

        Fig. 19.1 Neer classification for proximal humeral fractures.‌

         

         

         

      3. Lesser tuberosity (LT)

      4. Humeral shaft (HS).

    3. Definition of fracture parts:

      1. Displacement >1cm, or

      2. 45-degree angulation.3

    4. Classification using the Neer system assigned on basis of computed tomography (CT) scans and radiographs are not very reliable or reproducible.4

       

  3. Valgus impacted fractures (▶Fig. 19.2)

    1. Not included in Neer’s original classification

    2. Accounts for 14 to 35% of four-part fractures

    3. Preserved medial soft tissue hinge preserves blood supply to articular segment

       

       

       

       

      Fig. 19.2 (a, b) Valgus impacted fracture.

       

    4. Three-part fractures:

      1. Most patients treated nonoperatively report good or excellent results.5

    5. Four-part fractures:

      1. Open reduction and internal fixation (ORIF) and closed reduction percutaneous pinning (CRPP) provide satisfactory results in most patients.6

  4. Vascularization of the humeral head‌

    1. Quantifying arterial vascularization of the humeral head:

      1. Anterolateral ascending branch of the anterior circumflex provides 36% of the

        blood supply to the humeral head

      2. Posterior circumflex supplies posterior portion of greater tuberosity and a

        small posterior inferior part of the head:

        1. Posterior humeral circumflex artery constitutes 64% of the blood supply

          to the humeral head.

      3. Possible explanation for the relatively low rates of osteonecrosis

      4. Protecting the posterior humeral circumflex artery during surgical approach

        may minimize loss of the blood supply to the humeral head.7,8

    2. Humeral head ischemia and necrosis predictors:

      1. There is 97% positive predictive value of ischemia if following criteria are met:

        1. Anatomic neck fracture

        2. Short calcar (<8 mm displacement)

        3. Disrupted medial hinge (>2 mm displacement).9

      2. Using above criteria:

        1. Avascular Necrosis (AVN) group: 30% had all predictors

        2. Non-AVN group: 4.7% had all predictors.

      3. The three criteria are not sufficient in determining necrosis:

        1. Recommend three-dimensional CT to better evaluate the calcar region.10

           

  5. Management of proximal humeral fractures

    The severity of fracture comminution and displacement may have a more significant effect on functional outcomes than the choice of treatment. There is clear difference in prognosis between three- and four-part fractures, but not between two- and three-part fractures.11,12

    1. Nonoperative approach:

      1. Entails use of sling or collar, cuff sling, and early physical therapy13

      2. Conservative treatment of proximal humeral fractures in older patients provides adequate pain relief:

        1. However, it provides limited functional outcomes.12

    2. ORIF:

      1. Most common, often used for younger patients, and results depend on bone quality and reduction

      2. Minimally invasive lateral approach is the optimal treatment for Neer’s type 2 and type 3 proximal humeral fractures:

        1. Nailing provides less stability for more than two fragmented fractures.14,15

      3. Allows for reliable fracture healing and little residual shoulder pain:16

        1. Mechanical failure of plates occur often due to malreduction.

           

      4. Avoiding varus can decrease rate of postoperative failures:17

        1. Quantification of the deltoid muscle perfusion with dynamic contrast-enhanced ultrasound shows that benefits of the minimally invasive plate osteosynthesis approach on soft tissue might not be as beneficial as expected.18

      5. Medial support in locked plating (▶Fig. 19.3):

        1. Evidence that medial support was established:

          1. Anatomic reduction of medial cortex

          2. Proximal fragment impacted laterally into the distal fragment

          3. Oblique locking screw was positioned inferomedially in the proximal head fragment.

        2. Lack of medial support resulted in:

          1. Increased loss of head height

          2. Increased risk of penetration of screws into the articular surface

          3. Increased loosening of screws.19

    3. Hemiarthroplasty:

      1. Well-accepted procedure to treat four-part and three-part fractures associated with severe osteopenia, and head splitting and severe articular impression fractures

         

        Fig. 19.3 (a, b) Medial support in open reduction and internal fixation (ORIF).

         

         

         

      2. Satisfactory results in terms of range of motion, and pain relief can be expected in most patients.20

    4. Closed reduction external fixation (CREF):

      1. External fixation achieves safe healing and effective management for displaced proximal humeral fractures21

      2. Percutaneous insertion of Kirschner wires from the upper lateral part of the humeral head through the medullary canal minimizes complications.22

    5. Total shoulder arthroplasty (TSA):

      1. Reduces shoulder pain effectively for acute three- and four-part proximal

        humeral fractures

      2. Late TSA is a satisfactory reconstructive option when primary treatment of proximal humeral fractures fail.23

    6. Reverse total shoulder arthroplasty (rTSA):

      1. Attractive approach as the prosthesis can compensate for tuberosity complications24

      2. Using a dedicated stem is a viable solution to treat complex humeral fractures as reliable restoration of elevation can be expected25

      3. Quicker recovery but there are limited reconstructive options if complications occur

      4. Use of rTSA has increased for treatment of three- and four-part proximal humeral fractures in the elderly

      5. Lack of long-term studies with rTSA, so should be used conservatively for patients with high functional demands.26–28

         

  6. Comparison of approaches

    1. Surgical versus nonoperative treatment:

      1. Randomized controlled trials have shown no clinically important difference in patient-reported outcomes, upper-limb functions, and quality of life between two groups:29,30

        1. Selection bias occurs as patients are often excluded due to “clear indications for surgery.”31

      2. Fewer nonunions and complications with nonoperative treatment.29,32

    2. Hemiarthroplasty versus rTSA:

      1. rTSA shows better results than hemiarthroplasty in forward elevation, abduction; constant score; disabilities of the shoulder, arm, and hand (DASH) score; American shoulder and elbow surgeons (ASES); and tuberosity healing:

        1. No difference in external rotation.33

      2. Since the past decade, shoulder surgeons are performing more rTSAs for proximal humeral fractures than hemiarthroplasties (HSA)27

      3. Hemiarthroplasty has significantly fewer adverse events than rTSA

      4. For three- and four-part fractures, rTSA provides significantly better functional outcomes than hemiarthroplasty.34

         

    3. ORIF versus hemiarthroplasty:

      1. ORIF provides better results with three- and four-part fractures2

      2. Better restoration of normal anatomy with ORIF than with hemiarthroplasty:

        1. However, no difference in function with ORIF and hemiarthroplasty35

        2. Since 2010, shoulder surgeons are performing more rTSAs for proximal humeral fractures than HSA27

        3. Question still remains about ideal treatment for these fractures.

 

References

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  2. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am 2009;91(7):1689–1697

  3. Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52(6):1077–1089

  4. Bernstein J, Adler LM, Blank JE, Dalsey RM, Williams GR, Iannotti JP. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am 1996;78(9):1371–1375

  5. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus: the results of non-operative treatment. J Bone Joint Surg Br 2002;84(4):504–508

  6. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991;73(2):295–298

  7. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head: an anatomical study. J Bone Joint Surg Am 1990;72(10):1486–1494

  8. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma 2012;26(4):212–215

  9. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427–433

  10. Campochiaro G, Rebuzzi M, Baudi P, Catani F. Complex proximal humerus fractures: Hertel’s criteria reliability to predict head necrosis. Musculoskelet Surg 2015; 99(99, Suppl 1):S9–S15

  11. Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg 2009;18(4):612–621

  12. Torrens C, Corrales M, Vilà G, Santana F, Cáceres E. Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma 2011;25(10):581–587

  13. Schumaier A, Grawe B. Proximal humerus fractures: evaluation and management in the elderly patient. Geriatr Orthop Surg Rehabil 2018;9:2151458517750516

  14. Liu K, Liu PC, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional delto-pectoral approach for treatment of proximal humerus fractures. Med Sci Monit 2015;21:496–504

  15. Iacobellis C, Serafini D, Aldegheri R. PHN for treatment of proximal humerus fractures: evaluation of 80 cases. Chir Organi Mov 2009;93(2):47–56

  16. Hatzidakis AM, Shevlin MJ, Fenton DL, Curran-Everett D, Nowinski RJ, Fehringer EV. Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus: a multi-center retrospective observational study. J Bone Joint Surg Am 2011;93(23):2172–2179

  17. Agudelo J, Schürmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007;21(10):676–681

  18. Fischer C, Frank M, Kunz P, et al. Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures. Injury 2016;47(8):1725–1731

  19. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185–191

  20. Hartsock LA, Estes WJ, Murray CA, Friedman RJ. Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29(3):467–475

  21. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong) 2009;17(2):142–145

  22. Benetos IS, Karampinas PK, Mavrogenis AF, Romoudis P, Pneumaticos SG, Vlamis J. External fixation for displaced 2-part proximal humeral fractures. Orthopedics 2012;35(12):e1732–e1737

     

  23. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995;4(4):271–280

  24. Wall B, Walch G. Reverse shoulder arthroplasty for the treatment of proximal humeral fractures. Hand Clin 2007;23(4):425–430, v–vi

  25. Garofalo R, Flanagin B, Castagna A, Lo EY, Krishnan SG. Reverse shoulder arthroplasty for proximal humerus fracture using a dedicated stem: radiological outcomes at a minimum 2 years of follow-up-case series. J Orthop Surg Res 2015;10(1):129

  26. Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res 2009;95(1):48–55

  27. Acevedo DC, Mann T, Abboud JA, Getz C, Baumhauer JF, Voloshin I. Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons. J Shoulder Elbow Surg 2014;23(9):1363–1367

  28. Gallinet D, Ohl X, Decroocq L, Dib C, Valenti P, Boileau P; French Society for Orthopaedic Surgery (SOFCOT). Is reverse total shoulder arthroplasty more effective than hemiarthroplasty for treating displaced proximal humerus fractures in older adults? A systematic review and meta-analysis. Orthop Traumatol Surg Res 2018;104(6):759–766