Surgeon offers tips for when to select plates, pins or replacement for patients with shoulder fractures

The goals of treatment include anatomic reduction and achieving a stable fixation.

Issue: August 2011

When determining whether a patient will need a pin, plate or replacement surgery for a shoulder fracture, it is important to keep in mind the goals of the surgical procedure, and to analyze the likelihood of successful fixation and stable reduction, according to Leesa M. Galatz, MD.

“Overall, if you care for fractures, you should be open to consider all options. I believe it is important to fix what you can, the best way possible,” Galatz, who is an associate professor in the shoulder and elbow service at Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, said at the Current Concepts in Joint Replacement 2011 Spring Meeting.

Patient characteristics, such as age, medical comorbidities and osteopenia, as well as fracture characteristics, such as how many parts are fractured, bone displacement, joint congruity and whether the break is a high- or low-energy injury must also be considered.

Indications reviewed

If a stable, closed reduction can be obtained using closed or minimally invasive manipulation, Galatz said that pinning is the most likely choice to treat the fracture. Fractures with minimal metaphyseal comminution are amenable to pinning, as the presence of comminution in the metaphysic renders a fracture particularly unstable, likely requiring plate fixation. General indications for pinning include the two-part surgical neck fractures, selected three-part fractures and valgus impacted four-part fractures.

“Remember that not all four parts are created equal,” she said. A valgus impacted fracture is a good indication for pinning, whereas, a more comminuted four part with lateral displacement of the head relative to the shaft, may not be.

Galatz considers primary fixation in almost every proximal humerus fracture because the outcome tends to be better — patients heal better with their own bone; anatomic tuberosity healing is more reliable; and, if a revision arthroplasty is needed later, the likelihood of good results is high if the tuberosities are healed in anatomic position.

Galatz emphasized that a stable reduction is critical for successful percutaneous pinning. If the reduction is not stable after pin placement, alternative fixation method should be performed.

“The goals are to restore soft tissue anatomy and bone anatomy,” she said. “I don’t like to leave the operating room without stability. I don’t want to come back because of failure.”

Galatz noted that humeral head replacement is indicated if the patient has a head split fracture, incongruent joint surface, or a high risk of avascular necrosis in an elderly patient.

If a patient requires humeral head replacement, it is best to attempt to minimize the likelihood for a second procedure using careful tuberosity reduction and repair.

Stability, anatomic reduction

Galatz said almost any fracture is amenable to plating. Locking plates available today offer an opportunity to provide anatomic reduction and stable fixation in the proximal humerus that would be difficult to obtain using other methods. She noted that this method is recommended for younger patients, even in fractures with a high risk of avascular necrosis.

“Goals of surgical treatment should be anatomic reduction, stable fixation in order to maximize function and [produce a] painless shoulder,” Galatz said. “When looking at humeral head replacement, the same goals exist with restoring soft tissue and bony anatomy.” — by Tara Grassia

Reference:

Galatz LM. Shoulder Fxs: Pin, plate or replace? Presented at the Current Concepts in Joint Replacement 2011 Spring Meeting. May 22-25. Las Vegas.

Leesa M. Galatz, MD, can be reached at Washington University Orthopedics, One Barnes-Jewish Hospital Plaza, Suite 11300, West Pavilion, Saint Louis, MO 63110; 314-747-2813; email: galatzl@wudosis.wustl.edu.

Disclosure: Galatz has no relevant financial disclosures.