Surgeons find no consensus on best treatment for proximal humerus fractures

While many proximal humerus fractures can be treated nonoperatively, different techniques, methods and prostheses can be used to treat the most serious of these injuries, according to sources.

Nearly 85% of proximal humerus fractures can be treated nonoperatively, Hannan Mullett, MD, told Orthopaedics Today Europe. Conservative treatment is the best option for elderly patients who present at his practice with proximal humerus fractures who have low functional demand and a fracture that is not reconstructable.

However, a young patient who is active and has a displaced fracture will typically have good outcomes with operative fixation, Mullett said.

Open surgery goals

The goal of open reduction and internal fixation (ORIF) for proximal humerus fractures is clear for any surgeon, Simon M. Lambert, BSc, MBBS, FRCS, FRCSEdOrth, told Orthopaedics Today Europe.

“The aim of ORIF of proximal humeral fractures is the restoration of the shape and form of the proximal humerus so the rotator cuff is brought back to its optimal length-tension relationship around the centroid of glenohumeral motion with smooth surfaces articulating in the glenohumeral joint and under the coraco-acromio-deltoid arch,” he said.

The objective of proximal humerus fracture management is to restore or maintain the patient’s ability to use “the hand of the affected extremity in a functional manner, uninhibited by pain and appropriate to their anticipated needs,” Lambert said.

Restore the tuberosities

ORIF tends to offer better outcomes for young, active patients with this type of fracture. Hemi-arthroplasty should be reserved for older, less active patients, according to Mullett.

“My philosophy is if they have reasonable bone stock and there is a good chance of restoring the tuberosities, and the bone unites, generally the results are better with ORIF rather than prosthetic options,” he said.

The literature shows ORIF offers better outcomes than nonoperative techniques with severely displaced fractures in young and middle-aged patients, Tuomas Lähdeoja, MD, told Orthopaedics Today Europe, and said ORIF is preferred at the clinic where he works over a closed procedure because with ORIF restoration of the bony anatomy is possible in most fractures.

Available evidence now points to locking plate ORIF as being better than other methods, according to Lähdeoja, of Helsinki.

“We try our best to base our treatment choices on evidence. If in the future trials show that nails actually perform better in the treatment of fractures which benefit from operative treatment in the first place at all, we are ready to change our preferred methods,” he said.

According to Lähdeoja, osteoporotic humeral fractures are problematic. There is no real consensus about how they should be treated and evidence about operative treatment is lacking, he said, but trials going on now worldwide should “provide some solid answers to these questions.”

Pinning and interlocking plates

Pinning is not stable enough of a procedure and fractures that can be treated with pins often are treated just as well nonoperatively. Furthermore, nailing has too many negative outcomes associated with the approach itself and is not used where Lähdeoja works.

“There is some research evidence pointing to nailing leading to more shoulder problems due to violation of the rotator cuff. This is especially true for diaphyseal fractures, but I do think this generalizes to any nailing of the humerus,” he said, noting surgeons tend to operate only on displaced and comminuted fractures and putting those together with a nail is technically challenging to say the least.

Interlocking plates have represented possibly the biggest advancement in ORIF procedures, but have not been “the great panacea we had hoped for,” Mullett said. Historically, plates had poor outcomes in patients with osteoporotic bone and screw back out occurred, but newer locking plates improved the screw back out rates. However, in most studies nearly 20% of patients treated with locking plates needed reoperations, he said.

A 2015 study by B. Schliemann and colleagues supports use of a new radiolucent carbon fiber-reinforced polyetheretherketone plate for proximal humerus fractures. At 2-year follow-up, they found it may provide satisfactory clinical and radiological outcomes vs. conventional locking plates and reported the plates were associated with improved Constant-Murley and Oxford Shoulder scores vs. traditional plates.

IM fixation a regional practice

Percutaneous pinning and intramedullary (IM) fixation are other options for the treatment of these fractures. Variations of IM fixation are used regionally throughout Europe, Mullet said. He tends to reserve IM fixation for pathological fractures and noted a difficult consequence of the technique is it can be difficult to perform a revision operation in someone after IM fixation.

Another option is indirect reduction and percutaneous pinning.

“The most significant complication is pin tract infection and loss of reduction. I suppose the major proponent of this technique is Herbert Resch from Austria and he had great results in pinning, but they were not reproduced by others to the same extent. It is an option, but I tend to use it in younger patients with good bone quality and minimal displacement,” Mullett said.

Pierre Hoffmeyer, MD, an Orthopaedics Today Europe Editorial Board member, said his clinic will typically use IM nailing to repair proximal humerus fractures. He said it is less invasive than an open procedure. Patients also prefer the procedure because it does not leave them with a large scar afterwards, he said.

“We use IM nailing for 2-part fractures. In 2-part fractures, one block is the humeral head and the other block is the diaphysis, and they are separated by a fracture usually around the neck of the humerus or a little lower. You can get a reduction and put a nail down through an incision that is pretty minimal. Therefore, you do not have the soft tissue aggression you have when you do an open reduction through a deltopectoral approach, or a rotator cuff type approach. This is more lateral,” Hoffmeyer said.

The nail must be placed deeply in the head and not protrude into the subacromial space thereby causing pain and limitation of movement, and locking screws are necessary. While locking screws are generally easy to use, they can catch a nerve or pinch the biceps tendon, he said.

Though effective, he said the technique has drawbacks as it goes through the humeral head and cartilage rather than the tendonous insertion footprint of the supraspinatus. Going through the musculoskeletal junction and the top of the humeral head minimizes injury to the rotator cuff, Hoffmeyer said.

Multiple part fractures

For 3-part or 4-part fractures, Hoffmeyer said his clinic’s philosophy is more an AO Swiss philosophy based on proximal humerus fractures being intra-articular fractures that need to be as rigidly fixed as possible.

“I see X-rays sometimes in publications where people can reduce nicely 3-, or even 4-part fractures, with nails or locking screws. I think this is a difficult technique. We prefer doing either a deltopectoral approach or a lateral-type deltoid splitting rotator cuff approach, reducing the fragments under direct vision, and holding them together with a plate system or a tension band system. The deltoid split approach is especially useful for instance in fixing a tuberosity fracture after a dislocation,” Hoffmeyer said.

Arthroscopic fixation is typically not used for any proximal humerus fractures, according to Hoffmeyer and Mullett.

Reverse shoulder arthroplasty

An advance in the last 10 years is reverse geometry shoulder arthroplasty (RSA), which is useful in older patients who are independent with reasonable life expectancy, Mullet said.

“The advantage of RSA over hemi-arthroplasty is it is designed for people with rotator cuff deficiency. In the short- to medium-term results of a reverse geometry shoulder replacement over hemi, you generally get better forward elevation in the order of 20° to 50° better,” he said. “The complication rates are higher though in the order of 15%,” and they typically consist of dislocation, infection and periprosthetic fracture.

“Dislocation is the most common complication following RSA,” Mullet said.

Lähdeoja said RSA is a promising technique for patients 75 years of age and older who have comminuted C-type fractures, but its use in fracture care should be restricted to controlled trials to evaluate effectiveness and outcomes vs. established methods.

Lambert said there seems to be a rush to use RSA when ORIF could actually offer better surgical outcomes in some patients.

“There is a rapid trend to RSA for the early management of many proximal humeral fractures, even those in which ORIF would be indicated, and in the younger patients. This should be very carefully examined: revision of the failed RSA is probably the most difficult operation in revision shoulder arthroplasty, and revision is surely going to be required in many of these implants in the future. The art of ORIF should not be lost in the rush to RSA,” he said.

RSA and subscapularis restoration

RSA should be reserved for patients in whom the subscapularis can be restored or preserved for stability, in patients with pre-existing cuff tear arthropathy and for the very elderly population with lower functional demands, according to Lambert.

Shoulder hemi-arthroplasty can be a useful technique for a specific group of patients, he said.

“For the older, bone-incompetent, medically-incompetent, and, possibly, socially-isolated patient with a more complex fracture, ORIF carries high risks of mechanical failure and nonunion with redisplacement. In these cases, shoulder hemi-arthroplasty has been shown to be more predictive of a functionally useful outcome than either ORIF or nonoperative treatment,” Lambert said.

Mullett typically uses bone graft or a bone graft substitute to augment operative fixation and said products being developed for the market show promise for this treatment.

“We have used autogenous bone graft or injectable bone graft substitute with improved results. We did a number of biomechanical studies that showed improvement. One of the locked plates now has the ability to inject bone graft substitute. That is an advance that will hopefully be worthwhile,” he said.

A promising advance in proximal humerus fracture treatment is 3-D imaging, Hoffmeyer said, because mapping a fracture and planning the surgical procedure with radiographs is not completely effective.

“I would recommend doing a CT with 3-D imaging capabilities on every proximal humerus fracture...We have had situations where we have changed our attitude because of the 3-D CT scan” and we ultimately decided to repair the fracture rather than use a prosthesis, Hoffmeyer said – by Robert Linnehan

• References:
• Launonen AP, et al. Acta Orthop. 2015; 9:1-6. [Epub ahead of print].
• Schliemann B, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2014.12.028.

• For more information:
• Pierre Hoffmeyer, MD, can be reached at the University Hospitals of Geneva, 4 rue Gabrielle-Peret-Gentil, 1211 Genève 14, Switzerland; email: pierre.hoffmeyer@hcuge.ch.
• Tuomas Lähdeoja, MD, can be reached at Töölö Hospital, Helsinki University Central Hospital, Helsinki FIN-00029 HUS, Finland; email: tuomas.lahdeoja@hus.fi.
• Simon M. Lambert, BSc MBBS FRCS FRCSEdOrth, can be reached at Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdom; email: simonlambert@me.com.
• Hannan Mullett, MD, can be reached at Sports Surgery Clinic Santry Demense, Santry, Dublin 9, Ireland; email: hannanmullett@icloud.com.

Disclosures: Hoffmeyer, Lähdeoja and Mullett report no relevant financial disclosures. Lambert is chair of the Upper Extremity Expert Group of the AOTK, a consultant to the British Standards Institute Group on shoulder and elbow prostheses and related matters and a consultant to Stanmore Implants Worldwide.

What added information about proximal humeral fractures does 3-D imaging provide compared to standard radiographic views?

3-D imaging can be valuable

Medical imaging is performed for primary diagnosis of a proximal humeral fracture and aids in the establishment of a treatment plan. Standard radiographic evaluation is useful and often provides a sufficient presentation of relevant bony structures for primary diagnostics. Conventional X-rays with anterior-posterior view, axillary lateral and/or scapular “Y” lateral views all provide unique information to estimate the fracture configuration based on single “slices” from different angles. However, not always is a high-quality clear presentation of the relevant bony structures achieved. In these cases, standard radiographic images might be insufficient to classify the fracture and establish a treatment plan.

The 3-D CT can provide valuable additional information on the composition of the fractured region, enabling the clinician to visualize the fracture configuration as a whole. The collection of CT images is used for 3-D reconstruction that presents the imaging data in a more anatomical form. This useful visual information can contribute to correct classification of the fracture and can help establish an adequate treatment plan.

Recent studies have found variable (but generally slight to moderate) improvements in the intra-observer and interobserver reliability of widely used fracture classification systems such as Neer and AO/ATO, using 3-D CT images. Traditional classification systems, however, have not been developed based on information from new imaging techniques. New and modified classification systems have been suggested in the literature. When routine radiographic images are insufficient for adequate fracture classification and clinical decision making, 3-D imaging can provide essential additional visual information.

Alexander T.M. van de Water, BScPT, MSc, PhD, practices at Saxion University of Applied Sciences, Academy of Health, Enschede, The Netherlands.

Disclosure: van de Water reports no relevant financial disclosures.

Radiographs considered sufficient

A CT scan and 3-D reconstructions have shown slightly improved interobserver agreement on classification of proximal humeral fractures, compared to plain radiographs. However, in general, the interobserver agreement on the classification is low and implications for treatment recommendations unclear.

In general plain X-rays with a minimum of two perpendicular views are considered sufficient for decision-making in the evaluation of most patients with a proximal humeral fracture. Interestingly, a study found experienced shoulder surgeons agree better on treatment recommendations than on classification reviewing plain X-rays. Thus the classification systems may miss to describe details in the pathology of shoulder fractures that are of importance for the prognosis. For experienced surgeons, there are several factors of importance for the decision-making: Presence of head split fractures, the degree of valgus impaction or varus deformity, presence of posterior displacement or subluxation of the humeral head, displacement of the major and minor tubercle, or concomitant injuries to the glenoid or scapula. If plain X-rays are not conclusive, CT and 3-D reconstructions may be of importance for the evaluation of the fracture pattern and for decision-making in each individual case. Hopefully future research will improve the knowledge on fracture patterns and thereby improve our classification systems and treatment recommendations for proximal humeral fractures.

Anne Kathrine Belling Sørensen, MD, practices at the Shoulder and Elbow Unit, Orthopaedic Department, Herlev Hospital, University of Copenhagen, Denmark.

Disclosure: Sørensen reports no relevant financial disclosures.

• References:
• Brorson S, et al. BMC Musculoskelet Disord. 2012;doi:10.1186/1471-2474-13-114.
• Bruinsma WE, et al. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.00586.