Multiple factors should be considered in management of proximal humerus fractures

The decision to treat a proximal humerus fracture through either nonoperative or operative management depends on several patient and injury factors.

“Certainly, physiologic age, comorbidities and activity level factor in, and then our ability to classify these fractures continues to remain difficult because we cannot agree on the amount of displacement and what constitutes a worse fracture, so there is often disagreement amongst treating orthopedic surgeons within even the same group on how they would treat [the injury] and which ones should be operated on,” Mark A. Mighell, MD, director of the Shoulder and Elbow Fellowship program at the Florida Orthopaedic Institute, told Orthopedics Today.

Age tends to be one of the driving factors for management of proximal humerus fracture because, according to Brian S. Cohen, MD, of the Adena Bone and Joint Center, Chillicothe, Ohio, functional demands and bone quality differ between younger and older patients.

“The way we treat a fracture in a 12-year-old is going to be completely different than we would treat it in a 35-year-old, which would be completely different than we may treat it in an 85-year-old,” Cohen said. “In younger patients, our goal is to do whatever we can to utilize their bone to correct the fracture deformity and get solid fixation. When they return to function, they do so with their own shoulder; as opposed to in the older population where, because the bone usually has a softness to it related to osteoporosis, we may be replacing the shoulders in those patients because the bone is not a good quality to hold screws, pins or plates.”

Image: Christmas K

Edward V. Fehringer, MD, shoulder and elbow surgeon at Columbus Community Hospital in Columbus, Neb., said activity level and comorbidities, including diabetes, vascular disease and smoking history, as well as current and future functional demands should also be taken into account when choosing a treatment method. Besides patient factors, management of a proximal humerus fracture also depends on the fracture pattern.

“It is important we have an understanding of our patients’ history, their comorbidities and their expectations before we perform surgery,” said Mighell, who is also affiliate professor of the residency program at the University of South Florida. “People do not understand that even if surgery goes extremely well, they are still going to lose some degree of motion and strength, and their activity level may be different than prior to the injury. I do not think we explain that well enough to our patients and it is important to let them know when you have a bad fracture with displacement of your proximal humerus, you can get better, but you will never be the same as you were before.”

Nonoperative vs operative

In terms of prevalence, Fehringer noted proximal humerus fractures are generally seen in older patients, specifically those with osteopenia. The younger patient population is by no means immune from these fractures, however, especially if the injury is sustained through high-energy trauma, according to John M. Itamura, MD, an orthopedic surgeon specializing in upper extremity trauma and reconstruction at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles.

“There is definitely a bimodal distribution, the young patients from trauma and the older patients from gravity, balance and osteoporosis,” Itamura said. “It depends on what you are looking at, but there are definitely two separate populations.”

Fehringer noted while literature suggests 80% to 85% of proximal humerus fractures may be managed nonoperatively, surgical management may be needed when a patient has an open fracture, fracture dislocations of the proximal humerus, fractures with significant tuberosity displacement and when the shaft is 100% displaced from the humeral head. Older patients with significant medical comorbidities who experience a proximal humerus fracture with minimal displacement through a low-energy injury tend to be managed nonoperatively, according to Cohen. If an older patient experiences high-energy trauma, however, the patient may require a reverse shoulder replacement.

“The majority of these fractures occur in women in their 60s, 70s and 80s. There is probably a component of osteopenia or osteoporosis, and bone quality is not always outstanding,” Mighell said. “In that patient population, sometimes we are forced to even replace the shoulder due to the degree of displacement and comminution of the fracture.”

In a recently published study, Han and his colleagues found while nonoperative treatment was still the most common method for the management of a proximal humerus fracture, among patients who required surgical intervention, there was an increase in management with arthroplasty, including reverse total shoulder arthroplasty.

“We are frequently confronted with fractures that could be treated either operatively or nonoperatively and we have a discussion with the patient where we explain the pros and cons of treatment,” Mighell said. “I think our literature would tell us in physiologically younger, more active patients, greater degrees of displacement are probably not as well tolerated. For people who are trauma surgeons or have experiences with approaches to the shoulder, internal fixation can be rewarding.”

When treating proximal humerus fractures operatively, Fehringer noted some options surgeons have include the use of percutaneous pins, angular stable humeral nails and locked plate and screw constructs. They can also perform a hemiarthroplasty or reverse shoulder arthroplasty with fixation of the tuberosities.

Although nonoperative or operative methods may work better in specific patients, a study published in 2015 by Rangan and his colleagues showed of 250 patients in the United Kingdom who experienced a displaced fracture of the proximal humerus, no differences were found in patient-reported clinical outcomes during the 2 years between operative and nonoperative management. According to R. Sean Churchill, MD, Eastside section head of the Department of Orthopedic Surgery at Aurora Health Care, sometimes surgeons treat patients operatively to restore the anatomy when the clinical outcomes would be the same whether they were treated operatively or nonoperatively.

“There have been times where the X-rays look perfect and [the surgeon is] so pleased with how [it was] done and how the patient has healed, but if you step back and clinically look at it, some of these patients are not doing much better than they would have done with nonsurgical management and it would have saved them a lot of stress on their body,” he said.

“Overall, 80% of [proximal humerus fractures] do not come to surgery,” Churchill added. “[Patients] do just fine without surgery, and just because we have newer techniques and newer methods does not mean that [nonoperative treatment] should be pushed down to 60%. It means we still need to be looking at them and decide if 80% is right. Maybe only 10% need fixing instead of 20%. So just because we have newer techniques does not mean we need to abandon the nonsurgical method.”

Preventative measures

According to Cohen, injury prevention is key when it comes to proximal humerus fractures. He noted proper nutrition, staying active and medically managing osteoporosis as ways to prevent proximal humerus fractures. Itamura said improving balance in older patients can also help prevent falls that may lead to proximal humerus fractures.

“If we see patients get their balance better, perhaps the better the balance, the less likely they will fall,” Itamura said. “But a lot of this is because as our population ages, our bone quality gets worse.”

Receiving calcium with vitamin D and participation in light exercise, including yoga, tai chi or water aerobics could help older female patients maintain strong bone mineral density, according to Mighell.

“Most women should have bone mineral density testing done. I think it is preventive for these fractures,” he said. “Certainly smoking cessation becomes of significant importance, as we know that people who smoke, if they do have fractures, have a higher rate of the bone not healing or it takes the bone longer to heal.”

Churchill also said patients can be prescribed medication to help strengthen the bone either after a fracture or to help prevent fractures.

“There is a lot of research done on the different medications people can be given after they have had a fragility fracture or to help prevent a fragility fracture,” he said. “The research is ongoing with this. Everybody’s practice handles it a little differently. Most of the time the rheumatologist is the one who is managing the medical management of this, sometimes it is the primary care physician and once in a while an orthopedic surgeon is actively involved and manages those medications.”

While Fehringer noted avoiding trauma is helpful but often unpredictable, Cohen said being aware of changes in the environment may help patients avoid more major falls.

“Be aware of your surroundings and environment. Be careful on the ice or if there is a change in terrain, such as floor to carpet, be careful getting up in the middle of the night with the lights off,” Cohen said.

Improving technology, surgery

As with any fracture, Cohen said the most difficult portion of treating proximal humerus fractures is getting the bone to heal and avoiding displacement.

“We want to get the bones to heal because the fixation of the plate and screws or the pin will eventually lose their strength if the bone never heals,” he said. “So research is being done now on how we get these fractures to heal faster.”

There are no easy proximal humerus fractures, according to Cohen, and injuries that look straightforward on radiographs can reveal more complex issues during surgery. He added surgeons should be familiar with the patient’s anatomy prior to surgery and be prepared for anything that may occur during the procedure.

“We like to use the analogy of the golf bag, You want to have every club available in your golf bag because you do not want to be on the putting green using your driver because you do not have your putter,” Cohen said.

Mighell noted a systematic approach with accurate imaging of the fracture during surgery should help with visualization and appropriate anatomic reduction. He also said surgeons should choose the fixation method that works best for them.

“If you are going to fix proximal humerus fractures, you should have a systematic approach which requires accurate imaging of the fracture during the procedure,” he said. “While the patient is under anesthesia you can visualize the humeral head and the humeral shaft so that when you make your reduction, you know you have a near anatomic reduction. Once you have achieved this, you can proceed with your temporary or provisional fixation followed by your fixation.”

Timing of surgery is important for older patients, according to Itamura, while good intraoperative radiographs and knowledge of the device will help with younger patients.

“Some of the older [patients], I do not think you can get the jump on them right away and operate, but I think for the younger patients it is knowing the device you are using and make sure you get good X-rays intraoperatively and that will probably prevent a lot of complications,” he said.

Churchill noted surgeons should become familiar with the hardware available and stick to one specific method before switching methodologies.

“Surgeons will often jump from one implant to another implant and never become proficient with a certain product,” Churchill said. “Each implant or device will have specific characteristics that make it work better in specific situations. Surgeons should try and become proficient at a limited number of implants rather than continually switching.”

He added, “[Surgeons will] find as [their] skill level increases, your incisions become smaller, the soft tissue disruption becomes smaller and then the scarring becomes less.”

Research should focus on treatment of osteoporosis in older patients and less invasive fracture care among younger patients, according to Itamura.

“Probably for the older patients, the research is going to be in osteoporosis and improving balance, which would decrease the falls. In younger patients, less invasive fracture care that would allow good fixation, early motion with minimal risks may be the focus,” Itamura said.

Mighell noted during the next decade, research should help develop better technologies and improved biologics to help with the management of proximal humerus fractures.

“If you look at any of the meta-analyses of proximal humerus fractures, they show there is still an unacceptably high rate of hardware failure, loss of fixation and fracture collapse. What we need to focus on is better technologies and improved biologics for treating these injuries,” he said. “I think you will see in the next decade, we will develop ways to allow this fracture, which should be considered both a soft tissue injury and a fracture, to be better managed.” – by Casey Tingle

• References:
• Han RJ, et al. J Shoulder Elbow Surg. 2016;doi:10.1016/j.jse.2015.07.015.
• Rangan A, et al. JAMA. 2015;doi:10.1001/jama.2015.1629.

• For more information:
• R. Sean Churchill, MD, can be reached at Aurora Health Care Inc., 750 West Virginia St., P.O. Box 341880, Milwaukee, WI 53234; email: cheri.mantz@aurora.org.
• Brian S. Cohen, MD, can be reached at Adena Bone and Joint Center, 4437 State Route 159, Suite G15, Chillicothe, OH 45601; email: msmith4@adena.org.
• Edward V. Fehringer, MD, can be reached at Columbus Community Hospital, 4508 38th St., #133, Columbus, NE 68601; email: evfehringer@columbushosp.org.
• John M. Itamura, MD, can be reached at Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terr., Los Angeles, CA 90045; email: trace@longocommunications.com.
• Mark A. Mighell, MD, can be reached at the Florida Orthopaedic Institute, 13020 North Telecom Pkwy., Temple Terrace, FL 33637; email: kchristmas@foreonline.org.

Disclosures: Cohen reports he is a consultant for Arthrex. Fehringer reports he is a designer of a humeral nail for Wright Medical. Itamura reports he is a consultant for Wright Medical and Acumed. Mighell reports he is a speaker and consultant for Stryker and Donjoy Orthopedics. Churchill reports no relevant financial disclosures.

Should there be an age cutoff for the surgical management of a severely displaced proximal humerus fracture?

Nonoperative treatment is key

The treatment of displaced proximal humeral fractures in older patients remains an unsolved dilemma for the practicing orthopedic surgeon. While there is solid evidence from high quality comparative studies that surgical intervention has some benefits compared to nonoperative management for many upper extremity fractures (i.e., distal radius, forearm, clavicle), this is not the case for the proximal humerus. There are three prospective, randomized trials (including the 250 patient Profher study) that have compared operative fixation (with proximal humeral locking plates) to nonoperative treatment of displaced three- and four-part proximal humeral fractures in primarily older patients. None have shown any advantage with operative intervention. This rather discouraging finding is amplified by the fact that patients in both groups fare poorly, with low shoulder-specific and general health status scores. While these studies have some methodological flaws (the Profher study enrolled an average of only one surgical patient per year per site), it is clear that proximal humeral locking plate fixation has not been the solution we hoped for when dealing with osteoporotic bone of the proximal humerus.

While there is some evidence from randomized trials that primary hemiarthroplasty may be superior to nonoperative care for select older patients with displaced proximal humeral fractures, the improvement is marginal at best (slightly less pain, no difference in function) and both groups ended up with about 90° of shoulder flexion, far from optimal. It remains to be seen if the allure of the reverse shoulder arthroplasty (with spectacular successes, but higher costs and complication rates) is justified by the results in this setting. Prospective studies are underway.

I have seen many presentations replete with case after case of anatomic healing following fixation of displaced proximal humeral fractures in older patients, only to return to my referral fracture clinic and see dismal failures of same. The bottom line is with the implants and techniques currently available, outcome after a displaced proximal humeral fracture in an older patient correlates mainly with age and pre-injury shoulder function. Surgical intervention in general does not improve this outcome and introduces a host of complications that are distressing for the patient and expensive for the health care system. For this reason, with some exceptions such as fracture-dislocations, our standard approach to displaced proximal humeral fractures in older patients should be nonoperative.

• Reference:
• Rangan A, et al. JAMA. 2015;doi:10.1001/jama.2015.1629.

Michael D. McKee, MD, FRCS(C), is a professor in the Division of Orthopaedics, Department of Surgery at St. Michael’s Hospital, University of Toronto in Toronto.
Disclosure: McKee reports no relevant financial disclosures.

Consider operative intervention

Proximal humerus fractures are the third-most common fracture in older patients. Non- or minimally displaced, these fractures usually heal uneventfully, leading to good functional outcomes. When severely displaced, the anatomic relationship between the rotator cuff, humeral head and humeral shaft is disturbed, leading to dysfunction of the shoulder. The humeral head–glenoid relationship is also altered, often leading to subluxation, post-traumatic arthrosis and joint collapse. These sequelae often lead to a painful and dysfunctional shoulder joint, causing patient dissatisfaction and frustration that can markedly diminish quality of life regardless of patient age.

When an older patient presents with a severely displaced proximal humerus fracture, the surgeon is presented with a few important questions:

1. How displaced is the fracture? Will the bone heal so at least there is a stable humerus that is in one piece? Will the glenohumeral joint relationship be acceptable? If the answer to these questions is the fracture is too displaced to heal with an acceptable glenohumeral joint relationship, then operative intervention should be considered.
2. What is the physiologic age of the patient? How healthy is the patient? How risky is a major and somewhat elective operative procedure for the individual? Age by itself usually does not give an absolute indication of the patient’s general health or ability to undergo surgery. It also does not guarantee success or failure of healing after the procedure. A detailed medical and social history gives the clinician a good idea of the patient’s comorbid conditions that may increase the risk of both complications with surgery and having a poor result.
3. How active and independent is the patient? Will a significant loss of shoulder function adversely affect the patient’s quality of life? In one large study of more than 1,000 proximal humerus fractures treated in Edinborough, Scotland, between 1992 and 1996, fewer than 10% of patients in the series were in a nursing home and approximately two-thirds of patients lived independently. The authors summarized “proximal humeral fractures often occur in the fit older independent patient who is still a net contributor to society but might well be converted to a degree of social dependency by the fracture.” In 2016, older patients are more fit than they were 20 years ago, often leading active lifestyles and enjoying activities, such as hiking, skiing, biking and swimming. Older patients with a displaced proximal humerus fracture are understandably concerned they may not be able to return to these activities, in addition to functional independence, as a result of their proximal humerus fracture.
   A detailed activity history gives the surgeon a good feel for the patient’s desired activity after treatment of the shoulder. For example, a patient who is sedentary with multiple comorbid conditions should have a higher threshold for opting for surgical treatment than a healthy elderly patient who exercises and/or plays sports on a regular basis.
4. Can the fracture be treated effectively with an operation? Is the risk-benefit ratio favorable to the patient, given the surgeon’s ability to effectively repair the fracture and/or perform a replacement? Multiple operative treatment options exist for displaced proximal humerus fractures. Advances in percutaneous pinning, suture fixation, intramedullary nailing, plate and screw fixation, hemiarthroplasty and reversed arthroplasty provide the surgeon with an armamentarium of surgical procedures that have been shown to effectively lead to healing and a functional shoulder without debilitating pain. It is important the surgeon has a good understanding of his or her own limitations when recommending a particular procedure for the patient and should have the internal judgement to decide when to perform the procedure or to refer the patient to a subspecialist. The patient needs to understand the potential for requiring revision procedures, and the surgeon should also have that in mind when performing the operation.

• Reference:
• Court-Brown CS, et al. Acta Orthop Scand. 2001;doi:10.1080/000164701753542023.

Armand M. Hatzidakis, MD, is a shoulder and upper extremity specialist at Western Orthopaedics in Denver.
Disclosure: Hatzidakis reports he is a consultant and paid speaker for, has stock options in, and receives IP royalties and research support from Tornier; is on the design team for the Tornier Aequalis IM nail; and receives IP royalties and research support, and is a consultant to and paid speaker for Wright Medical.

Medicare trends

The management of proximal humerus fractures in the older patient requires an appreciation of a multitude of factors beyond the imaging studies. In South Florida, I see highly independent and active patients well into their 90s. Defining an age limit for offering surgery is both unfair and unjustified. Analysis of patient factors, such as level of activity, comorbidities and bone quality, can be just as critical as analysis of the radiographs and CT scan. The decision to offer surgery to an 80-year-old patient who plays tennis four times a week is different than an 80-year-old patient who lives a sedentary life in a nursing facility.

My preference is always to fix the fracture. However, fixation of fractures with severe greater tuberosity comminution or complex fracture-dislocations can be challenging in the older population. For those fractures which I cannot successfully perform osteosynthesis, I now frequently utilize the reverse shoulder replacement.

Recently, the Journal of Shoulder and Elbow Surgery published our analysis of the recent Medicare trends in surgical management. Between 2009 and 2012, there was no increase in the overall utilization of surgery, despite a growing Medicare population. The use of open reduction and internal fixation also remained unchanged. However, use of reverse shoulder replacement increased nearly three-fold as hemiarthroplasty saw less utilization. However, as of 2012, the most common surgery performed for proximal humerus fractures in Medicare patients was hemiarthroplasty.

• Reference:
• Rosas S, et al. J Shoulder Elbow Surg. 2016;doi:10.1016/j.jse.2015.08.011.

Jonathan C. Levy, MD, FAAOS, is the chief of orthopedics and program director of the Holy Cross Shoulder and Elbow Fellowship and medical director of the Holy Cross Orthopedic Research Institute in Fort Lauderdale, Fla.
Disclosure: Levy receives royalties, consultant fees and research support from DJO Orthopedics.