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Nonoperative, operative treatment of proximal humerus fractures may have similar outcomes
Findings showed some patient, clinical factors may not respond well to nonoperative treatment.
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Depending on their demographics, patients with proximal humerus fractures who undergo nonoperative treatment may experience outcomes similar to patients who undergo operative treatment, according to a presenter.
Andrew Jawa, MD, said six randomized trials that compare nonoperative and operative fixation among patients with proximal humerus fractures all showed similar outcomes between the treatments.
“So, why do we operate on so many?” Jawa said. “I think part of this has to do with the fact that all patients are not the same.”
Natural history may be another reason orthopedic surgeons may regularly turn to operative treatment of these fractures, he noted.
“I think we have forgotten what it looks like to treat patients nonoperatively,” Jawa said. “We are taught since the time of Neer that many of these three-part fractures should be fixed and the four-part[s] should get ‘hemis,’ and we have forgotten how to treat them nonoperatively.”
Factors for nonoperative success
Results of nonoperative treatment do not apply to young patients, according to Jawa.
“Young is changing and I think people’s expectations are different and that may push us to do surgery. I think that is reasonable with a discussion with the patient,” he said.
Jawa also said patients with avascular necrosis may do well with either operative or nonoperative treatment of a proximal humerus fracture.
“The nonunion rate is higher nonoperatively, the pectoralis … brings the humeral shaft forward so there is a higher rate of nonunion and you need to discuss this with the patient,” Jawa said, and he noted there are some challenges with managing nonunions.
Preserving the entire proximal part of the humerus is helpful, he said.
In addition, the risk of instability is increased if the tuberosities do not heal, Jawa said.
Patients with pain and stiffness who later go on to have degenerative changes can be difficult when the posterior tuberosity goes posteriorly, according to Jawa. He noted sclerosis in the shoulder joint can be difficult to broach during surgery and can result in patients whose shoulders are both stiff and unstable. Patients with sclerosis can undergo reverse shoulder arthroplasty, although it is difficult to perform. The advantage of RSA is it is more forgiving, according to Jawa.
Reverse shoulder arthroplasty
Once a patient develops a malunion and nonoperative treatment is no longer feasible, RSA is an option to consider, according to Jawa. However, patients who undergo RSA after a malunion do not do as well as patients who initially undergo RSA.
Patients undergoing an osteotomy may also not do well with RSA, he added, as the osteotomy may compromise outcomes. Similarly, patients with significant shaft translation or posterior tuberosity displacement have been found to not do well with RSA.
“There are no trials of RSA vs. nonop,” Jawa said. “We do have a retrospective study that shows they do the same, but we do not have anything more than that at this point.” – by Casey Tingle
Reference:
Jawa A. ICL 204: Proximal humerus fractures. Presented at: American Shoulder and Elbow Surgeons Annual Meeting. Oct. 12-14, 2018; Chicago.
For more information:
Andrew Jawa, MD, can be reached at Boston Shoulder and Sports Center, 840 Winter St., Waltham, MA 02451; email: andrewjawa@gmail.com.
Disclosure: Jawa reports he is a paid consultant for and receives research support from DJ Orthopaedics.