Shoulder:Proximal Humeral Fracture

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Proximal Humeral Fracture

Bullet Points

  • Assessment of an acute proximal humerus fracture includes a complete trauma series radiography and, where surgical treatment is considered, a CT scan with three-dimensional reconstruction.
  • The decisive elements of choice between osteosynthesis and implant are essentially the patient’s age, the risk of humeral head necrosis and bone strength.
  • The surgical treatment is difficult and should, in cases of osteosynthesis, lead to an anatomical result.
  • According to the literature there is no difference between antegrade intramedullary nailing and plate osteosynthesis.
  • The reverse implant is increasingly the treatment of choice for the elderly.
  • Where stability permits, early, passive mobility rehabilitation should be commenced. If this is not the case, then rehabilitation should be deferred and the patient immobilized in the meantime.

Keywords

Shoulder; Proximal humerus fracture; Arthroscopy; Osteosynthesis; Hemi arthroplasty; Intramedullary nailing; Plate ; Reverse implant.


Prevalence

Proximal humeral fractures are limited to those located above the insertion point of the superior edge of the pectoralis major. They represent 5% of all fractures in patients over 40 years of age.[1]

Their incidence, having drastically increased between 1970 (87/100'000 individuals) and 1995 (304/100'000 individuals) seems, for no clear reason, to have reached a plateau since 2010 (297/100'000 individuals in 2015).[2][3]

Anatomy

Morphology

Anatomical restitution, and especially the position of the tuberosities after fixation and during all reconstruction work, is essential. The height of the greater tuberosity in relation to the head is crucial. Normally, the tuberosity lies 8±1.2 mm (range, 6 to 10 mm) below the superior most portion of the humeral head.[4]

In non-pathologic conditions, the greater tuberosity is never above the top of the humeral head. As little as 5 mm of displacement not only creates impingement, but also insufficiency in the posterosuperior rotator cuff due to lack of tension relative to the Blix curve (Figure). Malunion can result in a mechanical block to shoulder abduction or external rotation and altered rotator cuff mechanics, causing weakness. Surgical fixation is consequently recommended for fractures with residual displacement greater than 5 mm, or 3 mm in active patients involved in frequent overhead activity. Similarly, a greater tuberosity that is too low will also harm the rotator cuff.[5][6]

Different situations or pathological position of the greater tuberosity cause impingement and loss of strength: A) Type II cephalotubercular valgus impacted fracture and B) displaced fracture of the greater tuberosity resulting in decreased mobility and loss of strength through relaxation of the cuff. Reproduce from[5], with permission.


The superior edge of the pectoralis major and the top of the humeral head is a reliable measure that can be used intraoperatively to decide the height of the humerus prosthesis or humeral head in comminuted fractures of the proximal humerus. Pectoralis major tendons inserted 54 to 56 mm distal to the superior aspect of the humeral head and 47 mm distal to superomedial tip of greater tuberosity.[7][8] The distance between the superior edge of the pectoralis major and the top of the humeral head might be shorter (49 mm) in Asiatic women.[9] In a study using the pectoralis major tendon as a reference intraoperatively reconstruction of the height of the humerus prosthesis measured by evaluating the radiological humeral length in comparison to the contralateral side within 7 mm +/- 7 mm could be shown.[10]


The pectoralis major insertion is also very reproducible regarding its relationship to retroversion. The mean distance to the posterior fin of the prosthesis was 10 mm and the mean angle 25 degrees.[11]


The pectorals major insertion has a reproducible relation to the bicipital groove, making it a good landmark for tuberosities positioning in case of fracture reconstruction.[12]


The lateral offset of the greater tuberosity relative to the diaphyseal axis is another important anatomic variable, but sometimes difficult to restore due to the comminuted, and often porotic nature of fractured tuberosities, giving them an eggshell appearance. The offset is on average 18±2 mm (range, 1 to 22 mm)(Figure).[13]


Role of the lateral offset: A) Superomedial malposition of the greater tuberosity after a subtubercular varus impacted fracture. Reproduced from [5], with permission.


Every effort should be made to restore this relationship intraoperatively whether by anatomic reconstruction with osteosynthesis (Figure) or during arthroplasty surgery. In the setting of chronic non-union, allograft reconstruction has also been described.[14][15][16]

Restitution of the offset by allograft: A) Coronal CT Scan of a right shoulder. Note the loss of bone from the greater tuberosity. B) Radiograph of the same patient after allograft reconstruction of the humeral head and reinsertion of the rotator cuff. Reproduced from[14], with permission.

Lastly, the head-shaft relationship must be restored. The neck-shaft angle, posterior tilt and retroversion are key factors.[17]

If the above-mentioned key points are not taken into account, or left uncorrected, the sequelae could include malunions that are particularly difficult to treat.

Vascular

The perfusion of the proximal humerus arises from the anterior and posterior humeral circumflex arteries, themselves terminal branches of the axillary artery (Figure). Due to the location of these vessels in close proximity to the fracture, they can be subject to lesions (Figure). The anterior humeral circumflex artery courses along the inferior border of the subscapularis. The artery gives off an anterolateral ascending branch that courses along the lateral aspect of the bicipital groove before entering the humeral head and becoming the arcuate artery. The anterior humeral circumflex vessel continues postero-laterally to anastomose with the posterior humeral circumflex vessel. The posterior humeral circumflex artery travels with the axillary nerve through the quadrilateral space before it goes on to its anastomosis with the anterior humeral circumflex. It has been believed that the anterolateral branch of the anterior humeral circumflex artery is the main source of perfusion of the humeral head with the posterior vessels only perfusing a small portion of the head. It seems that 64 % of the humeral head blood supply is derived from the posterior humeral circumflex artery and the anterior vessel only accounted for 36 % of the perfusion,[18] This finding and the numerous extraosseous anastomoses that can compensate explain the rather low rate of avascular necrosis. The humeral head have thus the possibility to revascularize after injury. Isolated surgical neck and isolated greater tuberosity fractures have a very low incidence of osteonecrosis as the blood supply to the humeral head is relatively preserved. Four-part fractures have a higher incidence of osteonecrosis than three-part fractures. Four-part fractures with associated dislocation have the highest risk for osteonecrosis.The presence of humeral head ischemia in the acute injury setting is not a predictor of subsequent avascular necrosis. The predictive accuracy of characteristics of humeral head ischemia, from most predictive to least predictive, are: calcar length less than 8 mm, disrupted medial hinge, humeral head angulation more than 45 degrees, and head-split fracture. Hertel et al. evaluated predictors of humeral head ischemia at the time of surgery in a prospective study of 100 intracapsular proximal humerus fractures. They found the most accurate predictive measures of humeral head ischemia, from most accurate to least accurate, were: a calcar length <8 mm, disruption of the medial hinge, basic fracture pattern, displacement of the humeral head >45 degrees, displacement of the tuberosities >10 mm, glenohumeral dislocation and head-split fractures (equally predictive).[19]

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Nerve

The axillary nerve comes off the of the brachial plexus (middle trunk, posterior division, posterior cord) carrying fibers from C5 and C6. The axillary nerve travels through the quadrangular space with the posterior circumflex humeral artery and vein to innervate the teres minor and deltoid muscles and supply sensation over the lateral shoulder. The axillary nerve is located approximately 7 cm from the tip of the acromion.[20]

Types of Fracture and Classification

Codman's Classification

Codman's classification

Neer’s Classification

The classification does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

Proximal humerus fractures are classified based on the relationship of 4 fracture fragments (greater tuberosity, lesser tuberosity, articular surface, shaft). Parts are considered separate part if displacement is > 1cm or angulation is >45°.

Duparc’s Classification

This classification is mainly used in France. Duparc et al. distinguished extra-articular fractures from articular fractures (Figures).[21]

Tuberosity fracture.
Subtubercular fracture. The fracture is extra-articular at the surgical neck level.
Humeral head fracture. This two-fragment fracture is entirely intra-articular. It detaches the humeral head at the anatomical neck, isolating it from any vascular connection arising from the capsule. The humeral head may be meshed, enucleated, impacted or free.
Type I cephalotubercular fracture. The fracture is articular, complex but with minimal displacement.
Type II cephalotubercular fracture. The displacement is large, but the head remains impacted on the diaphysis.
Type III cephalotubercular fracture. The humeral head remains in front of the glenoid but is totally detached from the tuberosity and the diaphysis, the latter being usually dislocated in the axillary fossa.
Type IV cephalotubercular fracture that corresponds to a fracture-dislocation. The head can be dislocated forwards or backwards to determine an anterior or posterior fracture-dislocation.

Essential points

The anatomic requirements to be respected during any intervention for proximal humerus fractures are:

  1. The height of the greater tuberosity relative to the proximal humeral head;
  2. The lateral offset of the greater tuberosity relative to the diaphyseal axis;
  3. The neck-shaft angle, posterior tilt and humeral retroversion.

Conservative Treatment (Nonoperative Treatment)

Non- or minimally displaced proximal humerus fractures are most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year. Effectively, the shoulder tolerates a substantial degree of malunion and many of these fractures are minimally displaced. Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.[22] Overall fracture displacement (i.e. impacted varus fractures) has a minor impact of fracture healing and functional outcome.[23] Court-Brown et al. showed that the age of the patient was the major factor in overall outcome, the best results occurring in younger patients.[24]

Tejwani et al.[25] performed a prospective study of 67 patients with 1-part proximal humerus fractures. At 1-year follow up the American Shoulder and Elbow Surgeons Shoulder (ASES) score and functional status was similar to pre-injury status. However, range of motion of the affected shoulder was diminished in both external and internal rotation. Anterior forward flexion was preserved.

Hanson et al.[23] prospectively analyzed 160 patients with proximal humerus fractures of all Neer types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.

Long period of immobilization are not recommended. Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.[26] Practically, if controlled X-rays does not show secondary displacement at 10 days, a passive mobilization should be encourage.

Adjuvant procedures

Acromioplasty

Acromioplasty is not indicated for acute fractures, except perhaps to improve the workspace in the case of arthroscopic treatment.[27]

Long head of the biceps

The consequences of proximal humerus osteosynthesis are characterised by the development of rotator interval fibrosis and adhesions at the long head of the biceps. These result in reduced joint mobility which may explain the postoperative stiffness that is sometimes observed. Moreover, the tendon can become unstable and even interpose between fragments, preventing its reduction. Lastly, trauma causes tendinopathy and even lacerations that can lead to persistent pain. Therefore, it is recommended to routinely perform a tenodesis of the long head of the biceps.[28][29][30][31][32]

This is done by opening the rotator interval to explore the long head of the biceps tendon. This exposes the biceps and also provides a landmark to define the greater and lesser tuberosities for subsequent anatomic reduction. A tenotomy-tenodesis is performed with sutures joining the fibrous “roof” of the bicipital groove to the tendon. Alternatively, tenodesis may be performed lower to the pectoralis major tendon. This location facilitates visualization of the bicipital groove which can be used to assess version during the reconstruction. The intra-articular part of the tendon is then resected. The rotator interval is left open, so as to control reduction of the humeral head and tuberosity, and to limit mobility loss.

Osteosynthesis

Closed osteosynthesis (arthroscopy, percutaneous surgery, intramedullary nailing) should be contrasted with open procedures (transosseous suture, plate osteosynthesis). The first have two essential merits: reducing the risk of infection and avoiding the direct approach with its consequences (bone and soft tissue devascularization, postoperative adhesions). However, they only apply to extra-articular or less complex articular fractures, such as fractures of the surgical neck or type II cephalotubercular valgus impacted fractures. Several types of osteosynthesis have been used, from “osteosynthesis à minima” by osteosuture with nonabsorbable thread, to the solid screw epiphyseal plate or its derivatives.

Arthroscopy

The treatment of tuberosity (Figure and Movie) or humeral head (Figure) fractures, with or without extension to the surgical neck, is now validated.


Type 2 cephalotubercular fracture treated by arthroscopic reduction: A) Anteroposterior radiograph of the left shoulder. The lesser tuberosity fracture is non-displaced as opposed to the greater tuberosity. B) Anteroposterior and C) axial radiographs, 6 weeks after arthroscopic anchor-based fixation of the greater tuberosity. The lesser tuberosity fracture was neglected and the upper limb immobilized for 1 month using a Dujarier bandage. The green arrows indicate anchor points
Video of an arthroscopic greater tuberosity repair (left shoulder)
Arthroscopic treatment of a humeral head fracture: A) Anteroposterior radiograph and B) CT scan of the left shoulder, revealing a humeral head fracture. Six months after arthroscopic reduction without fixation, the Lamy frontal and lateral radiographs confirm a perfect reduction. The rotator cuff and tuberosities are intact, so secondary displacements are limited. Reproduce from [33], with permission.

Surgical technique

This technique has many advantages including being minimally invasive and having both intra-articular and subacromial reduction control. However, it is technically demanding, and not an option for all surgeons and for all fractures. As a general guideline, arthrosopic fixation of the greater tuberosity is generally possible if the thickest part of the fragment if less than 10 mm. Fractures with more distal extension can be challenging to secure laterally if anchor-based fixation is attempted. Surgery is performed with the patient’s arm in light traction and placed in a half-seated or lateral decubitus position. The posterior approach is used, except in cases of posterior dislocation of the humeral head. Other approaches (lateral, anterior, ...) are performed on demand, depending on the type of fracture. The hematoma is drained, and a suction pipe is connected directly to the trocar, allowing the joint to be filled and emptied until a satisfactory view is obtained. An intra-articular and then subacromial assessment is performed after a bursectomy. The type of fracture and its dimensions are assessed and the fractures reduced. Joint fractures do not necessarily require stabilization (concept of the egg cup). Several types of repair are recommended to obtain an anatomic reduction of the tuberosities (single point, double row or tension band).

Percutaneous Pinning or Screw Fixation

Commonly used in paediatric orthopaedics, this technique has also been performed in adults for over 50 years, particularly those with good bone quality and 2- or 3-part fractures.[34]

It is minimally invasive and therefore decreases the risk of vascular compromise. Another advantage of this technique is that it can be converted, at any time, if adequate reduction or stability cannot be obtained. Fractures are primarily stabilized with ascending fasciculated pins, using at least three diverging ‘palm tree’ pins in the epiphysis (Hacketal, Kapandji). Superior to inferior pins may also be used for greater tuberosity stabilization.

The percutaneous approach has been difficult to establish as a reference technique due to its many disadvantages. Firstly, it is contraindicated for type 2 to 4 articular fractures, with low bone density and significant comminution, all conditions often found elderly patients. Secondly, the variable mechanical quality of the synthesis obtained can lead to long periods of postoperative immobilization and therefore stiffness. Moreover, the reduction technique and pin placement are very demanding. Lastly, many complications such as migration or joint penetration by pins, as well as potential neurological lesions have been reported.[35][36][37][38][39] Moreover, there is a risk of injury to important anatomic structures about the shoulder. Lateral pins should be distal enough to avoid injury to the anterior branch of the axillary nerve, and multiple fluoroscopic views should be obtained to avoid penetration of the humeral head cartilage. There may be a risk of injury to the cephalic vein, the biceps tendon, and the musculocutaneous nerve with use of anterior pins, and these pins should be employed with caution. Greater tuberosity pins should be placed with the arm in external rotation, should be aimed for a point 20 mm from the inferior aspect of the humeral head, and should not overpenetrate the cortex.[40]

A special case, which immediately contraindicates osteosynthesis, is the external fixator used during polytrauma or open fractures with skin damage (Figure).


Illustration of an external shoulder fixator assembly


Surgical Technique

The patient is placed in a beach-chair position. The arm must be free, allowing the use of fluoroscopy installed close to the patient's head. The main objective is not necessarily a perfect anatomical reduction, but to align the fragments using gentle and non-traumatic manipulation. Closed reduction and percutaneous fixation of proximal humeral fractures, with or without screws, is based on external manoeuvres using ligamentotaxis.[41]

For ascending pinning, the pins must be curved at the end to allow for epiphyseal divergence. Pin insertion can be supraepitrochlear, supracondylar, median supraolecranean, or at the tip of the deltoid V. Each approach carries neurological risks related to the local anatomy or joint stiffness in the elbow. For direct pinning, if the reduction proves to be insufficient, a short superoexternal incision is made under fluoroscopic control at the lateral edge of the acromion. A deltoid split is performed, without detachment from the acromion. A spatula or Rochet punch pressed against the epiphysio-metaphyseal hinge enables careful removal of the humeral head (Figure).

A spatula is used to elevate the humeral head

This surgical action often results in a spontaneous reduction of the tuberosities. Repositioning may also be facilitated by a bone hook placed in the subacromial space holding the greater tuberosity, while the arm is rotated externally. At this stage, the primary stability of the assembly is completed by pinning between the diaphysis and humeral head and between the tuberosity(s) and humeral head. Cannulated screws of 4.0mm or 4.5mm diameter with washers can then be inserted. Alternatively, threaded pins (which reduce the risk of recession compared to smooth pins) are cut, bent and left subcutaneously (Figure).

Diagram showing the final pin assembly. With permission from Pierre Hoffmeyer.


Percutaneous Antegrade Intramedullary Nailing

At first sight, fixation of an epiphysis by an intramedullary nail may seem heretical, but this concept has proved itself and is now validated. Because it is intramedullary, it represents biomechanically stable osteosynthesis (Figure), especially in cases of medial comminution.[42]

A) Diagram of intramedullary nailing. With permission from Pierre Hoffmeyer. Preoperative (B) and postoperative (C) anteroposterior radiographs of the intramedullary nailing of a type II cephalotubercular valgus impacted fracture.


The latest nails now benefit from anteroposterior locks, which enable improved tuberosity reconstruction. It seems that adding an unlocked calcar screw in the context of an intramedullary nail does not improve biomechanical properties.[43]

For certain bifocal cephalotubercular and diaphyseal fractures, nailing is the treatment of choice (Figure).

Anteroposterior (A) and Lamy incidence (B) radiographs of a large notch posterior dislocation fracture (C) associated with an oblique diaphyseal fracture. Intraoperative view (D) of a femoral allograft fixed with two 3.5mm malleolar screws and fixation of the lesser tuberosity with an anteroposterior 4.5mm screw. Postoperative radiograph of the end result after intramedullary nailing (E).


The usual indications are subtubercular fractures, with or without a tuberosity shear, and type II cephalotubercular valgus impacted fractures. There are problems related to percutaneous intramedullary nailing. It requires multiple muscular and tendinous perforations (deltoid, rotator cuff) and potentially dangerous excisions. It also rules out simple adjuvant procedures, such as bone grafting, long head of the biceps surgery and cerclage of the tuberosities.

Surgical technique

This is a procedure performed under fluoroscopic guidance, in the beach-chair position. The incision is anterior or posterior (Neviaser's portal) at the acromioclavicular interval for valgus or varus misaligned fractures respectively. The nail must be inserted medially so as to pierce the head in a vascularized muscular, and not tendinous, area. It must therefore pierce the humeral head in the cartilaginous area and not at the tuberosity. Distal locking (diaphyseal) is performed first, which enables compression of the fracture site by retrograde impaction using a weight. Compression is maintained by two or three proximal screws locked into the nail.

Osteosuture

Osteosuture includes open reduction and wire fixation. Strapping of the tuberosity is often sufficient to support the humeral head. Various adjuvant techniques having the same rationale can be applied: transosseous fixation, wires emanating from anchor point(s) or fixed on a diaphyseal screw as an external brace (Figure). This is a technically simple and rapid treatment. It is ideal for isolated and displaced tuberosity fractures and may also be used for type II cephalotubercular fractures.[44]

A) Anteroposterior radiograph of a type II cephalotubercular fracture. B) Passage of threads through the various rotator cuff tendons. The wires are then folded over a diaphyseal screw to make a Hawkins tension band (C and D).(34) Lamy radiographs. Frontal and lateral views (E and F).

Operative technique

The patient is placed in a half-seated position. A 4-5 cm deltopectoral or transdeltoid approach is used, depending on the type of fracture (lesser or greater tuberosity). The fracture is located after a bursectomy. The rotator cuff is repaired using an anchor or transosseous sutures.

Plate osteosynthesis

Modern proximal humerus plating employs locking plates which have improved the biomechanical properties of fixation compared to traditional compression plates. This is particularly important for achieving fixation in the humeral head, where fixation must be unicortical. The angulation of the solid screws can be fixed or variable and various mechanisms are used for locking the screw in the plate (i.e. locking in its housing by a threaded lock nut, or threads in the screw head which lock into the plate). The plate permits 1) anatomic reduction, 2) surgery on the long head of the biceps, 3) transplant options (humeral head, or Bilboquet in cases of osteoporosis), and 4) a firm assembly stabilized by locked screws (i.e. not free anteroposterior screws) for the treatment of tuberosities and the humeral head in cases of ‘head split’ (Figure), and lastly, tension-band suturing of the rotator cuff/tuberosities to the plate. It is therefore preferred for type II to IV complex cephalotubercular fractures where osteosynthesis has been opted for (Video).

Video of a plate osteosynthesis for a right 3-part proximal humeral fracture.
Frontal (A), Lamy lateral (B) and axial (C) radiographs, 6 weeks after a type II right-sided cephalotubercular ‘head split’ fracture. Note the two anteroposterior malleolar screws that permit compression of the head fracture, while the plate stabilizes the lesser tuberosity fracture.


Initially, a high rate of humeral head perforation was reported with locking plate fixation. However, this was likely to due to lack of recognition (inadequate fluoroscopy) and the misconception that all screws must be long. The only locking screws that must be long are the lower calcar screws in cases of medial comminution (Figure). The upper screws must be short (maximum 35 mm) and serve only to stabilize the greater tuberosity.

A) Anteroposterior fluoroscopic image taken after locked plate osteosynthesis of a left-sided type II cephalotubercular fracture. Observe the short upper screws, the two lower long calcar screws, and the oblique lower screw supported on good quality distal diaphyseal bone, thereby reducing the size of required incision (6.5 cm).


Surgical Technique (Operative Treatment)

Deltopectoral approach

The deltopectoral approach is the most commonly used. It enables osteosynthesis in the vast majority of fractures. A small centimetric posterior approach may also be associated in cases of humeral head dislocation (Figure). In fact, the bicipital groove can often be the starting point for a fracture of the humeral head segment confined behind the glenoid.

Coronal (A) and axial (B) CT sections of a left-side type IV cephalotubercular fracture. In this situation, the head should not be reduced via the deltopectoral approach, but simply make a small posterior approach through which a tamp is passed (green arrow) which will push the head backwards (C). Anteroposterior and Lamy lateral postoperative radiographs (D and E, respectively).


The biceps tendon is tenodesed in most cases to facilitate reduction and identify the tuberosities. The upper border of the pectoralis major tendon can serve as a site of tenodesis. The subscapularis, supraspinatus, and infraspinatus are tagged with nonabsorbable sutures. These sutures are then subsequently passed through holes in the plate and to provide a tension-band construct. Such fixation often provides the best fixation of the tuberosities since the tendinous structures are often stronger than osteoporotic bone. The deltopectoral approach provides only a limited view of the greater tuberosity, which can be improved by putting the arm in abduction and internal rotation after placement of a Brown retractor.

The intertubercular fracture line is situated 8 mm lateral to the bicipital groove. At this stage, devascularization of the bone fragments should be avoided by conserving the anterior circumflex and ascending bicipital arteries. The idea is to stay lateral to the bicipital groove. The approach to the humeral head fragment is intertubercular by widening the separation of the two tuberosities. Reduction is performed using a 2.5 mm pin (Figure).

A 2.5 mm Kirchner pin is inserted into the humeral head and used as a ‘joystick’ to manipulate the head fragment. With permission from Pierre Hoffmeyer.


Distally, the anterior insertion of the deltoid is elevated using a periosteal elevator and the plate is slipped-in subperiosteally. The plate is temporarily secured with one cortical screw and then the height is adjusted as needed to ensure the that the inferior locking screws are at the medial calcar. In order to limit the length of the incision the distal screw is inserted obliquely. The sutures from the rotator cuff tendon may need to be passed through the plate prior to securing to the diaphysis depending on the plate design (Figure).

Osteosynthesis of a type II cephalotubercular fracture. Four sutures have been passed through the rotator cuff tendon (A). The sutures are then passed through the plate before fixation. Once osteosynthesis is completed, the next step is to tension the sutures, thereby reinforcing the assembly (B).
Transdeltoid approach

A so-called mini-invasive transdeltoid variant is an option. The patient is placed in a half-seated position. A 4-5 cm approach is used in line with the acromion. The axillary nerve is isolated and the plate is then slipped between the cortex and the nerve (Figure).

However, the authors of this article have stopped performing this approach because we have observed a higher rate of postoperative stiffness with this approach. Furthermore, implant removal for or conversion to arthroplasty (either at the initial surgery or for failure of fixation) is more easily performed through a deltopectoral approach.

A) Locating the axillary nerve. B) Reduction of the fracture, support by pins and introduction of the plate. C-E) Fluoroscopic images and final result (F).


Complications of plate osteosynthesis

The following table summarize the initial complication rate of proximal humeral fixation by plate.[45]

Complication Header text
Screw penetration 33.3
Osteonecrosis 14.6
Infection 12.5
Heterotopic ossification 8.3
Malunion 8.3
Removal of hardware 8.3
Hardware failure 6.5
Nonunion 4.2
Osteoarthrosis 2.1
Postoperative capsular contracture 2.1

The risk of complications and the long-term outcomes in patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus treated with open reduction and plate fixation (ORIF) has been evaluated by Robinson et al.[46] They found 24% of postoperative stiffness, 7% of fixation failure/nonunion, and 4% of late osteonecrosis or posttraumatic osteoarthritis. The patients' mean levels of pain, function, and satisfaction with treatment were good to excellent, supporting the use of primary open reduction and plate fixation (ORIF) in medically fit patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus.[46] Wijgman et al. reviewed the results of 60 patients with 3 or 4 part fractures who underwent open reduction internal fixation (ORIF) with a T-plate or cerclage wires and found 87% had good/excellent results based on the Constant score. Interestingly 22 pts (37%) had avascular necrosis, yet 17 of these 22 (77%) patients had excellent/good Constant scores.[47]

Hemiarthroplasty

The simple humeral implant is a remedy in cases of technically impossible osteosynthesis or fractures posing a risk of significant necrosis in young patients. It is restricted to cephalotubercular fractures of types III to IV in young patients. Reconstruction requires restoration of the humeral length, correct implant retroversion, restoration of the epiphyseal width, stable implant fixation, and a robust osteosynthesis of the tuberosities.

Functional results vary depending on the patient’s age, and especially the anatomical consolidation of the tuberosities. They can be excellent when it comes to mobility and pain. But, if the tuberosities are not consolidated then mobility results are poor, with an average anterior elevation of 90°. They do, however, remain acceptable for pain.[48]

Surgical technique

The approach is most commonly deltopectoral. The joint is accessed by working through the fracture fragments in the setting of a 4-part fracture, or dividing the lesser and greater tuberosities in the setting of a 3-part fracture. The humeral head fragment is extracted. As with plate fixation, the rotator cuff is tagged with multiple sutures for subsequent fixation of the tuberosities.[49]

Correct positioning of the implant and the tuberosities is an essential step, which will determine the quality of the functional result (cf above). The lateral offset is restored either by introducing a graft between the implant and the greater tuberosity if the implant does not fill the space, or by using a wide metaphyseal implant with no graft.[50]

Height can be assessed fluoroscopically by restoring a Gothic arch appearance or by locating the insertion point of the pectoralis major.[51][52]

In fact, the distance separating the upper edge of this tendon from the great tendon at the top of the humeral head is relatively constant (5.5 cm). With regard to the rotation of the implant, 20-30° retroversion (measured from a flexed elbow relative to the forearm) is normally recommended. This is 10° less than the anatomical retroversion, measured on the bi-epicondylar axis, taking into account the physiological valgus. Before implanting the final stem, a number 2.0 drill-hole is made at the metaphyseal level, through which two non-absorbable sutures are threaded to be used for fixation of the tuberosities in the vertical plane.

The stems may be cemented or non-cemented. The cement mantle should not reach the tuberositis which could jeopardise their integration.[53]

A “black and tan” technique is an effective method for ensuring this. The implant is reduced and the tuberosities are stabilized using Boileau’s technique.[54]

Reverse Shoulder Arthroplasty

In patients aged over 65 with highly comminuted fractures, a compromised rotator cuff, articular surface disruption, a short metaphyseal hinge, initial varus angulation > 20 degrees, or fracture dislocation, reverse implants are now more frequently performed than osteosynthesis and hemiarthroplasty. A systematic review of level I and II studies shows that reverse shoulder arthroplasty (RSA) grants better outcomes and is associated with fewer complications than hemiarthroplasty at short term follow-up.[55]

Effectively, for these elderly patients, with comorbidities and osteoporosis, hemiarthroplasty failure is a significant risk. While reverse shoulder arthroplasty does not rely as much on tuberosity healing, function proves to be higher when the tuberosities heal. Therefore, the tuberositis should be preserved and every effort should be made to achieve healing in the setting of reverse shoulder arthroplasty. Reverse shoulder arthroplasty is contraindicated in young and active patients, apart from exceptional lifesaving situations, and in cases of infection or when the axillary nerve is involved. In fact, except for partial mobility recovery, the complication rate remains high.[56]

Surgical (Operative) Technique

Apart from time spent on the glenoid, implantation is in all respects similar to hemiarthroplasty. Exposure of the glenoid is easy given the absence of the proximal humerus. The glenoid cartilage is then removed using a curette and carefully milled by hand, given the absence of osteoarthritis. The glenoid baseplate should be placed so that the glenosphere is flush or slightly overhangs the lower edge of the glenoid (Figure) to avoid frictional impingements.[57] Jain et al. performed a systematic review to compared clinical and functional outcomes of reverse shoulder arthroplasty in proximal humeral fractures with and without tuberosity healing. They reported that reverse shoulder arthroplasty with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity. Repairing tuberosities improve rotations and anterior stability.[58][59] Reverse shoulder arthroplasty for fracture with a 135° prothesis inclination is associated with higher tuberosity healing rates compared to 145° or 155°.[60] Cemented stems are usually preferred to cemented stems due to poor bone quality and lower revision rate according to the Australian registry.

The glenosphere should preferably be neutral or only minimally lateralized. In our experience lateralized and inferior eccentric glenospheres are associated with lower rates of tuberosity healing (Unpublished data). The implant is then reduced and the tuberosities reinserted according to the technique described by Boileau et al. Higher rates of tuberosity healing have been reported with 135 degrees stems as opposed to 155 degrees stems, but no study has directly compared these to date.

Frontal, axial and lateral Lamy radiographs after a reverse total shoulder implant. Note the lower positioning of the glenoid baseplate, the satisfactory reconstruction of the tuberosities, and the absence of cement at the autograft level.

Rehabilitation

Rehabilitation (or the absence thereof) after a proximal humerus fracture is crucial, and partly conditions the outcome.

After surgery everything conspires to create a stiff shoulder: the patient’s fear, pain, hemarthrosis and periarticular hematoma, muscle contusion, capsular tear, bicipital tendinopathy, etc.. Ideally, the shoulder should be rehabilitated as soon as possible, depending on the stability of the osteosynthesis. Once mobility has been regained, we never recommend reinforcement, but rather a gradual and reasonable resumption of activity.[61]

In general, the hand, wrist and elbow should be actively mobilized as soon as possible.

Stable Osteosynthesis

These are fixations obtained using antegrade intramedullary nailing or plates. Assisted active mobilization can be immediate. No immobilization is recommended. Physiotherapy is only intra-hospital the day after surgery to teach a rehabilitation protocol.[62]

Osteosynthesis with Relative Stability

This type of rehabilitation applies to osteosuture and screwing of the tuberosities. Early and aggressive rehabilitation can in fact be harmful by provoking secondary displacement. The patient is immobilized using a sling elbow at the side or neutral abduction-rotation pillow, depending on the tuberosities involved (lesser and greater, respectively). Passive mobilization is recommended, as short pendulum exercises repeated at least 5 times a day, elevation by self mobilization in the supine position, elbow stretched, with slow, highest possible elevations, and rotations with elbows bent at 90°, using a baton held in both hands, but only mobilized by the healthy upper limb.[63]

‘Dry’ physiotherapy or balneotherapy may be prescribed. It includes progress monitoring and correct performance of the exercises, patient motivation, relaxing massages of the scapular belt and passive mobilization exercises.

Non-stable osteosynthesis and implants

Fasciculated retrograde nailing, insertion, partial fixation and implants are usually immobilized for 1 month to allow consolidation of the fragments. Physiotherapy is deferred until later.

Decision Making

Successful treatment depends on not only technical but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated to the success of the surgery.[64][65] Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced. Surgical management is also considered in proximal humerus fractures associated with humeral shaft fractures.


Humeral head fractures

It is difficult to codify the treatment of such a rare fracture. The following guidelines, though not based on experience, have the merit of common sense. In the elderly, the risk of humeral head necrosis immediately invokes reverse shoulder arthroplasty. In young patients, simple reduction, with or without associated osteosynthesis using screws or pins, seems valid.[66]

Displaced tuberosity fractures with a stable epiphyseal-diaphyseal union

Surgical management is considered in fractures where the greater tuberosity is displaced >5 mm. If the fragment is small and considered to be a type A1 bony rotator cuff lesion then arthroscopic reinsertion or open osteosuture give similar results. A large and solid fragment lends itself to screwing and nailing, while osteosuture will be preferred in cases of porous and split bone.[67][68]

Type II-IV cephalotubercular in the young

It seems acceptable to restore anatomy in young or biologically healthy patients. Epiphyseal plate osteosynthesis and antegrade nailing give similar results. The first is preferred in cases where the medial hinge is preserved. Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).[69] Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results were achieved with fixation methods.[70]

Hemiarthroplasty is justified when there is a high risk of humeral head necrosis.[71]

Type II-IV cephalotubercular in the elderly

It seems reasonable to immediately resort to reverse shoulder arthroplasty in elderly patients having many comorbidities and lesser functional needs. A reverse implant seems all the more indicated when the displacement is large. The best treatment is osteosynthesis, then any conservative treatment, and lastly hemiarthroplasty. Osteosynthesis is the option having the most frequent revisions according to a recent meta-analysis.[72][73]

Isolated sub-tubercular fractures

Closed nailing or plate osteosynthesis are coeval. Plates are preferred in young patients to conserve their rotator cuff and facilitate their removal, and nails are used on older patients for whom removal of material is debatable. Fasciculated nailing are reserve for paediatric cases as it has not been proven in adults in comparative studies.[74][75]

References

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  2. ↑ Kannus P, Niemi S, Sievanen H, Parkkari J. Stabilized Incidence in Proximal Humeral Fractures of Elderly Women: Nationwide Statistics From Finland in 1970-2015. J Gerontol A Biol Sci Med Sci. 2017;72(10):1390-3.
  3. ↑ Sumrein BO, Huttunen TT, Launonen AP, Berg HE, Fellander-Tsai L, Mattila VM. Proximal humeral fractures in Sweden-a registry-based study. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2017;28(3):901-7.
  4. ↑ Pearl ML, Volk AG. Coronal plane geometry of the proximal humerus relevant to prosthetic arthroplasty. J Shoulder Elbow Surg. 1996;5(4):320-6.
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  7. ↑ Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006;15(6):675-8
  8. ↑ Sahu D, Jagiasi JD, Valavi AS, Ubale T. The Distance between the Pectoralis Major Tendon Insertion and the Top of the Humeral Head is a Reliable Landmark: An Anatomic Study. Joints. 2019 Dec 13;7(2):37-40
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  10. ↑ Greiner SH, Kääb MJ, Kröning I, Scheibel M, Perka C. Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2008;17(5):709-14
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  66. ↑ Godeneche A, Freychet B, Gunst S, Daggett M, Viste A, Walch G. Arthroscopic Reduction of Acute Traumatic Posterior Glenohumeral Dislocation and Anatomic Neck Fracture Without Internal Fixation: 2-Year Follow-up. Orthop J Sports Med. 2017;5(12):2325967117745486.
  67. ↑ Liao W, Zhang H, Li Z, Li J. Is Arthroscopic Technique Superior to Open Reduction Internal Fixation in the Treatment of Isolated Displaced Greater Tuberosity Fractures? Clin Orthop Relat Res. 2016;474(5):1269-79.
  68. ↑ Lädermann A, Burkhart SS, Hoffmeyer P, Neyton L, Collin P, Yates E, et al. Classification of full-thickness rotator cuff lesions: a review. EFORT Open Rev. 2016;1(12):420-30.
  69. ↑ Erasmo R, Guerra G, Guerra L. Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate. Injury. 2014;45 Suppl 6:S43-8
  70. ↑ Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006 Apr;88(4):502-8.
  71. ↑ Gadea F, Favard L, Boileau P, Cuny C, d'Ollone T, Saragaglia D, et al. Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthopaedics & traumatology, surgery & research : OTSR. 2016;102(8):963-70.
  72. ↑ Du S, Ye J, Chen H, Li X, Lin Q. Interventions for Treating 3- or 4-part proximal humeral fractures in elderly patient: A network meta-analysis of randomized controlled trials. Int J Surg. 2017;48:240-6.
  73. ↑ van der Merwe M, Boyle MJ, Frampton CMA, Ball CM. Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(9):1539-45.
  74. ↑ Lee W, Park JY, Chun YM. Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration. J Orthop Trauma. 2017;31(9):e270-e4.
  75. ↑ Milin L, Sirveaux F, Eloy F, Mainard D, Mole D, Coudane H. Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases. Orthopaedics & traumatology, surgery & research : OTSR. 2014;100(3):265-70.
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