A review of management options for proximal humeral fractures

Abstract

Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.

Keywords: Hemiarthroplasty; plate fixation; proximal humeral fracture; reverse arthroplasty; shoulder fracture..

Fig. (1)

Proximal humeral fractures according to Neer Classification a) One part b) Two part c) Three part d) Four part.

Fig. (2)

One part fracture treated conservatively with successful union.

Fig. (3)

Reconstruction of a pre-operative CT demonstrating a four part fracture.

Fig. (4)

Inadequate fixation in a 51 year old lady with a four part proximal humeral fracture.

Fig. (5)

Inadequate fixation of two part fracture resulting in varus displacement and penetration of screws through humeral head necessitating removal.

Fig. (6)

Two part fracture in 74 year old man treated successfully with an intramedullary nail.

Fig. (7)

3 part fracture dislocation in a 61 year old lady treated with primary hemiarthroplasty.

Fig. (8)

3 part fracture in an 82 year old lady treated with primary reverse arthroplasty.