Fractures of the proximal humerus in osteoporotic bone
The purpose of this article was to review critically the current treatment options for fractures of the proximal humerus in patients with severe osteoporosis. The main difficulties lie in correctly diagnosing the fracture and hence selecting the most appropriate method of treatment. The reliability of the diagnosis can be increased by systematically appending additional information to a basic fracture classification. Classification is best carried out on a morphological basis, whereby a descriptor of bone quality can be added in order to introduce the degree of osteoporosis into the decision-making algorithm. Any classification system that claims to provide both treatment and prognosis is inappropriate, because prognosis will depend hopefully on the treatment. Approaches to treatment differ widely amongst centers and surgeons. It is still unclear as to what would be the optimal treatment. Factors such as the individual’s functional requirements and ability to cooperate should be given careful consideration. At our institution, hemiarthroplasty is the method of choice for ischemic humeral heads and/or when anatomic reconstruction cannot be obtained. In all other displaced fractures, the main objective is preservation of the head since the best functional results can generally be obtained with internal fixation. Selection of a balanced osteosynthesis, adapted to the weak bone, is mandatory. Bulky, stiff implants are inadequate and may cause additional damage. Load sharing, not load bearing, compound constructions are the aim. Obtaining metaphyseal elastic buttressing is the key element in achieving the necessary load-sharing fixation. The system should allow controlled impaction and be forgiving towards occasional load peaks that will occur and are beyond patient control. Thin and flexible implants are required to realize this type of fixation. Given the polypragmatic approach that is current in clinical practice there is room for further improvement of techniques and implants.
KeywordsArthroplasty Fracture Internal fixation Osteoporosis Plate fixation Shoulder
- 6.Codmann EA (1934) Fractures in relation to the subacromial bursa. In: Codmann EA (ed) The shoulder, rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Krieger, Malabar, Florida, pp 313–331Google Scholar
- 7.Hertel R, Hempfing A, Stiehler M, Leunig M (2003) Predictors of humeral head ischemia following intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg (in press)Google Scholar
- 8.Hertel R, Mees C, Schöll E, Ballmer FT, Siebenrock K (2001) Morphologic classification of fractures of the proximal humerus. A validated, teachable and practicable alternative. Eighth International Conference on Shoulder Surgery (ICSS), 23–26 April. Cape Town, South AfricaGoogle Scholar
- 10.Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, Bigliani LU (2003) Two-part and three-part fractures of the proximal humerus treated with suture fixation. J Orthop Trauma 17:319–325Google Scholar