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Management of Complex Proximal Humerus Fractures: What Is the Role of Open Reduction and Internal Fixation?

  • Geriatric Orthopedics (E Meinberg, Section Editor)
  • Published:
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Abstract

Purpose of Review

Proximal humerus fractures are challenging injuries to treat and will become more common with an aging population. The purpose of this paper is to review the recent literature regarding the role of open reduction and internal fixation for this injury.

Recent Findings

Complex proximal humerus fractures present a significant challenge in the elderly. The introduction of locked plating has improved surgical management of these injuries; however, complications including avascular necrosis, primary screw cutout, and secondary screw cutout remain obstacles. Newer technologies aim to combat these issues, with promising early results.

Summary

Complex proximal humerus fractures call for experienced surgeons and remain challenging with high complication rates with open reduction and internal fixation. Newer fixation methods aim to reduce these complications.

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References

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  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–7 Available from: http://linkinghub.elsevier.com/retrieve/pii/S0020138306003238.

    Article  Google Scholar 

  2. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am. 2007 [cited 2014 May 8];89(Suppl 3):44–58. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17908870.

    Article  Google Scholar 

  3. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16394745.

    Article  Google Scholar 

  4. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–89 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5455339.

    Article  Google Scholar 

  5. Neer CS. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52(6):1090–103 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5455340.

    Article  Google Scholar 

  6. Fjalestad T, Hole MØ, Blücher J, Hovden IAH, Stiris MG, Strømsøe K. Rotator cuff tears in proximal humeral fractures: an MRI cohort study in 76 patients. Arch Orthop Trauma Surg. 2010;130(5):575–81 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19685061.

    Article  Google Scholar 

  7. Gallo RA, Sciulli R, Daffner RH, Altman DT, Altman GT. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clin Orthop Relat Res. 2007;458:70–7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17308477.

    PubMed  Google Scholar 

  8. Visser CP, Tavy DL, Coene LN, Brand R. Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: comparison with clinical neurological examination. Clin Neurol Neurosurg. 1999;101(2):86–91 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10467902.

    Article  CAS  Google Scholar 

  9. Green A. Proximal humerus fractures and fracture-dislocations. In: Browner BD, Jupiter J, Krettek C, Anderson P, editors. Skeletal trauma: basic science, management, and reconstruction, vol. 2. 5th ed. Philadelphia: Elsevier/Saunders; 2015. p. 1423–53.

    Google Scholar 

  10. Clement ND, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of proximal humeral fractures in the elderly: predictors of mortality and function. Bone Joint J. 2014;96–B(7):970–7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24986953.

    Article  Google Scholar 

  11. Bernstein J, Adler LM, Blank JE, Dalsey RM, Williams GR, Iannotti JP. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am. 1996;78(9):1371–5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8816653.

    Article  CAS  Google Scholar 

  12. Meinberg E, Agel J, Roberts C. Fracture and dislocation classification compendium 2018. J Orthop Trauma. 2018;32 1–170 p.

  13. Hertel R, Knothe U, Ballmer FT. Geometry of the proximal humerus and implications for prosthetic design. J Shoulder Elb Surg. 2002;11(4):331–8 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274602000216.

    Article  Google Scholar 

  14. Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, et al. Deltoid tuberosity index: a simple radiographic tool to assess local bone quality in proximal humerus fractures. Clin Orthop Relat Res. 2015;473(9):3038–45 Available from: http://link.springer.com/10.1007/s11999-015-4322-x.

    Article  Google Scholar 

  15. Mather J, MacDermid JC, Faber KJ, Athwal GS. Proximal humerus cortical bone thickness correlates with bone mineral density and can clinically rule out osteoporosis. J Shoulder Elb Surg. 2013;22(6):732–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23183030.

    Article  Google Scholar 

  16. Spross C, Zeledon R, Zdravkovic V, Jost B. How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction–internal fixation of proximal humeral fractures. J Shoulder Elb Surg. 2017;26(9):1566–72 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274617301337.

    Article  Google Scholar 

  17. Jung S-W, Shim S-B, Kim H-M, Lee J-H, Lim H-S. Factors that influence reduction loss in proximal humerus fracture surgery. J Orthop Trauma. 2015;29(6):276–82 Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00005131-201506000-00004.

    Article  Google Scholar 

  18. Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011;42(11):1283–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21310406.

    Article  Google Scholar 

  19. Mazzucchelli RA, Jenny K, Zdravkovic V, Erhardt JB, Jost B, Spross C. The influence of local bone quality on fracture pattern in proximal humerus fractures. Injury. 2018;49(2):359–363. https://doi.org/10.1016/j.injury.2017.12.020

    Article  Google Scholar 

  20. Grawe B, Le T, Lee T, Wyrick J. Open reduction and internal fixation (ORIF) of complex 3- and 4-part fractures of the proximal humerus. Geriatr Orthop Surg Rehabil. 2012;3(1):27–32 Available from: http://journals.sagepub.com/doi/10.1177/2151458511430662.

    Article  Google Scholar 

  21. Hinds RM, Garner MR, Tran WH, Lazaro LE, Dines JS, Lorich DG. Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation. J Shoulder Elb Surg. 2015;24(6):889–96 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274614005850.

    Article  Google Scholar 

  22. Goch AM, Christiano A, Konda SR, Leucht P, Egol KA. Operative repair of proximal humerus fractures in septuagenarians and octogenarians: does chronologic age matter? J Clin Orthop Trauma. 2017;8:50–3.

    Article  Google Scholar 

  23. Schumaier A, Grawe B. Proximal humerus fractures: evaluation and management in the elderly patient. Geriatr Orthop Surg Rehabil. 2018;9:215145851775051.

    Article  Google Scholar 

  24. Rockwood C. The shoulder. 4th ed. Philadelphia: Saunders; 2009.

    Google Scholar 

  25. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elb Surg. 13(4):427–33 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15220884.

    Article  CAS  Google Scholar 

  26. Gavaskar AS, Tummala NC. Locked plate osteosynthesis of humeral head-splitting fractures in young adults. J Shoulder Elb Surg. 2015;24(6):908–14 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25476989.

    Article  Google Scholar 

  27. Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elb Surg. 7(6):586–90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9883418.

    Article  CAS  Google Scholar 

  28. Thorsness R, English C, Gross J, Tyler W, Voloshin I, Gorczyca J. Proximal humerus fractures with associated axillary artery injury. J Orthop Trauma. 2014;28(11):659–63 Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00005131-201411000-00009.

    Article  Google Scholar 

  29. Ninck J, Heck S, Gick S, Koebke J, Pennig D, Dargel J. Versorgung von Humeruskopffrakturen. Unfallchirurg. 2013;116(11):1000–5 Available from: http://link.springer.com/10.1007/s00113-012-2242-8.

    Article  CAS  Google Scholar 

  30. Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced three- and four-part proximal humerus fractures. J Orthop Trauma. 2010;24(4):250–4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20335760.

    Article  Google Scholar 

  31. Handoll HHG, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11(11):CD000434 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26560014.

    Google Scholar 

  32. Bergdahl C, Ekholm C, Wennergren D, Nilsson F, Möller M. Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: data from the Swedish Fracture Register. BMC Musculoskelet Disord. 2016;17(1):159 Available from: http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-016-1009-8.

    Article  Google Scholar 

  33. Burkhart KJ, Dietz SO, Bastian L, Thelen U, Hoffmann R, Müller LP. The treatment of proximal humeral fracture in adults. Dtsch Arztebl Int. 2013;110(35–36):591–7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24078839.

    PubMed  PubMed Central  Google Scholar 

  34. Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res. 2009;95(1):48–55 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1877056808000042.

    Article  CAS  Google Scholar 

  35. Thorsness R, Iannuzzi J, Noyes K, Kates S, Voloshin I. Open reduction and internal fixation versus hemiarthroplasty in the management of proximal humerus fractures. Geriatr Orthop Surg Rehabil. 2014;5(2):56–62 Available from: http://journals.sagepub.com/doi/10.1177/2151458514527292.

    Article  Google Scholar 

  36. Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elb Surg. 2013;22(10):e8–11 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274613000906.

    Article  Google Scholar 

  37. Olerud P, Ahrengart L, Söderqvist A, Saving J, Tidermark J. Quality of life and functional outcome after a 2-part proximal humeral fracture: a prospective cohort study on 50 patients treated with a locking plate. J Shoulder Elb Surg. 2010;19(6):814–22 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274609005382.

    Article  Google Scholar 

  38. Newman JM, Kahn M, Gruson KI. Reducing postoperative fracture displacement after locked plating of proximal humerus fractures: current concepts. Am J Orthop (Belle Mead NJ). 2015;44(7):312–20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26161759.

    Google Scholar 

  39. Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury. 1998;29(5):349–52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9813677.

    Article  CAS  Google Scholar 

  40. Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017;99–B(3):383–92 Available from: http://online.boneandjoint.org.uk/doi/10.1302/0301-620X.99B3.BJJ-2016-1028.

    Article  Google Scholar 

  41. Hessmann MH, Hansen WSM, Krummenauer F, Pol TF, Rommens PM. Locked plate fixation and intramedullary nailing for proximal humerus fractures: a biomechanical evaluation. J Trauma. 2005;58(6):1194–201 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15995470.

    Article  Google Scholar 

  42. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23(2):113–9 Available from: https://insights.ovid.com/crossref?an=00005131-200902000-00006.

    Article  Google Scholar 

  43. Spross C, Platz A, Rufibach K, Lattmann T, Forberger J, Dietrich M. The PHILOS plate for proximal humeral fractures—risk factors for complications at one year. J Trauma Acute Care Surg. 2012;72(3):783–92 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22491570.

    Article  Google Scholar 

  44. Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011;42(4):408–13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21176833.

    Article  Google Scholar 

  45. • Gupta AK, Harris JD, Erickson BJ, Abrams GD, Bruce B, McCormick F, et al. Surgical management of complex proximal humerus fractures—a systematic review of 92 studies including 4500 patients. J Orthop Trauma. 2015;29(1):54–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25162974. Updated systematic review of current literature regarding complex proximal humerus fracture.

    Article  Google Scholar 

  46. • Spross C, Jost B, Rahm S, Winklhofer S, Erhardt J, Benninger E. How many radiographs are needed to detect angular stable head screw cut outs of the proximal humerus—a cadaver study. Injury. 2014;45(10):1557–63 Cadaveric study illustrating difficulty in verifying screw placement intraoperatively.

    Article  Google Scholar 

  47. Osterhoff G, Hoch A, Wanner GA, Simmen H-P, Werner CML. Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures. Injury. 2012;43(10):1651–6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22579397.

    Article  Google Scholar 

  48. Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23(3):163–72 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19516088.

    Article  Google Scholar 

  49. Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91(6):1320–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19487508.

    Article  Google Scholar 

  50. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009 [cited 2014 May 21];91(7):1689–97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19571092.

    Article  Google Scholar 

  51. Xu J, Zhang C, Wang T. Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. J Orthop Surg Res. 2014;9(1):31 Available from: http://josr-online.biomedcentral.com/articles/10.1186/1749-799X-9-31.

    Article  Google Scholar 

  52. Saltzman BM, Erickson BJ, Harris JD, Gupta AK, Mighell M, Romeo AA. Fibular strut graft augmentation for open reduction and internal fixation of proximal humerus fractures. Orthop J Sport Med. 2016;4(7):232596711665682 Available from: http://journals.sagepub.com/doi/10.1177/2325967116656829.

    Article  Google Scholar 

  53. Rodia F, Theodorakis E, Touloupakis G, Ventura A. Fixation of complex proximal humeral fractures in elderly patients with a locking plate: a retrospective analysis of radiographic and clinical outcome and complications. Chinese J Traumatol = Zhonghua chuang shang za zhi. 2016;19(3):156–9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27321296.

    Article  Google Scholar 

  54. Schliemann B, Hartensuer R, Koch T, Theisen C, Raschke MJ, Kösters C, et al. Treatment of proximal humerus fractures with a CFR-PEEK plate: 2-year results of a prospective study and comparison to fixation with a conventional locking plate. J Shoulder Elb Surg. 2015;24(8):1282–8 Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615000142.

    Article  Google Scholar 

  55. • Fulkerson E, Paterson P. Proximal humeral fracture fixation using the PH Cage: a retrospective study of 125 patients to a minimum of 6 months post treatment. In: Orthopaedic Trauma Association Annual Meeting 2017. 2017. p 162. Early results of proximal humerus cage construct showing lower complication rate.

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  1. Department of Orthopaedic Surgery, University of Cincinnati, 231 Albert Sabin Way ML 212, Cincinnati, OH, 45229, USA

    Rafael Kakazu & John D. Wyrick

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Correspondence to Rafael Kakazu.

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John Wyrick reports personal fees from Stryker and Smith and Nephew, outside the submitted work. Rafael Kakazu declares no conflict of interest.

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Kakazu, R., Wyrick, J.D. Management of Complex Proximal Humerus Fractures: What Is the Role of Open Reduction and Internal Fixation?. Curr Geri Rep 7, 264–271 (2018). https://doi.org/10.1007/s13670-018-0261-1

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