Fix or Replace?

  • Paolo Paladini
  • Giovanni Merolla
  • Carlo Alberto Augusti
  • Giuseppe Porcellini


Proximal humeral fractures account for about 10% of all fractures, and the incidence is increasing. The majority of minimally displaced fractures are successfully treated nonoperatively, but the optimal management of displaced or complex fracture remains controversial. Devascularization of the humeral head, associated injury to the rotator cuff, and the high prevalence of osteoporosis in elderly patients make the decision-making and the treatment very challenging. Current evidences are not able to give a useful guideline among prosthetic replacements, intramedullary nails, fixed angle locked plates, and conservative methods. Arthroplasty surgery should be more useful in fracture pattern, in which the humeral head is at risk of avascular necrosis, while internal fixation should be better in a fracture pattern, whereby the risk of devascularization is low. Different fracture patterns have been associated with a higher risk of humeral head necrosis: medial metaphyseal head extension more than 8 millimeters, disruption of the posteromedial hinge, and any fracture disrupting the anatomical humeral head. The presence of any of these features should prompt the clinician to consider arthroplasty surgery as a more reliable treatment option. Reverse total shoulder arthroplasty (RTSA) appears to provide range of motion superior to that of hemiarthroplasty (HA) and open reduction and internal fixation (ORIF). RTSA predictably restored active elevation over horizontal plane in all patients within 4 months. RTSA realized even significant cost savings compared with ORIF and HA.

Conclusion: Summarizing, the elderly patients treated with reverse total shoulder arthroplasty had better clinical outcomes, better forward elevation, higher tuberosity healing rates, and a lower rate of revision surgery compared with those who had hemiarthroplasty and open reduction and internal fixation for the treatment of a comminuted proximal humeral fracture.


Shoulder fractures Reverse total shoulder arthroplasty Hemiarthroplasty 


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Paolo Paladini
    • 1
  • Giovanni Merolla
    • 1
  • Carlo Alberto Augusti
    • 1
  • Giuseppe Porcellini
    • 2
  1. 1.Unit of Shoulder and Elbow SurgeryCervesi HospitalCattolicaItaly
  2. 2.Orthopaedic Department, Policlinico di ModenaUniversity of Modena and Reggio EmiliaModenaItaly

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