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Malunions of the Proximal Humerus

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Malunions

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Abstract

Proximal humerus malunions can create a painful, poorly functional shoulder. Fortunately, this type of malunion is generally well tolerated in the low-demand elderly patient and can be mainly managed non-operatively. The difficulty occurs in predicting which patients are at an increased risk for developing a symptomatic malunion and, as such, may benefit from early surgical intervention. For those surgical candidates presenting in a delayed fashion, the challenge then lies in deciding between the numerous surgical interventions that may result in the best outcome while minimizing complications. Ultimately, surgical options are divided into humeral head-preserving or head-sacrificing techniques and must take into consideration the blood supply, joint congruity, remaining bone stock, health of cartilage, and status of soft tissues, particularly the rotator cuff. When deciding on management, one must consider several factors, including the patient’s degree of discomfort and dysfunction, comorbidities, psychological status, and overall functional status. When surgical intervention is offered, it is imperative to discuss the procedure goals which include pain relief and improved function, but rarely can full restoration be achieved. Surgical interventions have proven to be technically challenging often yielding high satisfaction rates but with equally high risk for complication.

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References

  1. Konrad GG, Mehlhorn A, Kühle J, Strohm PC, Südkamp NP. Proximal humerus fractures – current treatment options. Acta Chir Orthop Traumatol Cechoslov. 2008;75(6):413–21.

    CAS  Google Scholar 

  2. McLaurin TM. Proximal humerus fractures in the elderly are we operating on too many? Bull Hosp Jt Dis. 2004;62(1–2):24–32.

    Google Scholar 

  3. Jensen GF, Christiansen C, Boesen J, Hegedüs V, Transbøl I. Relationship between bone mineral content and frequency of postmenopausal fractures. Acta Med Scand. 1983;213(1):61–3.

    Article  CAS  Google Scholar 

  4. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92.

    Article  Google Scholar 

  5. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011;25(10):612–7.

    Article  Google Scholar 

  6. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elb Surg. 2013;22(4):542–9.

    Article  Google Scholar 

  7. 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.

    Article  Google Scholar 

  8. Duparc F. Malunion of the proximal humerus. Orthop Traumatol Surg Res. 2013;99(1 Suppl):S1–11.

    Article  CAS  Google Scholar 

  9. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am. 1998;80(10):1484–97. Erratum in: J Bone Joint Surg Am 1999;81(3):439.

    Article  CAS  Google Scholar 

  10. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elb Surg. 2001;10(4):299–308.

    Article  CAS  Google Scholar 

  11. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007;89(8):1001–9.

    Article  CAS  Google Scholar 

  12. Nho SJ, Strauss EJ, Lenart BA, Provencher MT, Mazzocca AD, Verma NN, Romeo AA. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg. 2010;18(11):645–56.

    Article  Google Scholar 

  13. Pfahler M, Branner S, Refior JH. The role of the bicipital groove in tendopathy of the long biceps tendon. J Shoulder Elb Surg. 1999;8(5):419–24.

    Article  CAS  Google Scholar 

  14. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician. 2003;67(6):1271–8.

    Google Scholar 

  15. Hinov H, Wilson F, Adams G. Arthroscopically treated proximal humeral fracture malunion. Arthroscopy. 2002;18(9):1020–3.

    Article  Google Scholar 

  16. Dines DM, Warren RF, Inglis AE, Pavlov H. The coracoid impingement syndrome. J Bone Joint Surg Br. 1990;72(2):314–6.

    Article  CAS  Google Scholar 

  17. Blonna D, Rossi R, Fantino G, Maiello A, Assom M, Castoldi F. The impacted varus (A2.2) proximal humeral fracture in elderly patients: is minimal fixation justified? A case control study. J Shoulder Elb Surg. 2009;18(4):545–52.

    Article  Google Scholar 

  18. Bono CM, Renard R, Levine RG, Levy AS. Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder. J Bone Joint Surg Br. 2001;83(7):1056–62.

    Article  CAS  Google Scholar 

  19. Ferenczi A, Ostertag A, Lasbleiz S, Petrover D, Yelnik A, Richette P, et al. Reproducibility of sub-acromial impingement tests, including a new clinical manoeuver. Ann Phys Rehabil Med. 2018;61(3):151–5.

    Article  Google Scholar 

  20. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42(2):80–92; discussion 92.

    Article  CAS  Google Scholar 

  21. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964–78.

    Article  Google Scholar 

  22. Silva L, Andréu JL, Muñoz P, Pastrana M, Millán I, Sanz J, et al. Accuracy of physical examination in subacromial impingement syndrome. Rheumatology (Oxford). 2008;47(5):679–83.

    Article  CAS  Google Scholar 

  23. Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elb Surg. 2001;10(5):421–7.

    Article  CAS  Google Scholar 

  24. Toolanen G, Hildingsson C, Hedlund T, Knibestöl M, Oberg L. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study. Acta Orthop Scand. 1993;64(5):549–52.

    Article  CAS  Google Scholar 

  25. Fjalestad T, Hole MØ, Blücher J, Hovden IA, 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.

    Article  Google Scholar 

  26. Willis M, Min W, Brooks JP, Mulieri P, Walker M, Pupello D, Frankle M. Proximal humeral malunion treated with reverse shoulder arthroplasty. J Shoulder Elb Surg. 2012;21(4):507–13.

    Article  Google Scholar 

  27. Siegel JA, Dines DM. Techniques in managing proximal humeral malunions. J Shoulder Elb Surg. 2003;12(1):69–78.

    Article  Google Scholar 

  28. Pinkas D, Wanich TS, DePalma AA, Gruson KI. Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg. 2014;22(8):491–502.

    Article  Google Scholar 

  29. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res. 2006;442:121–30.

    Article  Google Scholar 

  30. Balg F, Boulianne M, Boileau P. Bicipital groove orientation: considerations for the retroversion of a prosthesis in fractures of the proximal humerus. J Shoulder Elb Surg. 2006;15(2):195–8.

    Article  Google Scholar 

  31. Jacobson JA, Duquin TR, Sanchez-Sotelo J, Schleck CD, Sperling JW, Cofield RH. Anatomic shoulder arthroplasty for treatment of proximal humerus malunions. J Shoulder Elb Surg. 2014;23(8):1232–9.

    Article  Google Scholar 

  32. Frich LH, Sojbjerg JO, Sneppen O. Shoulder arthroplasty in complex acute and chronic proximal humeral fractures. Orthopedics. 1991;14(9):949–54.

    CAS  Google Scholar 

  33. Zyto K, Kronberg M, Brostrom LA. Shoulder function after displaced fractures of the proximal humerus. J Shoulder Elb Surg. 1995;4(5):331–6.

    Article  CAS  Google Scholar 

  34. Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elb Surg. 2009;18(4):612–21.

    Article  Google Scholar 

  35. Ladermann A, Denard PJ, Burkhart SS. Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning. Arthroscopy. 2012;28(9):1220–9.

    Article  Google Scholar 

  36. Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the proximal humerus: Malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elb Surg. 1993;2(1):11–21.

    Article  CAS  Google Scholar 

  37. Mansat P, Guity MR, Bellumore Y, Mansat M. Shoulder arthroplasty for late sequelae of proximal humeral fractures. J Shoulder Elb Surg. 2004;13(3):305–12.

    Article  Google Scholar 

  38. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br. 2002;84(4):504–8.

    Article  CAS  Google Scholar 

  39. Court-Brown CM, McQueen MM. The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients. Acta Orthop Scand. 2004;75(6):736–40.

    Article  Google Scholar 

  40. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res. 1983;179:116–28.

    Article  Google Scholar 

  41. Morris ME, Kilcoyne RF, Shuman W. Humeral tuberosity fractures: evaluation by CT scan and management of malunion. Orthop Trans. 1987;11:242.

    Google Scholar 

  42. Green A, Deren ME, McKee M. Corrective surgical neck osteotomy for varus malunion of the proximal humerus. Techn Shoulder Elbow Surg. 2016;17(2):93–7.

    Article  Google Scholar 

  43. Solonen KA, Vastamaki M. Osteotomy of the neck of the humerus for traumatic varus deformity. Acta Orthop Scand. 1985;56(1):79–80.

    Article  CAS  Google Scholar 

  44. Benegas E, Zoppi Filho A, Ferreira Filho AA, Ferreira Neto AA, Negri JH, Prada FS, Zumiotti AV. Surgical treatment of varus malunion of the proximal humerus with valgus osteotomy. J Shoulder Elb Surg. 2007;16(1):55–9.

    Article  Google Scholar 

  45. Paavolainen P, Björkenheim JM, Slätis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand. 1983;54(3):374–9.

    Article  CAS  Google Scholar 

  46. Russo R, Visconti V, Ciccarelli M, Cautiero F, Gallo M. Malunion of complex proximal humerus fractures treated by biplane and triplane osteotomy. Tech Shoulder Elbow Surg. 2008;9(2):70–5.

    Article  Google Scholar 

  47. Ranalletta M, Bertona A, Rios JM, Rossi LA, Tanoira I, Maignón GD, Sancineto CF. Corrective osteotomy for malunion of proximal humerus using a custom-made surgical guide based on three-dimensional computer planning: case report. J Shoulder Elb Surg. 2017;26(11):e357–63.

    Article  Google Scholar 

  48. Martinez AA, Calvo A, Domingo J, Cuenca J, Herrera A. Arthroscopic treatment for malunions of the proximal humeral greater tuberosity. Int Orthop. 2010;34(8):1207–11.

    Article  Google Scholar 

  49. Calvo E, Merino-Gutierrez I, Lagunes I. Arthroscopic tuberoplasty for subacromial impingement secondary to proximal humeral malunion. Knee Surg Sports Traumatol Arthrosc. 2010;18(7):988–91.

    Article  Google Scholar 

  50. Ji JH, Moon CY, Kim YY, Shafi M. Arthroscopic fixation for a malunited greater tuberosity fracture using the suture-bridge technique: technical report and literature review. Knee Surg Sports Traumatol Arthrosc. 2009;17(12):1473–6.

    Article  Google Scholar 

  51. Kimn KC, Rhee KJ, Shin HD. Arthroscopic treatment of symptomatic malunion of the greater tuberosity of the humerus using the suture-bridge technique. Orthopedics. 2010;33(4):242–5.

    Article  Google Scholar 

  52. Kowalsky MS, Bell JE, Ahmad CS. Arthroscopic treatment of subcoracoid impingement caused by lesser tuberosity malunion: a case report and review of the literature. J Shoulder Elb Surg. 2007;16(6):e10–4.

    Article  Google Scholar 

  53. Antuña SA, Sperling JW, Sánchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral nonunions. J Shoulder Elb Surg. 2002;11(2):114–21.

    Article  Google Scholar 

  54. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elb Surg. 1995;4(4):271–80.

    Article  CAS  Google Scholar 

  55. Ballas R, Teissier P, Teissier J. Stemless shoulder prosthesis for treatment of proximal humeral malunion does not require tuberosity osteotomy. Int Orthop. 2016;40(7):1473–9.

    Article  Google Scholar 

  56. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319–37.

    Article  Google Scholar 

  57. Martinez AA, Calvo A, Bejarano C, Carbonel I, Herrera A. The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus. J Orthop Sci. 2012;17(2):141–7.

    Article  Google Scholar 

  58. Raiss P, Edwards TB, Collin P, Bruckner T, Zeifang F, Loew M, et al. Reverse shoulder arthroplasty for malunions of the proximal part of the humerus (type-4 fracture sequelae). J Bone Joint Surg Am. 2016;98(11):893–9.

    Article  Google Scholar 

  59. Raiss P, Alami G, Bruckner T, Magosch P, Habermeyer P, Boileau P, Walch G. Reverse shoulder arthroplasty for type 1 sequelae of a fracture of the proximal humerus. Bone Joint J. 2018;100-B(3):318–23.

    Article  CAS  Google Scholar 

  60. Hyun YS, Huri G, Garbis NG, McFarland EG. Uncommon indications for reverse total shoulder arthroplasty. Clin Orthop Surg. 2013;5(4):243–55.

    Article  Google Scholar 

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Authors and Affiliations

  1. UC Davis Health, Volunteer Clinical Faculty, Premier Orthopaedic and Trauma Specialists, Pomona, CA, USA

    Christopher B. Hayes

  2. Department of Orthopaedic Surgery, University of California at Davis, Sacramento, CA, USA

    Ryan L. Anderson & Philip R. Wolinsky

  3. Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA

    Gillian L. S. Soles

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  1. Christopher B. Hayes
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  2. Ryan L. Anderson
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  3. Gillian L. S. Soles
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  4. Philip R. Wolinsky
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Editors and Affiliations

  1. Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, UT Health, San Antonio, TX, USA

    Animesh Agarwal

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Hayes, C.B., Anderson, R.L., Soles, G.L.S., Wolinsky, P.R. (2021). Malunions of the Proximal Humerus. In: Agarwal, A. (eds) Malunions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1124-1_3

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  • DOI: https://doi.org/10.1007/978-1-0716-1124-1_3

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