251 C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Current Concepts Review
Proximal Humeral Fracture Treatment in Adults Dirk Maier, MD, Martin Jaeger, MD, Kaywan Izadpanah, MD, Peter C. Strohm, MD, and Norbert P. Suedkamp, MD Investigation performed at the Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Freiburg, Germany
ä
Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.
ä
The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).
ä
Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.
ä
Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.
ä
The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Challenges in the treatment of proximal humeral fractures are complex and the variety of fracture patterns complicates classification. To prevent failures, it is essential to choose the most suitable treatment, including nonoperative therapy, minimally invasive osteosynthesis, open reduction and plate fixation, intramedullary nail osteosynthesis, and primary arthroplasty. Surgical treatment requires anatomic reduction and stable fixation, proving difficult, particularly in osteoporotic bone. In the United States, the introduction of locking plates caused a substantial rise of operative treatment1. Comparing treatment of proximal humeral fractures in the period 1999 to 2000, including 14,774 patients, with that of proximal humeral fractures in the period 2004 to 2005, including 16,138 patients, the
rate of operative treatment increased by 25.6% (p < 0.0001). At the same time, the rate of revision surgical procedures showed a significant proportional increase (p = 0.043). This review is intended to assist in therapeutic decisionmaking. It outlines established classification systems and current evidence-based guidelines. Nonetheless, the definitive choice of treatment remains a multifactorial, individualized decision considering patient, fracture, and surgeon-specific aspects. Epidemiology In the United States, the incidence of proximal humeral fractures within the Medicare population (sixty-five years of age or older) was approximately 250 per 100,000 in the period 1999
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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hinge with displacement of >2 mm. Majed et al.10 found low to moderate interobserver reliabilities among classification systems despite the use of three-dimensional computed tomography (CT) models. The Codman-Hertel description system achieved the highest interobserver score, followed by the Neer, Resch et al., and AO/OTA classifications.
Fig. 1
Radiographs showing (Fig. 1-A) varus (disruption) type two-part fracture and (Fig. 1-B) valgus (lateral) impaction-type three-part fracture. Typically, the greater tuberosity fragment lies superior to the head fragment. R = right.
to 20051. The proportion of women was approximately 80%1,2. Fractures were caused by low-energy trauma in 87%, suggesting an effect of osteoporosis2. Proximal humeral fractures represent the third most common osteoporotic fracture type3. Classification Systems In 1934, Codman4 introduced the segment theory for the classification of proximal humeral fractures. He described twelve basic patterns depending on the involvement of the four main segments (shaft, head, greater tuberosity, and lesser tuberosity). However, the Codman classification system did not distinguish between anatomic and surgical neck fractures and did not include displacement. Neer5 proposed a classification system based on displacement of one or more of the four main segments (four-segment classification) and defined six groups: I, minimal displacement; II, displaced anatomic neck fracture; III, displaced surgical neck fracture; IV, displaced greater tuberosity fracture; V, displaced lesser tuberosity fracture; and VI, fracture-dislocation. Displacement was defined as an angulation of >45° or a separation of >1 cm. Complimentary to these six groups, in his classification system, Neer defined one, two, three, and four-part fractures to indicate the number of main segments affected by displacement. Neer6 also pointed out that displacement was defined rather arbitrarily and the intention was not to dictate treatment. The AO/OTA classification distinguishes three basic fracture types (A, extra-articularunifocal; B, extra-articular-bifocal; and C, articular) and comprises a total of twenty-seven subtypes7. Resch et al.8 differentiated between varus and valgus fractures. The varus fracture may present as an impaction or distraction (disruption) type. Valgus fractures may be impacted in straight lateral or posterolateral direction (Fig. 1). Hertel et al.9 introduced the binary description system based on the Codman twelve basic fracture patterns. In addition, they identified the morphologic risk factors for humeral head ischemia. Reliable predictors of ischemia were a short (5-mm displacement of the greater tuberosity (p < 0.05). Thus, visualization and eventual repair of the rotator cuff are recommended during fracture fixation. Ultrasonography or MRI should complement nonoperative treatment for early detection of rotator cuff injuries. Standard imaging studies of proximal humeral fractures consist of not less than two (if feasible, three) standard radiographs (true anterior-posterior, outlet, axillary view). Additional CT is recommended if fracture lines cannot be reliably detected, as seen particularly in complex three and four-part fractures with multi-fragmented involvement of the head and tuberosities. Three-dimensional CT models simplify both the description of fracture patterns and preoperative planning but do not improve interrater reliability14. Treatment The Neer criteria of displacement are subject to continuous revision. In general, operative treatment should be considered in head-to-shaft displacement of >50% of the diaphyseal diameter and in varus or valgus deviation of >20° from the physiological 130° head-to-shaft inclination15,16. A biomechanical study showed that 45° of varus deformity significantly decreased (p = 0.039) abduction efficiency of the supraspinatus tendon17. A varus deformity of 20° caused significantly higher forces (p = 0.015) to accomplish early shoulder abduction. Lately, indications for the operative treatment of isolated greater
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Radiographs showing nonoperative treatment in a sixty-four-year-old man. Upper left and right panels: Three-segment fracture with minor displace-
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Nonoperative Treatment Prospective, randomized controlled trials defined the indications, results, and limits of nonoperative treatment. Olerud et al.21 reported two-year outcomes after displaced three-part fractures in sixty elderly patients randomized to either nonoperative treatment or locking plate osteosynthesis. Locking plate osteosynthesis showed advantages in functional outcome and quality of life, although revision surgery was required in 30% of patients. Fjalestad et al.22 found equal functional outcomes for locking plate osteosynthesis and nonoperative treatment of displaced three and four-part fractures in a series of fifty patients who were sixty years of age or older. The average Constant score, adjusted for age and sex, was 74% in both groups. This study also included fractures with severe displacement (malangulation of >45° and tuberosity displacement of >1 cm). However, displacement between the head and shaft did not have to exceed 50% of the diaphyseal diameter. A prospective study of 160 patients with nonoperatively treated proximal humeral fractures found significantly lower results (p < 0.0001) of the involved shoulders for the Constant score (D 8.2 points) and the Disabilities of the Arm, Shoulder and Hand (DASH) score (D 10.2 points) compared with those of the unaffected, contralateral shoulders23. Foruria et al.24 investigated whether morphologies of proximal humeral fractures would influence functional outcomes. In posteromedial impaction fractures, outcome (American Shoulder and Elbow Surgeons [ASES] score, DASH score, range of motion) deteriorated, as the articular surface displaced inferiorly, increasing its distance to the undersurface of the acromion. Superior or medial displacement (>10 mm) of the greater tuberosity and the superposition of the greater tuberosity fragment and the articular surface were associated with inferior outcomes in valgus impaction fractures. Overall, valgus impaction fractures yielded less favorable results24. Prolonged periods of continuous immobilization (more than two weeks) significantly deteriorated long-term outcome (p < 0.01) in a series of 104 patients with minimally displaced proximal humeral fractures25. Mobilization at one week instead of three weeks alleviated short-term pain. Hence, supervised physiotherapy should be initiated within two weeks after injury. Figure 2 shows a clinical example of nonoperative treatment.
ment. Middle left and right panels: Follow-up radiographs after three months show consolidation of the fracture without signs of secondary displacement. Lower left and right panels: Excellent shoulder function three months after nonoperative treatment. L = left.
tuberosity fractures have become more stringent18. Favorable outcomes were observed when greater tuberosities with displacement of >5 mm underwent anatomic reduction and fixation19. A current Cochrane review of various treatment and rehabilitation interventions included twenty-three randomized trials with a total of 1238 participants20. The authors concluded that there was insufficient evidence to inform the treatment of proximal humeral fractures.
Complications of Nonoperative Treatment In general, closed reduction without fixation improves neither fracture alignment nor functional outcome. In contrast, potential risks for soft-tissue and neurovascular complications should be considered when performing closed reduction maneuvers23. Delayed union or nonunion was found in 7% of 160 patients managed nonoperatively23. In a prospective study including ninety-three patients with proximal humeral fractures showing different degrees of displacement, osteonecrosis of the humeral head developed in 6.5% of patients within one year24. The rate of osteonecrosis was 21.6% in a study including thirtyseven patients with displaced fractures26. EMG detected posttraumatic axillary nerve lesions in six (30%) of twenty patients
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Each Kirschner wire is held in place by a locking screw. The Humerusblock represents a dynamic type of fixation, neutralizing stress forces at the fracture site. Elasticity of the construct contributes toward lowering the incidence of secondary displacement in osteoporotic bone. In type-B1 and B2 (AO/OTA) fractures, the mean intraindividual Constant score reached 91%7. In type-C1 and C2 (AO/OTA) fractures, the mean intraindividual Constant score reached 87%32. Gorschewsky et al.33 managed ninety-seven patients with displaced two, three, and four-part fractures with one or two titanium helix wires. The Constant score averaged 76 points after a one-year follow-up. The results were inferior in patients with three-part fractures (73 points) and those with four-part fractures (53 points) compared with patients with two-part fractures (95 points). The preliminary results of minimally invasive (polyaxial) locking plate fixation are promising34,35. Minimally invasive osteosynthesis advanced from percutaneous and arthroscopically assisted osteosynthesis of greater and lesser tuberosity fractures to techniques performed exclusively arthroscopically31,36,37. Suture anchors showed biomechanical superiority over screws for greater tuberosity fixation38. Arthroscopic double-row suture anchor fixation of comminuted and displaced (>5 mm) greater tuberosity fractures yielded encouraging results (mean ASES score, 88.1 points)39. Figure 3 illustrates a clinical case of minimally invasive osteosynthesis. Fig. 3
Radiographs showing a thirty-five-year-old male athlete who had undergone arthroscopically assisted percutaneous screw osteosynthesis. Upper left and right panels: coronal and axial CT images show a multi-fragmented and slightly displaced fracture of the greater tuberosity with metaphyseal involvement. Middle left and right panels: After arthroscopically controlled reduction, cannulated screws were used to fix the greater tuberosity and the non-displaced surgical neck component of the fracture. Osteosynthesis enabled functional rehabilitation. Lower left and right panels: After implant removal, there was anatomic healing of the greater tuberosity.
after a mean duration of thirteen weeks22, with half resolved within one year. Operative Treatment Six randomized trials involving 270 participants compared surgical with conservative treatment11,21,22,27-29. Pooled results for patient-reported measures of function and quality of life were inconclusive20. However, surgical group patients were more likely to undergo secondary surgery, in one of every nine operatively managed patients. Minimally Invasive Osteosynthesis Minimally invasive osteosynthesis is best qualified for proximal humeral fractures reducible by closed means. Bogner et al.30 and Resch and coworkers31 introduced techniques of percutaneous reduction and fracture fixation with cannulated screws and Kirschner wires. The Resch Humerusblock consists of a metal block that is fixed to the humeral shaft by a cannulated cortical screw. Two crossed 2.2-mm Kirschner wires are passed through the block at an angle of 45° to fix the head fragment.
Complications of Minimally Invasive Osteosynthesis The Humerusblock achieved considerably lower rates of secondary displacement (9.8%) compared with percutaneous Kirschner wire osteosynthesis without locked cortical fixation31,32,36. Osteonecrosis occurred in four (8.0%) of fifty patients with three and four-part fractures30. Helix wiring caused postoperative complications in eleven (12%) of ninety-five patients, including three cases of secondary displacement, five cases of partial or total osteonecrosis, two cases of fracture dehiscence requiring early implant removal, and one case of reflex sympathetic dystrophy of the affected upper extremity. Advice against this procedure is justified by unacceptably high rates of secondary displacement, nonunion, and insufficient stability to enable early functional recovery40,41. Likewise, other intramedullary implants without locking mechanisms (e.g., Rush pins, Pre´ vot, Ender, Zifko, Hackethal nailing) have high rates of secondary displacement42,43. Implant-related complications occurred in nine (17%) of fifty-four patients after minimally invasive locking plate osteosynthesis34. The overall rate of osteonecrosis was 5.5%. There were no nonunions34. Intramedullary Locking Nail Osteosynthesis The indications for intramedullary locking nail osteosynthesis are three and four-part fractures with metaphyseal comminution or diaphyseal involvement but only minor displacement of the tuberosities. Zhu et al.44 compared intramedullary locking nail osteosynthesis and locking plate osteosynthesis for the treatment of two-part fractures. After three years of followup, ASES (90.0 versus 94.0 points), Constant scores (93.3 versus 94.5 points), pain, and shoulder motion did not differ significantly. Both duration of surgery (p = 0.013) and blood loss
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locking nail osteosynthesis (one [4.0%] of twenty-five) compared with those following locking plate osteosynthesis (eight [31%] of twenty-six) for the treatment of displaced two-part fractures44. However, the prospective multicenter comparison (n = 152) of angular stable intramedullary locking nail osteosynthesis (n = 76) and locking plate osteosynthesis (n = 76) resulted in equivalent complication rates (22% and 28%, respectively)45. Iatrogenic rotator cuff lesions occurred in two (2.6%) of seventy-six cases following intramedullary locking nail osteosynthesis requiring arthroscopic treatment with implant removal. Angular stable locking of intramedullary nails might be beneficial in osteosynthesis of osteopenic bone as it has been proven to have superior biomechanical stability when compared with conventional locking techniques46.
Fig. 4
Radiographs showing a sixty-two-year-old woman who had undergone locking nail osteosynthesis. Upper left and right: Osteoporotic bone with fracture (two-part) involving the surgical neck. Lower left and right: Postoperative radiographs four months after locking nail osteosynthesis (MultiLoc Proximal Humeral Nail; Synthes, Zuchwil, Switzerland). Angular stable locking bolts were inserted proximally and distally.
(p < 0.01) were significantly greater in the plate group. A multicenter matched-pair analysis enrolled 152 patients with displaced two, three, and four-part fractures treated with either anterograde angular and sliding stable proximal interlocking nails or locking plates45. After one year, the mean Constant scores were equal for age (81%) and sex (75%). Figure 4 is an example of intramedullary locking nail osteosynthesis. Complications of Intramedullary Locking Nail Osteosynthesis A prospective randomized study (n = 51) found significantly fewer complications (p = 0.024) following intramedullary
Open Reduction and Locking Plate Osteosynthesis Indications for open reduction and locking plate osteosynthesis comprise two, three, and four-part fractures with tuberosity or head fragment displacement. Open osteosynthesis provides superior control of anatomic reduction and more comprehensive fixation options compared with minimally invasive procedures. The anatomic, deltopectoral surgical approach is most commonly used47. The extended deltoid-splitting approach may improve posterior exposure but places the anterior terminal branch of the axillary nerve at risk48. A retrospective study observed no differences in clinical, radiographic, and electrophysiological outcomes between these two approaches49. Cloverleaf, buttress, and semitubular plates have been largely replaced by preshaped locking plates, which enhance primary biomechanical stability50. A prospective multicenter study showed a mean Constant score of 70.6 points one year after monoaxial locking plate fixation51. Another multicenter study found almost identical results52. In a systematic review of intermediate and long-term results (n = 514), the average Constant score was 73.6 points53. A significantly lower score (p = 0.02) was observed in four-part fractures (67.7 points) when compared with two-part fractures (77.4 points). Recently, efforts were made to determine factors predicting functional outcome and failure rates (Table I). Hardeman et al.54 noted superior results in younger patients. Increased displacements, type-C (AO/OTA) fractures, varus fractures, and fractures with compromised humeral head vascularity were associated with inferior results. Anatomic reduction led to superior outcomes. Gardner et al.55 emphasized the importance of restoration of the medial column and recommended placing superiorly directed oblique locking calcar screws. Cement augmentation did not improve maintenance of reduction. Krappinger et al.56 pointed out the relevance of preoperative assessment of local bone mineral density. Local bone mineral density, restoration of the medial column, nonanatomic reduction, and age were significant predictors of fixation failure (p < 0.01). Osteosynthesis of osteoporotic fractures with non-reconstructable comminution of the medial column is prone to failure. Gardner et al.57 restored mechanical integrity of the medial column using a segment of fibula allograft, which was placed endosteally and incorporated into the locking plate construct. Clinical and radiographic
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TABLE I Factors Influencing the Outcome of Open Reduction and Locking Plate Osteosynthesis Prognostic Factor
Variable
Authors 56
54
Increase in age
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Hardeman et al.
Decrease in local bone mineral density
Increase in failure rate
Krappinger et al.
56
51
54
Increase in initial fracture displacement and complexity
Decrease in functional outcome
S¨udkamp et al. , Hardeman et al.
Increase in initial varus deformity
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Gardner et al. , 54 Hardeman et al.
Decrease in quality of reduction
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Hardeman et al.
Decrease in restoration of medial support
Increase in failure rate and loss of reduction
Gardner et al. , Krappinger et al.
Decrease in head fragment vascularity
Decrease in functional outcome
Bastian and Hertel , Hardeman et al.
results after a minimum follow-up of forty-nine weeks were promising58. The mean Constant score reached 87 points. Loss of reduction (varus collapse) occurred in only one patient. All fractures united. Polyaxial locking plates did not prove clinical superiority compared with monoaxial locking systems59. Figure 5 illustrates a clinical case of treatment with locking plate osteosynthesis.
56
55
56
54
55
56
74
54
peak stresses at the bone-implant interface and allow impaction62. Several elastic (dynamic) fixation methods (e.g., the Resch Humerusblock with modifications, tubular steel plate fixation
Complications of Locking Plate Osteosynthesis A multicenter study encountered complications in fifty-two (34%) of 155 patients within twelve postoperative months51. Notably, twenty-five (48%) of fifty-two complications were caused by a suboptimal surgical technique. Intraoperative screw perforation of the humeral head was observed in twenty-one (14%) of 155 patients as the most common complication. Almost one-fifth of patients had to undergo revision surgery. Zhu et al.44 reported screw penetration of the articular surface as the most frequent complication leading to revision surgery in five (19%) of twentysix cases within three postoperative months. A systematic review (n = 514) described an overall complication rate of 48.8%, including a revision rate of 13.8%53. Varus malunion was observed in 16.3% of cases, osteonecrosis in 10.8%, intra-articular screw perforation in 7.5%, subacromial impingement in 4.8%, infection in 3.5%, nonunion in 3.4%, and miscellaneous complications in 2.5%. In a comparative clinical trial, augmentation with calcium phosphate cement significantly decreased (p = 0.02) displacement and intra-articular screw penetration in fractures with metaphyseal comminution60. However, little knowledge exists regarding its influence on fracture-healing and long-term implications in general. Osteosynthesis in Patients with Osteoporosis Osteoporosis promotes fragmentation and implant displacement after osteosynthesis56. Fixing osteoporotic bone with stronger and stiffer implants (e.g., locking plates) may aggravate this problem. The so-called mixer describes a relative motion of rigid implants (e.g., locking screws) against the epiphyseal (head) segment and may cause its excavation or destruction61. On the contrary, implants with low stiffness and elastic characteristics minimize the
Fig. 5
Radiographs showing a fifty-two-year-old man who had undergone locking plate osteosynthesis. Upper left and right panels: Valgus-impacted threepart fracture with greater tuberosity displacement. Lower left and right panels: Follow-up radiographs show anatomic healing ten months after locking plate osteosynthesis (PHILOS plate; Synthes, Zuchwil, Switzerland).
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Fig. 6
Radiographs showing a seventy-eight-year-old woman who had undergone primary hemiarthroplasty. Upper panel: Osteoporotic four-part fracture with posteromedial displacement is seen on CT images. Both tuberosities exhibited sufficient bone substance to enable metaphyseal healing and the rotator cuff was intact. Lower panel: Follow-up radiographs at eight months show anatomic healing of both tuberosities and centering of the prosthetic humeral head (Epoca Shoulder Arthroplasty System; Synthes, Zuchwil, Switzerland). Both tuberosities were anatomically fixed with a circumferential multifilament cable cerclage (Tubercable; Synthes, Zuchwil, Switzerland).
combined with suture cerclage of both tuberosities, isolated suture fixation, tension banding) have been reported for osteoporotic fracture treatment8,61,63. Hertel61 emphasized the importance of anatomic reduction (medial column, tuberosities) and recognized metaphyseal buttressing as the key element of load-sharing fixation. However, concepts of strengthening the weaker bone appear promising. Locking plate osteosynthesis of osteoporotic four-part fractures combined with autologous iliac bone impaction grafting achieved excellent clinical and radiographic results in twenty-one patients64. To date, to our knowledge, no clinical reports exist on the use of growth factors for the treatment of proximal humeral fractures. Polymethylmethacrylate (PMMA) cement augmentation of cannulated screws significantly enhanced (p < 0.05) implant anchorage in humeral head specimens of human cadavers65.
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Primary Hemiarthroplasty Primary hemiarthroplasty may solve complex fracture situations, where adequate reduction and fixation cannot be achieved. Possible indications are a short (
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Current Concepts Review
Proximal Humeral Fracture Treatment in Adults Dirk Maier, MD, Martin Jaeger, MD, Kaywan Izadpanah, MD, Peter C. Strohm, MD, and Norbert P. Suedkamp, MD Investigation performed at the Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Freiburg, Germany
ä
Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.
ä
The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).
ä
Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.
ä
Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.
ä
The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Challenges in the treatment of proximal humeral fractures are complex and the variety of fracture patterns complicates classification. To prevent failures, it is essential to choose the most suitable treatment, including nonoperative therapy, minimally invasive osteosynthesis, open reduction and plate fixation, intramedullary nail osteosynthesis, and primary arthroplasty. Surgical treatment requires anatomic reduction and stable fixation, proving difficult, particularly in osteoporotic bone. In the United States, the introduction of locking plates caused a substantial rise of operative treatment1. Comparing treatment of proximal humeral fractures in the period 1999 to 2000, including 14,774 patients, with that of proximal humeral fractures in the period 2004 to 2005, including 16,138 patients, the
rate of operative treatment increased by 25.6% (p < 0.0001). At the same time, the rate of revision surgical procedures showed a significant proportional increase (p = 0.043). This review is intended to assist in therapeutic decisionmaking. It outlines established classification systems and current evidence-based guidelines. Nonetheless, the definitive choice of treatment remains a multifactorial, individualized decision considering patient, fracture, and surgeon-specific aspects. Epidemiology In the United States, the incidence of proximal humeral fractures within the Medicare population (sixty-five years of age or older) was approximately 250 per 100,000 in the period 1999
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:251-61
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http://dx.doi.org/10.2106/JBJS.L.01293
252 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 3 F E B R UA RY 5, 2 014 d
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hinge with displacement of >2 mm. Majed et al.10 found low to moderate interobserver reliabilities among classification systems despite the use of three-dimensional computed tomography (CT) models. The Codman-Hertel description system achieved the highest interobserver score, followed by the Neer, Resch et al., and AO/OTA classifications.
Fig. 1
Radiographs showing (Fig. 1-A) varus (disruption) type two-part fracture and (Fig. 1-B) valgus (lateral) impaction-type three-part fracture. Typically, the greater tuberosity fragment lies superior to the head fragment. R = right.
to 20051. The proportion of women was approximately 80%1,2. Fractures were caused by low-energy trauma in 87%, suggesting an effect of osteoporosis2. Proximal humeral fractures represent the third most common osteoporotic fracture type3. Classification Systems In 1934, Codman4 introduced the segment theory for the classification of proximal humeral fractures. He described twelve basic patterns depending on the involvement of the four main segments (shaft, head, greater tuberosity, and lesser tuberosity). However, the Codman classification system did not distinguish between anatomic and surgical neck fractures and did not include displacement. Neer5 proposed a classification system based on displacement of one or more of the four main segments (four-segment classification) and defined six groups: I, minimal displacement; II, displaced anatomic neck fracture; III, displaced surgical neck fracture; IV, displaced greater tuberosity fracture; V, displaced lesser tuberosity fracture; and VI, fracture-dislocation. Displacement was defined as an angulation of >45° or a separation of >1 cm. Complimentary to these six groups, in his classification system, Neer defined one, two, three, and four-part fractures to indicate the number of main segments affected by displacement. Neer6 also pointed out that displacement was defined rather arbitrarily and the intention was not to dictate treatment. The AO/OTA classification distinguishes three basic fracture types (A, extra-articularunifocal; B, extra-articular-bifocal; and C, articular) and comprises a total of twenty-seven subtypes7. Resch et al.8 differentiated between varus and valgus fractures. The varus fracture may present as an impaction or distraction (disruption) type. Valgus fractures may be impacted in straight lateral or posterolateral direction (Fig. 1). Hertel et al.9 introduced the binary description system based on the Codman twelve basic fracture patterns. In addition, they identified the morphologic risk factors for humeral head ischemia. Reliable predictors of ischemia were a short (5-mm displacement of the greater tuberosity (p < 0.05). Thus, visualization and eventual repair of the rotator cuff are recommended during fracture fixation. Ultrasonography or MRI should complement nonoperative treatment for early detection of rotator cuff injuries. Standard imaging studies of proximal humeral fractures consist of not less than two (if feasible, three) standard radiographs (true anterior-posterior, outlet, axillary view). Additional CT is recommended if fracture lines cannot be reliably detected, as seen particularly in complex three and four-part fractures with multi-fragmented involvement of the head and tuberosities. Three-dimensional CT models simplify both the description of fracture patterns and preoperative planning but do not improve interrater reliability14. Treatment The Neer criteria of displacement are subject to continuous revision. In general, operative treatment should be considered in head-to-shaft displacement of >50% of the diaphyseal diameter and in varus or valgus deviation of >20° from the physiological 130° head-to-shaft inclination15,16. A biomechanical study showed that 45° of varus deformity significantly decreased (p = 0.039) abduction efficiency of the supraspinatus tendon17. A varus deformity of 20° caused significantly higher forces (p = 0.015) to accomplish early shoulder abduction. Lately, indications for the operative treatment of isolated greater
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Radiographs showing nonoperative treatment in a sixty-four-year-old man. Upper left and right panels: Three-segment fracture with minor displace-
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Nonoperative Treatment Prospective, randomized controlled trials defined the indications, results, and limits of nonoperative treatment. Olerud et al.21 reported two-year outcomes after displaced three-part fractures in sixty elderly patients randomized to either nonoperative treatment or locking plate osteosynthesis. Locking plate osteosynthesis showed advantages in functional outcome and quality of life, although revision surgery was required in 30% of patients. Fjalestad et al.22 found equal functional outcomes for locking plate osteosynthesis and nonoperative treatment of displaced three and four-part fractures in a series of fifty patients who were sixty years of age or older. The average Constant score, adjusted for age and sex, was 74% in both groups. This study also included fractures with severe displacement (malangulation of >45° and tuberosity displacement of >1 cm). However, displacement between the head and shaft did not have to exceed 50% of the diaphyseal diameter. A prospective study of 160 patients with nonoperatively treated proximal humeral fractures found significantly lower results (p < 0.0001) of the involved shoulders for the Constant score (D 8.2 points) and the Disabilities of the Arm, Shoulder and Hand (DASH) score (D 10.2 points) compared with those of the unaffected, contralateral shoulders23. Foruria et al.24 investigated whether morphologies of proximal humeral fractures would influence functional outcomes. In posteromedial impaction fractures, outcome (American Shoulder and Elbow Surgeons [ASES] score, DASH score, range of motion) deteriorated, as the articular surface displaced inferiorly, increasing its distance to the undersurface of the acromion. Superior or medial displacement (>10 mm) of the greater tuberosity and the superposition of the greater tuberosity fragment and the articular surface were associated with inferior outcomes in valgus impaction fractures. Overall, valgus impaction fractures yielded less favorable results24. Prolonged periods of continuous immobilization (more than two weeks) significantly deteriorated long-term outcome (p < 0.01) in a series of 104 patients with minimally displaced proximal humeral fractures25. Mobilization at one week instead of three weeks alleviated short-term pain. Hence, supervised physiotherapy should be initiated within two weeks after injury. Figure 2 shows a clinical example of nonoperative treatment.
ment. Middle left and right panels: Follow-up radiographs after three months show consolidation of the fracture without signs of secondary displacement. Lower left and right panels: Excellent shoulder function three months after nonoperative treatment. L = left.
tuberosity fractures have become more stringent18. Favorable outcomes were observed when greater tuberosities with displacement of >5 mm underwent anatomic reduction and fixation19. A current Cochrane review of various treatment and rehabilitation interventions included twenty-three randomized trials with a total of 1238 participants20. The authors concluded that there was insufficient evidence to inform the treatment of proximal humeral fractures.
Complications of Nonoperative Treatment In general, closed reduction without fixation improves neither fracture alignment nor functional outcome. In contrast, potential risks for soft-tissue and neurovascular complications should be considered when performing closed reduction maneuvers23. Delayed union or nonunion was found in 7% of 160 patients managed nonoperatively23. In a prospective study including ninety-three patients with proximal humeral fractures showing different degrees of displacement, osteonecrosis of the humeral head developed in 6.5% of patients within one year24. The rate of osteonecrosis was 21.6% in a study including thirtyseven patients with displaced fractures26. EMG detected posttraumatic axillary nerve lesions in six (30%) of twenty patients
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Each Kirschner wire is held in place by a locking screw. The Humerusblock represents a dynamic type of fixation, neutralizing stress forces at the fracture site. Elasticity of the construct contributes toward lowering the incidence of secondary displacement in osteoporotic bone. In type-B1 and B2 (AO/OTA) fractures, the mean intraindividual Constant score reached 91%7. In type-C1 and C2 (AO/OTA) fractures, the mean intraindividual Constant score reached 87%32. Gorschewsky et al.33 managed ninety-seven patients with displaced two, three, and four-part fractures with one or two titanium helix wires. The Constant score averaged 76 points after a one-year follow-up. The results were inferior in patients with three-part fractures (73 points) and those with four-part fractures (53 points) compared with patients with two-part fractures (95 points). The preliminary results of minimally invasive (polyaxial) locking plate fixation are promising34,35. Minimally invasive osteosynthesis advanced from percutaneous and arthroscopically assisted osteosynthesis of greater and lesser tuberosity fractures to techniques performed exclusively arthroscopically31,36,37. Suture anchors showed biomechanical superiority over screws for greater tuberosity fixation38. Arthroscopic double-row suture anchor fixation of comminuted and displaced (>5 mm) greater tuberosity fractures yielded encouraging results (mean ASES score, 88.1 points)39. Figure 3 illustrates a clinical case of minimally invasive osteosynthesis. Fig. 3
Radiographs showing a thirty-five-year-old male athlete who had undergone arthroscopically assisted percutaneous screw osteosynthesis. Upper left and right panels: coronal and axial CT images show a multi-fragmented and slightly displaced fracture of the greater tuberosity with metaphyseal involvement. Middle left and right panels: After arthroscopically controlled reduction, cannulated screws were used to fix the greater tuberosity and the non-displaced surgical neck component of the fracture. Osteosynthesis enabled functional rehabilitation. Lower left and right panels: After implant removal, there was anatomic healing of the greater tuberosity.
after a mean duration of thirteen weeks22, with half resolved within one year. Operative Treatment Six randomized trials involving 270 participants compared surgical with conservative treatment11,21,22,27-29. Pooled results for patient-reported measures of function and quality of life were inconclusive20. However, surgical group patients were more likely to undergo secondary surgery, in one of every nine operatively managed patients. Minimally Invasive Osteosynthesis Minimally invasive osteosynthesis is best qualified for proximal humeral fractures reducible by closed means. Bogner et al.30 and Resch and coworkers31 introduced techniques of percutaneous reduction and fracture fixation with cannulated screws and Kirschner wires. The Resch Humerusblock consists of a metal block that is fixed to the humeral shaft by a cannulated cortical screw. Two crossed 2.2-mm Kirschner wires are passed through the block at an angle of 45° to fix the head fragment.
Complications of Minimally Invasive Osteosynthesis The Humerusblock achieved considerably lower rates of secondary displacement (9.8%) compared with percutaneous Kirschner wire osteosynthesis without locked cortical fixation31,32,36. Osteonecrosis occurred in four (8.0%) of fifty patients with three and four-part fractures30. Helix wiring caused postoperative complications in eleven (12%) of ninety-five patients, including three cases of secondary displacement, five cases of partial or total osteonecrosis, two cases of fracture dehiscence requiring early implant removal, and one case of reflex sympathetic dystrophy of the affected upper extremity. Advice against this procedure is justified by unacceptably high rates of secondary displacement, nonunion, and insufficient stability to enable early functional recovery40,41. Likewise, other intramedullary implants without locking mechanisms (e.g., Rush pins, Pre´ vot, Ender, Zifko, Hackethal nailing) have high rates of secondary displacement42,43. Implant-related complications occurred in nine (17%) of fifty-four patients after minimally invasive locking plate osteosynthesis34. The overall rate of osteonecrosis was 5.5%. There were no nonunions34. Intramedullary Locking Nail Osteosynthesis The indications for intramedullary locking nail osteosynthesis are three and four-part fractures with metaphyseal comminution or diaphyseal involvement but only minor displacement of the tuberosities. Zhu et al.44 compared intramedullary locking nail osteosynthesis and locking plate osteosynthesis for the treatment of two-part fractures. After three years of followup, ASES (90.0 versus 94.0 points), Constant scores (93.3 versus 94.5 points), pain, and shoulder motion did not differ significantly. Both duration of surgery (p = 0.013) and blood loss
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locking nail osteosynthesis (one [4.0%] of twenty-five) compared with those following locking plate osteosynthesis (eight [31%] of twenty-six) for the treatment of displaced two-part fractures44. However, the prospective multicenter comparison (n = 152) of angular stable intramedullary locking nail osteosynthesis (n = 76) and locking plate osteosynthesis (n = 76) resulted in equivalent complication rates (22% and 28%, respectively)45. Iatrogenic rotator cuff lesions occurred in two (2.6%) of seventy-six cases following intramedullary locking nail osteosynthesis requiring arthroscopic treatment with implant removal. Angular stable locking of intramedullary nails might be beneficial in osteosynthesis of osteopenic bone as it has been proven to have superior biomechanical stability when compared with conventional locking techniques46.
Fig. 4
Radiographs showing a sixty-two-year-old woman who had undergone locking nail osteosynthesis. Upper left and right: Osteoporotic bone with fracture (two-part) involving the surgical neck. Lower left and right: Postoperative radiographs four months after locking nail osteosynthesis (MultiLoc Proximal Humeral Nail; Synthes, Zuchwil, Switzerland). Angular stable locking bolts were inserted proximally and distally.
(p < 0.01) were significantly greater in the plate group. A multicenter matched-pair analysis enrolled 152 patients with displaced two, three, and four-part fractures treated with either anterograde angular and sliding stable proximal interlocking nails or locking plates45. After one year, the mean Constant scores were equal for age (81%) and sex (75%). Figure 4 is an example of intramedullary locking nail osteosynthesis. Complications of Intramedullary Locking Nail Osteosynthesis A prospective randomized study (n = 51) found significantly fewer complications (p = 0.024) following intramedullary
Open Reduction and Locking Plate Osteosynthesis Indications for open reduction and locking plate osteosynthesis comprise two, three, and four-part fractures with tuberosity or head fragment displacement. Open osteosynthesis provides superior control of anatomic reduction and more comprehensive fixation options compared with minimally invasive procedures. The anatomic, deltopectoral surgical approach is most commonly used47. The extended deltoid-splitting approach may improve posterior exposure but places the anterior terminal branch of the axillary nerve at risk48. A retrospective study observed no differences in clinical, radiographic, and electrophysiological outcomes between these two approaches49. Cloverleaf, buttress, and semitubular plates have been largely replaced by preshaped locking plates, which enhance primary biomechanical stability50. A prospective multicenter study showed a mean Constant score of 70.6 points one year after monoaxial locking plate fixation51. Another multicenter study found almost identical results52. In a systematic review of intermediate and long-term results (n = 514), the average Constant score was 73.6 points53. A significantly lower score (p = 0.02) was observed in four-part fractures (67.7 points) when compared with two-part fractures (77.4 points). Recently, efforts were made to determine factors predicting functional outcome and failure rates (Table I). Hardeman et al.54 noted superior results in younger patients. Increased displacements, type-C (AO/OTA) fractures, varus fractures, and fractures with compromised humeral head vascularity were associated with inferior results. Anatomic reduction led to superior outcomes. Gardner et al.55 emphasized the importance of restoration of the medial column and recommended placing superiorly directed oblique locking calcar screws. Cement augmentation did not improve maintenance of reduction. Krappinger et al.56 pointed out the relevance of preoperative assessment of local bone mineral density. Local bone mineral density, restoration of the medial column, nonanatomic reduction, and age were significant predictors of fixation failure (p < 0.01). Osteosynthesis of osteoporotic fractures with non-reconstructable comminution of the medial column is prone to failure. Gardner et al.57 restored mechanical integrity of the medial column using a segment of fibula allograft, which was placed endosteally and incorporated into the locking plate construct. Clinical and radiographic
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TABLE I Factors Influencing the Outcome of Open Reduction and Locking Plate Osteosynthesis Prognostic Factor
Variable
Authors 56
54
Increase in age
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Hardeman et al.
Decrease in local bone mineral density
Increase in failure rate
Krappinger et al.
56
51
54
Increase in initial fracture displacement and complexity
Decrease in functional outcome
S¨udkamp et al. , Hardeman et al.
Increase in initial varus deformity
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Gardner et al. , 54 Hardeman et al.
Decrease in quality of reduction
Increase in failure rate and decrease in functional outcome
Krappinger et al. , Hardeman et al.
Decrease in restoration of medial support
Increase in failure rate and loss of reduction
Gardner et al. , Krappinger et al.
Decrease in head fragment vascularity
Decrease in functional outcome
Bastian and Hertel , Hardeman et al.
results after a minimum follow-up of forty-nine weeks were promising58. The mean Constant score reached 87 points. Loss of reduction (varus collapse) occurred in only one patient. All fractures united. Polyaxial locking plates did not prove clinical superiority compared with monoaxial locking systems59. Figure 5 illustrates a clinical case of treatment with locking plate osteosynthesis.
56
55
56
54
55
56
74
54
peak stresses at the bone-implant interface and allow impaction62. Several elastic (dynamic) fixation methods (e.g., the Resch Humerusblock with modifications, tubular steel plate fixation
Complications of Locking Plate Osteosynthesis A multicenter study encountered complications in fifty-two (34%) of 155 patients within twelve postoperative months51. Notably, twenty-five (48%) of fifty-two complications were caused by a suboptimal surgical technique. Intraoperative screw perforation of the humeral head was observed in twenty-one (14%) of 155 patients as the most common complication. Almost one-fifth of patients had to undergo revision surgery. Zhu et al.44 reported screw penetration of the articular surface as the most frequent complication leading to revision surgery in five (19%) of twentysix cases within three postoperative months. A systematic review (n = 514) described an overall complication rate of 48.8%, including a revision rate of 13.8%53. Varus malunion was observed in 16.3% of cases, osteonecrosis in 10.8%, intra-articular screw perforation in 7.5%, subacromial impingement in 4.8%, infection in 3.5%, nonunion in 3.4%, and miscellaneous complications in 2.5%. In a comparative clinical trial, augmentation with calcium phosphate cement significantly decreased (p = 0.02) displacement and intra-articular screw penetration in fractures with metaphyseal comminution60. However, little knowledge exists regarding its influence on fracture-healing and long-term implications in general. Osteosynthesis in Patients with Osteoporosis Osteoporosis promotes fragmentation and implant displacement after osteosynthesis56. Fixing osteoporotic bone with stronger and stiffer implants (e.g., locking plates) may aggravate this problem. The so-called mixer describes a relative motion of rigid implants (e.g., locking screws) against the epiphyseal (head) segment and may cause its excavation or destruction61. On the contrary, implants with low stiffness and elastic characteristics minimize the
Fig. 5
Radiographs showing a fifty-two-year-old man who had undergone locking plate osteosynthesis. Upper left and right panels: Valgus-impacted threepart fracture with greater tuberosity displacement. Lower left and right panels: Follow-up radiographs show anatomic healing ten months after locking plate osteosynthesis (PHILOS plate; Synthes, Zuchwil, Switzerland).
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Fig. 6
Radiographs showing a seventy-eight-year-old woman who had undergone primary hemiarthroplasty. Upper panel: Osteoporotic four-part fracture with posteromedial displacement is seen on CT images. Both tuberosities exhibited sufficient bone substance to enable metaphyseal healing and the rotator cuff was intact. Lower panel: Follow-up radiographs at eight months show anatomic healing of both tuberosities and centering of the prosthetic humeral head (Epoca Shoulder Arthroplasty System; Synthes, Zuchwil, Switzerland). Both tuberosities were anatomically fixed with a circumferential multifilament cable cerclage (Tubercable; Synthes, Zuchwil, Switzerland).
combined with suture cerclage of both tuberosities, isolated suture fixation, tension banding) have been reported for osteoporotic fracture treatment8,61,63. Hertel61 emphasized the importance of anatomic reduction (medial column, tuberosities) and recognized metaphyseal buttressing as the key element of load-sharing fixation. However, concepts of strengthening the weaker bone appear promising. Locking plate osteosynthesis of osteoporotic four-part fractures combined with autologous iliac bone impaction grafting achieved excellent clinical and radiographic results in twenty-one patients64. To date, to our knowledge, no clinical reports exist on the use of growth factors for the treatment of proximal humeral fractures. Polymethylmethacrylate (PMMA) cement augmentation of cannulated screws significantly enhanced (p < 0.05) implant anchorage in humeral head specimens of human cadavers65.
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Primary Hemiarthroplasty Primary hemiarthroplasty may solve complex fracture situations, where adequate reduction and fixation cannot be achieved. Possible indications are a short (
