G Model
JINJ-5748; No. of Pages 2 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Proximal humerus fractures: Is there more than one way to skin a cat?
Descriptions of the assessment and treatment of patients with proximal humerus fractures date back to antiquity. Ever since caregivers have been pursuing the most effective means of treatment for these potentially life altering injuries. Over time treatment practices have ranged from closed reduction with various traction contraptions and prolonged immobilization with straps, splints, casts and portable traction devices. Eventually closed reductions and re-approximation of the fracture fragments and immobilization gave way to open reduction and internal fixation, multi-locking intramedullary nails and shoulder replacement [1]. Early on, before radiographs were available, these fractures were diagnosed and their treatment was based on an appreciation of surface anatomy, pain patterns and palpable crepitus. A primarily descriptive classification scheme for these injuries was proposed several decades ago and has been subsequently modified as our understanding of these injuries has advanced. Nearly every orthopaedic resident, despite it not being particularly helpful in guiding treatment nor predicting outcomes, memorizes this latest classification scheme. In fact, not only doesn’t this classification scheme aid the physician nor the patient, its been shown to have a poor interobserver reliability and unreliable reproducible. Along with fractures of the distal radius and hip, proximal humerus fractures are one of the most common osteoporosis related fractures occurring in the older population. The frequency of proximal humerus fractures in these often-fragile patients has been estimated to be between 63 and 105 per 100,000 population per year. By some estimates these fractures account for approximately 5% of all fractures of the appendicular skeleton. Unfortunately, the prevalence of this injury is increasing exponentially with the ageing of the world’s population and the incidence is expected to nearly triple over the next 30 years. A dramatic increase in these types of fractures is expected to occur primarily in ageing women and mirrors the osteoporosis tsunami that many countries are experiencing [2]. Fortunately, the vast majority of these fractures represent nondisplaced or minimally displaced fractures, which often can be managed with short-term immobilization and early range of motion. For the more displaced fractures treatment options are many including ORIF with a variety of implants including conventional plates and screws. Although, well-planned and well-executed ORIF in the right patient often resulted in positive outcomes, many of these efforts were associated with impressive failures and complications, including nonunion, fixation failure, avascular necrosis and shoulder pain and stiffness. As a result of these less than optimal outcomes, proximal replacements quickly
became a common means of treating these more displaced fractures, particularly in the older patient with associated osteoporosis. More recently, plates with locking capabilities have been used to treat these stubborn fractures. These implants, when used well, appeared to have improved post-operative outcomes. Unfortunately, avascular necrosis, nonunion, implant failure, and penetration of the shoulder joint with the implants and shoulder stiffness still occur with disappointing regularity. Intramedullary humeral nails, which were generally reserved for the treatment of humeral shaft fractures, have been modified (shortened, increased number of proximal locking options) and are being advocated for use in the treatment some of these fractures, with some promising results. In many centres hemi shoulder arthroplasty and total shoulder arthroplasty have been advocated for the treatment of these fractures, particularly in older patients. More recently reverse total shoulder arthroplasty, where the ball (‘‘glenosphere’’) is attached to the glenoid, and a ‘‘socket’’ is inserted into the humerus, has been used for the treatment of these difficult fractures. These prostheses have also shown great promise in the treatment of patients with rotator cuff arthropathy and osteoarthritis [3]. The treatment of proximal humerus fractures is a hot topic, a recent non-exhaustive search of the medical literature available resulted in no less than 800 publications, many of which were published in Injury, addressing various issues related to proximal humerus fractures. Consequently, during this same period of time there has been a large increase in the number of articles published addressing the pathophysiology, prevention and treatment of osteoporosis as well. It appears as goes osteoporosis so goes fragility fractures of the proximal humerus. C. Michael Robison in his chapter on Proximal Humerus Fractures in R&G aptly stated; ‘‘More ink than blood may have been spilt in the debate over these injuries, and their discussion in the orthopaedic literature is disproportionate to their prevalence’’ [4]. Call to action: in light of all of this it appears that the development of an evidence based clinical protocol for the treatment of proximal humerus fractures is long overdue. Creating such a protocol will require a thoughtful, all-inclusive, randomized multicenter trial, with adequate numbers of eligible patients to allow a comparison of the various treatment options. With the rapid changes in treatment of these injuries over the past 10 years simply churning the available, typically level IV evidence, to produce yet another meta-analysis on the subject, will fail to advance the treatment of these fractures. Without an evidence based protocol surgeons will continue to treat these patients based on opinion, personal experience and preferences as opposed to
http://dx.doi.org/10.1016/j.injury.2014.05.017 0020–1383/ß 2014 Published by Elsevier Ltd.
Please cite this article in press as: Proximal humerus fractures: Is there more than one way to skin a cat?. Injury (2014), http:// dx.doi.org/10.1016/j.injury.2014.05.017
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JINJ-5748; No. of Pages 2 2
Editorial / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
objective evidence. It is high time that a well controlled and adequately powered trial be undertaken, along the lines of the Lower Extremity Assessment Project (LEAP), Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) and the Multicenter Orthopaedic Outcomes Network (MOON) to determine the best treatment for these injuries. Doing so will once and for all define the most effective treatment for proximal humerus fractures and better serve our patients. Failure to do so will continue to promote this fragmented, and in many cases unsatisfactory means of approaching this common fracture [5–8]. References [1] Handoll HH, Ollivere BJ. Interventions for treating proximal humerus fractures in adults. Cochrane Database Syst Rev 2010;8:CD000434. [2] CourtBrown CM, Crag A, McQueen MM. The epidemiology of proximal humerus fractures. Acta Orthop Scand 2001;72:365–71.
[3] Gomberawalla MM, Miller BS, Coale RM, Bedi A, Gagnier JJ. Meta-analysis of joint preservation versus arthroplasty for the treatment of displaced 3- and 4-part 185 fractures of the proximal humerus. Injury 2013;44(November (11)):1532–9. http://dx.doi.org/10.1016/j.injury.2013.03.030 [Epub 9 May 2013]. [4] Michael Robison C. In: Bucholz RW, Heckman JD, Court-Brown C, editors. Fractures of the Proximal Humerus. Rockwood and Green’s fractures in adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. [5] http://www.niams.nih.gov/News_and_Events/Spotlight_on_Research/2013/ acl_reconstruction.asp. [6] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002;347(December (24)): 1924–31. [7] MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am 2004;86A(August (8)):1636–45. [8] Schemitsch EH, Bhandari M, Guyatt G, Sanders DW, Swiontkowski M, Tornetta P, et al. Study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) investigators. J Bone Joint Surg Am 2012;94(October (19)):1786–93.
Please cite this article in press as: Proximal humerus fractures: Is there more than one way to skin a cat?. Injury (2014), http:// dx.doi.org/10.1016/j.injury.2014.05.017
JINJ-5748; No. of Pages 2 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Editorial
Proximal humerus fractures: Is there more than one way to skin a cat?
Descriptions of the assessment and treatment of patients with proximal humerus fractures date back to antiquity. Ever since caregivers have been pursuing the most effective means of treatment for these potentially life altering injuries. Over time treatment practices have ranged from closed reduction with various traction contraptions and prolonged immobilization with straps, splints, casts and portable traction devices. Eventually closed reductions and re-approximation of the fracture fragments and immobilization gave way to open reduction and internal fixation, multi-locking intramedullary nails and shoulder replacement [1]. Early on, before radiographs were available, these fractures were diagnosed and their treatment was based on an appreciation of surface anatomy, pain patterns and palpable crepitus. A primarily descriptive classification scheme for these injuries was proposed several decades ago and has been subsequently modified as our understanding of these injuries has advanced. Nearly every orthopaedic resident, despite it not being particularly helpful in guiding treatment nor predicting outcomes, memorizes this latest classification scheme. In fact, not only doesn’t this classification scheme aid the physician nor the patient, its been shown to have a poor interobserver reliability and unreliable reproducible. Along with fractures of the distal radius and hip, proximal humerus fractures are one of the most common osteoporosis related fractures occurring in the older population. The frequency of proximal humerus fractures in these often-fragile patients has been estimated to be between 63 and 105 per 100,000 population per year. By some estimates these fractures account for approximately 5% of all fractures of the appendicular skeleton. Unfortunately, the prevalence of this injury is increasing exponentially with the ageing of the world’s population and the incidence is expected to nearly triple over the next 30 years. A dramatic increase in these types of fractures is expected to occur primarily in ageing women and mirrors the osteoporosis tsunami that many countries are experiencing [2]. Fortunately, the vast majority of these fractures represent nondisplaced or minimally displaced fractures, which often can be managed with short-term immobilization and early range of motion. For the more displaced fractures treatment options are many including ORIF with a variety of implants including conventional plates and screws. Although, well-planned and well-executed ORIF in the right patient often resulted in positive outcomes, many of these efforts were associated with impressive failures and complications, including nonunion, fixation failure, avascular necrosis and shoulder pain and stiffness. As a result of these less than optimal outcomes, proximal replacements quickly
became a common means of treating these more displaced fractures, particularly in the older patient with associated osteoporosis. More recently, plates with locking capabilities have been used to treat these stubborn fractures. These implants, when used well, appeared to have improved post-operative outcomes. Unfortunately, avascular necrosis, nonunion, implant failure, and penetration of the shoulder joint with the implants and shoulder stiffness still occur with disappointing regularity. Intramedullary humeral nails, which were generally reserved for the treatment of humeral shaft fractures, have been modified (shortened, increased number of proximal locking options) and are being advocated for use in the treatment some of these fractures, with some promising results. In many centres hemi shoulder arthroplasty and total shoulder arthroplasty have been advocated for the treatment of these fractures, particularly in older patients. More recently reverse total shoulder arthroplasty, where the ball (‘‘glenosphere’’) is attached to the glenoid, and a ‘‘socket’’ is inserted into the humerus, has been used for the treatment of these difficult fractures. These prostheses have also shown great promise in the treatment of patients with rotator cuff arthropathy and osteoarthritis [3]. The treatment of proximal humerus fractures is a hot topic, a recent non-exhaustive search of the medical literature available resulted in no less than 800 publications, many of which were published in Injury, addressing various issues related to proximal humerus fractures. Consequently, during this same period of time there has been a large increase in the number of articles published addressing the pathophysiology, prevention and treatment of osteoporosis as well. It appears as goes osteoporosis so goes fragility fractures of the proximal humerus. C. Michael Robison in his chapter on Proximal Humerus Fractures in R&G aptly stated; ‘‘More ink than blood may have been spilt in the debate over these injuries, and their discussion in the orthopaedic literature is disproportionate to their prevalence’’ [4]. Call to action: in light of all of this it appears that the development of an evidence based clinical protocol for the treatment of proximal humerus fractures is long overdue. Creating such a protocol will require a thoughtful, all-inclusive, randomized multicenter trial, with adequate numbers of eligible patients to allow a comparison of the various treatment options. With the rapid changes in treatment of these injuries over the past 10 years simply churning the available, typically level IV evidence, to produce yet another meta-analysis on the subject, will fail to advance the treatment of these fractures. Without an evidence based protocol surgeons will continue to treat these patients based on opinion, personal experience and preferences as opposed to
http://dx.doi.org/10.1016/j.injury.2014.05.017 0020–1383/ß 2014 Published by Elsevier Ltd.
Please cite this article in press as: Proximal humerus fractures: Is there more than one way to skin a cat?. Injury (2014), http:// dx.doi.org/10.1016/j.injury.2014.05.017
G Model
JINJ-5748; No. of Pages 2 2
Editorial / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
objective evidence. It is high time that a well controlled and adequately powered trial be undertaken, along the lines of the Lower Extremity Assessment Project (LEAP), Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) and the Multicenter Orthopaedic Outcomes Network (MOON) to determine the best treatment for these injuries. Doing so will once and for all define the most effective treatment for proximal humerus fractures and better serve our patients. Failure to do so will continue to promote this fragmented, and in many cases unsatisfactory means of approaching this common fracture [5–8]. References [1] Handoll HH, Ollivere BJ. Interventions for treating proximal humerus fractures in adults. Cochrane Database Syst Rev 2010;8:CD000434. [2] CourtBrown CM, Crag A, McQueen MM. The epidemiology of proximal humerus fractures. Acta Orthop Scand 2001;72:365–71.
[3] Gomberawalla MM, Miller BS, Coale RM, Bedi A, Gagnier JJ. Meta-analysis of joint preservation versus arthroplasty for the treatment of displaced 3- and 4-part 185 fractures of the proximal humerus. Injury 2013;44(November (11)):1532–9. http://dx.doi.org/10.1016/j.injury.2013.03.030 [Epub 9 May 2013]. [4] Michael Robison C. In: Bucholz RW, Heckman JD, Court-Brown C, editors. Fractures of the Proximal Humerus. Rockwood and Green’s fractures in adults. 6th ed., Philadelphia: Lippincott Williams & Wilkins; 2006. [5] http://www.niams.nih.gov/News_and_Events/Spotlight_on_Research/2013/ acl_reconstruction.asp. [6] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002;347(December (24)): 1924–31. [7] MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am 2004;86A(August (8)):1636–45. [8] Schemitsch EH, Bhandari M, Guyatt G, Sanders DW, Swiontkowski M, Tornetta P, et al. Study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures (SPRINT) investigators. J Bone Joint Surg Am 2012;94(October (19)):1786–93.
Please cite this article in press as: Proximal humerus fractures: Is there more than one way to skin a cat?. Injury (2014), http:// dx.doi.org/10.1016/j.injury.2014.05.017
