Fractures of the proximal humerus

Current Opinion in Orthopaedics

Volumn 14, Issue 4, 2003, Pages 269-280

  Reid, J Spence ^a  

^a PENN STATE MILTON S HERSHEY MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BONE CEMENT; CALCIUM PHOSPHATE; POLY(METHYL METHACRYLATE);

ALGORITHM; ARM FRACTURE; ARM MOVEMENT; ARTHROPLASTY; AVASCULAR NECROSIS; BONE PLATE; BONE STRENGTH; CLINICAL PROTOCOL; CONSERVATIVE TREATMENT; FLUOROSCOPY; FRACTURE FIXATION; FRACTURE NONUNION; FRACTURE TREATMENT; HUMAN; HUMERUS FRACTURE; HUMERUS HEAD; INCIDENCE; INTRAMEDULLARY NAILING; KIRSCHNER WIRE; MUSCLE ISOMETRIC CONTRACTION; MUSCLE STRENGTH; ORTHOPEDIC SURGERY; OSTEOSYNTHESIS; PERCUTANEOUS PIN FIXATION; POSTOPERATIVE CARE; PRIORITY JOURNAL; REHABILITATION MEDICINE; REVIEW; SUTURE; TENSION BAND WIRING; THREE DIMENSIONAL IMAGING; TREATMENT INDICATION; TREATMENT OUTCOME;

EID: 0043269730     PISSN: 10419918     EISSN: None     Source Type: Journal    
DOI: 10.1097/00001433-200308000-00010     Document Type: Review

References (54)

1. Court-Brown CM, Garg A, McQueen MM: The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001, 72:365-371.
2. Kannus P, Palvanen M, Niemi S, et al.: Osteoporotic fractures of the proximal humerus in elderly Finnish persons: sharp increase in 1970-1998 and alarming projections for the new millennium. Acta Orthop Scand 2000, 71:465-470.
3. Lee SH, Dargent-Molina P, Breart G, et al.: Risk factors for fractures of the proximal humerus: results from the EPIDOS prospective study. J Bone Miner Res 2002, 17:817-825. This report is part of the larger osteoporotic fracture study (EPIDOS, Epidemiologie de l'Osteoporose Study) conducted in France from 1992 to 1998. The subjects were 6901 white women older than 75 years enrolled as a cohort in five French regions. These authors identified two factors that related to the risk of incurring a proximal humerus fracture: bone fragility and falls. In the multivariate analysis, three bone fragility indicators were found to be significant: BMD, calcaneal ultrasound speed of sound, and maternal history of hip fracture. Four fall-related factors were found to be significant: history of falls, physical activity score, balance score, and presence of foot pain. Fall-related factors were significantly associated with humeral fractures only in women with low BMD. Women with a low BMD and high fall risk score were twice as likely (12.1 per 1000 woman-years) to sustain a proximal humerus fracture than women with either one or no risk factors. These results suggest that women who have both types of risk factors should have the highest priority for prevention.
4. Neer CS II: Displaced proximal humeral fractures, I: classification and evaluation. J Bone Joint Surg Am 1970, 52:1077-1089.
5. Bernstein J, Adler LM, Blank JE, et al.: Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am 1996, 78:1371-1375.
6. Neer CS II: Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg 2002, 11:389-400. This review article is an excellent overview of the 30-year history of the Neer classification and its use in guiding treatment of proximal humerus fractures. The problem of intraobserver reliability and interobserver reproducibility of this classification system is directly addressed. The author reminds us that this classification system was never intended to rely only on the radiographs to assign a fracture type. Rather, it was intended that in unclear cases, the intraoperative findings would be an adjunct to confirm the fracture classification. The validity of the four-part system remains intact in that each category has its own natural history, prognosis, and treatment requirement. Neer reviews and updates his treatment recommendations for each fracture classification.
7. Muller ME, Nazarian S, Koch P, et al.: The Comprehensive Classification of Fractures of Long Bones. Berlin: Springer-Verlag; 1990.
8. 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, 84:504-508. This article describes a very common type of proximal humerus fracture occurring in fit elderly subjects. This fracture is unique to the AO classification and is distinct from the three-part fracture in the Neer classification in that the humeral head component is not rotated. These authors retrospectively evaluated 125 patients treated without surgery and followed for 1 year. Good or excellent results were documented in 80.6% of patients and depended on the age of the patient and displacement of the fracture. These authors suggested that this common fracture does not require surgical treatment.
9. Sjoden GO, Movin T, Guntner P, et al.: Poor reproducibility of classification of proximal humeral fractures: additional CT of minor value. Acta Orthop Scand 1997, 68:239-242.
10. Kristiansen B, Christensen S: Fractures of the proximal end of the humerus caused by convulsive seizures. Injury 1984, 16:108-109.
11. Hoffmeyer P: The operative management of displaced fractures of the proximal humerus. J Bone Joint Surg Br 2002, 84:469-480. This succinct review article originally appeared in the European Instructional Course Lectures in 1991.
12. Cofield RH: Comminuted fractures of the proximal humerus. Clin Orthop 1988, (230):49-57.
13. Brems JJ: Shoulder arthroplasty in the face of acute fracture: puzzle pieces. J Arthroplasty 2002, 17(suppl 1):32-35. Excellent practical review of the problems and pitfalls associated with shoulder hemiarthroplasty to reconstruct an acute fracture. Techniques to insure correct prosthesis positioning, rotator cuff repair, and tuberosity healing are emphasized.
14. Koval KJ, Gallagher MA, Marsicano JG, et al.: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997, 79:203-207.
15. Court-Brown CM, Garg A, McQueen MM: The translated two-part fracture of the proximal humerus: epidemiology and outcome in the older patient. J Bone Joint Surg Br 2001,83:799-804.
16. Jakob RP, Miniaci A, Anson PS, et al.: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991, 73:295-298.
17. Kristiansen B, Angermann P, Larsen TK: Functional results following fractures of the proximal humerus: a controlled clinical study comparing two periods of immobilization. Arch Orthop Trauma Surg 1989, 108:339-341.
18. Gibson JN, Handoll HH, Madhok R: Interventions for treating proximal humeral fractures in adults (Cochrane Review). In The Cochrane Library, Issue 2, 2002. Oxford: Update Software. This meta-analysis identified 10 randomized trials that met the inclusion criteria. The trials were small, and bias could not be ruled out. Trial heterogeneity prevented pooling of results. Six trials evaluated conservative treatment, three compared surgery with conservative treatment, and one compared two surgical techniques. In the studies addressing conservative treatment, there was no compelling evidence that the type of immobilization made any difference in time to fracture union and the functional result. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that mobilization at 1 week instead of 3 weeks alleviated pain in the short term without compromising long-term outcome. Two studies provided evidence that patients could monitor their own physical therapy program and achieve a satisfactory outcome if given sufficient instruction. Operative reduction improved fracture alignment but resulted in a higher complication rate than conservative treatment and a higher reoperation rate compared with hemiarthroplasty. In severe injuries, hemiarthroplasty resulted in less pain, better short-term function, and less need for help with activities of daily living compared with conservative treatment. Overall, the available randomized trails were insufficient to provide good evidence for guiding decision-making in proximal humeral fracture treatment. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long-term outcomes. There is a need for good-quality evidence for the management of these fractures.
19. Hughes M, Neer CS II: Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975, 55:850-858.
20. Neer CS II: Displaced proximal humeral fractures, II: treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970, 52:1090-1103.
21. Misra A, Kapur R, Maffulli N: Complex proximal humeral fractures in adults - a systematic review of management. Injury 2001, 32:363-372.
22. Kwon BK, Goertzen DJ, O'Brien PJ, et al.: Biomechanical evaluation of proximal humeral fracture fixation supplemented with calcium phosphate cement. J Bone Joint Surg Am 2002, 84:951-961. These authors investigated the biomechanical characteristics of three common fixation techniques for stabilizing displaced proximal humerus fractures. The cloverleaf plate, the angled blade plate, and multiple Kirschner wires were evaluated using a three-part cadaveric fracture model. This was a matched-pairs study using 18 pairs of fresh-frozen humeri in which the opposite side was stabilized with the same implant but supplemented with Skeletal Repair System calcium phosphate cement. Specimens were loaded in abduction and external rotation to evaluate interfragmentary motion and then loaded to failure in external rotation. Overall, there were no significant differences between the specimens treated with the blade plate and cloverleaf plate. The specimens treated with Kirschner wires demonstrated significantly greater interfragmentary motion than both plated specimens. Three of the six specimens fixed with Kirschner wires failed during the cyclic portion of the test. In all three modes of fixation, the torsional load to failure was significantly higher for the specimens fixed with cement than it was for those specimens fixed without cement (P=0.028). The addition of calcium phosphate cement increased the stiffness of even the most osteoporotic specimens to levels that were higher than those of the most osteodense specimens that had been treated with internal fixation alone. The mechanism of failure in the plated specimens (blade and cloverleaf) with the addition of cement was different from that of those fixed without cement. In the specimens without cement, failure occurred when the screws or blade pulled out of the cancellous bone of the humeral head. With the addition of cement, screw pullout in the humeral head was much less common, and failure occurred via plate deformation or through the diaphyseal region. The use of calcium phosphate cement may be a clinically useful adjunct to internal fixation, particularly in patients who are osteopenic.
23. Hessmann M, Baumgaertel F, Gehling H, et al.: Plate fixation of proximal humeral fractures with indirect reduction: surgical technique and results utilizing three shoulder scores. Injury 1999, 30:453-462.
24. Ebraheim N, Wong FY, Biyani A: Percutaneous pinning of the proximal humerus. Am J Orthop 1996, 25:500-501, 506.
25. Jaberg H, Warner JJ, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 1992, 74:508-515.
26. Rowles DJ, McGrory JE: Percutaneous pinning of the proximal part of the humerus: an anatomic study. J Bone Joint Surg Am 2001, 83:1695-1699.
27. Herscovici D Jr, Saunders DT, Johnson MP, et al.: Percutaneous fixation of proximal humeral fractures. Clin Orthop 2000, (375):97-104.
28. Kristiansen B: Treatment of displaced fractures of the proximal humerus: transcutaneous reduction and Hoffmann's external fixation. Injury 1989, 20:195-199.
29. Naidu SH, Bixler B, Capo JT, et al.: Percutaneous pinning of proximal humerus fractures: a biomechanical study. Orthopedics 1997, 20:1073-1076.
30. Koval KJ, Blair B, Takei R, et al.: Surgical neck fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques. J Trauma 1996, 40:778-783.
31. Chen CY, Chao EK, Tu YK, et al.: Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma 1998, 45:1039-1045.
32. Resch H, Povacz P, Frohlich R, et al.: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997, 79:295-300.
33. Hawkins RJ, Bell RH, Gurr K: The three-part fracture of the proximal part of the humerus: operative treatment. J Bone Joint Surg Am 1986, 68:1410-1414.
34. Ruch DS, Glisson RR, Marr AW, et al.: Fixation of three-part proximal humeral fractures: a biomechanical evaluation. J Orthop Trauma 2000, 14:36-40.
35. Zyto K, Ahrengart L, Sperber A, et al.: Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br 1997, 79:412-417.
36. Zingg U, Brunnschweiler D, Keller H, et al.: Percutaneous minimal osteosynthesis of fractures of the proximal humerus in elderly patients. Swiss Surg 2002, 8:11-14. This study reports the short-term results in 31 patients of a minimally invasive technique to stabilize displaced proximal humerus fractures. According to the Neer classification, there were 10 two-part, 15 three-part, and six four-part fractures. The mean age of the patients was 72 years, and the follow-up period averaged 15.8 months (range, 9-31 months). The technique involved closed reduction under fluoroscopic visualization with retrograde placement of terminally threaded Kirschner wires to stabilize the head fragment to the shaft. In the three-part and four-part fractures, the fixation of the tuberosities was accomplished with cannulated screws in 17 patients, additional k-wires in three patients, and tension band wiring in one patient. To assess the functional and subjective results, the Constant score and an adapted version of the Oxford Shoulder Score were used. There were no local complications such as hematomas or wound infections. The function of the injured arm was compared with the uninjured arm by Constant score, and an average functionality of 82.6% was assigned to the injury. All fractures but one healed fully, and there was one case of avascular necrosis with humeral head collapse. The subjective results were very good in 18 patients, good in seven, satisfying in three, and poor in three patients.
37. Khodadadyan-Klostermann C, Raschke M, Fontes R, et al.: Treatment of complex proximal humeral fractures with minimally invasive fixation of the humeral head combined with flexible intramedullary wire fixation - introduction of a new treatment concept. Langenbecks Arch Surg 2002, 387:153-160. This small study reports the results of a combined approach to the stabilization of three-part and four-part proximal humerus fractures. A limited deltoid splitting approach was used to reconstruct the tuberosities to the head fragment with screw or cerclage wire fixation. Retrograde intramedullary fixation with elastic nails was used to stabilize the shaft to the reconstructed head fragment. Eighteen patients with a mean age of 56 years were reviewed at an average of 16.5 months after surgery. Forty percent had an excellent result by the Neer and Constant scores. Forty-five percent had a satisfactory result and 15% an unsatisfactory result. Secondary loss of fixation was noted in five cases. Nail perforation of the humeral head was noted in four cases, requiring early implant removal within 5 to 6 weeks. Three cases of avascular necrosis of the humeral head were noted. Two of these required conversion to hemiarthroplasty. The authors recommended extending this study to a larger group and comparing it with the new generation of implants.
38. Esser RD: Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clin Orthop 1994, (299):244-251.
39. Wijgman AJ, Roolker W, Patt TW, et al.: Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002, 84:1919-1925. These authors evaluated their intermediate and long-term results for 60 patients with three-part or four-part proximal humerus fractures. Average age at time of surgery was 48 years. All fractures were surgically stabilized by either T-plate or cerclage wires within 48 hours of injury. At an average follow-up of 10 years, the Constant score and a visual analogue pain score were calculated, and radiographs were obtained of the proximal humerus. Eighty-seven percent had a good or excellent result, and 13% had a poor result. Poor results were secondary to pain or restricted motion. Ninety percent of patients were able to either return to their preinjury work level or perform activities of daily living that they had performed preinjury. Twenty-two patients (37%) developed avascular necrosis during the follow-up period. Seven of these 22 had a three-part fracture dislocation, eight had a four-part fracture dislocation, and seven had a fracture without dislocation. Seven of the 22 patients had complete humeral head collapse, and four had a good Constant score and three a poor score. Fifteen patients had partial head collapse, and 13 had a good or excellent Constant score and two a poor score. Overall, the subgroup of patients with avascular necrosis had 9% excellent, 68% good, and 23% poor results by Constant score. Sixteen of the 22 patients with avascular necrosis were satisfied with their final outcome. These authors pointed out that this study was limited because it was impossible to quantitate what was a satisfactory reduction or stable fixation during surgery. The details regarding which fractures were reconstructed with hemiarthroplasty because of difficulty with internal fixation are unknown. The clinical importance of this article is the recognition that a very satisfactory outcome can be achieved in the face of avascular necrosis. Therefore, internal fixation of even a four-part fracture dislocation in a relatively young patient is warranted.
40. Moda SK, Chadha NS, Sangwan SS, et al.: Open reduction and fixation of proximal humeral fractures and fracture-dislocations. J Bone Joint Surg Br 1990, 72:1050-1052.
41. Sehr JR, Szabo RM: Semitubular blade plate for fixation in the proximal humerus. J Orthop Trauma 1988, 2:327-332.
42. Hintermann B, Trouillier HH, Schafer D: Rigid internal fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br 2000, 82:1107-1112.
43. Mouradian WH: Displaced proximal humeral fractures: seven years' experience with a modified Zickel supracondylar device. Clin Orthop 1986, (212):209-218.
44. Lin J, Hou SM, Hang YS: Locked nailing for displaced surgical neck fractures of the humerus. J Trauma 1998, 45:1051-1057.
45. Adedapo AO, Ikpeme JO: The results of internal fixation of three- and four-part proximal humeral fractures with the Polarus nail. Injury 2001, 32:115-121.
46. Stableforth PG: Four-part fractures of the neck of the humerus. J Bone Joint Surg Br 1984, 66:104-108.
47. Zuckerman JD, Cuomo F, Koval KJ: Proximal humeral replacement for complex fractures: indications and surgical technique. Instr Course Lect 1997, 46:7-14.
48. Hartsock LA, Estes WJ, Murray CA, et al.: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998, 29:467-475.
49. Becker R, Pap G, Machner A, et al.: Strength and motion after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1-6 years. Acta Orthop Scand 2002, 73:44-49. This article evaluated 27 patients with displaced four-part fractures of the proximal humerus treated with hemiarthroplasty. The average follow-up time was 45 months (range, 12-76 months). Isometric strength measurements (Kintrex) and three-dimensional motion analysis (Elite-System) were performed on the operated and unoperated shoulders. Clinical assessment was based on the Constant score and Neer scoring system. Mean isometric adduction torque of the operative side was 73% compared with the intact side (P < 0.003). Mean isometric abduction strength was 89% compared with the intact side. Mean shoulder abduction was 89° on the operated side and 153° on the intact side (P < 0.001). Isolated glenohumeral abduction was 57° on the operative shoulder and 87° on the intact side (P < 0.001). Delay in treatment resulted in nearly linear decrease in clinical outcome. Hemiarthroplasty performed within 1 week of injury resulted in a mean Neer score of 97. After 5 to 15 weeks, the mean Neer score fell to 87, and after 20 to 36 weeks, it fell to 76. Maximal abduction of the shoulder was 117° in those patients operated on within 14 days of injury and 59° in patients operated on after 14 days (P < 0.001). Heterotopic ossification occurred in more than 50% of patients. Despite significant decreases in strength and motion, 23 of 27 patients were satisfied with the result.
50. Antuna SA, Sperling JW, Sanchez-Sotelo J, et al.: Shoulder arthroplasty for proximal humeral malunions: long-term results. J Shoulder Elbow Surg 2002, 11:122-129. These authors reported on 50 proximal humeral malunions treated with hemiarthroplasty or total shoulder replacement and followed for an average of 9 years. Patient ages ranged from 37 to 80 years. Thirteen had a four-part malunion, 24 had a three-part malunion, six had a two-part greater tuberosity malunion, and seven had a two-part surgical neck malunion. Thirty-five of 50 patients were initially treated conservatively. The mean pain scores decreased from 4.6 to 2.1 (P < 0.005). Postoperatively, 11 patients continued to have moderate to severe pain. Active elevation improved from 65° to 102° (P < 0.05). By the Neer score, 25 had an excellent or satisfactory result, and 25 had an unsatisfactory result. By the patients' own assessments, 29 shoulders were much better, 10 were better, and 11 did not improve. All shoulders with tuberosity nonunion or resorption had a poor result.
51. Siegel JA, Dines DM: Proximal humerus malunions. Orthop Clin North Am 2000, 31:35-50.
52. Beredjiklian PK, Iannotti JP: Treatment of proximal humerus fracture malunion with prosthetic arthroplasty. Instr Course Lect 1998, 47:135-140.
53. Lee CK, Hansen HR: Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures. J Trauma 1981, 21:788-791.
54. Chesser TJ, Langdon IJ, Ogilvie C, et al.: Fractures involving splitting of the humeral head. J Bone Joint Surg Br 2001, 83:423-426.