a report by

Pierre J Hoffmeyer

Professor and Chairman, Department of Orthopaedic Surgery, University Hospitals of Geneva

Displaced proximal humerus fractures are on the rise and, in many

cases, are still the source of painful loss of function if not adequately

treated. Many treatment options exist depending on the fracture

pattern, the bone stock and the vascular status of the fractured

fragments. Recently, many fixation techniques using various implants

have been introduced; some implants have been successful, others less

so. The indications for the newer plates with locking screws or locked

nails have yet to be evaluated. Arthroplasty remains a useful option

when the fracture is not reconstructible due to extensive comminution

or inadequate osteoporotic bone. Whether the fracture is

reconstructed or a prosthesis inserted, the rehabilitation protocol is a

very important part of the treatment plan and must be strictly adhered

to if good results are to be expected.

Introduction

Displaced fractures of the proximal humerus are frequent articular injuries

that are a source of pain, functional loss and disability. These articular

fractures are complex injuries involving the glenohumeral space, the

subacromial space, the rotator cuff and the capsule. Furthermore,

adjacent neurological and vascular structures are also at risk when these

fractures occur.

Definition of ‘Displaced’

A fracture is said to be displaced when the morphologic disruption of the

fragments hampers normally smooth and painless articular function. This

concerns about 20% of all proximal humerus fractures. In the past,

authors have used measurements (1cm translation and/or 45° angular

displacement) to define the fragment displacement necessary for surgical

intervention.1 Today, any displacement presumably leading to poor

function may qualify for surgical fixation. However, surgical indication is

obviously not related solely to fracture displacement and must be

associated with patient expectations and activity.

Pathophysiology

These fractures are essentially related to osteoporosis, which accounts for

many of the difficulties encountered when performing internal fixation.2,3

This signifies that the bone fragments will be of a low mineral content and

that the holding power of the implants will be compromised. This implies

using techniques or implants designed for fragility fractures. The

vascularisation of the proximal humerus is of a terminal type, similar to

other epiphyses such as the femoral head or talus. The main sources of

blood supply are the anterior circumflex and posterior circumflex arteries,

the vessels of the rotator cuff and the intraosseous metaphyseal artery. If

the main nutrient arteries to the humeral head are interrupted, avascular

necrosis with subsequent collapse of the articular surface will occur.4 Neer

has contributed to establishing an estimation of prognosis with the

fragment classification of proximal humeral fractures, which other authors

have refined.5 Other factors affecting outcome are the complexity of the

surgical approach, the obligatory use of indirect reduction techniques

because the articular surfaces cannot be visualised intra-operatively and

the lack of perfect fixation techniques. Once the purely surgical hurdles

have been passed, there remains the rehabilitative process, which is also a

cause for controversy. All these problems have led some authors to refer

to this fracture as being still ‘unsolved’.6

Imaging

Accurate imaging is mandatory for precise classification, a strategically

essential step for establishing the operative tactics. Strict anteroposterior

(AP) and axillary views with a clear view of the glenohumeral space will

show fragment displacement, allowing pre-operative planning. Spiral

3-D computed tomography (CT) scanning is an ideal imaging modality

showing from all perspectives the exact relationships and positions

between all involved fragments. Surgical planning is enhanced by these

techniques and hopefully a better outcome will be achieved in these

difficult injuries.

Patient Positioning for the Intervention

In most cases the patient is operated on in a beach chair position under

a general anaesthetic and the question arises as to whether an

interscalene bloc is indicated. This is only possible after a careful

neurological examination has ruled out any pre-existing neurological

Surgical Management of Displaced Fractures of the Proximal Humerus

© T O U C H B R I E F I N G S 2 0 0 7

Pierre J Hoffmeyer is Professor of Orthopaedics, Head of theOrthopaedic and Trauma Service and Chairman of theDepartment of Surgery of the University Hospital of Geneva,Switzerland. He is a member of many national andinternational societies, including the European Shoulder andElbow Society, and is active in the Swiss Association forOsteosynthesis. Professor Hoffmeyer is the author of over200 scientific publications and book chapters. He wastrained in Geneva, Vancouver and Rochester, MN.

Orthopaedic Surgery Shoulder

78

In case of an isolated greater

tuberosity fracture or an impacted

three fragment necessitating little

reduction a deltoid split rotator cuff

approach can be performed.

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Surgical Management of Displaced Fractures of the Proximal Humerus

injury; in cases of doubt one should abstain and use other antalgic

modalities, including patient-controlled antalgia pumps and the generous

use of ice applications (see Figure 1).

Surgical Approaches

As a rule, when reduction manoeuvres must be undertaken it is safest

to use an extensile delto-pectoral approach and the axillary may be

palpated as it lies anteriorly to the subscapularis muscle. The individual

tendons and fragments are then carefully identified using the biceps

tendon as a marker. The tuberosity fragments can then be reduced

around the head. In case of an isolated greater tuberosity fracture or an

impacted three fragment necessitating little reduction a deltoid split

rotator cuff approach can be performed. For intramedullary nailing a

small incision made superiorly over the greater tuberosity may be

sufficient. Very rarely, in cases of an associated posterior dislocation, a

posterior incision might be necessary. In any case the use of an image

intensifier is useful for evaluating fracture reduction.3

Fixation Modalities

Osteosynthesis

See Figure 2. In certain situations, such as two-part fractures at the

surgical neck in strong bone, a standard plate and screw fixation may

be sufficient. With weaker bone, the newer locking plates afford

excellent stability.7 Displaced fractures of the greater tuberosity are

adequately fixed with heavy non-resorbable sutures; displaced lesser

tuberosity fractures are better fixed with isolated compression screws.

Strong fixation will allow stable fixation and immediate mobilisation

of the shoulder.

Osteosuture

See Figure 3. In case of a three-fragment fracture or a four-fragment

valgus-impacted fracture in a patient with porotic or soft bone, it may be

useful to proceed with a supple fixation involving steel wire or heavy non-

resorbable suture.8 The sutures are passed through the bony fragments

at the tendon–bone interface of each main tendon. These are tied around

a screw and washer inserted distally to the fracture into the metaphysis

after the main cephalic fragment has been reduced with a K-wire

manoeuvred as a joystick. In this situation, locking plates can be used to

buttress the fragments. However, care must be taken not to use screws

that are too long in the cephalic fragment with the danger of over-

penetration and breaching into the articular space. The advantage of this

technique is the solid fixation obtained allowing immediate post-

operative mobilisation.

Intramedullary Nailing

See Figure 4. Some authors have advocated the use of closed techniques

such as locked intramedullary nailing to obtain an acceptable reduction

and an adequate fixation of the fracture fragments.9 Further evaluation

of these techniques, applied to articular fractures, is still needed.

Fascicular Pinning

See Figure 5. In an effort to minimise the surgical approach, some

authors advocate the use of multiple percutaneous K-wires. This

necessitates accurate reduction, which can be obtained with

percutaneous joystick manoeuvring. This is a demanding technique and

it is not really possible to mobilise the shoulder before sufficient bony

healing has taken place.

Arthroplasty

See Figure 6. In cases of comminuted, displaced four-fragment fractures

in weak bone or if a dislocation has completely detached the cephalic

fragment, arthroplasty is indicated. The surgical difficulties include

obtaining adequate prosthetic head height, suitable torsion or strong

tuberosity fixation. For the head height, a pre-operative plan using the

contra-lateral shoulder as a model can be useful. Concerning prosthetic

retro-torsion, it is imperative that in a resting position the humeral head

Figure 1: A – Patient Under General Anesthetic in Semi-sittingPosition with a Head Rest Allowing Adequate Exposure of theShoulder and Thoracic Quadrant; B – Note the ExtensiveEcchymosis Following the Fracture Dislocation

Figure 2: A – Impacted Three-part Fracture; B – 3-DReconstruction; C – Osteosynthesis Using Locking Plate withSutures Securing the Cuff to the Plate; D – Post-op X-ray

Figure 3: A – Three-part Fracture; B – OsteosutureReconstruction; C – One-year X-Ray Result

A

A B

BA C

B

C D

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Orthopaedic Surgery Shoulder

squarely faces the glenoid. For the tuberosity fixation, no real solutions

have yet come up. Some authors advocate a thin prosthetic base, which

allows the impaction of spongiosa bone graft, taken from the excised

humeral head, between the stem and the tuberosities. Other authors

advocate large bases around which the tuberosities can be more securely

fixed. All authors agree on the importance of this fixation as bony union

of the tuberosities is the key for success. Because of the difficulties in

obtaining this fixation some authors have recommended using a reverse

prosthesis in this situation. This last option still needs further evaluation.

Rehabilitation

After surgery the upper extremity is placed in a sling for six weeks and

hand and wrist mobility exercises are encouraged immediately in all

cases. If a satisfactory fixation has been obtained at surgery, then early

shoulder mobilisation exercises are important for the first six weeks,

essentially passive at first and then followed by active motion with a

goal to muscle strengthening. An early rehabilitation programme in a

swimming pool with physiotherapy supervision is also recommended.

In the case of arthroplasty, obtaining tuberosity union is key, but

because tuberosity fixation is usually not rigid, it may be prudent to

protect the construct in a sling, allowing only minimal motion for

hygiene purposes for the first six weeks. Thereafter, and upon X-ray

and clinical evaluation, a more aggressive rehabilitation programme

may be undertaken.

Conclusion

Displaced proximal humerus fractures are on the rise and, in many cases,

are still a source of painful loss of function if not adequately treated.

These fractures always involve the articular space, whether

glenohumeral or subacromial. Once the indication for operative

treatment has been ascertained it remains to choose between the many

surgical options available. This will depend on the patient’s expectations

and their overall medical condition. Locally, the fracture pattern, the

bone stock and the vascular status of the fractured fragments all play a

role in the choice of the treatment method. Some authors have

advocated arthroscopic techniques to aid in visualisation.10 Recently,

many fixation techniques using various implants have been introduced;

some implants have been successful, others less so.6,11–13 The results of

the newer plates with locking screws or of the locked nails have yet to

be evaluated.7,9 Arthroplasty remains a useful last-ditch option when the

fracture is not reconstructible due to extensive comminution or

inadequate osteoporotic bone. Whether the fracture is reconstructed or

a prosthesis inserted, the rehabilitation protocol is an extremely

important part of the treatment plan and must be strictly adhered to if

good results are to be obtained.14 ■

1. Neer CS, Four-segment classification of proximal humeralfractures: purpose and reliable use, J Shoulder Elbow Surg,2002;11:389–400.

2. Court-Brown CM, Caesar B, Epidemiology of adult fractures:a review, Injury, 2006;37:691–7.

3. Hoffmeyer P, The operative management of displacedfractures of the proximal humerus, J Bone Joint Surg Br,2002;84:469–80.

4. Sanchez-Sotelo J, Proximal humerus fractures, Clin Anat,2006;19:588–98.

5. Hertel R, Fractures of the proximal humerus in osteoporoticbone, Osteoporos Int, 2005;16:S65–72.

6. Kollig E, Kutscha-Lissberg F, Roetman B, et al., PrimäreHemiprothetik nach komplexem Oberarmkopfbruch –Funktionelle Spätergebnisse, Zentralbl Chir, 2003;128:125–30.

7. Bjorkenheim JM, Pajarinen J, Savolainen V, Internal fixationof proximal humeral fractures with a locking compressionplate: a retrospective evaluation of 72 patients followed fora minimum of 1 year, Acta Orthop Scand, 2004;75:741–5.

8. Hawkins RJ, Bell RH, Gurr K, The three-part fracture of theproximal part of the humerus. Operative treatment, J BoneJoint Surg Am, 1986;68:1410–14.

9. Cuny C, Darbelley L, Touchard O, et al.,Fractures à quatrefragments de l’humérus proximal traitées par enclouageléger antérograde à vis autostables. A propos de 31 cas, RevChir Orthop Reparatrice Appar Mot, 2003;89:507–14.

10. Dawson FA, Four-part fracture dislocation of the proximalhumerus: an arthroscopic approach, Arthroscopy, 2003;19:662–6.

11. Gorschewsky O, Puetz A, Klakow A, et al., The treatment of

proximal humeral fractures with intramedullary titaniumhelix wire by 97 patients, Arch Orthop Trauma Surg,2005;125:670–75.

12. Neer CS, Displaced proximal humeral fractures. II. Treatmentof three-part and four-part displacement, J Bone Joint Surg Am,1970;52:1090–103.

13. Sadowski C, et al., Fixation of fractures of the proximalhumerus with the PlantTan Humerus Fixator Plate: earlyexperience with a new implant, J Shoulder Elbow Surg,2003;12:148–51.

14. Lubbeke A, Stern R, Grab B, et al., Upper extremity fracturesin the elderly: consequences on utilization of rehabilitationcare, Aging Clin Exp Res, 2005;17:276–80.

Figure 4: A – Osteoporotic Fracture; B – Treatment with LockedIM Mailing

Figure 6: A – Four-part Fracture Dislocation in an Elderly Patient;B – Prosthesis with Graft Impaction*; C – X-ray Result

Figure 5: A – Fracture Dislocation in a Young Patient; B – ClosedPinning; C – Result

A

A

C

C

B

B

A B

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