Chapter 37: Proximal Humeral Fractures

Philipp N. Streubel, Joaquin Sanchez-Sotelo, Scott P. Steinmann

Chapter Outline

Introduction

Proximal humeral fractures, defined as fractures occurring at or proximal to the surgical neck of the humerus, lead to 185,000 emergency department visits in the United States alone202 and affect 2.4% of women over the age of 75 years.233 It is the commonest fracture affecting the shoulder girdle in adults292 and its incidence is rising. Studies of approximately 50 years ago showed that proximal humeral fractures comprised 4% of all fractures and approximately one-half of all humerus fractures.182,343 The current fracture epidemiology described in Chapter 3 shows that nowadays proximal humeral fractures account for almost 7% of all fractures and make up 80% of all humeral fractures. In patients above the age of 65 years proximal humeral fractures are the second most frequent upper extremity fracture, and the third most common nonvertebral osteoporotic fracture after proximal femur and distal radius fractures, accounting for >10% of fractures in this patient population.18,19,58,233,256 This is illustrated in Tables 3-8 and 3-11
In the adult population, proximal humeral fractures have a unimodal distribution.77,202 The incidence of proximal humeral fractures fluctuates with age. Extrapolation of the data shown in Chapter 3 shows that the incidence of proximal humeral fractures in males and females aged 20 to 29 years is 7.5 and 9.1/105/year, respectively and that the incidences in the 80 to 89 years population are 390 and 512/105/year. Comparison with data from the same area 15 years earlier77 shows similar incidences in the 20- to 29-year patients but a 197% increase in the incidence of proximal humeral fractures in 80- to 89-year females. Of interest is the fact that there has been a 358% increase in the incidence of proximal humeral fractures in 80- to 89-year males suggesting that improved male health has resulted in more osteoporotic fractures. Females are more commonly affected than males and it has been demonstrated that 15% to 30% of fractures occur in males24 but it seems likely that this proportion will rise. 
The incidence has been shown to increase exponentially at a rate of over 40% every 5 years at age 40 in females and age 60 in males.202,222,343 The calculated annual incidence has been stated to be 36/105/year for males and 78/105/year for females202,247 but the 2010/11 data presented in Chapter 3 confirms that the incidence is increasing and was recorded as being 61/105/year in males and 120/105/year in females. It seems likely that the average age of patients who present with proximal humeral fractures is also rising. In 2002 the average age of patients with proximal humeral fractures was 63 years233 but Table 3-3 shows the average age to be 66 years in 2010/11. Men who present with proximal humeral fractures are on average 8 to 10 years younger than women.301 The average age of patients with displaced two-part surgical neck fractures is 72 years, and the vast majority of patients are 50 years or older.78 
As has already been pointed out proximal humerus fractures have become progressively more frequent over the past few decades. Among Finnish women 80 years of age or older the frequency of proximal humeral fractures increased from 88/105/year fractures in 1970 to 298/105/year in 2007.193 In Finnish patients aged 60 years or older, low-energy proximal humeral fractures increased from 32/105/year in 1970 to 105/105/year in 2002.308 In the United States, the number of patients presenting with proximal humeral fractures is expected to reach 275,000 by 2030.202 
The vast majority of proximal humeral fractures are treated nonoperatively.24,202,343 However, surgical treatment is becoming more frequent, with fracture reconstruction increasing at a higher rate than prosthetic replacement.24 There is a high regional variation in fracture incidence, ranging from 0.57 to 4.97 per 1,000 Medicare enrollees across the United States, with an overall higher incidence in the East Coast compared to the rest of the country.24 The rate of surgically treated fractures shows similar variability, ranging from less than 10% to 40% or more. Interestingly, in regions with lower incidence of fractures, surgical treatment is more likely.24 
White females have the highest risk of suffering a proximal humerus fracture.65,153,197 As with other osteoporosis-related fractures, additional risk factors for proximal humeral fractures include low bone mass and an increased risk of falls.24 Furthermore patients with poor vision, use of hearing aid, diabetes mellitus, depression, alcohol consumption, use of anticonvulsive medication, and a maternal history of hip fracture have been identified as being at increased risk of sustaining a proximal humeral fracture.17,65,153,197,233,289 A personal history of spinal or upper or lower extremity fracture has also been found to be more prevalent in patients with proximal humeral fractures than in controls.301 Fractures are more frequent during winter months, possibly because of an increased risk of falls both outside and at home, where most fractures occur.247 Hormonal replacement therapy and calcium intake have been found to be protective factors.65,182,197 
Although most studies support good outcomes of nonoperative treatment of nondisplaced fractures, a recent prospective study has shown that marked functional impairment may occur even in nondisplaced proximal humeral fractures with over two-thirds of patients having chronic pain.58 This is of relevance taking into account that elderly patients with two-part proximal humeral fractures are generally considered healthy, with over 90% living at home and taking care of their own dressing and personal hygiene.78 The impact of lost quality of life in this patient population may therefore be considerable. 
Overall, patients with proximal humerus are more fit than patients suffering proximal femur fractures, but less than those with distal radius fractures.77 However, more complex fractures are found in more frail and older patients. As a consequence, up to one-third of patients with proximal humeral fractures may require hospital admission, despite nonoperative treatment.247 
Proximal humeral fractures pose an increased risk for subsequent distal radius and proximal femur fractures.182 Patients with proximal humeral fractures have a greater than 5 times risk of suffering a hip fracture within 1 year than matched pairs without proximal humeral fractures.69,301 An increased risk for hip fracture however continues over the years, with a lifetime risk of suffering a hip fracture after a proximal humeral fracture of 16%, which is identical to that after distal radius fractures and 1.5 times higher than that of nonfractured patients.230 Patients with proximal humeral fractures carry a 2.5-fold risk of a subsequent spinal fracture, a 2.8-fold risk of a subsequent upper extremity fractures and a 2-fold risk of a subsequent lower extremity fractures.301 
When analyzing individuals 45 years or older, patients with proximal humeral fractures have a higher mortality rate than age-matched controls. This risk has been found to be more marked in subjects at the younger extreme of this group and is likely related to increased comorbidity as a possible underlying cause for fracture.361 

Mechanisms of Injury for Proximal Humerus Fractures

Approximately half of all proximal humeral fractures occur at home with the majority occurring as a consequence of falls on level ground.202,222,247 In individuals 60 years or older, over 90% of proximal humeral fractures result from a fall from a standing height.78 In younger individuals there is a higher incidence of proximal humeral fractures occurring outside the home, as a result of higher-energy trauma, such as a fall from a height, motor vehicle accidents (MVAs), sports, or assaults.77,202,247,380 Analysis of the proximal humeral fractures presented in Chapter 3 shows that 9.4% were caused by falls from a height, MVAs, sports, or assaults. The average age of this group was 42.5 years and 71% were males. 
The proximal humerus can fracture as a consequence of three main loading modes: compressive loading of the glenoid onto the humeral head, bending forces at the surgical neck, and tension forces of the rotator cuff at the greater and lesser tuberosities. When the glenoid impacts on the humeral head during a fall in individuals with normal bone, the proximal humeral epiphysis appears to be able to resist local compressive loads. The energy is then transferred further distally, where the weaker metaphyseal bone may yield, resulting in a surgical neck fracture. In individuals with osteoporotic bone, weaker epiphyseal bone may yield simultaneously with the surgical neck, thereby leading to more complex multifragmentary fractures. In isolated greater tuberosity fractures, and in the exceptionally rare isolated lesser tuberosity fracture the mechanism of fracture is usually a dislocation of the glenohumeral joint with tension failure of the fragment secondary to the pull of the rotator cuff on the tuberosities.222 Tension forces may also play a role in multifragmentary fractures, where tuberosity fractures are caused in combination with compression of the humeral head. These tension forces play a further role in displacement because of the unopposed pull of the rotator cuff muscles on the tuberosities, once they have become unstable. 
Apart from bone quality fracture configuration is influenced by the amount of kinetic energy conveyed to the shoulder, and by the position of the upper limb during injury. High-energy fractures in normal bone result in marked comminution of the surgical neck area with extension into the proximal humeral shaft with the integrity of the proximal humeral epiphysis usually being preserved. When falling onto the outstretched hand with the shoulder in flexion, abduction, and internal rotation the glenoid forces the humeral head into valgus, hinging around the inferomedial aspect of the stronger calcar bone.99 In the event that the patient falls directly onto the shoulder the deforming force on the humeral head will create a varus deformity which, due to the natural retroversion of the humeral head will most probably cause a posterior rotational deformity of the head segment. 

Associated Injuries with Proximal Humeral Fractures

The great majority of proximal humeral fractures occur as isolated injuries.68,77 However, since they occur primarily in frail elderly patients and young patients involved in higher-energy trauma, associated injuries may occur. In one of the largest series of proximal humeral fractures, in patients between the ages of 10 and 99 years, Court-Brown et al. found that 90% of fractures were isolated injuries. Ninety-seven of 1,015 patients (9.6%) had other musculoskeletal injuries, including distal radius fractures in 3% and proximal femur fractures in 2% of cases. One-third of associated distal radius fractures were in the same arm as the proximal humerus fracture. Contralateral distal radial fractures occurred in less than 1% of cases and only 0.3% of patients were considered to have major trauma with an Injury Severity Score of 15 or more.77 Interestingly, a subsequent study from the same institution showed that along with distal radius and proximal femur fractures, elderly patients with proximal humeral fractures were at high risk of having associated fractures, with 16% of proximal humerus fracture occurring simultaneously with another fracture.68 
In polytrauma patients, proximal humeral fractures frequently exhibit marked comminution extending into the humeral shaft.104,190 Furthermore, in the presence of fracture dislocations, glenoid rim and neck fractures and avulsion fractures of the coracoid may occur.190 Other injuries such as subarachnoid hemorrhage, craniofacial fractures, hemothorax, and closed liver injuries have also been described.136 
Unlike polytrauma in the younger patient population, standing falls account for 80% of multiple fractures in elderly patients 65 years or older.68 Sixteen percent of elderly patients with proximal humeral fractures present with an additional fracture. Seven percent of proximal humeral fractures in this patient group occur concomitantly with proximal femur fractures with a further 2% occurring with distal radius and pelvic fractures and 1% with scapula and finger fractures.68 As in high-energy fractures, associated glenoid rim and coracoid fractures may occur in elderly patients (Fig. 37-1). 
Figure 37-1
Eighty-seven-year old patient who sustained a complex proximal humerus fracture.
 
A: AP view of the right shoulder showing four-part valgus-impacted proximal humerus fracture. B: Axial CT images. An avulsion fracture of the coracoid and anterior rim fracture of the glenoid can be seen.
A: AP view of the right shoulder showing four-part valgus-impacted proximal humerus fracture. B: Axial CT images. An avulsion fracture of the coracoid and anterior rim fracture of the glenoid can be seen.
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Figure 37-1
Eighty-seven-year old patient who sustained a complex proximal humerus fracture.
A: AP view of the right shoulder showing four-part valgus-impacted proximal humerus fracture. B: Axial CT images. An avulsion fracture of the coracoid and anterior rim fracture of the glenoid can be seen.
A: AP view of the right shoulder showing four-part valgus-impacted proximal humerus fracture. B: Axial CT images. An avulsion fracture of the coracoid and anterior rim fracture of the glenoid can be seen.
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The association of arterial injuries with proximal humeral fractures is rare and is reported in the literature as isolated case reports. Vascular injury mainly affects the axillary artery and can occur either as a traumatic dissection due to kinking because of direct trauma by the medially displaced shaft (Fig. 37-2) or as an avulsion of one of the circumflex arteries.148 Fracture displacement, age older than 50 years and brachial plexus injury are risk factors for vascular injury.262 Early recognition is important as upper extremity amputation may be required in up to 21% of cases.262 
Figure 37-2
Sixty-eight-year old female with a proximal humerus fracture and absent distal pulses.
 
A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
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A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
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Figure 37-2
Sixty-eight-year old female with a proximal humerus fracture and absent distal pulses.
A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
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A: AP view of the left shoulder showing marked medial displacement of the humeral shaft. B: Axillary view of the left shoulder shows anterior displacement of the humeral shaft segment. C: CT angiography. Axial cuts show interruption of flow of the axillary artery at the level of the proximal medial spike of the displaced humeral shaft. D: 3D reconstruction showing interrupted flow distal to occlusion of the axillary artery by the humeral shaft spike. E: Intraoperative image showing axillary artery contusion and thrombosis.
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Electromyographic evidence of neurologic injury can be present in as many as 67% of proximal humeral fractures. The most frequently affected nerves are the axillary nerve (58%) and suprascapular nerve (48%), with combined neurologic lesions being frequent.404 Although neurologic injuries most frequently occur in displaced proximal humeral fractures caused by high-energy trauma, up to one-third can occur as a consequence of a standing fall.165,404 As with vascular injuries, the axillary nerve can be injured by medial displacement of the humeral shaft segment. Combined nerve injuries, as a consequence of traction injuries of the brachial plexus, can also occur ranging from neurapraxia to complete nerve transections. Approximately 50% of neurologic injuries occur in the presence of an arterial injury.165 
The association of rotator cuff tears with proximal humeral fractures has been found to increase with age.421 However it should be remembered that because of age-related rotator cuff degeneration, a high proportion of tears may be present before injury and are diagnosed incidentally during fracture assessment. Full-thickness tears have been found in only 6% of proximal humerus patients under 60 years of age compared to 30% in those patients above 60 years of age.236 Some studies have shown rotator cuff tears in as many as 50% of proximal humeral fractures, reaching 61% in patients 60 years or older.109,128,233,282,351,419 It remains unclear whether rotator cuff integrity may play a role in fracture displacement and whether it affects outcome.282,419 Tears believed to have been caused as a consequence of acute trauma most frequently occur along the rotator cuff interval between the tendons of supraspinatus and subscapularis. Partial- and full-thickness substance tears have also been described.116,128 
Gunshot injuries to the shoulder may result in proximal humeral fractures. Injuries may range from isolated simple surgical neck fractures to severely comminuted fractures with neurovascular injury and soft tissue loss (Fig. 37-3). 
Figure 37-3
Thirty-eight-year old female who suffered a severe injury to her left shoulder during a failed suicide attempt with a shotgun.
 
A and B: AP and lateral views of the left shoulder show marked comminution of the proximal shoulder and fracture of the acromion and glenoid with presence of multiple pellets in the soft tissues. C: 3D reconstruction of the left shoulder confirming the injuries seen on plain radiographs.
A and B: AP and lateral views of the left shoulder show marked comminution of the proximal shoulder and fracture of the acromion and glenoid with presence of multiple pellets in the soft tissues. C: 3D reconstruction of the left shoulder confirming the injuries seen on plain radiographs.
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Figure 37-3
Thirty-eight-year old female who suffered a severe injury to her left shoulder during a failed suicide attempt with a shotgun.
A and B: AP and lateral views of the left shoulder show marked comminution of the proximal shoulder and fracture of the acromion and glenoid with presence of multiple pellets in the soft tissues. C: 3D reconstruction of the left shoulder confirming the injuries seen on plain radiographs.
A and B: AP and lateral views of the left shoulder show marked comminution of the proximal shoulder and fracture of the acromion and glenoid with presence of multiple pellets in the soft tissues. C: 3D reconstruction of the left shoulder confirming the injuries seen on plain radiographs.
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Signs and Symptoms of Proximal Humeral Fractures

Alert patients with isolated proximal humeral fractures complain of localized shoulder pain and limitation of movement in the affected extremity. In the polytraumatized patient, proximal humeral fractures may go unnoticed clinically as attention is directed toward more life-threatening injuries. Furthermore due to the bulk of the deltoid, fracture deformity is not readily identifiable as in other anatomic locations. Proximal humeral fractures in polytraumatized patients are usually detected during the secondary survey following ATLS guidelines. 
Clinical examination usually shows soft tissue swelling and in many cases a large ecchymosis is readily apparent, especially in elderly patients. Loss of the normal convex contour of the shoulder can be seen in more severe fracture patterns and in fracture dislocations. However in the acute phase local soft tissue signs may be absent, particularly in overweight patients. Open fractures are rare but should be ruled out by confirming skin integrity. Open wounds are most commonly seen on the medial aspect of the upper arm adjacent to the axilla because pectoralis major pulls the proximal humerus anteromedially. 
Neurovascular injury is unusual but has to be excluded by careful clinical examination. Axillary nerve sensation should be examined as this is the most frequently affected nerve. Hypoesthesia over the lateral aspect of the proximal arm suggests an axillary nerve injury. Theoretically motor function of the axillary nerve can be assessed by palpating the deltoid as the patient attempts to actively extend, abduct, and flex the shoulder but pain often precludes this. 
The biceps, brachioradialis, and triceps reflexes should be examined in every patient. 
The radial pulse and capillary refill of the fingers should be assessed and compared to the contralateral side. Because of the rich collateral circulation of the upper extremity, only minor clinical findings may occur after vascular injury. A weak or asymmetric pulse should therefore result in further investigation even in minimally displaced fractures. 

Imaging and Other Diagnostic Studies for Proximal Humerus Fractures

Radiographs

The initial assessment of proximal humeral fractures should include a standard shoulder trauma radiograph series consisting of three views: An anteroposterior (AP) view of the shoulder perpendicular to the plane of the scapula (the Grashey view), a Neer (scapula Y) view, and an axillary view (Figs. 37-4 and 37-5). 
Figure 37-4
Radiographic trauma series.
 
A: AP Grashey view of the left shoulder. Note the tangential view of the glenoid articular surface. B: Neer lateral (Y) view of the left shoulder. C: Axillary view. Note how the humeral head is centered on the glenoid in the transverse plane.
A: AP Grashey view of the left shoulder. Note the tangential view of the glenoid articular surface. B: Neer lateral (Y) view of the left shoulder. C: Axillary view. Note how the humeral head is centered on the glenoid in the transverse plane.
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Figure 37-4
Radiographic trauma series.
A: AP Grashey view of the left shoulder. Note the tangential view of the glenoid articular surface. B: Neer lateral (Y) view of the left shoulder. C: Axillary view. Note how the humeral head is centered on the glenoid in the transverse plane.
A: AP Grashey view of the left shoulder. Note the tangential view of the glenoid articular surface. B: Neer lateral (Y) view of the left shoulder. C: Axillary view. Note how the humeral head is centered on the glenoid in the transverse plane.
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Figure 37-5
Valgus-impacted proximal humerus fracture.
 
A: AP Grashey view. B: Neer lateral (Y) view. C: Axillary view.
A: AP Grashey view. B: Neer lateral (Y) view. C: Axillary view.
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Figure 37-5
Valgus-impacted proximal humerus fracture.
A: AP Grashey view. B: Neer lateral (Y) view. C: Axillary view.
A: AP Grashey view. B: Neer lateral (Y) view. C: Axillary view.
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The Grashey AP view of the shoulder is taken in neutral arm rotation with the torso rotated 30 to 45 degrees bringing the side opposite to the injured shoulder forward (Fig. 37-6). The x-ray beam is thereby aimed perpendicular to the plane of the scapula, imaging the glenoid in profile and avoiding overlap between the glenoid and the humeral head. The Neer view is taken with the patient facing toward the cassette and the x-ray source located posteriorly. With the affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source. The scapula is thereby imaged perpendicular to the Grashey view (Fig. 37-7). 
Figure 37-6
AP Grashey view of the shoulder.
 
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula, imaging the glenoid in profile and avoiding overlap between the glenoid and the humeral head.
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula, imaging the glenoid in profile and avoiding overlap between the glenoid and the humeral head.
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Figure 37-6
AP Grashey view of the shoulder.
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula, imaging the glenoid in profile and avoiding overlap between the glenoid and the humeral head.
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula, imaging the glenoid in profile and avoiding overlap between the glenoid and the humeral head.
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Figure 37-7
Neer view (lateral Y) of the shoulder.
 
With the affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source. This gives a view that is perpendicular to Grashey view.
With the affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source. This gives a view that is perpendicular to Grashey view.
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Figure 37-7
Neer view (lateral Y) of the shoulder.
With the affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source. This gives a view that is perpendicular to Grashey view.
With the affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source. This gives a view that is perpendicular to Grashey view.
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The axillary view is taken with the arm in neutral rotation and abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette which is located on top of the shoulder (Fig. 37-8). Ideally the glenoid and coracoid process should be visible. Frequently, pain does not allow sufficient abduction to obtain a useful axillary view. A modified Velpeau axillary view is then performed. This view is obtained with the x-ray beam being projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette. This can be done with the upper extremity in a sling (Fig. 37-9). The combination of these views offers a detailed assessment of the fracture. As the Grashey and Neer views offer a perpendicular view of the fracture it is therefore important to maintain the arm in the same rotation during both views. By taking Grashey and Neer views with the arm hanging gravity will provide traction which facilitates the understanding of fracture morphology. A formal traction view taken while the distal arm is actively pulled may be helpful if there is fracture comminution, especially at the metadiaphyseal junction. The axillary view is important to assess the relationship of the humeral head and glenoid to look for glenohumeral dislocation. 
Figure 37-8
Axillary view of the shoulder.
 
The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.
The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.
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Figure 37-8
Axillary view of the shoulder.
The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.
The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.
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Figure 37-9
Velpeau axillary view of the shoulder.
 
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette. This can be done with the upper extremity in a sling.
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette. This can be done with the upper extremity in a sling.
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Figure 37-9
Velpeau axillary view of the shoulder.
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette. This can be done with the upper extremity in a sling.
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette. This can be done with the upper extremity in a sling.
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Computed Tomography

Computed tomography (CT) of proximal humeral fractures is helpful in providing further understanding of fracture configuration.16 It also allows a more detailed understanding of the degree of osteopenia, the presence and location of bone impaction, and the extent of fracture comminution. Modern spiral multidetector CT scanners obtain axial images in 0.6-mm increments of 1-mm thick slices. Coronal and sagittal reformatted images are usually performed at 2-mm increments with 2-mm thick slices and therefore have a lower resolution than axial images. As with Grashey and Neer radiographs, coronal and sagittal CT reconstructions are performed perpendicular and parallel to the glenoid, respectively. Axial images can confirm displacement of the lesser and greater tuberosity fragments in the transverse plane, while confirming the spatial relationship between the humeral head and the glenoid (Fig. 37-10A). 
Figure 37-10
CT scan.
 
A: Axial cuts through the proximal humerus. The lesser and greater tuberosities can be seen displaced toward the periphery. The humeral head is centered on the glenoid. B: Oblique coronal CT reconstruction. Note valgus impaction of the humeral head with disruption of the greater tuberosity. The medial hinge between the humeral head and the proximal metaphysis is intact. C: Oblique sagittal CT reconstruction. Cut through the junction of the scapular body, scapular spine, and coronoid. Note the absence of atrophy of the rotator cuff muscles.
A: Axial cuts through the proximal humerus. The lesser and greater tuberosities can be seen displaced toward the periphery. The humeral head is centered on the glenoid. B: Oblique coronal CT reconstruction. Note valgus impaction of the humeral head with disruption of the greater tuberosity. The medial hinge between the humeral head and the proximal metaphysis is intact. C: Oblique sagittal CT reconstruction. Cut through the junction of the scapular body, scapular spine, and coronoid. Note the absence of atrophy of the rotator cuff muscles.
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Figure 37-10
CT scan.
A: Axial cuts through the proximal humerus. The lesser and greater tuberosities can be seen displaced toward the periphery. The humeral head is centered on the glenoid. B: Oblique coronal CT reconstruction. Note valgus impaction of the humeral head with disruption of the greater tuberosity. The medial hinge between the humeral head and the proximal metaphysis is intact. C: Oblique sagittal CT reconstruction. Cut through the junction of the scapular body, scapular spine, and coronoid. Note the absence of atrophy of the rotator cuff muscles.
A: Axial cuts through the proximal humerus. The lesser and greater tuberosities can be seen displaced toward the periphery. The humeral head is centered on the glenoid. B: Oblique coronal CT reconstruction. Note valgus impaction of the humeral head with disruption of the greater tuberosity. The medial hinge between the humeral head and the proximal metaphysis is intact. C: Oblique sagittal CT reconstruction. Cut through the junction of the scapular body, scapular spine, and coronoid. Note the absence of atrophy of the rotator cuff muscles.
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Coronal reconstruction images give more detail about the alignment of the humeral head and they allow assessment of comminution at the level of the humeral calcar, the integrity of the inferomedial hinge, and extent of metaphyseal fracture extension (Fig. 37-10B). Sagittal reconstructions help in determining whether there is a flexion or extension deformity of the proximal humerus with regard to the shaft. Furthermore, in this plane, using a soft tissue window, fatty atrophy of the rotator cuff muscles may be analyzed, which may be of value in patients with questionable preinjury rotator cuff pathology (Fig. 37-10C). 
Three-dimensional (3D) reconstruction images can be helpful in analyzing fracture configuration. Axial images and sagittal and coronal reconstructions may intersect the fracture fragments in an oblique fashion depending on the amount of arm rotation and the orientation of the fracture thereby limiting interpretation of the images. 3D reconstructions improve the spatial understanding of fracture morphology. Ideally 3D reconstructions should be performed with and without scapular subtraction. In the absence of the scapula, the proximal humerus can be analyzed from every angle. Having the scapula present however helps in establishing intraoperative reference points and deforming forces. One has to keep in mind that 3D reconstructions offer a surface view of the fracture that on its own does not allow assessment of impaction and bony deficiencies occurring within the fractured proximal humerus (Fig. 37-11). Furthermore, 3D reconstruction images are obtained by averaging images between the slices. The quality of 3D reconstruction is therefore dependent on the slice thickness of the axial CT scan images. 
Figure 37-11
CT three-dimensional surface rendering.
 
A: Anterior view of the fracture seen in Figures 37-5 and 37-10. Valgus impaction of the humeral head can be seen with peripheral displacement of the tuberosities. Note the typical location of the cleavage line between the greater and lesser tuberosities just lateral to the bicipital groove. B: Posterosuperior view. Absence of posteromedial comminution at the proximal metaphysis is seen in this specific fracture. C: Superior view with subtraction of the scapula.
A: Anterior view of the fracture seen in Figures 37-5 and 37-10. Valgus impaction of the humeral head can be seen with peripheral displacement of the tuberosities. Note the typical location of the cleavage line between the greater and lesser tuberosities just lateral to the bicipital groove. B: Posterosuperior view. Absence of posteromedial comminution at the proximal metaphysis is seen in this specific fracture. C: Superior view with subtraction of the scapula.
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Figure 37-11
CT three-dimensional surface rendering.
A: Anterior view of the fracture seen in Figures 37-5 and 37-10. Valgus impaction of the humeral head can be seen with peripheral displacement of the tuberosities. Note the typical location of the cleavage line between the greater and lesser tuberosities just lateral to the bicipital groove. B: Posterosuperior view. Absence of posteromedial comminution at the proximal metaphysis is seen in this specific fracture. C: Superior view with subtraction of the scapula.
A: Anterior view of the fracture seen in Figures 37-5 and 37-10. Valgus impaction of the humeral head can be seen with peripheral displacement of the tuberosities. Note the typical location of the cleavage line between the greater and lesser tuberosities just lateral to the bicipital groove. B: Posterosuperior view. Absence of posteromedial comminution at the proximal metaphysis is seen in this specific fracture. C: Superior view with subtraction of the scapula.
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Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) plays only a marginal role in the diagnosis of proximal humeral fractures. MRI may be helpful in confirming a nondisplaced fracture in a patient with shoulder trauma, normal radiographic findings, and clinical symptoms. Increased signal is usually seen in the T2 sequence and may be located through any of the common fracture sites. Furthermore, in fracture dislocations MRI will allow assessment of the glenoid labrum and rotator cuff and identify nondisplaced occult glenoid rim fractures. Studies have also suggested that MRI can be useful in assessing the integrity of the medial periosteal hinge to indicate whether there is vascularity of the humeral head in multifragmentary fractures.405 Further studies have also analyzed the use of Gadolinium-enhanced MRI for the direct assessment of humeral head perfusion.43,173 MRI can also be useful in determining whether a proximal humeral fracture may be pathologic. 

Other Imaging Techniques

Vascular imaging is required when there is a suspicion of a vascular injury. Several imaging methods are available. Although bi-planar angiography used to be considered the gold standard for the assessment of vascular injuries, CT angiography has become the diagnostic modality of choice as it allows rapid evaluation of the vascular system, while simultaneously allowing assessment of the bone and soft tissues265 (Fig. 37-2 C and D). 
Ultrasound has been shown to be a useful modality for the diagnosis of occult proximal humeral fractures.346 It may also have a role in the diagnosis of rotator cuff tears in nondisplaced fractures. Ultrasound is however dependent on the skill of the operator. In addition it may not be possible to achieve maximal internal rotation because of pain, this being required to perform rotator cuff ultrasound.395 Vascular Doppler ultrasound can be useful in the early assessment of a suspected vascular injury. 
Bone mineral densitometry with dual energy x-ray absorptiometry (DXA) may be appropriate in elderly patients with proximal humeral fractures or in those patients with risk factors for osteoporosis. As discussed earlier, fragility proximal humeral fractures in the elderly are associated with an increased risk of subsequent osteoporotic fractures. Bone density scanning should be the first step toward enrolling osteoporotic patients in a fracture prevention program. 

Proximal Humeral Fracture Classification

In 1934 Codman stated that the fracture lines of the proximal humerus reproducibly occurred between four major fragments these being the humeral head, the greater tuberosity, the lesser tuberosity, and the humeral shaft just proximal to the insertion of the pectoralis major tendon (Fig. 37-12). Codman described 16 different fracture combinations in his seminal work and his classification set the foundation for our understanding of proximal humeral fractures71 (Fig. 37-13). Although several proximal humerus fracture classification systems have been described since Codman the two most widely used are the Neer classification and the AO/OTA classification, both of which focus mainly on displaced fractures.99,257,284,390 
Figure 37-12
Depiction of the classic cleavage plane between the four “parts” of the proximal humerus (greater tuberosity, head of the humerus, lesser tuberosity, and shaft).
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Figure 37-13
Codman’s original depiction of proximal humerus fractures.
 
Fractures were described as occurring between the greater tuberosity (a), humeral head (c), lesser tuberosity (b) or shaft (d). From Codman71.
Fractures were described as occurring between the greater tuberosity (a), humeral head (c), lesser tuberosity (b) or shaft (d). From Codman71.
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Figure 37-13
Codman’s original depiction of proximal humerus fractures.
Fractures were described as occurring between the greater tuberosity (a), humeral head (c), lesser tuberosity (b) or shaft (d). From Codman71.
Fractures were described as occurring between the greater tuberosity (a), humeral head (c), lesser tuberosity (b) or shaft (d). From Codman71.
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Neer Classification

In 1970, Neer introduced the concept of fracture segments instead of fragments. In doing so it was emphasized that proximal humeral fractures can reproducibly yield up to four anatomic segments with or without additional fracture lines, rather than single fragments. Displaced fractures were arbitrarily defined as those in which a segment was translated by at least 1 cm or angulated by a minimum of 45 degrees. The resulting four segment classification offers a descriptive system of proximal humeral fractures, with the main purpose of conceptualizing the pathoanatomy of proximal humeral fractures and the terminology to identify each category.287 Fractures of less than 1 cm of displacement and less than 45 degrees of angulation are considered nondisplaced and are commonly called one-part fractures. The terminology for displaced fractures takes into account the number of displaced segments and the key segment that displaces. Specifically two-part fractures are named after the site of displacement as two-part greater tuberosity, two-part lesser tuberosity, two-part surgical neck, and two-part anatomic neck fractures. Isolated greater tuberosity fractures displace posteromedially by the unopposed pull of the supraspinatus and infraspinatus tendons. Lesser tuberosity fractures displace medially by the pull of the subscapularis tendon. Two-part surgical neck fractures frequently exhibit anteromedial displacement of the proximal humeral shaft because of the pull of the pectoralis major. Although theoretically five different types of three-part proximal humeral fractures could exist, Neer found that these fractures invariably occurred with a fracture through the surgical neck and a concomitant fracture of either the greater or the lesser tuberosity. The intact tuberosity and the pulling forces of its attached rotator cuff tendon determine three-part fracture displacement. In three-part greater tuberosity fractures the head segment is internally rotated by action of the subscapularis muscle. In three-part lesser tuberosity fractures the head segment is externally rotated and abducted by the action of the supraspinatus and infraspinatus muscles. Four-part fractures exhibit displacement of all segments. As with two-part fractures, the greater tuberosity is displaced posteromedially and the lesser tuberosity anteromedially. The humeral head exhibits valgus or varus tilt with or without displacement. 
Fractures combined with a glenohumeral dislocation are classified as fracture dislocations. In true fracture dislocations, the humeral head segment is displaced, either anterior or posterior to the glenoid rim, with rupture of the joint capsule. Fractures involving the articular surface, such as head-splitting and impaction fractures, are included in the group of fracture dislocations284,287 (Fig. 37-14). 
From Neer.287
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Figure 37-14
Neer’s four-part proximal humerus fracture classification.
From Neer.287
From Neer.287
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Siebenrock and Gerber assessed the reliability of the Neer classification among shoulder surgeons. The mean kappa coefficient for inter- and intraobserver reliability was 0.40 and 0.60, respectively.363 Similar results with poor to fair reliability have been found by other authors.117,221,254,362 Some studies suggest that reliability increases with surgeon experience and the use of CT imaging and 3D image rendering.29,50,117,221 However other studies have not shown that CT scanning increases reliability.117,254,371 

AO/OTA Classification

The AO/OTA classification is based on fracture location and the presence of impaction, angulation, translation, or comminution of the fracture, as well as whether a dislocation is present (Fig. 37-15). These fractures are classified as belonging to the 11 bone segment (1 for humerus, 1 for proximal segment) and they are subclassified into types, groups, and subgroups. Finally each subgroup fracture is assigned a level of severity.280 
Figure 37-15
AO/OTA classification for proximal humerus fractures.257,280
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Type A fractures are extra-articular unifocal fractures associated with a single fracture line, type B are extra-articular bifocal fractures associated with two fracture lines, and type C are articular fractures which involve the humeral head or anatomic neck. Type A fractures are grouped into greater tuberosity fractures (A1), surgical neck fractures with metaphyseal impaction (A2), and surgical neck fractures without metaphyseal impaction (A3). Type B fractures are grouped into surgical neck fractures with metaphyseal impaction and a displaced fracture of either the greater or the lesser tuberosity (B1), nonimpacted surgical neck fractures with a displaced fracture of either the greater or the lesser tuberosity (B2), and surgical neck fracture with a displaced fracture of either the greater or the lesser tuberosity and glenohumeral dislocation (B3). Type C fractures are grouped into anatomic neck fractures with slight displacement (C1), anatomic neck fractures with marked displacement (C2), and anatomic neck fractures with glenohumeral dislocation (C3). Each fracture type is further subgrouped according to displacement, valgus or varus angulation of the humeral head, comminution, and the presence and direction of glenohumeral joint dislocation. Fractures can thereby be assigned 1 of 52 different fracture types. 
Although this classification system theoretically provides a comprehensive method of describing proximal humeral fractures, it is complex which reduces its clinical usefulness. Siebenrock and Gerber assessed the reliability of the AO classification among shoulder surgeons. The mean kappa coefficient for interobserver reliability was 0.53 when fractures were classified into one of three types (A to C) and 0.42 when fractures were classified into one of nine groups (A1 to C3). Mean kappa coefficient for intraobserver reliability was 0.58 for types and 0.48 for groups.363 Similar results have been shown by other authors.254,371 The addition of CT scanning does not appear to increase these values.254,371 
Both, Neer and AO/OTA classifications provide a nomenclature to describe fracture morphology. Although treatment may be guided by the fracture type a classification that correlates with outcome has not as yet been devised. Specifically, decision making between operative fixation and humeral head replacement continues to be controversial. As a general rule fractures in which the vascularity of the humeral head has been severely compromised are theoretically best treated with arthroplasty, whereas those in which perfusion of the head is at least partially preserved should benefit from operative fixation. Four-part fractures and fracture dislocations are considered to have the highest risk for humeral head necrosis. An exception to this are four-part valgus-impacted fractures, in which displacement of the tuberosities is present, but the head is tilted into valgus in relation to the humeral shaft and there is no translation. Overall favorable outcomes can be expected with operative fixation of these fractures.187,326 Court-Brown et al.76 further showed that impacted valgus fractures (AO/OTA B1.1) could be safely managed nonoperatively. 

Risk of Avascular Necrosis

The arcuate artery from the anterolateral ascending branch of the anterior circumflex humeral artery (ACHA) has historically been considered to provide the main arterial supply to the humeral head.147 Fractures through the anatomic neck have therefore been considered to permanently disrupt perfusion of the humeral head. However more recent literature has shown that branches from the posterior circumflex humeral artery (PCHA) to the posteromedial proximal humeral metaphysis provide equally important blood perfusion to the humeral head.46,95,227,266,267 Coudane et al.75 showed, with arteriography, that in patients with complex proximal humeral fractures the PCHA was preserved in 85% of cases as opposed to only 20% of the ACHA. 
In complex proximal humeral fractures, the posteromedial branches from the PCHA therefore become the main supply to the head. Several morphologic fracture features have been proposed to estimate the possibility of the disruption of this blood supply and hence to assess the risk of avascular necrosis (AVN). These features include varus displacement of the head,377 the size of metaphyseal fracture extension of the humeral head and the medial displacement of the humeral shaft in relation to the humeral head.170 Hertel et al. studied 100 intracapsular proximal humeral fractures, in which at least one component of the fracture was proximal to the anatomic neck, undergoing operative treatment. Several fracture characteristics, as possible predictors for humeral head ischemia, were studied and shown to correlate with intraoperative assessment of humeral head perfusion. Distal metaphyseal extension of the head fragment of 8 mm or less, disruption of the medial hinge between the humeral head and the shaft at the level of the calcar, and fractures through the anatomic neck were independent predictors for humeral head ischemia.170 Although this study has been widely used to help in decision making between fixation and replacement of proximal humeral fractures, a follow-up study from the same authors found a poor correlation between intraoperative ischemia and development of AVN.20 This discrepancy is further supported by a study of Croby et al., in which tetracycline was administered to 19 patients with three- and four-part fractures of the proximal humerus during 5 days preceding operative treatment. Humeral head biopsies were obtained from hemiarthroplasty surgery and analyzed using fluoroscopic microscopy. Fluorescence was observed in all specimens suggesting that vascular supply was not disrupted in any of the fracture patterns.81 

Fracture Frequency

In 2001 Court-Brown et al.77 published a comprehensive study on the distribution of proximal humerus fracture types. Over a 5-year period the senior author classified a total of 1,027 consecutive proximal humeral fractures based on standard radiographs. Nondisplaced or minimally displaced one-part fractures comprised half (49%) of all fractures. Two-part fractures occurred in 37% of cases. Surgical neck fractures represented three quarters of these and 28% of the whole group. Two-part greater tuberosity fractures occurred in almost 10% of cases with one-half occurring in the absence of an anterior glenohumeral dislocation and the other half in association with a dislocation. Two-part anatomic neck fractures were exceedingly rare and occurred in only 0.3% of proximal humeral fractures. Lesser tuberosity fractures only occurred in association with a posterior fracture dislocation and comprised only 0.2% of fractures. The vast majority of three-part fractures were greater tuberosity fractures comprising 9% of all fractures. Lesser tuberosity three-part fractures and three-part fracture dislocations occurred in 0.3% and 0.2%, respectively. Four-part fractures comprised only 3% of fractures, of which one-third were true fracture dislocations. Fractures involving the articular surface occurred in 0.7% of cases. Proximal humerus fractures can therefore be approximately distributed in the following manner. Half are nondisplaced or minimally displaced, one-quarter are two-part surgical neck fractures, one-tenth are three-part greater tuberosity fractures, one-tenth are two part greater tuberosity fractures or fracture dislocations, and every 30th proximal humerus fracture will be a four-part fracture. The remaining fractures can be considered to be exceedingly rare.77 

Outcome Measures for Proximal Humerus Fractures

In the early 1900s, E. Amory Codman, who is frequently cited as the father of shoulder surgery, introduced his “end result idea.” It was his belief that every treated patient should be followed long enough to determine whether treatment had been effective or not.70 Although his idea did initially face strong resistance, outcome assessment has become the backbone of clinical research, audit, and clinical governance.86 
Numerous measures have been used to assess outcomes after proximal humeral fracture. Historically and to the present date, results are most frequently reported on the basis of radiographic assessment3,5,6,12,14,15,33,49,51,59,60,61,67,90,96,102,114,136,139,140,141,160,161,162,174,177,188,190,191,201,208,209,211,220,225,232,237,241,250,258,259,260,261,268,277,288,291,293,296,298,299,303,304,309,312,314,315,317,318,319,323,327,339,345,353,354,358,359,377,378,383,384,388,397,400,402,406,420,423,426 and the occurrenceof complications.45,59,114,160,161,174,191,201,208,209,211,232,258,259,260,268,277,303,309,318,319,353,358,377,378,383,384,388,397,400,420 Other frequently reported measures include pain,42,140,162,209,211,225,237,250,303,339,348,394,402,416,426 strength, 42,162,250 range of motion,6,12,137,162,206,220,225,237,241,250,258,259,291,307,354,358,377,388,402,418,424,427 and patient satisfaction.241,259,261,315,348,359,418,427 

Radiographic Assessment

Radiographic follow-up is usually performed at set intervals these frequently being 6 weeks and 3, 6, and 12 months after injury or surgery. Follow-up radiographs should be obtained with the same projection that was used initially to allow for accurate comparison. Healing is determined by observing bridging callus, especially in fractures treated nonoperatively or with a lower rigidity construct. However when rigid fixation is used, callus formation is not readily apparent and bridging trabeculae are sought on radiographs to determine whether healing has occurred. 
Fracture alignment is assessed on intraoperative or immediate postoperative images and compared on subsequent out-patient reviews. The most frequently considered measures are tuberosity displacement and head-shaft angle53,114 Furthermore hardware position within the proximal humerus is frequently assessed to evaluate possible cutout, failure, or loosening.3,5,6,12,14,15,33,49,51,59,60,61,67,90,96,102,114,136,139,140,141,160,161,162,174,177,188,190,191,201,208,209,211,220,225,232,237,241,250,258,259,260,261,268,277,288,291,293,296,298,299,303,304,309,312,314,315,317,318,319,323,327,339,345,353,354,358,359,377,378,383,384,388,397,400,402,406,420,423,426 
AVN of the humeral head is the most frequently evaluated radiographic long-term outcome after nonreplacement reconstruction of proximal humeral fractures. Several degrees of severity of AVN are frequently reported, ranging from isolated changes in the trabecular organization to collapse of the humeral head with loss of sphericity.20,82,114 Changes in trabecular organization have been described as increased radiodensity with cystic and sclerotic regions and coarse trabeculae.20,82 
Serial radiographic assessment is a key component of long-term follow-up of arthroplasty for proximal humeral fractures. Implant loosening is monitored by assessing the appearance of progressive radiolucent lines between the implant and the bone. Furthermore osteolysis, with increased cavitation of bone adjacent to the implant, places the implant at increased risk of loosening and failure. In reverse total shoulder arthroplasty assessment of glenoid notching is required, as it may lead to glenoid component loosening and failure.61,369 

Complications

The most frequently reported complications after proximal humeral fractures are nonunion, malunion, implant failure, humeral head collapse, infection, post-traumatic arthritis, hardware penetration, axillary nerve dysfunction, revision surgery, and mortality. Multiple definitions exist for each of these. Clinical, radiographic, and laboratory criteria are used to diagnose and monitor these complications.45,59,114,161,160,174,191,201,208,209,211,318,319,232,258,259,260,268,277,303,309,353,358,377,378,383,384,388,397,400,420 

Pain

Pain is a key component of patient satisfaction. It is frequently quantified using a visual analog scale (VAS) and reported as a value from 0 to 10.42,140,162,209,211,225,237,250,303,339,348,394,402,416,426 

Range of Motion

Active and passive forward elevation, abduction, external rotation, and internal rotation are frequently reported.53 The use of a standardized technique with a goniometer is important to achieve reproducible measurements. 

Strength

Strength is frequently reported as a measure of the weight that can be lifted in a specific plane. The use of a dynamometer to assess strength in 90 degrees of abduction is often reported.42,49,59,114,191,208,209,211,229,258,259,303,353,357,383,384,402 A 25-year-old male with a normal shoulder is expected to lift 25 lb in this plane. Lower values are expected for females and older people.42,73,162,250 

Functional Outcomes Scales

Although each of the criteria that have been outlined help in determining certain aspects of the outcomes of proximal humeral fractures, they do not allow a quantitative assessment at a given point in time. Furthermore, they do not permit a summarized assessment of the overall function of the shoulder. Over the last decades several outcomes scales have been developed that summarize the results of the assessment of several aspects of shoulder function.7,23,70,73,86,87,103,142,143,162,183,234,235,249,328,330,372,391,399,413,417 Scores can then be obtained after applying an algorithm or by grouping responses.86 Several function scales rely mostly on criteria that are obtained by an evaluator.86,103,284 These include range of motion, strength, specific clinical signs, radiographic alignment, and healing. Other scales focus on the subjective patient perception of shoulder function and pain. These are frequently questionnaires that are answered directly by the patient and inquire about multiple activities in which different aspects of shoulder function are involved.23,87,183,234,249,330,417 Finally, some shoulder scores use a combined approach in which both evaluator-based and patient-based outcomes are included.73,328 
In addition to outcomes scales that focus on the shoulder or upper extremity, modern functional assessment frequently includes evaluation of overall patient health. Although scales that assess patient function in a broader spectrum may be less accurate in measuring changes in shoulder function, they play an important role in measuring the impact of a specific shoulder condition on the overall health and quality of life of the patient.391,399,413 

Currently Used Outcomes Scales

Over 150 clinical studies on proximal humeral fractures are referenced in the National Library of Medicine (PubMed) for the period 2009 to 2012. The shoulder scale most widely used for outcomes assessment was the disabilities of the arm, shoulder, and hand (DASH)6,31,33,52,57,58,90,119,126,140,159,164,177,188,190,194,208,229,288,298,299,300,303,307,317,337,353,354,388,406,420 followed by the Constant-Murley Scale,42,49,59,114,191,208,209,211,229,258,259,303,353,357,383,384,402 the American Shoulder and Elbow Surgeons (ASES) scale,114,137,160,161,220,237,241,291,293,307,348,354,359,416,418,426 Neer criteria,52,106,201,209,211,250,277,306 the University of California Los Angeles (UCLA) Shoulder Score,11,14,164,232,268,293,359,416 the Oxford Shoulder Scale (OSS),45,48,156,229,307,318,424 and the Simple Shoulder Test (SST).42,293,359,406,416,418 Other scales used during this time period include Quick-DASH,34 Shoulder Pain and Disability Index (SPADI),358 Subjective shoulder value (SSV) or Single Assessment Numerical Evaluation (SANE),21,59,137,258,259,303 and University of Pennsylvania (Penn) shoulder score.137,327 
Although used less frequently global quality of life assessment tools were also used, mainly in prospective clinical trials. The most frequently used tool was EuroQol 5D,57,58,90,229,298,299,300,348,416 followed by SF3648,90,119,188,190,307,322,383 and the Short Musculoskeletal Function Assessment (SMFA).190 
DASH and Quick-DASH.
The DASH questionnaire is a patient-based, self-administered outcome instrument developed to measure symptoms and disability of the upper extremity. It evaluates six domains: daily activities, symptoms, social function, work function, sleep, and confidence. It consists of 30 questions regarding the level of difficulty in performing a set of activities. Each question is rated on a Likert scale from 1 (no difficulty) to 5 (unable to do). Lower values represent higher function.183 
The Quick-DASH is an 11-item questionnaire derived from the DASH through item reduction using a concept-retention approach, in which the domains from the original instrument were retained while the amount of items of each domain were reduced. As for DASH, higher scores represent higher disability. Like the DASH, Quick-DASH has two optional modules, one for function at work and one for function during sports and performing arts.23 
Constant-Murley Score.
The Constant-Murley Score has a subjective patient-based component and an objective evaluator-based component. Subjective parameters include pain and shoulder function based on the ability to perform activities of daily living. For pain, scoring ranges from 0 for “severe” pain to 15 for no pain. A total of 20 points can be obtained with regard to shoulder function. The evaluator-based assessment includes active shoulder range of motion and strength. Range-of-motion is quantified by scores for elevation and external and internal rotation. A maximum of 10 points are scored when at least 151 degrees of elevation can be reached. A total of 10 points can be obtained for external rotation and internal rotation, respectively and are quantified according to rotational maneuvers that place the hand into defined positions with regard to the head, neck, and trunk. A total of 25 points can be scored for strength and are obtained by a 25-year-old male who is able to lift at least 25 lb to 90 degrees of abduction. Proportional values are assigned for the lifted weight and adjusted for age and gender. The maximum score is 100 points, with higher values representing higher function.73 
ASES Standardized Shoulder Assessment Form.
The ASES Standardized Shoulder Assessment Form consists of an evaluator-based and a patient-based subjective component. The patient-based component assesses pain, instability, and activities of daily living. Pain is determined with the use of a 10-cm VAS to quantify pain from 0 (no pain at all) to 10 (pain as bad as it can be). A similar VAS is used for instability. Activities of daily living are assessed with 10 questions that are answered on a four-point ordinal scale ranging from 0 (unable to do the activity) to 3 (no difficulty in performing the activity). The evaluator-based component includes range of motion, several shoulder specific clinical signs, strength, and instability. The score is obtained from the patient-based component with the following formula: (10–points on VAS for pain) × 5 + 5/3 × (total points for activities of daily living).328 
Neer Criteria.
In 1970 Neer published his criteria for the evaluation of results of proximal humeral fractures. They include four variables: (1) pain, (2) function, (3) range of motion, and (4) anatomy. Pain represents a total of 35 points, ranging from “totally disabled” (0 points) to “none” (35 points). Function represents 30 points and comprises strength, reach, and stability, each yielding up to 10 points. Range of motion represents 25 points, and is comprised of flexion (up to 6 points), extension (up to 3 points), abduction (up to 6 points), external rotation (up to 5 points), and internal rotation (up to 5 points). Anatomy represents 10 points, ranging from 0 to 10 points with regard to rotation, angulation, articular congruity, tuberosity displacement, hardware failure, heterotopic ossification, nonunion, and AVN of the humeral head. A maximum score of 100 can thereby be obtained. Results are classified as excellent for 90 points or more, satisfactory for 80 to 89 points, unsatisfactory for 70 to 79 points and failure for 69 points or less.284 
UCLA.
The original UCLA shoulder scale was first published by Amstutz et al.7 for the assessment of shoulder arthroplasty. The scale was subsequently modified by Ellman et al.103 for the evaluation of rotator cuff surgery. It evaluates pain, function, range of motion, strength, and patient satisfaction. Pain and function can yield a maximum of 10 points, whereas the remaining items can score a maximum of 5 points each, leading to a maximum overall score of 35 for an asymptomatic and normal shoulder. 
Oxford Shoulder Scale.
The Oxford Shoulder Score is a patient-based questionnaire that includes 12 questions with regard to pain and activities of daily living. Each question can be answered on a Likert scale from 0 to 5. The total score ranges from 0 to 60 with lower scales reflecting better outcomes.87 
Simple Shoulder Test.
The SST includes 11 questions regarding shoulder function and pain. Each question is answered with a yes/no option. Affirmative questions are then counted and reflect the final score.249 
Shoulder Pain and Disability Index.
The SPADI is a patient-based questionnaire that includes 13 questions assessing the domains of pain and disability. Each question is answered using a VAS. Results are presented as a percentage of the maximum achievable score. Higher scores reflect more pain and disability.330 
Subjective Shoulder Value and Single Assessment Numerical Evaluation.
Gerber et al.143 introduced SSV as a means to assess outcomes after surgery for massive rotator cuff tear surgery. It consists of a single question asking the patient to estimate the function of the affected shoulder as a percentage of function of an entirely normal shoulder. The same question was further validated by Williams et al.417 as the SANE in a cohort of patients undergoing surgery for shoulder instability. 
University of Pennsylvania Shoulder Score.
The PENN shoulder scale is a 100-point shoulder-specific self-reported patient-based questionnaire consisting of three subscales: pain, satisfaction, and function. Pain and satisfaction are rated using a 10-point Likert scale. Pain is assessed at different levels of activity (at rest, normal activities, and strenuous activities) and can achieve a maximum of 10 points each. Satisfaction can reach a maximum of 10 points. Function is assessed using a total of 20 questions, each answered on a scale from 0 to 3. Function can thereby reach a maximum of 60 points. The maximum total score is 100 points with higher scores representing higher function.234,235 

Validity, Responsiveness, Reproducibility

As with any gauging tool, outcomes scales require a certain set of criteria to be able to provide accurate measurements. Outcomes measurement tools should be valid, reliable, and sensitive to change. For a scale to be valid it needs to be developed in a manner that assesses what is important to the patient. Furthermore, it needs to be easily obtainable and easy to evaluate.142 Despite the abundance of shoulder assessment scales, many do not fulfill these criteria. Furthermore, scales are frequently used for conditions different than those for which they were developed and validated, raising concern about their accuracy.86 This is the case in proximal humeral fractures. To our knowledge, only one study has to date specifically evaluated an upper extremity outcomes scales for proximal humeral fractures. Slobogean et al. studied the validity and reliability of the DASH and EQ-5D in patients with proximal humeral fractures. Both showed strong reliability with an intraclass correlation coefficient (ICC) of 0.77 for EQ-5D and 0.93 for DASH. Construct validity was determined with strong correlation between EQ-5D and DASH.372 These results are extremely helpful and allow researchers and clinicians to continue using these scales to assess the outcomes of proximal humeral fractures. 

Pathoanatomy and Applied Anatomy

Bone

The proximal humerus consists of the humeral head, the greater and lesser tuberosities, and the humeral shaft (Fig. 37-16). The region of transition between the articular cartilage and surrounding bone is defined as the anatomic neck, whereas the region immediately inferior to the tuberosities is termed the surgical neck. Several studies have analyzed the anatomy of the proximal humerus and have shown considerable variation between individuals. The mean radius of curvature of the humeral head is 25 mm, ranging from 23 to 29 mm. The humeral head height, defined as the perpendicular distance from the plane of the anatomic neck to the surface of the humeral head consistently is approximately three-fourths of the radius of curvature of the humeral head.313 Although the head size varies the surface arc covered by hyaline cartilage is approximately 160 degrees.313 In the coronal plane, the angle between the anatomic neck and the humeral shaft averages 41 degrees, ranging from 30 to 50 degrees.313,331 In the axial plane, the posterior angle of the anatomic neck of the humerus with relation to the epicondylar axis averages 17 degrees and ranges from 5 degrees of anteversion to 50 degrees of retroversion.36 In the coronal plane, the geometric center of the humeral head is located 4 to 14 mm medial to the axis of the humeral shaft. In the sagittal plane the center of the humeral head can be located from 4 mm anterior to 14 mm posterior to the axis of the humeral shaft. The humeral canal diameter averages 12 mm and ranges from 10 to 14 mm.313 
Figure 37-16
The bony anatomy of the proximal humerus viewed from (A) anteriorly, (B) laterally, and (C) superiorly.
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The greater tuberosity lies laterally on the proximal humerus and is the insertion point for the supraspinatus tendon superiorly, the infraspinatus tendon posterosuperiorly and the teres minor tendon posteriorly.272 The greater tuberosity is located on average 9 mm distal to the most proximal aspect of the humeral head (range: 6 to 10 mm). This head to tuberosity distance is important in facilitating adequate rotator cuff function. Too short a distance leads to insufficient rotator cuff tension and subacromial impingement, whereas a very low tuberosity may lead to excessive tendon strain and failure. Inability to reconstitute the correct head tuberosity distance has been shown to give poor results in both arthroplasty and fracture reduction.184 
The lesser tuberosity is situated anteriorly in the proximal humerus. It is the insertion site of the subscapularis muscle. The lesser and greater tuberosities are separated by the bicipital groove, which serves as the track for the long head of the biceps to travel from its supraglenoid insertion inside the glenohumeral joint to the anterior aspect of the arm. The bicipital groove has a spiral trajectory from superior and laterally toward the midline inferiorly. Proximally, the bicipital groove consistently lies 7 mm anterior to the intramedullary (IM) axis of the humerus and serves as a reliable reference point to establish humeral head retroversion.8 The bicipital groove is covered by the transverse ligament and the insertion of the coracohumeral ligament. The bone surrounding the bicipital groove is strong cortical bone and is therefore fractured only in cases of high-energy trauma or severe osteopenia. It is therefore a useful landmark for fracture reduction (Fig. 37-17). 
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Figure 37-17
Anatomy of the rotator cuff and biceps.
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Vascularity

Perfusion of the upper extremity is mainly from the axillary artery and its branches. Perfusion of the proximal humerus arises from the axillary artery where it passes between the pectoralis minor and teres major muscles. At this level, the axillary artery gives off the humeral circumflex arteries (Fig. 37-18). The ACHA runs horizontally behind the conjoined tendon over the anterior aspect of the surgical neck of the humerus to anastomose laterally with the PCHA. At the level of the biceps tendon the ACHA gives off a branch that ascends behind the long head of the biceps on the surface of the bicipital groove proximally (Fig. 37-19). Within 5 mm of the articular surface it penetrates the cortical bone, becoming the arcuate artery which provides vascularity to most of the humeral head46,147 (Fig. 37-20). 
Figure 37-18
Vascular supply of the humeral head.
 
The anterior circumflex humeral artery (ACHA) and posterior circumflex humeral artery (PCHA) branch off of the axillary artery. The ramus ascendens of the ACHA ends as the arcuate artery in the superolateral aspect of the proximal humerus. The PCHA provides multiple metaphyseal branches to the posteromedial aspect of the proximal humerus.
The anterior circumflex humeral artery (ACHA) and posterior circumflex humeral artery (PCHA) branch off of the axillary artery. The ramus ascendens of the ACHA ends as the arcuate artery in the superolateral aspect of the proximal humerus. The PCHA provides multiple metaphyseal branches to the posteromedial aspect of the proximal humerus.
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Figure 37-18
Vascular supply of the humeral head.
The anterior circumflex humeral artery (ACHA) and posterior circumflex humeral artery (PCHA) branch off of the axillary artery. The ramus ascendens of the ACHA ends as the arcuate artery in the superolateral aspect of the proximal humerus. The PCHA provides multiple metaphyseal branches to the posteromedial aspect of the proximal humerus.
The anterior circumflex humeral artery (ACHA) and posterior circumflex humeral artery (PCHA) branch off of the axillary artery. The ramus ascendens of the ACHA ends as the arcuate artery in the superolateral aspect of the proximal humerus. The PCHA provides multiple metaphyseal branches to the posteromedial aspect of the proximal humerus.
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Figure 37-19
Vascularity of the proximal humerus, anterior view.
 
Note the proximity of the ramus ascendens (AL branch) of the ACHA and the biceps tendon.
 
From Hettrich et al.173
Note the proximity of the ramus ascendens (AL branch) of the ACHA and the biceps tendon.
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Figure 37-19
Vascularity of the proximal humerus, anterior view.
Note the proximity of the ramus ascendens (AL branch) of the ACHA and the biceps tendon.
From Hettrich et al.173
Note the proximity of the ramus ascendens (AL branch) of the ACHA and the biceps tendon.
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Figure 37-20
Vascularity of the proximal humerus, Spalteholz technique coronal section.
 
Note intraosseous branching of the arcuate artery form the ACHA (A) and from metaphyseal branches of the PCHAP. From Brooks et al.46
Note intraosseous branching of the arcuate artery form the ACHA (A) and from metaphyseal branches of the PCHAP. From Brooks et al.46
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Figure 37-20
Vascularity of the proximal humerus, Spalteholz technique coronal section.
Note intraosseous branching of the arcuate artery form the ACHA (A) and from metaphyseal branches of the PCHAP. From Brooks et al.46
Note intraosseous branching of the arcuate artery form the ACHA (A) and from metaphyseal branches of the PCHAP. From Brooks et al.46
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The PCHA arises as a larger branch at the same level as the ACHA at the lower margin of the subscapularis muscle. It travels posteriorly with the axillary nerve giving off several branches that pierce the posteromedial aspect of the proximal humeral metaphysis providing vascularity to the humeral head. The PCHA finally crosses the quadrilateral space winding around the surgical neck and anastomosing anteriorly with the ACHA. While some authors have found the arcuate artery from the anterolateral ascending branch of the ACHA to be the main arterial supply to the humeral head,147 several studies have shown branches from the PCHA to the posteromedial head to be at least equally important46,95,227,266,267 (Figs. 37-20 and 37-21). 
Figure 37-21
Vascularity of the proximal humerus.
 
The axillary artery (1-white arrow heads) is pulled anteriorly. Note the larger size of the PCHA (2-small white arrows) in comparison to the ACHA (3-large black arrow).
The axillary artery (1-white arrow heads) is pulled anteriorly. Note the larger size of the PCHA (2-small white arrows) in comparison to the ACHA (3-large black arrow).
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Figure 37-21
Vascularity of the proximal humerus.
The axillary artery (1-white arrow heads) is pulled anteriorly. Note the larger size of the PCHA (2-small white arrows) in comparison to the ACHA (3-large black arrow).
The axillary artery (1-white arrow heads) is pulled anteriorly. Note the larger size of the PCHA (2-small white arrows) in comparison to the ACHA (3-large black arrow).
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Muscles

Several muscles play a role in proximal humeral fractures. The rotator cuff muscles play an important role in displacement of the proximal fracture segment, whereas pectoralis major is responsible for displacing the shaft segment (Fig. 37-22). Furthermore understanding of the deltoid anatomy and the interval between deltoid and pectoralis major is important to safely achieve fracture exposure. 
Figure 37-22
Deforming forces of proximal humeral fractures.
 
The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.
The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.
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Figure 37-22
Deforming forces of proximal humeral fractures.
The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.
The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.
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The rotator cuff is composed of the subscapularis anteriorly, the supraspinatus superiorly, and the infraspinatus and teres minor posteriorly. The subscapularis muscle originates from the subscapularis fossa on the anterior surface of the scapular body and inserts into the lesser tuberosity. The supra- and infraspinatus muscles originate from the posterior surface of the scapular body above and below the scapular spine, respectively. The teres minor muscle originates from the lateral border of the scapular body. These three muscles insert onto the greater tuberosity of the proximal humerus. The supraspinatus inserts superiorly, the infraspinatus posterosuperiorly, and the teres minor posteriorly.272 These muscles play a key role in shoulder function, and are essential to preserve a rotational fulcrum during activation of the deltoid. The subscapularis muscle is innervated by the upper and lower subscapular nerves which originate from the posterior cord of the brachial plexus. It derives its perfusion from the subscapular artery which is the largest branch of the axillary artery. The supra- and infraspinatus muscles are innervated by the suprascapular nerve which originates from the upper trunk of the brachial plexus. Blood supply is provided by the suprascapular artery which comes from the thyrocervical trunk which originates from the subclavian artery. The teres minor is innervated by the axillary artery and perfused by the posterior humeral circumflex and the circumflex scapular arteries which originate from the subscapular artery. 
The rotator interval is a triangular region delineated at the apex medially by the coracoid process, the supraspinatus superiorly, the subscapularis inferiorly and the bicipital groove laterally. It contains the coracohumeral and superior glenohumeral ligaments which play a key role in shoulder stability. In proximal humeral fractures rotator cuff tears may start through the rotator cuff interval. In arthroplasty reconstruction of proximal humeral fractures, separation of the lesser and greater tuberosities may be safely performed through the rotator interval to avoid damage to the rotator cuff. 
The long head of the biceps originates at the supraglenoid tubercle, traveling over the humeral head across the rotator interval into the intertubercular groove. During its course through the intertubercular groove the tendon is covered by the transverse humeral ligament. Muscle fibers of the long head join those of the short head at the level of the middle third of the humerus. Due to its location, the long head of the biceps can serve as a useful landmark for orientation particularly in comminuted fractures. The tendon can be identified in the proximal third of the arm and traced proximally to locate the intertubercular groove and tuberosities. 
The deltoid originates on the anterior aspect of the lateral third of the clavicle, the periphery of acromion, and the lateral third of the scapular spine. It is commonly described as consisting of three segmental units, anterior, middle and posterior, which respectively provide shoulder flexion, abduction and extension. The anterior deltoid originates from the clavicle and the anterior aspect of the acromion.204 A fibrous raphe extending from the anterolateral corner of the acromion distally separates the anterior from the middle deltoid. The deltoid fibers converge laterally inserting onto the deltoid tuberosity of the humerus in a trapezoidal fashion. The insertion measures 5 to 7 cm in length with a width of 22 mm proximally and 13 mm distally.204,329 Distally, interconnections of the deltoid and its fascia with the lateral intermuscular septum and the brachialis muscle allow for partial release of the deltoid during surgical approach without the need for repair.329 The deltoid muscle is innervated by the axillary nerve. Blood supply to the deltoid is provided by the PCHA. 
The pectoralis major muscle has two heads, the clavicular and the sternocostal. The clavicular portion originates on the anterior surface of the clavicle, medial to the deltoid insertion. The sternocostal head originates from the anterior surface of the sternum, the superior six costal cartilages and the fascia of the external oblique muscle. Both muscles and tendons converge laterally to insert onto the lateral aspect of the bicipital groove of the humerus. The pectoralis major is innervated by the lateral and medial pectoral nerves that originate from the lateral and medical cords of the brachial plexus, respectively. The blood supply is derived from the pectoral branch of the thoracoacromial trunk originating from the axillary artery. 
The cephalic vein runs in the deltopectoral interval. It serves as a useful landmark to identify the interval between the deltoid and pectoralis major muscles to allow safe access to the anterior aspect of the shoulder. More tributaries to the cephalic vein arise from the deltoid than from the pectoralis major.320 Some surgeons therefore recommend lateral retraction of the vein during the deltopectoral approach. Proximally the cephalic vein passes through the deltopectoral triangle just caudal to the clavicle to join the axillary vein. Perivascular fat can be found at the deltopectoral triangle, which can serve as a useful landmark to safely identify the cephalic vein. The course of the vein through the deltopectoral interval arches with a medial concavity and therefore most surgeons recommend medial retraction of the vein to minimize tension during retraction. 

Nerves

Several nerves are at risk of damage from manipulation of the proximal humerus or surgery. The axillary nerve can be injured by the initial injury, or secondarily by percutaneous fixation. The axillary nerve is one of the terminal branches of the posterior cord of the brachial plexus. Its motor fibers innervate the teres minor and deltoid muscles; the sensory component innervates the skin overlying the lateral aspect of the proximal arm. At the level of the proximal humerus, the axillary nerve passes from anterior to posterior, accompanied by the posterior circumflex artery, inferior to the anatomic neck through the quadrilateral space surrounded by teres major superiorly, the long head of the triceps medially, teres major inferiorly, and the humeral shaft laterally. After giving off the branch to the teres minor, it passes anteriorly on the undersurface of the deltoid at a distance ranging from 2 to 7 cm distal to the acromion.55,133,192 This distance has been found to be inversely proportional to the length of the deltoid.213 It crosses the anterior deltoid raphe between the anterior and middle deltoid in the form of a single terminal branch allowing for preservation of the innervation of the anterior deltoid when the nerve is isolated during the deltoid-splitting approach.133,134 
The musculocutaneous nerve is at risk from medial retraction when performing the deltopectoral approach. The musculocutaneous nerve originates from the lateral cord of the brachial plexus. The most proximal motor branch to the coracobrachialis muscle is located about 3 to 4 cm distal to the tip of the coracoid, being less than 5 cm in 75% of cases.66 The musculocutaneous nerve then enters the coracobrachialis at a mean distance of 5.6 cm inferior to the coracoid process.66,115,425 Farther distally, it pierces the biceps at an average of 10 cm distal to the coracoid. It then travels between biceps and the underlying brachialis muscle innervating both muscles. It ends as the lateral antebrachial cutaneous nerve providing sensation to the lateral aspect of the forearm.425 

Fracture Treatment Options

Nonoperative Treatment of Proximal Humeral Fractures

Nonoperative treatment continues to be used for the majority of proximal humeral fractures.198,217,396 The majority of proximal humeral fractures are nondisplaced or minimally displaced and nonoperative treatment is indicated. The use of nonoperative treatment can be determined by assessing fracture stability. Fracture stability can be assessed both radiographically and clinically. Radiographically, stable fractures exhibit impaction or interdigitation between bone fragments (Fig. 37-23). Most frequently impaction occurs between the humeral head and the shaft at the level of the surgical neck (Fig. 37-24). Furthermore, in four-part valgus-impacted fractures, the humeral head is tilted into valgus thereby impacting the anatomic neck into the surrounding metaphysis (Figs. 37-5, 37-10, and 37-11). While the greater and lesser tuberosities are fractured, their periosteal sleeve remains intact thereby avoiding displacement by the pull of the rotator cuff muscles. 
Figure 37-23
Stable proximal humeral fractures through the anatomic neck.
 
(A–C) Case 1: A: AP view. B: Neer Y view. C: Axillary view. D–F Case 2: D: AP view. E: MRI coronal view, T1-weighted image. F: MRI coronal view, T2-weighted image. Note increased signal along the anatomic neck of the humerus and integrity of the rotator cuff.
(A–C) Case 1: A: AP view. B: Neer Y view. C: Axillary view. D–F Case 2: D: AP view. E: MRI coronal view, T1-weighted image. F: MRI coronal view, T2-weighted image. Note increased signal along the anatomic neck of the humerus and integrity of the rotator cuff.
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Figure 37-23
Stable proximal humeral fractures through the anatomic neck.
(A–C) Case 1: A: AP view. B: Neer Y view. C: Axillary view. D–F Case 2: D: AP view. E: MRI coronal view, T1-weighted image. F: MRI coronal view, T2-weighted image. Note increased signal along the anatomic neck of the humerus and integrity of the rotator cuff.
(A–C) Case 1: A: AP view. B: Neer Y view. C: Axillary view. D–F Case 2: D: AP view. E: MRI coronal view, T1-weighted image. F: MRI coronal view, T2-weighted image. Note increased signal along the anatomic neck of the humerus and integrity of the rotator cuff.
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Figure 37-24
Nonoperative treatment of proximal humerus fractures.
 
A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
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A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
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Figure 37-24
Nonoperative treatment of proximal humerus fractures.
A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
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A–E: 78-year-old female with two-part surgical neck fracture. A and B: AP and axillary views of the left shoulder. Note impaction of the shaft into the proximal humerus. The axillary view shows apex anterior angulation at the fracture site with partial anterior displacement of the shaft fragment. Complete displacement is however prevented by impaction and interdigitation of the fracture fragments. C, D, and E: AP, Neer and axillary views at 4 months after injury. Note early bony healing of the fracture. There has been no change in fracture alignment. F–K: 89-year-old female with a four-part valgus-impacted proximal humerus fracture. F: AP view on the day of injury. G and H: AP and axillary views at 3 months after nonoperative treatment. Note residual posterior displacement of the greater tuberosity. I: Forward elevation at 3 months after injury. J: Internal rotation at 3 months after injury. K: External rotation at 3 months after injury.
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Clinically, fracture stability may be assessed by palpating the proximal humerus just distal to the acromion with one hand, while rotating the arm at the elbow with the other. If the proximal humerus is felt to move as a unit with the distal segment, the fracture is considered stable. Crepitation may be palpated and if it is it suggests bony contact. Lack of crepitation and absence of synchronous motion between the distal and proximal segments on the other hand suggest fracture displacement. Although this examination may be possible in some patients surgeons should be aware that pain, obesity, and the presence of other injuries may preclude its use in many patients. Clinical and radiographic follow-up are required in the early phase of nonoperative treatment to monitor fracture displacement (Fig. 37-25). 
Figure 37-25
Two-part surgical neck fracture.
 
A and B: AP and axillary views of the right shoulder. Note comminution at the metadiaphyseal junction. Alignment and bony contact between the proximal segment and the shaft is however preserved. C and D: AP and axillary views taken 2 weeks after the initial injury seen in A and B: Immobilization in a sling had been established for nonoperative treatment. Note marked displacement of the proximal shaft secondary to pull of the pectoralis major tendon. The patient had noted a dramatic decrease of pain 2 day prior to these images being taken.
A and B: AP and axillary views of the right shoulder. Note comminution at the metadiaphyseal junction. Alignment and bony contact between the proximal segment and the shaft is however preserved. C and D: AP and axillary views taken 2 weeks after the initial injury seen in A and B: Immobilization in a sling had been established for nonoperative treatment. Note marked displacement of the proximal shaft secondary to pull of the pectoralis major tendon. The patient had noted a dramatic decrease of pain 2 day prior to these images being taken.
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Figure 37-25
Two-part surgical neck fracture.
A and B: AP and axillary views of the right shoulder. Note comminution at the metadiaphyseal junction. Alignment and bony contact between the proximal segment and the shaft is however preserved. C and D: AP and axillary views taken 2 weeks after the initial injury seen in A and B: Immobilization in a sling had been established for nonoperative treatment. Note marked displacement of the proximal shaft secondary to pull of the pectoralis major tendon. The patient had noted a dramatic decrease of pain 2 day prior to these images being taken.
A and B: AP and axillary views of the right shoulder. Note comminution at the metadiaphyseal junction. Alignment and bony contact between the proximal segment and the shaft is however preserved. C and D: AP and axillary views taken 2 weeks after the initial injury seen in A and B: Immobilization in a sling had been established for nonoperative treatment. Note marked displacement of the proximal shaft secondary to pull of the pectoralis major tendon. The patient had noted a dramatic decrease of pain 2 day prior to these images being taken.
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Indications/Contraindications

The indications and contraindications for nonoperative management are shown in Table 37-1. Nonoperative treatment is considered as the standard of treatment for nondisplaced, minimally displaced, and stable proximal humeral fractures. Several criteria for nonoperative treatment have been described in the past centering around patient age and mental and health status. 
 
Table 37-1
Non-Operative Treatment
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Table 37-1
Non-Operative Treatment
Indications Relative Contraindications
Stable nondisplaced or minimally displaced fractures Displaced fractures with loss of bony contact
Patients not fit for surgery
Elderly patients with low functional demand
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Techniques

Several immobilization techniques have been described for nonoperative treatment of proximal humeral fractures. Immobilization of the arm to the chest using a simple collar and cuff sling, Gilchrist or Velpeau type shoulder immobilizer is generally well tolerated by patients.114,341 Due to the pull of the pectoralis major tendon on the proximal shaft segment, placement of a pad in the axilla may help in aligning the fracture. Regardless of the type of nonoperative treatment method, close follow-up is required to confirm acceptable alignment and fracture stability. Weekly radiographs should be performed during the first month of treatment, followed by biweekly radiographs until 6 weeks after injury or initial callus formation is visible. Final radiographs are taken at 3 months to confirm union. 
Shoulder immobilization is used during the first 4 to 6 weeks after injury. From the beginning, patients are instructed to perform active range-of-motion exercises of the wrist and hand. Pain usually subsides within 2 weeks after injury to allow passive range-of-motion exercises of the shoulder. These should be performed four to six times per day with the help of an assistant. An initial session with a physical therapist can aid in instructing the patient and his or her assistant on how to perform the exercises. Fracture stability will guide the arc of allowable motion. Ideally, patients should be able to achieve 90 degrees of forward elevation and rotation from the hand placed on the chest to neutral with the hand pointing straight forward. During the first 2 to 3 weeks, passive range-of-motion exercises are best tolerated in the supine position. As the patient adapts to these exercises, they can be continued in the sitting or standing position. In addition, Codman pendulum exercises can be performed for passive range-of-motion exercises of the shoulder. The patient is instructed to lean forward while standing. The upper extremity is then allowed to freely dangle from the shoulder assisted by gravity. As much as 90 degrees of forward shoulder elevation can thereby be achieved. The upper extremity is then passively moved by turning the trunk in a circular manner letting the arm dangle like a pendulum. As bony union is achieved, active-assisted range-of-motion exercises are started at 6 weeks, with strengthening exercises starting 3 months after the injury according to radiographic and clinical healing. 

Outcomes

Stable nondisplaced or minimally displaced proximal humeral fractures can be reliably treated nonoperatively. A high union rate with satisfactory functional outcome can be achieved.198,217,396 Predictors for outcomes have been found to be age, the American Society of Anesthesia (ASA) classification and the AO/OTA fracture classification.15 
Nonoperative treatment has been further advocated for several displaced fractures. Court-Brown et al. studied 131 two-part surgical neck fractures in patients with a mean age of 73 years for females and 69 for males. At 1-year follow-up, patients under the age of 50 consistently achieved higher functional scores and regained the ability to return to shopping and housework. Nonoperative treatment yielded results similar to those of surgical treatment even in fractures with translation of 66% or more.78 
Court-Brown et al. further assessed nonoperative treatment of four-part valgus-impacted fractures in elderly patients. Good or excellent results were achieved in 81% of patients according to Neer’s criteria. Interestingly, patients subjectively rated their results above the objective evaluation of the physician. No difference was found in patients with and without greater tuberosity displacement. Function only decreased in the presence of combined surgical neck and greater tuberosity displacement and was mainly related to loss of flexion and abduction power.76 Hanson et al. evaluated the outcomes of nonoperative treatment in 75 one-part, 60 two-part, 23 three-part fractures, and 2 four-part or head-splitting fractures. Four patients required surgery due to displacement and five required arthroscopic subacromial decompression due to impingement. At 1 year after the fracture, the injured shoulders averaged an 8.2 point loss of Constant score and a 10.2 point loss of DASH scores compared to the contralateral shoulder. The highest variability in outcomes was found in patients with two-part fractures.159 
Kristiansen et al.224 randomized a group of two-, three-, and four-part fractures to either closed treatment or external fixation. Of 11 fractures treated nonoperatively, nonunion occurred in 2 surgical neck fractures and 2 greater tuberosity fractures, and 2 patients developed AVN of the humeral head after 1 year. Of 13 patients treated with external fixation that were followed for 1 year, one deep infection occurred, two fractures did not unite, and AVN was seen in one case. The median Neer score was 79 after external fixation and 60 after nonoperative treatment. Satisfactory or excellent results were achieved in only four patients in the nonoperative group compared to eight in the external fixation group. 
Several studies have shown results contradicting those of Kristiansen et al. Court-Brown et al. did not find an improvement in outcomes in displaced two-part fracture treated surgically versus those treated nonoperatively.78 Furthermore, in a randomized controlled study comparing nonoperative treatment with tension band fixation of three- and four-part fractures, Zyto et al. found higher Constant scores after nonoperative than after operative treatment. While no differences were found with regard to pain, range of motion, strength, and activities of daily living subscales, a higher proportion of complications were found after operative treatment, including infection, AVN, nonunion, post-traumatic arthritis, pulmonary embolus, and Kirschner-wire (K-wire) penetration.428 Similar results were found by Fjalestad et al., who found no differences in Constant scores when randomizing patients to either nonoperative treatment or locking plate fixation of three- and four-part proximal humeral fractures.114 Another recent randomized controlled trial could not establish significant differences in Constant and Simple Shoulder Test scores in patients undergoing either nonoperative treatment or hemiarthroplasty for four-part fractures. Although the surgically treated group had better pain scores at 3 months after surgery, no differences were seen at 1 year.42 Sanders et al. compared the results of three-part fractures treated with locking plate fixation to a matched nonsurgical control group.348 Better range of motion was found after nonoperative treatment, while no differences were found in patient satisfaction and in the ASES self-assessment score. Over half of operatively managed patients required additional treatment compared to only 11% in the nonoperative group. Similar results were found by Olerud et al. in a prospective randomized study comparing locked plate fixation with nonoperative treatment of three-part fractures.299 Complications in the operative group included screw perforation of the articular surface in 17%. Reoperation was required in 30% of patients. Malunion was however observed in 86% of patients treated nonoperatively. 
Using CT imaging, Foruria et al. observed fracture healing in 98% of fractures and excellent or satisfactory results as determined by Neer criteria in 75% of fractures treated nonoperatively. Patients with valgus impaction and a greater tuberosity fragment and those with varus impaction had the greatest loss of function as determined by both ASES and DASH scores.119 Jakob et al.187 and Court-Brown et al.,76 however had previously published favorable outcomes in valgus-impacted fractures. 
Hodgson et al. studied the timing of physical therapy for two-part proximal humeral fractures. The authors found that at 16 weeks after injury patients who started physical therapy within 1 week achieved greater function and less pain than those immobilized for a period of 3 weeks. Although functional differences at 52 weeks were not statistically significant, residual shoulder disability was slower to resolve, even 2 years after injury in patients with prolonged immobilization.179,244 
Despite the overall favorable outcomes published in the literature for nonoperative treatment of nondisplaced fractures, recent data suggests that marked functional impairment may occur, with over two-thirds of patients disclosing chronic pain.58 However, based on the published literature, nonoperative treatment appears to provide outcomes that are comparable to those of either operative fixation or hemiarthroplasty, even in displaced three- and four-part fractures.42,78,114,224,299,348,428 Several randomized controlled trials assessing nonoperative treatment are currently under way and will further help in determining the ideal treatment option for proximal humeral fractures.48,90,156,229 

Operative Treatment of Proximal Humeral Fractures

Surgical Approaches

Two surgical approaches are commonly used to perform open reduction and internal fixation (ORIF). These are the deltopectoral approach and the deltoid-splitting approach. 
Deltopectoral Approach.
The deltopectoral approach is considered the workhorse for reconstructive shoulder surgery. It is classically described as an incision starting over the coracoid process and advanced along the deltopectoral groove with subsequent identification and lateral reflection of the cephalic vein.181 In the authors’ experience, an incision starting over the clavicle directed over 1 to 2 cm lateral to the coracoid process toward a point at the midline of the anterior arm 2 cm distal from the axillary crease will allow improved exposure (Fig. 37-26). The deltopectoral interval is not always apparent, especially in patients with muscle atrophy or previous surgery. To identify the cephalic vein a full-thickness skin flap is developed medially at the proximal extent of the incision to about 1 to 2 cm medial to the coracoid process. At this level a fat triangle is invariably found with its base at the clavicle. The cephalic vein can be readily identified traveling from this triangle distally. Most textbooks recommend dissecting the interval by retracting the cephalic vein laterally, based on the fact that lateral tributary veins are more frequent than their medial counterparts. However, mobilizing the cephalic vein medially allows for improved exposure by avoiding proximal tethering of the cephalic vein when lateral retraction of the deltoid is required (Fig. 37-26). Once the deltopectoral interval has been developed the subdeltoid space is identified and freed from hypertrophic bursal tissue. At this point, depending on the time elapsed since injury, fracture hematoma, fibrous scar tissue, or early callus formation is encountered. Careful soft tissue management is required to avoid devascularization of the fracture fragments. Of particular importance is identification of the long head of the biceps on the anterior aspect of the proximal shaft as this will facilitate fracture identification and reduction and plate placement. The biceps tendon is easily identified by digital palpation just medial to the insertion of the pectoralis major tendon (Fig. 37-26). Because of its proximity to the ascending branch of the ACHA extensive dissection of this tendon should be avoided. However, the biceps tendon may have been injured with the fracture and a tenodesis may be required to remove a possible source of pain. Furthermore, the presence of the biceps tendon may make fracture reduction more difficult. 
Figure 37-26
Deltopectoral approach.
 
A: Image shows anterior aspect of the shoulder to the left. Incision is marked out 1 cm lateral to the coracoid (arrow). This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial. The incision starts at the level of the clavicle proximally and distally for approximately 10 cm. B: A fat triangle can be identified just distal to the clavicle helping identification of the deltopectoral interval. The interval is usually 1 cm medial to the coracoid (large arrow). The cephalic vein (small arrow) is retracted medially after coagulating lateral tributaries. C: The coracoid helps orientation (arrow). The pectoralis major (between left index finger and cautery tip) is identified. The long head of the biceps will be located just medial to it. D: The long head of the biceps is identified aiding in orientation and exposure of the fracture of the proximal humerus.
A: Image shows anterior aspect of the shoulder to the left. Incision is marked out 1 cm lateral to the coracoid (arrow). This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial. The incision starts at the level of the clavicle proximally and distally for approximately 10 cm. B: A fat triangle can be identified just distal to the clavicle helping identification of the deltopectoral interval. The interval is usually 1 cm medial to the coracoid (large arrow). The cephalic vein (small arrow) is retracted medially after coagulating lateral tributaries. C: The coracoid helps orientation (arrow). The pectoralis major (between left index finger and cautery tip) is identified. The long head of the biceps will be located just medial to it. D: The long head of the biceps is identified aiding in orientation and exposure of the fracture of the proximal humerus.
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Figure 37-26
Deltopectoral approach.
A: Image shows anterior aspect of the shoulder to the left. Incision is marked out 1 cm lateral to the coracoid (arrow). This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial. The incision starts at the level of the clavicle proximally and distally for approximately 10 cm. B: A fat triangle can be identified just distal to the clavicle helping identification of the deltopectoral interval. The interval is usually 1 cm medial to the coracoid (large arrow). The cephalic vein (small arrow) is retracted medially after coagulating lateral tributaries. C: The coracoid helps orientation (arrow). The pectoralis major (between left index finger and cautery tip) is identified. The long head of the biceps will be located just medial to it. D: The long head of the biceps is identified aiding in orientation and exposure of the fracture of the proximal humerus.
A: Image shows anterior aspect of the shoulder to the left. Incision is marked out 1 cm lateral to the coracoid (arrow). This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial. The incision starts at the level of the clavicle proximally and distally for approximately 10 cm. B: A fat triangle can be identified just distal to the clavicle helping identification of the deltopectoral interval. The interval is usually 1 cm medial to the coracoid (large arrow). The cephalic vein (small arrow) is retracted medially after coagulating lateral tributaries. C: The coracoid helps orientation (arrow). The pectoralis major (between left index finger and cautery tip) is identified. The long head of the biceps will be located just medial to it. D: The long head of the biceps is identified aiding in orientation and exposure of the fracture of the proximal humerus.
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Deltoid-Splitting Approach.
The deltoid-splitting approach is favored by several authors since it allows a direct approach through the fracture site between the greater and lesser tuberosities.131,132,133 To perform this approach a longitudinal incision or a shoulder strap incision is performed and the raphe between the anterior and middle deltoid identified.333 This interval is divided using a vertical 4 cm incision starting at the anterolateral corner of the acromion.132,226,375 The axillary nerve can be identified by digital palpation on the undersurface of the deltoid traveling from posterior to anterior at an average of 5 cm distal to the acromion. A stay suture is placed at the inferior aspect of the split to avoid inadvertent propagation distally thereby protecting the axillary nerve (Fig. 37-27). Since the nerve crosses the anterior raphe as a single branch innervation of the anterior deltoid can be preserved by protecting it during dissection.131,132,133,333 Once identified, the raphe may be further split distal to the nerve to allow access to the lateral shaft for plate placement. Alternatively, a minimally invasive approach, using only the split above the nerve and percutaneously placed screws can be used. 
Figure 37-27
Deltoid split.
 
Anterolateral approach starting at the tip of the acromion. Note stay suture 5 cm from the acromion tip to avoid splitting of the deltoid and subsequent damage to the anterior branch of the axillary nerve. Sutures exiting the split can be seen. These provide additional fixation between the rotator cuff tendons and the implanted locking plate.
Anterolateral approach starting at the tip of the acromion. Note stay suture 5 cm from the acromion tip to avoid splitting of the deltoid and subsequent damage to the anterior branch of the axillary nerve. Sutures exiting the split can be seen. These provide additional fixation between the rotator cuff tendons and the implanted locking plate.
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Figure 37-27
Deltoid split.
Anterolateral approach starting at the tip of the acromion. Note stay suture 5 cm from the acromion tip to avoid splitting of the deltoid and subsequent damage to the anterior branch of the axillary nerve. Sutures exiting the split can be seen. These provide additional fixation between the rotator cuff tendons and the implanted locking plate.
Anterolateral approach starting at the tip of the acromion. Note stay suture 5 cm from the acromion tip to avoid splitting of the deltoid and subsequent damage to the anterior branch of the axillary nerve. Sutures exiting the split can be seen. These provide additional fixation between the rotator cuff tendons and the implanted locking plate.
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The deltoid-splitting approach has two major disadvantages. In anteroinferior fracture dislocations, the humeral head fragment may not be accessible through this approach. In addition, the terminal anterior branch of the axillary nerve may be inadvertently damaged thereby leading to potential deltoid dysfunction. 

Plate and Screw Fixation

ORIF is the most frequently used method of surgical treatment of proximal humeral fractures.24 Direct exposure of the fracture site offers the advantages of allowing direct fragment manipulation and visualization of reduction and implant position. However, surgical dissection may jeopardize fracture biology thereby potentially interfering with healing and increasing the risk of AVN of the humeral head.223,387 Careful soft tissue management and judicious debridement should therefore be followed. Despite the advantage of direct visualization and access to the fracture site, ORIF requires a clear understanding of fracture geometry and deforming forces to aid in fracture manipulation in a manner similar to that of closed reduction techniques. Furthermore, ORIF should be performed with the assistance of fluoroscopic vision to verify fracture reduction and allow adequate hardware placement (Fig. 37-28). 
Figure 37-28
Intraoperative views of plate and screw fixation of a proximal humerus fracture.
 
A: AP view. B: Lateral view of the proximal humerus. Note that the screw tips are kept short of the subchondral bone to prevent secondary perforation.
A: AP view. B: Lateral view of the proximal humerus. Note that the screw tips are kept short of the subchondral bone to prevent secondary perforation.
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Figure 37-28
Intraoperative views of plate and screw fixation of a proximal humerus fracture.
A: AP view. B: Lateral view of the proximal humerus. Note that the screw tips are kept short of the subchondral bone to prevent secondary perforation.
A: AP view. B: Lateral view of the proximal humerus. Note that the screw tips are kept short of the subchondral bone to prevent secondary perforation.
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The most widely used approach for ORIF is the deltopectoral approach. This approach has the advantage of allowing the surgeon to work through an internervous plane with a wide exposure. Furthermore, this approach allows the surgeon to convert from ORIF to hemiarthroplasty if required. The deltopectoral approach however requires significant soft tissue dissection to gain access to the lateral aspect of the proximal humerus for fracture reduction and plate placement. While several factors may affect humeral head vascularity after a proximal humerus fracture, the extensive surgical dissection required for ORIF through a deltopectoral approach has been suggested to play a role.223,387 An extended anterolateral deltoid-splitting approach has gained increasing popularity over the last decade as a less invasive and more biologically sound approach.131,133,134 While some debate exists regarding the clinical benefits of the anterolateral approach,168,420 it does allow a more direct access to the greater tuberosity133 and to the area between the greater and lesser tuberosities, just lateral to the bicipital groove.99 This allows for a more direct manipulation of the humeral head, as well as allowing plate and screw placement in line with the incision. However, the potential for injury to the anterior branch of the axillary nerve is its main disadvantage, as it may lead to anterior deltoid dysfunction. 
Multiple methods of ORIF have been developed since the advent of operative treatment of proximal humeral fractures. The most widely used methods have historically been tension band wiring and plate and screw fixation.3,4,5,6,12,14,26,31,32,47,49,52,56,62,67,74,80,85,86,91,92,96,101,105,107,108,110,111,112,114,116,118,121,123,127,130,131,132,133,134,139,140,151,152,155,158,160,162,164,166,167,168,169,171,172,174,176,177,178,185,190,191,199,200,201,203,206,208,209,210,211,215,216,223,226,228,229,231,232,238,350,252,253,354,260,261,263,268,273,279,288,295,296,299,300,302,303,304,305,407,309,311,312,316,322,327,332,337,338,339,340,342,345,347,348,349,353,355,356,360,366,370,373,374,375,376,377,378,384,385,386,388,397,398,400,403,406,412,415,422,423,426,428 Tension band wiring relies on incorporating the rotator cuff to neutralize the deforming forces. Wire or suture fixation through the entheses of the rotator cuff has the advantage of not relying on weak osteoporotic bone which is frequently seen in patients with these fractures but on stronger tendinous tissue.12 
Over the last 50 years compression plate and screw fixation has become the standard of care for treatment of several diaphyseal fractures as well as fractures of the distal humerus. Several studies have reported satisfactory healing rates and functional outcomes after conventional plate and screw fixation of proximal humeral fractures, especially in younger patient populations.108,273,350,355,415,422 Favorable outcomes have been reported even with minimal hardware using a combination of nonlocking third tubular plate fixation and suture tension band fixation for three- and four-part fractures.169 Other studies have however reported high rates of infection, humeral head necrosis, and subacromial impingement.223,306,392,412 Furthermore, high rates of postoperative displacement and varus collapse have been reported, especially in elderly patients and three- and four-part fractures.171,176 The inability of conventional plates and screws to resist varus deforming forces in the proximal humerus, particularly if the bone is osteoporotic, has led to locking plate fixation being used for these fractures. Unlike conventional screws and plates, locking plate technology allows for angular stability between the screws and plate. Biomechanical data has shown that constructs using locking plates are significantly stronger and more resilient than those using nonlocking screws, blade plates, and IM nails.100,244,366,356 Several clinical studies have shown high rates of healing and excellent functional recovery with proximal humerus locking plates.5,32,110,112,216,226,260,309,316,228,360 This has led to multiple precontoured proximal humerus plates becoming available in the market. Plate designs vary in terms of the number of proximal screws and their arrangement, as well as the ability to place screws at different angles with regard to the plate31,32,105,110,208,338,347,406 
Preoperative Planning.
As for any type of treatment, planning for ORIF of proximal humeral fractures requires a detailed understanding of fracture configuration. This is best achieved with a standard radiographic trauma series and CT scanning with 3D surface renderings. In many instances, preoperative assessment of fracture morphology and patient-related factors for AVN can reliably establish if the fracture will require reconstruction or replacement of the humeral head. Frequently, however, the final decision will be made intraoperatively. It is therefore recommended that, especially in complex fractures, a prosthesis be available at the time of ORIF. If ORIF is the planned procedure, a deltoid-splitting approach may be used. In equivocal cases, a deltopectoral approach is however recommended. 
A preoperative planning checklist is given in Table 37-2. Careful patient positioning and preoperative verification of adequate radiographic imaging are important to allow for accurate intraoperative assessment of fracture reduction and hardware placement. Clearance of the humeral head and glenoid from underlying radiopaque structures should be assured. EKG leads, side rails, and tubing may interfere with obtaining an unobstructed radiographic view of the fracture during surgery. 
 
Table 37-2
Open Reduction and Internal Fixation
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Table 37-2
Open Reduction and Internal Fixation
Preoperative Planning Checklist
  •  
    OR Table: Standard (beach chair) or radiolucent table (supine)
  •  
    Position/positioning aids:
    •  
      Beach chair: Head holder/shoulder positioner, hip positioner at thigh. Waist flexed 45 degrees, knees bent 30 degrees.
    •  
      Supine: Bump under ipsilateral scapula, rotating the trunk 30 degrees toward the injured side. Use of a plexiglass sheet under patients torso and protruding 30 cm of lateral border of the table underneath the injured shoulder may aid in positioning, especially on narrow radiolucent tables and with large patients.129
    •  
      Shoulders draped free to the level of medial scapular border
  •  
    Fluoroscopy location:
    •  
      Beach chair: At head of patient, coming in line with long axis of the bed.
  •  
    Supine on radiolucent table (Jackson): Entering perpendicular to table from opposite to operative extremity.
  •  
    Equipment:
    •  
      Large- and small-pointed reduction clamps (Weber)
    •  
      Power wire driver and drill
    •  
      Proximal humerus plating system (locking and nonlocking screws)
    •  
      2.5-mm terminally threaded Kirschner wires
    •  
      2.5/4.0 mm Schantz pins
    •  
      3.5 cannulated screw set
    •  
      Small drill or wire sleeve
    •  
      Small bone hook
    •  
      Blunt narrow periosteal elevator, bone tamp
    •  
      Mallet
X
A detailed understanding of the implant is important to allow adequate plate and screw placement. Too proximal plate placement should be avoided, as it will lead to subacromial impingement. The plate should be placed to allow for two screws to be directed from the plate toward the inferomedial aspect of the humeral head. Furthermore, the plate should be positioned in such a way that it does not impinge on the long head of the biceps. Varying distances from the bicipital groove will be recommended depending on the selected implant. 
Plate length should be selected on the basis of the comminution at the metadiaphyseal level. While there is no biomechanical data regarding how many diaphyseal screws should be used we routinely use three bicortical screws. In fractures with extensive diaphyseal extension customized plates may have to be specifically ordered to achieve this goal. 
Positioning.
Adequate patient positioning will allow unhindered fracture reduction, fluoroscopic visualization, and implant placement. Fluoroscopic AP and lateral views are performed before draping to confirm adequate visualization and accurately identify anatomic landmarks and fracture fragments. 
ORIF can be performed in the beach chair position or supine on a radiolucent table. 
Beach Chair Position. 
The beach chair position is most easily obtained with a special shoulder positioner that includes a head holder (Fig. 37-29). The shoulder should be accessible to the level of the medial border of the scapula posteriorly and the angle of the jaw superiorly. The bed is flexed 45 degrees at the waist and the knees bent 30 degrees. The C-arm is positioned at the head of the patient entering along the side of the table. Draping of the iliac crest should be performed if autograft is required (Fig. 37-29). 
Figure 37-29
Patient positioning.
 
Beach chair. A: A head holder is required to safely maintain control of the head during surgery. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm. B and C: If iliac crest bone graft is required as in this surgical neck nonunion, the contralateral iliac crest is prepared and draped. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm.
Beach chair. A: A head holder is required to safely maintain control of the head during surgery. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm. B and C: If iliac crest bone graft is required as in this surgical neck nonunion, the contralateral iliac crest is prepared and draped. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm.
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Figure 37-29
Patient positioning.
Beach chair. A: A head holder is required to safely maintain control of the head during surgery. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm. B and C: If iliac crest bone graft is required as in this surgical neck nonunion, the contralateral iliac crest is prepared and draped. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm.
Beach chair. A: A head holder is required to safely maintain control of the head during surgery. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm. B and C: If iliac crest bone graft is required as in this surgical neck nonunion, the contralateral iliac crest is prepared and draped. Intraoperative imaging can be obtained with a mini-C-arm (as seen) or a standard C-arm.
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In the beach chair position, the use of a specialized arm holder may be of help in positioning the upper extremity during imaging, fracture manipulation and plate placement. This is particularly useful if the procedure is performed with only one assistant (Fig. 37-30). Alternatively, a padded Mayo stand can be used. 
Figure 37-30
Beach chair position for deltoid-splitting approach.
 
The use of an arm holder can aid in intraoperative positioning.
The use of an arm holder can aid in intraoperative positioning.
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Figure 37-30
Beach chair position for deltoid-splitting approach.
The use of an arm holder can aid in intraoperative positioning.
The use of an arm holder can aid in intraoperative positioning.
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Supine Position. In the supine position, the torso may be tilted 30 degrees toward the injured side using a bump or wedge. A 70 × 40 × 1 cm plexiglass sheet may be placed under the patient’s torso so that it protrudes about 30 cm under the injured extremity. This allows the patient’s flank to be placed in line with the lateral border of the table, while supporting the arm during surgery.129 When the supine position is used on a radiolucent tabletop such as the Jackson OSI, the C-arm is ideally brought in perpendicular to the table from the opposite side. When a cantilever-type radiolucent table is used, the image intensifier is best placed parallel to the operating table. 
Surgical Approach.
Either the deltopectoral approach or a deltoid-splitting approach may be used. 
Technique.
The surgical technique is outlined in Table 37-3. Once the fracture site has been identified, the fracture lines should be exposed by limited periosteal elevation to allow assessment of fracture reduction. Careful preservation of the soft tissues is important for two reasons. Firstly it will reduce the risk of AVN and nonunion and secondly it will facilitate fracture reduction, by leaving intact periosteal sleeves to guide fragment position. The ultimate goal of proximal fracture fixation is to achieve stability of the reduced fragments. This is achieved by reducing the medial aspect of the surgical or anatomic neck and by approximating the tuberosities around the humeral head. Once this is achieved the hardware will function by sharing the load with the reconstructed proximal humerus, rather than having to support and bear the weight on its own. 
 
Table 37-3
Open Reduction and Internal Fixation
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Table 37-3
Open Reduction and Internal Fixation
Surgical Technique
  •  
    Verify adequate fluoroscopic visualization of AP and lateral views
  •  
    Expose proximal humerus
  •  
    Identify and tag tuberosities through cuff tendons
  •  
    Reduce humeral head
  •  
    Reduce tuberosities
  •  
    Manipulate shaft to reduce surgical neck
  •  
    Obtain temporary fixation with pins and transtendinous sutures
  •  
    Confirm reduction
  •  
    Place plate lateral to biceps groove and sufficiently inferior to avoid subacromial impingement
  •  
    Place two proximal screws
  •  
    Place single shaft screw
  •  
    Verify correction of apex anterior angulation at surgical neck
  •  
    Place second shaft screw
  •  
    Complete proximal and distal fixation
  •  
    Thread tuberosity sutures through plate holes and tie
  •  
    Confirm adequate screw length, stability, and absence of impingement with live fluoroscopy
  •  
    Irrigate and close
X
Identifying the biceps tendon will aid in locating the bicipital groove and correlating its position with the fracture morphology as shown on the preoperative images. Reduction of the tuberosities is achieved by placing strong sutures through the distal tendons of the rotator cuff for fragment manipulation. The greater tuberosity is controlled by two separate sutures placed into the infra- and supraspinatus tendons, while the lesser tuberosity is controlled with a suture placed through the subscapularis tendon (Fig. 37-31). Reduction of the humeral head is obtained by correcting varus–valgus angulation. In three- and four-part valgus-impacted fractures, the humeral head has to be disimpacted from the lateral proximal humeral metaphysis (Fig. 37-32). This should be done with gentle manipulation using an elevator though the split between the greater and lesser tuberosities, while longitudinal traction on the arm is applied. Once the position of the head has been corrected, the tuberosities can be reduced to their anatomic positions. In three-part greater tuberosity fractures, manipulation of the subscapularis allows for correction of an internal rotation deformity of the humeral head, while an elevator may be used to correct a flexion deformity. Temporary K-wire fixation is frequently used for initial stabilization of the fracture fragments. These may follow patterns similar to those of percutaneous pin fixation and should be outside of the planned position of the plate. In two-part proximal humeral fractures a K-wire placed into the shaft segment anterior to the biceps tendon can be helpful as a temporary anchor to tension the rotator traction sutures and provide preliminary fixation. 
Figure 37-31
Sutures through the rotator cuff tendons can aid in obtaining control of the proximal fragments.
 
Incorporation of sutures into the final construct may provide additional stability.
Incorporation of sutures into the final construct may provide additional stability.
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Figure 37-31
Sutures through the rotator cuff tendons can aid in obtaining control of the proximal fragments.
Incorporation of sutures into the final construct may provide additional stability.
Incorporation of sutures into the final construct may provide additional stability.
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Figure 37-32
Three-part greater tuberosity proximal humerus in a 42-year-old female.
 
A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
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A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
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Figure 37-32
Three-part greater tuberosity proximal humerus in a 42-year-old female.
A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
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A, B, C: Subtle displacement at the inferomedial aspect of the humeral neck differentiates this injury from a two-part greater tuberosity fracture. D and E: 3D reconstructions confirming fracture geometry. F–H: Final reduction and fixation. Note residual impaction of the lateral anatomic neck.
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Once preliminary fixation has been achieved, AP and lateral views are obtained by turning the arm in a 90-degree arc. Reduction of the medial proximal humeral metaphysis should be carefully confirmed as well as the correction of an apex anterior deformity at the level of the surgical neck. A plate is then selected to allow at least three screws to be placed into the distal shaft segment. The plate position is also selected to avoid subacromial impingement135 and to allow two screws to be placed into inferomedial aspect of the humeral head. In the sagittal plane, the plate is placed posterior to the biceps tendon to avoid impingement with this structure and to allow adequate positioning of screws into the humeral head (Fig. 37-33). Once final plate placement has been defined, two locking screws are placed into the proximal segment. Rotational alignment is again verified and a single screw is placed into the shaft segment. At this point, angular correction will still be possible through rotation around this single shaft screw. Final verification of adequate reduction of angulation of the surgical neck is performed on the lateral view and a second shaft screw is placed. Subsequently, a minimum of five or six screws are routinely placed into the proximal segment. Screw placement should be performed by drilling through the near cortex only and then using a depth gauge as a sound until subchondral bone is palpated. This avoids inadvertent perforation of the articular surface, theoretically reducing the possibility of secondary screw penetration.26 While biomechanical studies have suggested that the screw tips be placed in subchondral bone to achieve greatest stability,243 it is recommended that shorter screws be used to decrease the risk of late head penetration and glenoid damage191 (Fig. 37-28). 
Figure 37-33
Ideal plate placement.
 
Multiple plate designs are available. Plate position should avoid impingement onto the bicipital groove and allow placement of three bicortical screws at the level of the humeral shaft and proximal screw(s) into the medial calcar region of the proximal humerus.
Multiple plate designs are available. Plate position should avoid impingement onto the bicipital groove and allow placement of three bicortical screws at the level of the humeral shaft and proximal screw(s) into the medial calcar region of the proximal humerus.
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Figure 37-33
Ideal plate placement.
Multiple plate designs are available. Plate position should avoid impingement onto the bicipital groove and allow placement of three bicortical screws at the level of the humeral shaft and proximal screw(s) into the medial calcar region of the proximal humerus.
Multiple plate designs are available. Plate position should avoid impingement onto the bicipital groove and allow placement of three bicortical screws at the level of the humeral shaft and proximal screw(s) into the medial calcar region of the proximal humerus.
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Several reduction techniques have been described to achieve adequate fracture reduction. One of these involves the use of a 2- or 2.7-mm K-wire placed through the most proximal hole of the plate into the humeral head. The K-wire is then used to manipulate the head until adequate alignment has been achieved and the plate fixed onto the proximal segment.332 This technique requires a good understanding of where to place the K-wire as it will define plate position in both the craniocaudal dimension and in the sagittal plane. Nonlocking screws can be used to pull the shaft segment onto the plate, thereby aiding in correcting any residual malalignment and achieving cortical plate apposition. 
Once the plate and screws have been placed transtendinous sutures are tied onto the plate to provide additional fixation (Fig. 37-34). Most modern plate designs offer special holes for this purpose. The fracture is then taken through functional range of motion of the shoulder to confirm stability and absence of impingement. Under live fluoroscopy, screw position should be carefully checked to rule out humeral head perforation. 
Figure 37-34
Final plate placement through a deltopectoral approach.
 
Note transtendinous sutures threaded through the plate to reinforce the construct.
Note transtendinous sutures threaded through the plate to reinforce the construct.
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Figure 37-34
Final plate placement through a deltopectoral approach.
Note transtendinous sutures threaded through the plate to reinforce the construct.
Note transtendinous sutures threaded through the plate to reinforce the construct.
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The use of IM fibular strut grafting has been described to improve stability of varus-impacted fractures in which the medial calcar may not be reliably reconstructed. Several techniques have been described, with the common goal being to create a buttress at the inferior aspect of the anatomic neck to prevent delayed varus collapse13,64,130,288 (Fig. 37-35). 
Figure 37-35
 
A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
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A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
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Figure 37-35
A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
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A, B, C: Thirty-two-year old male with a high-energy two-part surgical neck fracture of the proximal humerus. D: Posteromedial comminution is present, raising concern about possible delayed displacement after fixation. F and G: Intraoperative fluoroscopy views showing reduction and fixation using a combination of and intramedullary cortical strut and plate and screw fixation. H and I: Radiographic follow-up 6 months after surgery.
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If a minimally invasive approach is selected using a deltoid split, distal screw fixation into the humeral shaft is achieved through stab incisions. These should be placed in such a manner that injury to the axillary nerve is avoided. This has also to be taken into account for screw placement into the inferior aspect of the proximal segment, as screw trajectory may be in line with the axillary nerve.338,349,375 Special aiming jigs have been developed to aid with plate insertion and safe screw placement.338,349 
Postoperative Care.
Patients are followed at 2 weeks, 6 weeks, and 3 months after surgery. Patients are immobilized for 6 weeks in a sling while active range-of-motion exercises of the elbow, wrist, and hand are encouraged. Depending on the fracture pattern and stability that was achieved, passive range of motion is started between 2 and 4 weeks after surgery with forward elevation, external rotation, and pendulum exercises. If healing has adequately progressed both clinically and radiographically at 6 weeks active-assisted range of motion is started. 
Potential Pitfalls and Preventive Measures.
These are listed in Table 37-4. Despite their theoretical advantages, recent data has shown that locking plates can carry a significant rate of complications including screw back out, screw cut out, plate failure, malunion, and nonunion52,67,101,263,305,342,388,373,378,397 which frequently require reoperation.62,105,178 Several factors have been associated with loss of reduction with locking plates, including preoperative varus deformity, advanced age, smoking, varus malreduction, failure to incorporate the rotator cuff to the construct with tension bands, and inadequate medial support.4,135,218,232,239,268,279,302,303,304,305,378,360,377 
 
Table 37-4
Open Reduction and Internal Fixation
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Table 37-4
Open Reduction and Internal Fixation
Potential Pitfalls and Preventions
Pitfall Preventions
Vascular disruption of the proximal humerus Careful dissection.
Atraumatic manipulation of the humeral head, especially in four-part fractures.
Minimize medial retraction around the humeral neck.
Malreduction Sequential confirmation of adequate reduction in two planes under fluoroscopic vision.
Subacromial impingement Verify plate placement using guides and fluoroscopic vision.
Confirm placement after preliminary fixation and before definitive screw placement.
Achieve adequate tuberosity reduction.
Head screw perforation/penetration Avoid self-drilling screws.
Drill through lateral cortex only, use depth gauge as sound, stopping at subchondral bone. Select a screw 4 mm shorter than measured.
Loss of fixation Achieve reduction of medial humeral metaphysis.
Confirm adequate placement in the sagittal plane to enable correct screw placement into humeral head.
Achieve adequate reduction of tuberosities.
Incorporate sutures around rotator cuff tendons into plate construct.
Select appropriate screw length and number both into the head and into the shaft.
Assure adequate engagement of locking screw into plate.
Glenoid erosion from perforating/penetrating screws Intraoperatively, detailed assessment of screws in humeral head under “live” dynamic fluoroscopic view.
Postoperatively, careful monitoring of head subsidence and possible cut out. Early screw removal if penetrating.
Axillary nerve injury If using deltoid split, place stay sutures to avoid inadvertent distal propagation of window.
During percutaneous screw placement avoid high risk holes
Verify plate placement underneath the axillary nerve before initial screw placement.
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Südkamp et al. found that over half of complications associated with proximal humeral locking plate fixation occurred intraoperatively. Primary screw perforation of the humeral head was the most common complication. The frequency of screw penetration was increased in cases of fracture collapse and secondary penetration388 (Fig. 37-36). Careful selection of screw length is therefore advised. Furthermore inadvertent head penetration while drilling should be avoided as this creates a path for easier head perforation.67 
Figure 37-36
 
A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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Figure 37-36
A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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A–I: Thirty-six-year old male with four-part valgus-impacted fracture dislocation of the right proximal humerus managed with open reduction and locking plate fixation. J–M: At 8 months head collapse leads to secondary screw penetration. N–Q: After removal of hardware progressive head collapse occurs with severe humeral head necrosis.
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Gardner et al.135 demonstrated the impact that the absence of medial support has on subsequent loss of reduction, increased rate of screw perforation, and overall loss of height by critical retrospective appraisal of radiographs of proximal humeral fractures treated with locked plates. The importance of the medial support was also demonstrated in a study by Yang et al. who showed that in a prospective observational study of 64 consecutive patients treated with a locking proximal humerus plate, those with an intact medial support had significantly better functional outcomes at 1 year (Constant score of 81 [medial support] vs. 65 [no medial support], p = 0.002).423 
Treatment-Specific Outcomes.
Tables 37-5 and 37-6 detail the outcomes for plate and screw fixation of proximal humeral fractures in a number of studies. Table 37-5 shows the results in a number of published studies and Table 37-6 shows the main complications in the same studies. It shows that despite the advent of locking plates, complications after plate and screw fixation of proximal humerus fracture continue to be high. Complications of varus collapse and hardware loosening of conventional screws and plates appear to have been replaced by screw penetration and cutout in locked plates.388,389 Several studies report good-to-excellent outcomes after locked plate fixation,52,114,151,209,226,388,406,426 but others report only fair results.178,279,300 Interestingly, some studies have shown no advantage of locked plate fixation over nonoperative treatment of displaced proximal humeral fractures with regard to range of motion and functional scores.299,348 Similar outcomes have also been reported for treatment using intamedullary nail fixation,151 whereas others have shown significantly better ASES scores, pain scores, and strength after locked plate fixation, with the disadvantage of higher complication rates.426 Furthermore, similar results have been reported between ORIF and hemiarthroplasty in complex proximal humeral fractures, as long as adequate reduction and stable fixation is achieved after ORIF.21 Other authors have however found significantly higher Constant scores after locked plate fixation than after hemiarthroplasty.378 According to the most recent Cochrane Review, little evidence exists to support ORIF versus other treatment modalities in displaced proximal humeral fractures.157 
Table 37-5
Published Results of the Treatment of Proximal Humeral Fractures with Plates. Where Possible the Fracture Types are Defined by the Neer Classification with Two-, Three- and Four-Part Fractures and Fracture Dislocation (FD) and Head-Splitting (HS) Fractures
Fracture Type (Neer parts) Age (years) Follow-up (months)
Authors Technique 2 3 4 FD HS Mean (Range) Mean (Range) Outcome Scores Results
Esser202,233 Plate 0 17 8 6 55 (19–62) 74 (12–144) ASES 92% Ex/Good
Hessmann et al.171 Plate 50 37 11 5 (30–80) 34 (24–72) Constant 69% Ex/Good
Hinterman et al.176 Blade plate 0 31 7 72 (52–92) 41 (29–54) Constant 79% Ex/Good
Wijgman et al.415 Plate/wire 0 22 11 27 48 (19–79) 120 (48–264) Constant 87% Ex/Good
Wanner et al.412 Plate 10 33 17 62 (17–89) 17 (6–42) Constant Fair (average)
Machani et al.253 Locking plate 19 37 6 61 (19–76) 19 (11–39) HSS 60% Ex/Good
Meier et al.263 Plate 4 13 19 69 (23–88) 22 (13–28) Constant Fair (average)
Hirschmann et al.178 Locking plate 31 47 41 68 12 Constant Fair (average)
Moonot et al.279 Locking plate 0 20 12 60 (18–87) 11 (3–24) Constant Fair (average)
Laflamme et al.226 Locking plate 17 10 0 (Valgus fractures) 64 (38–88) 19 (12–34) Constant/UCLA Good (average)
Helwig et al.164 Locking plate 34 38 8 7 64 (16–93) 27 (12–73) Constant/UCLA/DASH 60% Ex/Good
Brunner et al.52 Locking plate 45 66 35 7 4 65 (19–94) 84% for 1 year Constant Good (average)
Südkamp et al.388 Locking plate 187 63 83% for 1 year Constant Good (average)
Gradl et al.151 Locking plate 26 30 16 4 63 12 (12–14) Constant/DASH Good (average)
Olerud et al.300 Locking plate 50 0 0 75 (55–93) 24 Constant/DASH Fair (average)
Yang et al.423 Locking plate 8 32 24 62 18 (14–38) Constant 48% Ex/Good
Zhu et al.426 Locking plate 26 0 0 51 36 Constant/ASES Excellent (average)
Röderer et al.340 Locking plate 107 66 (18–91) 10 (6–12) IADL
Olerud et al.299 Locking plate 0 27 0 72 (56–92) 24 minimum Constant/DASH/EG-5D Fair (average)
Voigt et al.406 Locking plate 0 48 8 74 (60–87) 86% for 1 year Constant/SST/DASH Good (average)
Konrad et al.209 Locking plate 153 65 86% for 1 year Constant/Neer Excellent (average)
Fjalestad et al.114 Locking plate 0 13 12 72 (60–86) 12 Constant/ASES Good (average)
Fankhauser et al.110 Locking plate AO/OTA A (4) B(15) C(9) 64 (28–82) 12 Constant Good (average)
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Table 37-6
The Complications Published in the Papers Detailed in Table 37-5
%
Authors Technique Revision Surgery AVN Implant Loosening Joint Penetration Infection Nerve Injury Nonunion OA Dislocation Malunion Subacromial Impingement
Deep Super
Esser202,233 Plate 0 0 4 16
Hessmann et al.171 Plate 9 4 3 1 1 15
Hinterman et al.176 Blade plate 21 5 3 8 8
Wijgman et al.415 Plate/wire 0 37 3
Wanner et al.412 Plate 12 3 5 2 3
Meier et al.263 Plate 28 0 25 6 3
Machani et al.253 Locking plate 0 0 13 10 8 3
Hirschmann et al.178 Locking plate 22 3 4 1 2 12
Moonot et al.279 Locking plate 13 3 9 3 3 6 3
Laflamme et al.226 Locking plate 7 0 33
Helwig et al.164 Locking plate 0 17 16 13 6 1
Brunner et al.52 Locking plate 25 8 40 1 1 3 3
Südkamp et al.388 Locking plate 19 4 12 21 2 1 2 2
Gradl et al.151 Locking plate 13 3 7 8 12
Olerud et al.300 Locking plate 16 0 19 28 2 2
Yang et al.423 Locking plate 13 3 5 8 3 3
Zhu et al.426 Locking plate 19 0 19
Röderer et al.340 Locking plate 33 5 9 19 3
Olerud et al.299 Locking plate 30 10 39 29 7 4 7
Voigt et al.406 Locking plate 21 10 27 17
Konrad et al.209 Locking plate 16 1 23 15 1 1 1
Fjalestad et al.114 Locking plate 16 8 4 28 12
Fankhauser et al.110 Locking plate 8 8 8 4 8 12 12
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Several ongoing studies are comparing the results of ORIF with nonoperative treatment as well as arthroplasty.48,156,229,403 These will help to guide the orthopedic surgeon in the treatment of proximal humeral fractures. 

Tension Band Fixation

Tension band fixation has been used in the treatment of proximal humeral fractures for several decades.285 Several techniques of tension band fixation have been described in the literature using steel wire or either absorbable monofilament or nonabsorbable braided suture.74,85,92,162,169,185,231,295,311,428 While tension band fixation is most frequently used as an adjunct to plates and screw fixation, IM nailing, and arthroplasty,12,74,85,169,219,310,407 satisfactory clinical outcomes can be obtained when used as the sole fixation method.74,85,92,162,169,185,231,295,311,428 
The main goal of tension band fixation is the neutralization of tension forces generated by the rotator cuff at the level of the tuberosities, and bending at the level of the surgical neck. Based on the load-sharing properties of tension band fixation, neutralization of tension forces on the surface of the proximal humerus will generate compression between fragments during motion, thereby promoting healing and allowing early rehabilitation. As described by Hertel, the humeral head can be conceptualized as a thin shell of subchondral bone with negligible bony structure inside its volume. Stabilization of this fragment in multifragmentary proximal humeral fractures relies mainly on peripheral loading of the rim of the head onto the surrounding tuberosities, in the same manner an empty eggshell can be held in an egg cup.169 In most instances in which the anatomic neck of the proximal humerus is affected, the tuberosities are separated, and hence the egg cup is broken. The purpose of tension band fixation is to create a cohesive egg cup by linking the tuberosities against each other thereby allowing support to the humeral head (Fig. 37-37).169 
Figure 37-37
From Hertel169.
 
In proximal humerus fractures, the tuberosities hold the humeral head in a manner similar to an egg cup holding the shell of an egg. By restoring stability between the two broken shells of the cup (greater and lesser tuberosity fragments-A), the head can theoretically be held without major fixation to the head being required (B).
In proximal humerus fractures, the tuberosities hold the humeral head in a manner similar to an egg cup holding the shell of an egg. By restoring stability between the two broken shells of the cup (greater and lesser tuberosity fragments-A), the head can theoretically be held without major fixation to the head being required (B).
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Figure 37-37
From Hertel169.
In proximal humerus fractures, the tuberosities hold the humeral head in a manner similar to an egg cup holding the shell of an egg. By restoring stability between the two broken shells of the cup (greater and lesser tuberosity fragments-A), the head can theoretically be held without major fixation to the head being required (B).
In proximal humerus fractures, the tuberosities hold the humeral head in a manner similar to an egg cup holding the shell of an egg. By restoring stability between the two broken shells of the cup (greater and lesser tuberosity fragments-A), the head can theoretically be held without major fixation to the head being required (B).
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The main challenge is to place the sutures or wires of the tension band through tissue that will resist loading of the proximal humerus during early rehabilitation. While some authors have described transosseous placement of wires or sutures, this may fail, especially in elderly, osteoporotic patients. Placement of sutures into the stronger distal segment of the rotator cuff tendons should provide more secure fixation. 
The main advantage of tension band fixation is the minimal amount of hardware that is required. This can potentially reduce the risk of implant-related subacromial impingement. Furthermore, if used as the sole method of fixation, no risk of penetration into the humeral head exists. However, compared to percutaneous techniques, tension band fixation requires open fracture exposure, thereby theoretically increasing the risk of soft tissue damage. 
Preoperative Planning.
A preoperative planning checklist is shown in Table 37-7. It summarizes the important aspects of preoperative planning. Preoperative planning of tension band fixation not only requires an understanding of the concepts explained in the section on plate fixation but it also requires a clear understanding of the fragmentation of tuberosities and humeral shaft to determine the ideal placement of sutures and wires. As a load-sharing construction, tension band fixation is ideally used in fractures with minimal comminution of the main fracture parts. Several studies however suggest that in four-part valgus-impacted fractures, the head segment can be left unreduced, while the tuberosities are fixed onto the humeral shaft. Furthermore, comminution of the surgical neck may be managed by impacting the shaft into the humeral head and then proceeding with tension band fixation. 
 
Table 37-7
Tension Band Fixation
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Table 37-7
Tension Band Fixation
Preoperative Planning Checklist
  •  
    OR Table: Standard (beach chair) or radiolucent table (supine)
  •  
    Position/positioning aids:
    •  
      Beach chair: Head holder/shoulder positioner, hip positioner at thigh. Waist flexed 45 degrees, knees bent 30 degrees.
    •  
      Supine: Bump under ipsilateral scapula, rotating the trunk 30 degrees toward opposite side.
    •  
      Shoulder draped free to the level of medial scapular border.
  •  
    Fluoroscopy location:
    •  
      At head of patient, coming in line with long axis of the bed.
  •  
    Equipment:
    •  
      Power drill
    •  
      Heavy suture/wire: Nonabsorbable (#5 polyester, #2 polyethylene; 20-gauge steel wire); absorbable (#2 PDS)
    •  
      Large-pointed reduction clamps
    •  
      14 gauge colpotomy or spinal needle
    •  
      Blunt narrow periosteal elevator, bone tamp
    •  
      Mallet
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Positioning.
Positioning for tension band wire fixation follows the same principles as for plate and screw fixation. 
Surgical Approach.
Most authors recommend a deltoid-splitting approach for the fixation of two-part greater tuberosity fractures, whereas either a deltopectoral or deltoid-splitting approach can be used for other two-part fractures as well as three- and four-part fractures. 
Technique.
Several techniques have been described in the literature. Hawkins et al. described tension band wiring for the management of three-part fractures using a deltopectoral approach. After reduction and temporary clamp fixation of the displaced tuberosity fragment onto the head a 14-gauge colpotomy needle is used to pass parallel 20-gauge stainless steel wires through the subscapularis tendon and lesser tuberosity toward the medial aspect of the greater tuberosity posteriorly. The needle thereby penetrates the lateral aspect of the head segment. Each wire is then passed in a figure-of-eight pattern through a separate humeral shaft cortical hole and tied.162,428 
Ochsner and Ilchman295 described a tension band technique replacing stainless steel with heavy resorbable polydioxanone (PDS) suture, the theoretical advantage being that future hardware removal was not required. According to their technique, the greater and lesser tuberosities are tagged with separate sutures through their respective rotator cuff tendons and fixed distally through separate cortical holes in the proximal shaft segment. 
Flatow et al. described the use of heavy nonabsorbable suture fixation of the greater tuberosity in displaced two-part greater tuberosity fractures. Using a deltoid-splitting approach the greater tuberosity fragment is identified and mobilized. Multiple traction sutures are placed through the rotator cuff for fragment manipulation. The frequently associated rotator cuff tear is repaired and traction sutures placed through cortical bone tunnels in the proximal shaft, thereby reducing the fracture.116 A similar technique is used for three-part greater tuberosity fractures, in which, using a deltopectoral approach, the head segment is reduced onto the shaft and fixed with heavy nonabsorbable polyester or polyethylene multifilament sutures through the subscapularis and lesser tuberosity proximally and separate cortical holes medial to the biceps tendon distally. The greater tuberosity is then reduced and fixed as described above.311 
Cornell et al. modified Hawkins’ technique by impacting the humeral head segment into the shaft and fixing it with a 6.5-mm screw from the shaft into the subchondral bone in the center of the head. Two tension band constructs are then created with 18-gauge stainless steel wire as described by Hawkins.74,162 
Darder et al. used a tension band technique in addition to modified K-wires for the treatment of four-part fractures.85 Three-millimeter K-wires with a 1 mm orifice at one of the ends to allow threading of the tension band wire are placed through the greater and lesser tuberosities into the humeral canal once reduction has been obtained. The tension band wire is then brought through each K-wire and through a cortical hole in the proximal humeral shaft.85 
A more recent study by Dimakopoulos et al. used transosseous suture fixation for four-part valgus-impacted and three-part greater and lesser tuberosity fractures and two-part greater tuberosity fractures. The procedure was performed through a deltoid split. A total of six sutures were pulled through drill holes established with a 2.7-mm drill bit through each of the fracture parts.92 
Postoperative Care.
Rehabilitation after tension band fixation starts with pendulum exercises for the first 6 weeks after surgery. Active-assisted range of motion is started thereafter and transitioned to strengthening at 3 months, if clinical and radiographic healing has been established. 
Potential Pitfalls and Preventive Measures.
A list of potential pitfalls and preventative measures is given in Table 37-8. Complications after tension band fixation include painful steel wire, AVN of the humeral head, infection, and transient axillary neurapraxia. Hawkins reported 2 patients with AVN after the treatment of 14 patients with three-part proximal humeral fractures.162 Flatow et al. reported one transient neurapraxia in 12 patients undergoing tension band fixation of two-part greater tuberosity fractures through a deltoid-splitting approach. A stay suture had not been placed in this patient, but full recovery was achieved by 9 months after surgery.116 Ochsner and Ilchmann had two deep infections in 22 patients undergoing tension band fixation with either steel wire or PDS suture. One infection, requiring a subsequent arthrodesis, occurred in 10 patients who underwent fixation with steel wire, while one infection, that resolved with surgical debridement, occurred in 12 patients fixed with PDS suture. A 50% AVN rate was observed. This was unrelated to the type of material used for fixation and was determined primarily by the initial fracture pattern.295 Other authors have found no AVN when treating two- or three-part fractures.311 In the largest series on tension band fixation published to date, Dimakopoulos et al. found an AVN rate of 7%. Nonunion occurred in 2% of cases, while malunion was seen in 5%.92 
 
Table 37-8
Fracture
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Table 37-8
Fracture
Potential Pitfalls and Preventions
Pitfall Preventions
Construct failure Multiple suture placement
Use of braided heavy nonabsorbable suture
Axillary nerve palsy Use deltopectoral approach if possible
If deltoid split is used, carefully identify the axillary nerve and protect it throughout the procedure. Use a stay suture to avoid inadvertent distal splitting of the deltoid split into the nerve
Painful hardware Use of suture instead of steel wire
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Treatment-Specific Outcomes.
Hawkins et al. reported that 8 of 15 patients achieved a good result based on Hawkins criteria. Average active elevation and external rotation were 126 degrees and 29 degrees, respectively, ranging from 60 to 170 degrees and from 15 to 60 degrees, respectively.162 Based on subjective criteria, Flatow et al. reported 12 good or excellent outcomes after the treatment of 12 two-part greater tuberosity fractures, all of which healed.116 Park showed excellent or satisfactory outcomes based on Neer criteria in 89% of patients treated with tension band fixation who had two-part greater tuberosity or surgical neck, or three-part greater tuberosity fractures. There were no differences in functional outcomes according to fracture classification.311 
Zyto et al.428 did not show improved outcomes after tension band fixation compared to nonoperative treatment in displaced three- and four-part proximal humeral fractures Ilchmann et al.185 found similar results for three-part fractures, while improved function was observed with operative fixation in the case of four-part fractures.185 In a series of 165 patients with two-, three-, and four-part proximal humeral fractures, Dimakopoulos et al. observed a mean Constant score of 91 5 years after braided nonabsorbable suture tension band fixation. This represented 94% of the function of the contralateral shoulder.92 

Closed Reduction and Percutaneous Fixation

Closed reduction with percutaneous fixation of proximal humeral fractures has the theoretical advantage of minimizing soft tissue trauma, thereby promoting healing and reducing the risk of AVN of the humeral head. Two-part, three-part, and valgus-impacted four-part fractures of the proximal humerus can be treated with closed reduction and percutaneous fixation (CRPF) by surgeons that have a thorough understanding of the radiographic morphology of the proximal humerus, as assessment of fracture reduction will rely entirely on fluoroscopic imaging. Furthermore, a detailed understanding of the structures at risk of iatrogenic injury is required. These include the cephalic vein and long head of the biceps anteriorly and the axillary nerve on the medial, posterior, lateral, and anterior aspects of the surgical neck.344 Rowles and McGrory showed in a cadaveric study that, when using a standard pin placement technique, the biceps tendon and cephalic vein may be pierced in 30% and 10% of cases, respectively. Furthermore, pins are located at an average of 3 mm from the anterior branch of the axillary nerve.344 Similar findings have been confirmed by other authors.192 Pin placement along established safe windows is therefore required to minimize the risk of iatrogenic neurovascular injury. 
Bone quality plays an important role in achieving adequate fixation with CRPF and to avoid pin migration and construct failure.207,264 Several authors have observed a correlation between pin migration and construct failure with increased age.113,194 In two-part surgical neck fractures with comminution of the calcar, pin fixation may be insufficient to withstand varus deforming forces and should therefore be avoided. The size of tuberosity fractures and the absence of comminution should be such that percutaneous manipulation can be reliably performed and adequate fixation with pins and screws achieved. Four-part valgus-impacted fractures can be managed with CRPF because of the special morphologic characteristics of this fracture. In this fracture the head has been pushed into valgus, thereby pushing the tuberosities peripherally, and leaving an intact medial hinge between the humeral head and calcar.187 Furthermore, the tuberosities have a periosteal connection with the humeral shaft. Integrity of the medial hinge and periosteal continuity, in the absence of gross tuberosity migration, are important for CRPF to be successful. 
Preoperative Planning.
A preoperative planning checklist is given in Table 37-9. Successful CRPF requires a good understanding of fracture morphology and considerable operative experience. AP, axillary, and lateral Y scapula views are essential to understand the fracture pattern. CT images with 3D reconstructions are valuable to clearly establish the amount of fragment involvement and the degree of displacement and comminution. Depending on the fracture pattern, the surgeon should decide whether he or she feels that the best possible result can be offered with CRPF. Patients should be counseled about the risks associated with this specific technique, including axillary nerve injury, pin tract infection and pin migration. A clear understanding of these risks and the requirement for close follow-up for radiographic monitoring are essential for optimal patient compliance. Finally patient age and any risk factors for poor bone stock should be taken into account as they will reduce pin stability and may necessitate either the use of adjuvant stabilization or the use of a different surgical technique. 
 
Table 37-9
Closed Reduction and Percutaneous Fixation
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Table 37-9
Closed Reduction and Percutaneous Fixation
Preoperative Planning Checklist
  •  
    OR Table: Standard (beach chair) or radiolucent table (supine)
  •  
    Position/positioning aids:
    •  
      Beach chair: Head holder/shoulder positioner, hip positioner at thigh. Waist flexed 45 degrees, knees bent 30 degrees.
    •  
      Supine: Bump under ipsilateral scapula, rotating the trunk 30 degrees toward opposite side.
    •  
      Shoulders draped free to the level of medial scapular border.
  •  
    Fluoroscopy location:
    •  
      Beach chair: At head of patient, coming in line with long axis of the bed.
    •  
      Supine: Entering perpendicular to table from opposite to operative extremity.
  •  
    Equipment:
    •  
      Radiation reduction gloves
    •  
      Power wire driver and drill
    •  
      2.5-mm terminally threaded Kirschner wires
    •  
      3.5-mm cannulated screw set (fully threaded)
    •  
      Small drill or wire sleeve
    •  
      Small bone hook
    •  
      Blunt narrow periosteal elevator, bone tamp
    •  
      Mallet
X
Positioning.
CRPF can be performed in the beach chair position or supine on a radiolucent table. The beach chair position is facilitated by using a special shoulder or head holder. The shoulder should be accessible to the level of the medial border of the scapula posteriorly and the angle of the jaw superiorly. The bed is flexed 45 degrees at the waist and 30 degrees at the knees. In the supine position, the torso is tilted 30 degrees toward the injured side using a bump or wedge, allowing access to the medial border of the scapula and extension of the arm for fracture reduction. Adequate patient positioning will allow unhindered fracture reduction, fluoroscopic visualization, and implant placement. For the beach chair position, the C-arm is positioned at the head of the patient, while it is placed perpendicular to the table coming in from the opposite side for the supine position. Fluoroscopic AP, axillary, and Y-lateral views are performed before draping to confirm adequate visualization and accurately identify the anatomic landmarks and fracture fragments. It is furthermore recommended that closed reduction maneuvers are trialed before draping to confirm adequate patient positioning. 
Surgical Approach.
In two-part surgical neck fractures, the procedure may be performed entirely with closed reduction techniques. More complex fractures require strategically placed percutaneous instruments to achieve fragment reduction. An anterior reduction portal is obtained with a 1- to 2-cm skin incision just lateral to the biceps tendon that can be reliably positioned under fluoroscopic guidance on the lateral third of the humerus at the level of the surgical neck.324 After the skin and deltoid fascia have been incised, the underlying deltoid is bluntly dissected in line with its fibers. Digital palpation can aid in identifying the long head of the biceps. In four-part fractures, the humeral head can be accessed through the split between the greater and lesser tuberosities just lateral to the bicipital groove. The tuberosities may also be manipulated through this incision. A lateral incision just distal to the acromion will allow a small bone hook to be introduced to aid reduction of a medially and posteriorly displaced greater tuberosity. Further reduction may be improved with the use of a ball spike pusher. The axillary nerve may be palpated on the undersurface of the deltoid, through either incision aiding in the safe placement of instruments and implants. 
Technique.
The surgical technique is outlined in Table 37-10. While the technique for closed and percutaneous reduction follows an established pattern, several percutaneous fixation methods have been described in the literature. We will describe the most widely published technique involving fixation using terminally threaded 2.5-mm K-wires placed in several planes.102,186,187,319,393 Because of concerns about pin migration and insufficient construct stiffness the addition of a mechanism that allows linkage between pins has been studied.33,59 The purpose is to anchor the pins to avoid migration and provide angular stability to improve implant stiffness. Furthermore, pin guidance through predetermined trajectories has been suggested to improve pin positioning within the strongest bone inside the humeral head.35,51,94,188,325 
 
Table 37-10
Closed Reduction and Percutaneous Fixation
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Table 37-10
Closed Reduction and Percutaneous Fixation
Surgical Technique
  •  
    Take AP external rotation and axillary fluoroscopic views of unaffected shoulder for intraoperative referencing.
  •  
    Confirm adequate visualization of fracture in AP, axillary and Neer views, before draping.
  •  
    Perform reduction maneuvers before draping, confirming adequate positioning
  •  
    After draping identify and draw major landmarks on skin, including expected location of axillary nerve
  •  
    Perform close reduction of surgical neck fracture component
  •  
    Establish anterior reduction portal if required
  •  
    Create distal entry portals for retrograde pins and dissect bluntly onto bone
  •  
    Over wire sleeve, transfix surgical neck fracture with two lateral pins and one anterior if required
  •  
    Fluoroscopically confirm adequate reduction and fixation
  •  
    Reduce tuberosities and fix with pins
  •  
    Confirm reduction and fixation
  •  
    Replace pins for cannulated screws if planned
  •  
    Cut pins short to leave subcutaneously
  •  
    Close reduction portal
  •  
    Immobilize in sling
X
Two-Part Fractures. Two-part surgical neck fractures are reduced by manipulating the distal segment into 80 to 90 degrees of abduction to match the deformity of the proximal segment. Manipulation of the distal segment requires longitudinal traction to oppose the fracture surfaces, and posterior pressure to correct apex anterior angulation. Correction of rotation is then undertaken under fluoroscopic guidance. Rotation is judged by obtaining a perfect profile view of the proximal humerus. With the elbow bent at 90 degrees, the distal segment is aligned with the forearm in 30 degrees of external rotation in relation to the imaging plane. Manipulation of the proximal segment may be performed with the use of percutaneously placed 2.5-mm K-wires or 4.0 Schantz pins. Inability to achieve reduction by closed means may suggest interposition of the long head of the biceps in the fracture site. An anterior percutaneous portal as described above allows palpation of the biceps tendon and release from the fracture site if necessary. Furthermore, a periosteal elevator may be used to shoehorn the proximal segment over the shaft. This maneuver should be done with great care to avoid comminution at the fracture site. Once adequate reduction has been achieved, fracture fixation is obtained with the use of 2.5 mm terminally threaded K-wires. The surgical neck component is usually transfixed with a minimum of three K-wires directed from distal to proximal, placed in two planes at different angulations. Three pins are routinely used, one from anterior to posterior and two from lateral to medial. Anterior pins increase torsional stiffness of the construct and should be added if two lateral pins are deemed to provide insufficient stability.281 However, anterior pins risk perforating the long head of the biceps or cephalic vein and should therefore be used carefully.344 Based on biomechanical data, two pins from the tuberosities into the medial proximal humeral cortex can increase construct rigidity compared to retrograde lateral pins alone.97 To avoid injury to the axillary nerve, lateral pins should enter the humeral cortex at a point at least twice the distance from the upper aspect of the head to the inferior head margin with the wire angulated approximately 45 degrees to the cortical surface. After blunt dissection, to further reduce the risk of neurologic injury, pins should be placed through a sleeve, into the humeral head in 30 degrees of retroversion. To maximize stability, pins should diverge both at the fracture site and inside the humeral head, and be advanced to the level of the subchondral bone, avoiding penetration of the articular surface186,196,344 (Fig. 37-38). 
From Rowles et al.344
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Figure 37-38
Typical pin configuration for closed reduction and percutaneous fixation.
From Rowles et al.344
From Rowles et al.344
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X
Pin placement should be carefully checked fluoroscopically, in both the AP and axillary views with maximum internal and external rotation. Pins directed into the posterior aspect of the humeral tuberosity are at greatest risk of penetrating the articular surface without being detected on fluoroscopy. An AP image with the shoulder in 60 degrees of external rotation has been shown to reliably exclude this.205 
Three-Part Fractures. Since the great majority of three-part fractures involve a separate greater tuberosity fragment, the head segment is internally rotated. The humeral shaft and head segment are therefore aligned at the surgical neck by placing the arm into adduction and internal rotation. Apex anterior deformity is corrected with a posterior force and K-wires placed as for two-part surgical neck fractures. The arm is then placed into neutral rotation and abduction. A percutaneously placed bone hook is used to secure the greater tuberosity and to reduce it into the correct position. Engagement of the fragment at the rotator cuff insertion site is recommended to reduce the risk of fragmentation. Fixation is achieved with two K-wires placed from the tuberosity and directed into the medial cortex of the proximal humerus. To avoid injury to the axillary nerve at that level, the tip of the K-wire should exit the medial cortex at least 2 cm distal to the most distal aspect of the humeral head.344 If desired, definitive fixation may be completed by either cutting the wires subcutaneously or by replacing them with cannulated screws.326 Since interfragmentary compression is not absolutely necessary for fixation, and may increase the risk of secondary fragmentation, fully threaded screws are recommended. This improves stability. 
Valgus-Impacted Four-Part Fractures. Reduction of valgus-impacted four-part fractures begins with correcting the lateral tilt of the humeral head. With the shoulder in adduction, a blunt elevator is introduced through the anterior reduction portal. Access to the head is gained through the split between the greater and lesser tuberosities, almost invariably 5 mm behind the bicipital groove. Once coronal alignment of the head has been corrected, the head is fixed with two pins from the distal lateral humeral cortex into the humeral head. By reducing the humeral head, the greater tuberosity will usually regain its anatomic position, tethered by the bridging periosteum distally and the rotator cuff proximally.326 The greater tuberosity is then fixed either with K wires or cannulated screws (Fig. 37-39). These should be directed into the head proximally and into the shaft distally. The arm is then brought into 70 degrees of abduction and internal rotation to obtain an axillary view of the shoulder to visualize the profile of the anterior proximal humerus. The lesser tuberosity is then controlled with a bone hook and reduced under fluoroscopic guidance into its anatomic position. Provisional fixation with a K wire followed by fixation with an AP screw is obtained. The arm is then mobilized under fluoroscopic visualization to confirm adequate stability. The lateral pins are cut to allow subcutaneous placement. 
Figure 37-39
Valgus-impacted proximal humerus fracture treated with percutaneous reduction and pinning.
 
A and B: A periosteal elevator is introduced between the greater and lesser tuberosity fragments to elevate the humeral head. Provision fixation with one pin is provided. C: A bone hook is used to reduce the greater tuberosity. D: Final reduction and fixation with the use of multiple cannulated screws. From Resch et al.326
A and B: A periosteal elevator is introduced between the greater and lesser tuberosity fragments to elevate the humeral head. Provision fixation with one pin is provided. C: A bone hook is used to reduce the greater tuberosity. D: Final reduction and fixation with the use of multiple cannulated screws. From Resch et al.326
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Figure 37-39
Valgus-impacted proximal humerus fracture treated with percutaneous reduction and pinning.
A and B: A periosteal elevator is introduced between the greater and lesser tuberosity fragments to elevate the humeral head. Provision fixation with one pin is provided. C: A bone hook is used to reduce the greater tuberosity. D: Final reduction and fixation with the use of multiple cannulated screws. From Resch et al.326
A and B: A periosteal elevator is introduced between the greater and lesser tuberosity fragments to elevate the humeral head. Provision fixation with one pin is provided. C: A bone hook is used to reduce the greater tuberosity. D: Final reduction and fixation with the use of multiple cannulated screws. From Resch et al.326
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X
Postoperative Care.
Patients are followed weekly both clinically and radiographically to monitor fracture healing and detect any possible pin migration or skin problems. Patients are immobilized for 3 to 4 weeks in a sling, while active range-of-motion exercises of the elbow, wrist, and hand are encouraged. Passive range of motion is started thereafter with forward elevation, external rotation and pendulum exercises. If healing has adequately progressed at 6 weeks the pins are removed under local anesthesia and active range of motion is started. 
Potential Pitfalls and Preventative Measures.
A list of potential pitfalls and preventative measures is given in Table 37-11. In elderly patients and in patients with osteoporosis the pins may not gain sufficient bone stability putting the construct at risk of failure. Comminution of the greater tuberosity is a contraindication to CRPF as it will not provide reliable stability with pin or screw fixation alone. A limited open approach using a cerclage suture may be more useful. Calcar comminution in two-part surgical neck fractures may place the construct at risk of varus collapse. IM nailing or locked plate fixation may be preferable in this circumstance. If there is a vascular injury open reduction and fixation should be performed. In patients in whom close postoperative follow-up is unlikely to occur CRPF is contraindicated as weekly radiographs are required. 
 
Table 37-11
Closed Reduction and Percutaneous Fixation
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Table 37-11
Closed Reduction and Percutaneous Fixation
Potential Pitfalls and Preventions
Pitfall Preventions
Axillary nerve injury Mark possible location of axillary nerve on skin referencing measurements performed fluoroscopically.
Confirm axillary nerve position with digital palpation through reduction portal.
Use blunt dissection and sleeve for pin placement.
Place pins according to recommended guidelines (see text).
Construct failure (pin migration) Avoid CRPF in elderly patients.
Use terminally threaded pins.
Select fractures without tuberosity or calcar comminution.
Place pins in a divergent manner spreading their distance both at the fracture site and inside the head.
Humeral head pin penetration Establish three-dimensional direction of pins
Verify pin placement under live fluoroscopic visualization
Pin site infection Cut pins short for tip to be located 5 mm subcutaneously
Avoid active shoulder range of motion while pins in place
X
Careful pin placement is required to avoid iatrogenic injury to the axillary nerve, biceps tendon, cephalic vein, and humeral articular cartilage. 
Treatment-Specific Outcomes.
CRPF has received increased attention over the past few years. Table 37-12 summarizes the outcomes of the technique in the literature whereas Table 37-13 details the complications of the technique. While overall satisfactory outcomes have been reported, malunion and AVN rates of up to 22 and 26%, respectively have been reported (Table 37-13). Furthermore, premature pin removal, due to migration, has been reported to be required in up to 40% of cases.51 Outcomes have been correlated with both patient age and the underlying fracture type, with four-part valgus-impacted fractures having lower functional outcomes scores than three- and two-part fractures.35,161 Only two comparative studies have been published in the English literature and both compare standard CRPF with CRPF employing augmentation with an external pin linking mechanism. In both studies, linkage lead to significantly lower pin migration and higher functional scores, even in older patients.33,59 Brunner et al. reported on the use of the “Humerusblock” device, for distal lateral linking of the pins. While pin migration was eliminated, pin perforation into the humeral head occurred in 26% of cases.51 
Table 37-12
Published Results of the Treatment of Proximal Humeral Fractures with Closed Reduction and Percutaneous Fixation (CRPF) and a Number of Variants. Where Possible the Fracture Types are Defined by the Neer Classification with Two-, Three- and Four-Part Fractures and Fracture Dislocations (FD)
Fracture Type (Neer parts) Age (years) Follow-up (months)
Authors Technique 2 3 4 FD Mean (Range) Mean (Range) Outcome Scores Results
Kocialkowski and Wallace207 CRPF 22 61 (13–91) 19 (6–16) Neer 38% Ex/Good
Jakob et al.187 CRPF 0 0 19 49 (24–81) 4 (2–10) Neer 74% Ex/Good
Jaberg et al.186 CRPF 32 8 5 3 63 (17–85) 36 (24–84) Neer 70% Ex/Good
Fenichel et al.423 CRPF 24 26 0 50 (21–78) 30 (12–48) Constant 70% Ex/Good
Keener et al.196 CRPF 19 37 6 61 (19–76) 35 (12–77) Constant/ASES 58% Ex/Good
Blonna et al.33 CRPF 30 9 3 62 (27–83) 25 (12–45) Constant/DASH Means 70/21
Carbone et al.59 CRPF 0 15 11 78 (68–89) 24 Constant 52 (average)
Harrison et al.161 CRPF 5 12 10 59 (42–67) 84 (37–128) ASES 82 (average)
Resch et al.326 CRPF ± cannulated screws 0 9 18 54 (25–68) 24 (18–47) Constant Good (average)
Kayalar et al.194 CRPF ± retrograde IM K wires 5 13 0 48 (14–89) 23 (8–60) DASH 18 (average)
Seyhan et al.357 CRPF ± antegrade IM K wires 36 0 0 52 (41–86) 38 (30–60) Constant 83% Ex/Good
Bogner et al.35 Humerusblock 0 32 16 80 (70–96)) 34 (6–81) Constant 88% Ex/Good
Brunner et al.51 Humerusblock 25 22 11 70 (32–95) 15 (12–28) Constant 77% Ex/Good
Blonna et al.33 Hybrid 24 18 7 67 (37–91) 25 (12–40) Constant/DASH Means 78/16
Joeckell78 ButtonFix 8 4 5 69 (16–89) 18 (12–20) Constant 76% contralateral shoulder
Carbone59 MIROS 0 17 11 81 (76–85) 24 Constant 60 (average)
X
Table 37-13
The Complications Published in the Papers Detailed in Table 37-12
%
Authors Technique Revision Surgery AVN Implant Loosening Joint Penetration Infection Nerve Injury Nonunion OA Dislocation Malunion
Deep Super
Kocialkowski and Wallace207 CRPF 9 5 41 23 5 5 0
Jakob et al.187 CRPF 26 0
Jaberg et al.186 CRPF 17 21 10 2 8 4 0
Fenichel et al.423 CRPF 6 0 14 10
Keener et al.196 CRPF 4 4 4 17
Blonna et al.33 CRPF 2 4 4 17
Carbone et al.59 CRPF 8 27 4 15 0
Harrison et al.161 CRPF 26
Resch et al.326 CRPF ± cannulated screws 7 7 4 19
Kayalar et al.194 CRPF ± retrograde IM K wires 6 39 1 22
Seyhan et al.357 CRPF ± antegrade IM K wires 0 6 0
Bogner et al.35 Humerusblock 10 8 10 0
Brunner et al.51 Humerusblock 40 4 14 26 0
Blonna et al.33 Hybrid 4 2 2 2 4 2 2
Joeckell78 ButtonFix 6 6 6 0
Carbone59 MIROS 7 4 4 0
X
While some studies support the use of CRPF in elderly patients in conjunction with linking implants,51,59 we recommend the use of this technique in younger patients with adequate bone stock. Close radiographic follow-up should be obtained for early detection of pin perforation and pin migration. 

Intramedullary Nailing

IM fixation is an attractive alternative for the treatment of proximal humeral fractures given its theoretical biomechanical advantages in osteoporotic bone and by allowing stabilization with minimal surgical invasion.172 
Several IM devices have been used to treat proximal humeral fractures. The use of multiple solid, small diameter nails, such as Enders nails or Evans staples, has been described for IM fixation in an antegrade fashion with an insertion point through the humeral head.22,84,358,409 Similar implants, namely prebent K-wires, have also been used with a retrograde insertion from the lateral cortex into the proximal humeral head.102,393 These implants allow for gross alignment of displaced surgical neck fractures and may be used in conjunction with cerclage fixation of additional tuberosity fractures.85,310 
Modern proximal humeral IM nailing however is performed with the use of antegrade locking nails that vary between 8 and 12 mm in proximal diameter. These nails incorporate features derived from those used in the lower extremity to allow for greater construct rigidity and strength (Fig. 37-40). Several nails are available on the market, offering several different interlocking options and the option to incorporate suture fixation through the rotator cuff tendons.1,321 
Figure 37-40
Intramedullary nailing of proximal humerus fractures.
 
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
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A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
View Original | Slide (.ppt)
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
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Figure 37-40
Intramedullary nailing of proximal humerus fractures.
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
View Original | Slide (.ppt)
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
View Original | Slide (.ppt)
A–J: Twenty-five-year-old male with a high-energy proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Valgus impaction of the head is present with minor displacement of the greater tuberosity. Fixation is obtained with a modern intramedullary nail allowing multidirectional proximal interlocking and incorporation of transtendinous sutures through the cuff into the final construct. K–M: Fifty-seven-year-old female with a two-part surgical neck fracture treated with intramedullary nailing. N: At only 6 days after fixation catastrophic failure has occurred. Possibly due to inadequate intraoperative imaging a too anterior entry point was selected leading to suboptimal stability.
View Original | Slide (.ppt)
X
The main indications for proximal humerus interlocking IM nailing are displaced two-part surgical neck fractures, especially those with extension into the humeral diaphysis, and pathologic fractures.1,271,321 Three-part greater tuberosity fractures may also be amenable to fixation with IM nailing.1,122,150,195,246,271 While IM nailing of four-part fractures has been reported, poorer outcomes can be expected in this patient group.1,150 IM nailing is not recommended in varus four-part fractures with lateral displacement of the humeral head and in head-splitting fractures.271 
While IM nailing is the treatment of choice in two-part surgical neck fractures with marked comminution or distal diaphyseal extension, caution should be exercised in the latter, especially in the presence of preoperative nerve palsy. Nerve entrapment at the fracture site may lead to catastrophic neurologic injury during reaming and nail placement. 
Preoperative Planning.
A checklist for preoperative planning is given in Table 37-14. Preoperative planning for IM nailing of proximal humeral fractures follows the same guidelines as for other treatment modalities. Imaging of the contralateral uninjured shoulder is recommended for preoperative templating of fracture fixation. Placing the nail template over the uninjured humerus will help in determining the starting point. 
 
Table 37-14
Intramedullary Nailing
View Large
Table 37-14
Intramedullary Nailing
Preoperative Planning Checklist
  •  
    OR Table: Standard table with beach chair positioner or radiolucent table
  •  
    Position/positioning aids: For beach chair: Head holder/shoulder positioner; for supine: Lateral Plexiglas extension (see text)
  •  
    Fluoroscopy location: For beach chair: Entering from the head, in line with the patient. Supine: Entering perpendicular to table from opposite to operative extremity. Confirm adequate visualization of fracture in AP and Y lateral views (Neer)
  •  
    Equipment:
    •  
      Kirschner wires/Steinmann pins/Schantz pins
    •  
      Intramedullary Nail set: Guidewire, starter awl, reamers, aiming jig, screwdrivers, etc.
X
Availability of other fixation or reconstruction methods is recommended in case optimal outcomes cannot be achieved with IM nailing. Nails come in different diameters and lengths. Preoperative templating using both the injured and the unaffected contralateral side will be required for accurate implant selection. 
Positioning.
Careful patient positioning is required to facilitate fracture reduction, fluoroscopic visualization, and implant placement. Unlike ORIF of proximal humeral fractures, IM nailing does not allow shoulder abduction once the starting point has been created. An intraoperative axillary view is hence not possible. Imaging therefore requires a Neer lateral Y view and a Grashey AP view of the shoulder to be obtained by rotating the C-arm while keeping the shoulder adducted. 
As with the other surgical techniques, positioning can be done in either the beach chair or supine position. Slight extension of the shoulder is required to obtain adequate clearance of the humeral entry site from the anterolateral acromion. This may be somewhat easier to achieve in the beach chair position. In the beach chair position the C-arm enters the surgical field from the head of the patient, parallel to the patient’s body. AP and lateral views are obtained by rotating the C-arm around the long axis of the humerus. In the supine position the patient is placed on a radiolucent table with a Plexiglas board placed as a lateral extension as described for ORIF. The C-arm enters perpendicular to the long axis of the table from the side of the uninjured extremity. A bump is placed under the scapula of the injured side to roll the patient’s torso 30 degrees toward the uninjured side. A Grashey view is thereby obtained by rolling the C-arm back 60 degrees, whereas a Y lateral view is obtained by rolling the C-arm forward 30 degrees. Adequate imaging should be confirmed before draping. 
Surgical Approach.
The key to IM nailing of the proximal humerus is to gain optimal access into the humeral head in a location that allows maintenance of reduction once final seating of the nail has been achieved. The exact entry point will vary depending on nail design and patient anatomy. Nails with a proximal lateral bend will have an entry point closer to the footprint of the rotator cuff and theoretically will damage less articular surface. Straight nails on the other hand will enter the humeral head via a split in the musculotendinous junction of the rotator cuff into articular surface of the humeral head. Straight nails will avoid compromising the footprint of the rotator cuff, by splitting the supraspinatus musculotendinous junction more medially, but will damage a greater area of articular cartilage. 
For nails with a proximal lateral bend, a 3-cm incision is performed from the anterolateral corner of the acromion distally. For straight nails a more medial incision, in line with the acromioclavicular joint may be preferable. A proximal deltoid split is performed in line with the muscle fibers. Once the subdeltoid bursa has been incised and resected, the underlying rotator cuff is exposed. In more complex fractures a formal deltoid-splitting approach may be used paying close attention not to injure the axillary nerve. Alternatively, the middle deltoid may be detached subperiosteally from the acromion as a full-thickness flap of fascia and muscle. The anterior branch of the axillary nerve should be identified with digital palpation along the undersurface of the deltoid to confirm safe placement of pins for temporary stabilization as well as definitive proximal interlocking. 
After partial resection of the subacromial bursa the underlying supraspinatus tendon will be exposed. The biceps tendon is identified as a key landmark to assist in fracture reduction and establishing the proximal entry site. Once adequate fracture reduction has been obtained (see below), the supraspinatus tendon is split in line with its fibers 1 to 1.5 cm posterior to the biceps tendon. Depending on the type of nail, the tendon will be split either close to the footprint of the rotator cuff or at the level of the musculotendinous junction. Tendon edges are tagged with nonabsorbable suture for subsequent retraction and should be carefully protected during surgery. 
Technique.
The surgical technique is outlined in Table 37-15. For two-part surgical neck fractures, a Schantz pin, or two 2.5-mm K-wires directed from the lateral cortex into the head segment outside of the planned path of the nail will aid in fracture manipulation. Alignment of the distal segment is corrected with traction, rotation, and a posteriorly directed force onto the proximal humeral shaft. Once adequate reduction has been obtained and confirmed fluoroscopically, the starting point is selected using the C-arm. The AP view should show the starting point in a position that will not affect fracture reduction once final seating has been obtained. In the lateral Y view the entry point should be approximately 1 to 1.5 cm posterior to the anterior margin of the greater tuberosity. Trajectory of the guide pin should be from the starting point toward the center of the medullary canal at the level of the calcar. The entry hole is then created with an awl or a starting drill, using a soft tissue sleeve to protect the surrounding rotator cuff tendon. Depending on the type of implant a nail may then be inserted either directly or over a guidewire, with or without prior reaming. Due to the width of the proximal humeral canal and the need for a short nail in most instances, no cortical chatter will be obtained during reaming. Some mismatch between the shaft and nail can be expected. For three- and four-part fractures reduction of the head and tuberosities is required before nail insertion. Temporary fixation is achieved with K-wires outside of the predicted nail path. The placement of heavy nonabsorbable sutures around the bone tendon junction is useful to manipulate displaced tuberosities, obtain temporary stabilization and provide structural reinforcement to the final construct when tied to interlocking screws. It is important to keep in mind that fracture reduction, especially between the head and shaft has to be achieved before nail preparation and seating, since this will determine the spatial relationship between these two segments. During preparation of the starting point in three-part greater tuberosity fractures and four-part fractures, the fracture between the greater tuberosity and head segment has to be kept reduced as instrumentation will tend to separate the fragments, leading to inadvertent loss of fracture reduction during final nail seating and poorer outcomes.2 
 
Table 37-15
Intramedullary Nailing
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Table 37-15
Intramedullary Nailing
Surgical Technique
  •  
    Confirm adequate imaging
  •  
    Expose subdeltoid space through deltoid split
  •  
    Identify the biceps tendon and understand your fragments
  •  
    Reduce fracture using a combination of
    1.  
      Traction sutures into rotator cuff
    2.  
      Steinmann or Schantz pins or Kirschner wires
    3.  
      Shaft manipulation
  •  
    Confirm reduction fluoroscopically in two views
  •  
    Establish entry hole under two- view fluoroscopy
  •  
    Prepare nail as required per implant specific technique
  •  
    Introduce nail and verify position under fluoroscopy
  •  
    Place proximal fixation
  •  
    Complete distal fixation
  •  
    Incorporate tuberosity sutures into construct
  •  
    Confirm adequate screw length with live fluoroscopy
  •  
    Close
X
The nail is inserted by hand, until it lies at least 10 mm deep to the articular surface. Fracture alignment, nail depth, and rotation should be reassessed fluoroscopically. Depending on the type of nail selected, proximal interlocking implants are directed either toward the head or in a manner that ensures that the tuberosities are captured. While it is frequently stated that screws placed into the humeral should be just short of the subchondral bone, it may be safer to select screws that are 5 mm shorter than measured to avoid delayed screw penetration. As with ORIF, measurement of screw length should be performed by drilling the lateral cortex only and then advancing the depth gauge advanced to the level of subchondral bone. This will avoid head penetration with the drill, thereby reducing the risk of late screw protrusion. In three- and four-part fractures, nail insertion depth should not exceed 3 cm, as this is likely to lead to inadequate fixation of the tuberosities by the proximal locking screws. While incorporation of rotator cuff traction sutures into the final construct is advisable whenever possible, it is required if there is tuberosity comminution, as bony fixation with screws will be unreliable. 
After proximal locking has been performed the proximal humerus should be reassessed fluoroscopically to see if there is a fracture gap that may be corrected by impacting the distal segment proximally with gentle blows against the elbow. The distal segment is finally interlocked with one screw in the dynamic hole. This allows further collapse at the surgical neck to facilitate union. 
Due to the risk of iatrogenic injury to the axillary nerve during nailing, it is important to determine the relationship of the locking holes and the axillary and radial nerves. Modern implants are designed to place proximal and distal locking holes in a safe window away from these nerves. In smaller patients or in the presence of abnormal anatomy, this safe window may however be altered. 
The cuff split is closed with nonabsorbable sutures. The deltoid split is closed with absorbable sutures. If the deltoid was detached, osseous tunnels are drilled into the acromion for reattachment with heavy nonabsorbable sutures. Full-thickness stitches into the deltoid are required to allow for strong repair. 
Postoperative Care.
Patients are placed into a postoperative sling and pendulum exercises are started on the first postoperative day. Active range-of-motion exercises of the elbow, wrist and hand are encouraged. Passive forward elevation and external rotation is allowed depending on the fracture stability that has been achieved and the bone quality. It is recommended to err toward slow progression of motion to reduce the risk of secondary fracture displacement. Most frequently passive range-of-motion exercises are continued until the sixth postoperative week. Active-assisted range of motion is then started, with transition to strengthening exercises occurring at 3 months. 
Potential Pitfalls and Preventative Measures.
A list of potential pitfalls and appropriate preventative measures is given in Table 37-16. Regardless of the type of implant used, IM nailing violates the rotator cuff and this may lead to secondary symptoms.291,426 Proximal humerus nails with a lateral bend may increase the risk the damage to the footprint of the rotator cuff, which may lead to postoperative shoulder pain. Straight nails have been advocated as they disrupt the rotator cuff at the level of the musculotendinous junction which theoretically leads to less rotator cuff problems. 
 
Table 37-16
Intramedullary Nailing
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Table 37-16
Intramedullary Nailing
Potential Pitfalls and Preventions
Pitfall Preventions
Primary intraoperative fracture displacement Obtain fracture reduction before preparing nail entry site.
Determine correct starting point based on preoperative template
Careful fluoroscopic confirmation of fracture reduction and adequate entry site in AP and Y-lateral views.
Postoperative shoulder pain Careful sharp incision of rotator cuff, perpendicular to footprint.
Judicious soft tissue retraction during reaming and nail insertion.
Avoid impingement by adequately seating the nail at least 10 mm below the articular surface.
Glenohumeral screw protrusion Select final head screw length 5 mm shorter than measured when directed toward articular surface.
X
Correct entry point placement is crucial to avoid displacement of a well-reduced fracture during nail seating. Fluoroscopic confirmation in both the coronal and sagittal planes of the starting pin should precede entry portal establishment. Understanding of implant geometry and preoperative templating using the unaffected contralateral extremity helps in avoiding intraoperative fracture displacement and also improves biomechanical stability by optimizing implant position. 
Nail insertion depth and rotation should be checked before interlocking to allow for optimal implant placement. 
Treatment-specific Outcomes.
Antegrade nailing of displaced proximal humeral fractures has gained popularity because it is minimally invasive and satisfactory outcomes have been reported in many case series. However the main concern with antegrade locked IM nailing is the violation of the rotator cuff with the risk of subsequent shoulder pain.291,426 
The most frequent complication after locked IM nailing of proximal humeral fractures is backing out of the proximal screws.2,83,150,195,248 In one large case series of 115 patients treated with the Targon Proximal Humerus Nail (Aesculap, Tuttlingen, Germany), the most frequent complication after a mean follow-up of 8.7 months was backing out of one or more screws. This occurred in almost one-quarter of patients and required surgical removal of the screws to facilitate resolution of symptoms.271 Other complications include glenohumeral screw protrusion, osteonecrosis of the humeral head, nonunion, malunion, and tuberosity displacement.150,246,321,381 

Hemiarthroplasty

Hemiarthroplasty, also known as humeral head replacement, is indicated when the humeral head is deemed to be unreconstructable or when its biologic viability is likely to be severely compromised. Comminuted head-splitting fractures and head depression fractures involving more than 40% of the articular surface are frequently considered to be unreconstructable. Predictors of head ischemia are further considered in the decision-making process between operative fixation and replacement. Hertel and Bastian found that fractures through the anatomic neck of the humerus carried an increased risk of head ischemia. Furthermore, a metaphyseal extension of the humeral head of less than 8 mm, loss of the medial hinge and displacement of the humeral head further predicted loss of humeral head perfusion at the time of surgery. While these criteria are frequently used to argue in favor of replacement surgery, intraoperative ischemia has not been correlated with clinically significant AVN of the humeral head when fixation is chosen for treatment. Furthermore, some authors have found that AVN after proximal humerus fixation is associated with results that are comparable to those of hemiarthroplasty.378 
The main challenge associated with hemiarthroplasty is the unpredictability of outcomes. Results published in the literature follow a bimodal distribution, in which some patients attain a result that is close to the uninjured extremity, whereas others achieve adequate pain control with only fair function. Several factors play a key role in achieving optimal results. Adequate reduction of the tuberosities and restitution of the correct head-to-tuberosity height are paramount to provide the biomechanical conditions for the reconstruction to function properly. Furthermore, adequate fixation of the tuberosities has to be obtained to achieve tuberosity healing and maintain function in the long term. Finally, glenoid erosion may lead to delayed shoulder pain in the mid to long term. 
Unpredictability of outcomes after hemiarthroplasty for proximal humerus fractures may be further affected by the relatively low frequency with which this procedure is performed. According to a recent meta-analysis, surgeons perform on average three hemiarthroplasties for proximal humeral fractures per year, with case frequency per surgeon ranging from 0.21 to 9.6 per year.212 This calculation is obtained from surgeons involved in academic centers and it is therefore likely that many procedures are performed with an even lower frequency in the overall orthopedic surgeon population. 
Preoperative Planning.
A preoperative planning checklist is given in Table 37-17. As with any proximal humerus fracture standard trauma shoulder radiographs are required. A CT scan with sagittal, coronal, and 3D reconstructions is also desirable to achieve full understanding of fracture geometry and rule out associated injuries. The bone window should be used to assess fracture configuration and determine the morphology of the humeral head fragment. Furthermore, measurement of the greater tuberosity fragment and establishing the involvement of the medial calcar will aid in determining depth of stem placement. Associated fractures of the glenoid or acromion should be ruled out. The soft tissues in both axial and sagittal reconstructions should be analyzed to determine cuff muscle degeneration.149 Advanced atrophy or fatty infiltration suggesting pre-existing rotator cuff pathology should be considered as a relative indication for proceeding with reverse total shoulder arthroplasty instead of hemiarthroplasty. 
 
Table 37-17
Hemiarthroplasty
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Table 37-17
Hemiarthroplasty
Preoperative Planning Checklist
  •  
    OR Table: Standard table (beach chair)
  •  
    Anesthesia: General with interscalene block
  •  
    Position/positioning aids:
    •  
      Head holder/shoulder positioner, hip positioner at thigh. Waist flexed 60 degrees, knees bent 30 degrees, reverse Trendelenburg.
    •  
      Shoulders draped free to level of medial scapular border, mid third of the clavicle and mandibular angle.
    •  
      Articulated arm holder may aid in the presence of a single assistant.
    •  
      If arm draped free: Padded Mayo stand.
  •  
    Fluoroscopy location:
    •  
      At head of patient, coming in line with long axis of the bed.
  •  
    Equipment:
    •  
      Deltoid retractor (e.g., Browne retractor)
    •  
      Power drill
    •  
      2-mm drill bit
    •  
      #2 braided non absorbable suture
    •  
      Ruler
    •  
      Cement, antibiotic powder (Vancomycin + Tobramycin), methylene blue
    •  
      Shoulder implant system (reamers, broaches, head sizers, retroversion guide etc.)
X
As with any method of treatment, the surgeon should have sufficient experience and skills to treat a proximal humeral fracture with an arthroplasty prosthesis. Referral to a shoulder specialist or traumatologist with experience in the treatment of these difficult fractures should be undertaken to achieve the best possible outcome. 
In most fractures intraoperative fracture assessment will determine whether reconstruction with reduction and fixation is possible or whether arthroplasty will be required. Furthermore, the decision between hemiarthroplasty and reverse total shoulder arthroplasty may be made intraoperatively. It is therefore desirable to have instruments and implants available to allow intraoperative flexibility of final decision making. Several arthroplasty systems are available that use the same stem regardless of whether hemiarthroplasty or reverse total shoulder arthroplasty will be performed. This will reduce the amount of instrumentation as well as intraoperative time. 
Shoulder arthroplasty can be performed with regional or general anesthesia. If general anesthesia will be used, a preoperative interscalene block will aid in postoperative pain management. 
Positioning.
Patients undergoing arthroplasty of the shoulder are placed in the beach chair position. Special attention is given to being able to fully adduct the shoulder and achieve extension during reaming and cementing of the humerus. The patient should be positioned such that the medial border of the scapular is accessible posteriorly, the middle third of the clavicle anteriorly and the angle of the mandible superiorly. Several beach chair positioners are available with a posterior cutout at the level of the shoulder and a special superior segment that allow stabilization of the patient’s head. If two assistants are available, the operative arm is draped free. During the operative procedure, the distal aspect of the upper extremity can be positioned on the Mayo stand and abduction adjusted by elevating or lowering its position. If only one assistant is available, an articulated arm positioner is recommended. Bony prominences should be carefully padded. If surgical time is expected to be prolonged, a urinary catheter is recommended. 
Surgical Approaches.
Hemiarthroplasty is performed through the deltopectoral approach. A 10-cm incision is performed from the clavicle distally. At the level of the coracoid the incision should pass 1 cm lateral to it. At the height of the axillary fold the incision should end at a point located between the medial 40% and lateral 60% of the medial to lateral arm width. Proximally a medial skin flap is elevated just superficial to the deltoid muscle. The cephalic vein can be identified at the fat triangle located between the deltoid, clavicle and pectoralis major, approximately 1 cm medial to the coracoid process. The cephalic vein is then dissected either medially or laterally, while the branches are coagulated. The subdeltoid space is then released with blunt dissection. Fracture hematoma is evacuated. If intact, the clavipectoral fascia is incised along the lateral border of the conjoint tendon, carefully preserving the underlying subscapularis tendon. For improved exposure, 1 cm of the coracoacromial ligament may be removed and 1 to 2 cm of the pectoralis major tendon may be released distally. 
Technique.
The surgical technique is outlined in Table 37-18. Once the subdeltoid space has been released a deltoid retractor is inserted and the fracture site exposed. To extract the humeral head, the biceps tendon is identified distal to the fracture site and followed proximally. The bicipital groove is then identified. In most fractures requiring hemiarthroplasty a fracture line is present just lateral to the bicipital groove. This allows access to the joint cavity. The humeral head can then be removed and saved for subsequent bone grafting. The wound is irrigated to remove any clots from the fracture site. The greater tuberosity is then tagged with four large caliber (#2 or #5) braided nonabsorbable sutures that are placed through the posterior rotator cuff just proximal to its bony insertion. The lesser tuberosity is then tagged with two traction sutures through the distal subscapularis tendon. If the rotator interval is found to be intact, it is incised to the level of the glenoid. The long head of biceps is cut at its insertion onto the superior glenoid labrum and tagged for later tenodesis. The glenoid is then assessed to rule out any traumatic injury or pre-existing chondral damage. Associated glenoid fractures should be stabilized accordingly. Rarely, pre-existing osteoarthritis may require placement of a glenoid component. The humeral shaft is then prepared according to the technique described for the particular implant. In most instances, the humeral canal is reamed with progressively larger reamers until cortical contact is obtained. It is recommended to use the reamer as a sound by gently advancing the reamer with back and forth rotation of the reamer around its longitudinal axis. Aggressive rotation of the reamer in one single direction is discouraged to avoid a possible torsional fracture of the humeral shaft. Once the final reamer has been advanced, the proximal humerus is broached following the manufacturer’s guidelines. A fracture-specific stem should be used. These implants have a lean proximal geometry that allows for bone grafting around the proximal humeral metaphysis to improve tuberosity healing. A number of implants have a textured proximal metaphyseal segment to promote bony ingrowth. 
 
Table 37-18
Hemiarthroplasty
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Table 37-18
Hemiarthroplasty
Surgical Technique
  •  
    Expose proximal humerus
  •  
    Identify and tag tuberosity fragments
  •  
    Release rotator interval
  •  
    Identify and extract humeral head
    •  
      Use for bone graft
  •  
    Confirm rotator cuff integrity and healthy glenoid surface
  •  
    Prepare humeral canal
    •  
      Measure depth of insertion that allows balanced tuberosity reduction
  •  
    Place shaft sutures
  •  
    Cement humeral component in adequate retroversion and length
  •  
    Place humeral head
  •  
    Obtain graft from humeral head and place around proximal humeral stem
  •  
    Reduce tuberosities around stem and tie
  •  
    Confirm stability and range of motion
  •  
    Place drain
  •  
    Close wound
  •  
    Immobilize in sling
X
The biceps tendon is then followed distally to identify the bicipital grove at the level of the proximal humeral shaft and two 2-mm drill holes are placed 1 cm apart and 1 cm from the proximal fracture edge into the humeral shaft. Two large caliber nonresorbable sutures are passed through these holes. A trial stem is then introduced that will allow a cement mantle of at least 1 mm between the implant and humeral shaft. Routine cementation of humeral stems for the management of proximal humeral fractures is recommended since this will allow both axial as well as rotational stability of the stem. One of the key aspects of hemiarthroplasty is to determine the correct height of the prosthesis. Several methods have been described to achieve this: 
  1.  
    The trial stem is inserted with a head closely resembling the size of the extracted native head. The native head is examined to evaluate the presence of a metaphyseal extension that will be missing on the humeral shaft. This “gap” should be visible at the moment of seating of the humeral stem. Conversely, the head may have fractured proximal to the inferior aspect of the anatomic neck, thereby leaving a fragment of head attached to the humeral shaft. Resecting the head remnant at the anatomic neck will provide a medial reference point onto which the prosthetic head can be lowered.
  2.  
    The depth of stem insertion should allow reduction of the greater tuberosity into a gap formed between the prosthetic head and shaft laterally.
  3.  
    The head to tuberosity height should be between 5 and 9 mm.
  4.  
    Under fluoroscopic vision, the so-called gothic arch formed by the lateral border of the scapular body and the medial aspect of the proximal humeral shaft should be restituted with adequate stem placement.
To adequately establish humeral stem insertion it is recommended that a combination of these methods be used. Once the appropriate stem height has been determined, the depth of insertion should be marked on the trial stem with regard to an identifiable reference point on the humeral shaft. Most implants provide reference marks that are matched on the definitive implant. While cumbersome to use, most systems provide external jigs that can aid in inserting the stem to the appropriate depth. The humeral canal is then irrigated and a cement restrictor introduced 1 cm distal to the expected position of the tip of the stem to avoid distal cement migration and improve cement pressurization. The canal is then irrigated and dried and filled in a retrograde fashion with cement. Due to the low rate of humeral loosening, some surgeons recommend cementing only the proximal segment between the stem and the proximal humeral shaft, sufficient to allow rotational and axial stability of the implant. Cement removal is theoretically easier if revision is required. Antibiotics may be added to the cement to reduce the risk of infection. Methylene blue can be added to provide a color contrast with native bone which aids in cement removal should revision be required in the future. The stem is then inserted in 30 degrees of retroversion to the desired depth following the previously determined depth mark and reference point. Excessive cement is carefully removed to avoid interposition between fracture fragments. Once the cement has hardened, a trial head is placed and the tuberosities provisionally reduced to reassess stem height and address glenohumeral tracking. If this is deemed appropriate, the greater tuberosity sutures are brought around the medial aspect of the humeral stem. Most modern prostheses provide a slot through which the sutures can be threaded. The most superior and inferior sutures of the greater tuberosity are then passed from deep to superficial through the insertion of the distal subscapularis tendon. The remaining two greater tuberosity sutures are brought directly around the stem and the humeral head is impacted onto the stem. Cancellous bone graft obtained from the morselized humeral head is placed between the humeral stem and tuberosities and the greater tuberosity sutures tied to their respective tails. The greater tuberosity is then reduced and stabilized around the stem. The sutures from the greater tuberosity that have been passed through the subscapularis tendon are tied to their respective tails, thereby reducing the lesser tuberosity and fixing the greater and lesser tuberosities around the stem. Finally, each suture placed through drill holes in the shaft is passed through the anterior and posterosuperior cuff, respectively and tied, thereby providing an additional vertical anchor of the tuberosities into the humeral shaft. Two additional stitches may be placed at the level of the rotator interval. The long head of the biceps may be incorporated into the vertical fixation stitches or may be formally tenodesed to the pectoralis major tendon (Fig. 37-41). The wound is then irrigated and the deltopectoral interval closed with interrupted absorbable sutures. The subcutaneous tissues and skin are then closed. A drain may be used. 
Figure 37-41
Hemiarthroplasty.
 
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Figure 37-41
Hemiarthroplasty.
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
Posterior four-part fracture dislocation in a 47-year-old male. A, B: Radiographic AP and axillary views of the shoulder. C–H: CT scan images showing axial (C) cuts, coronal (D, E) reconstructions and three-dimensional surface renderings (F–H). I: Intraoperative images showing tag sutures to control the greater tuberosity and allow subsequent fixation around the final implant. J–L: Final implant placement and bone grafting. M: Definitive suture fixation as depicted in (N). O, P: Radiographic follow-up at 1 year after surgery.
View Original | Slide (.ppt)
X
In exceptional occasions, pre-existing osteoarthritis of the glenohumeral joint may require total shoulder arthroplasty. The glenoid component should be placed prior to final humeral stem placement. 
Postoperative Care.
Patients routinely stay at least one night in hospital. If a wound drain is used it is removed within 24 hours of surgery. Passive range-of-motion exercises are started on the first postoperative day. They are limited to neutral rotation and 90 degrees of forward elevation. Patients are followed up clinically and radiographically at 2 weeks, 6 weeks, and 3 months. Active-assisted range-of-motion exercises are started at 6 weeks and strengthening exercises at 3 months. With regard to long-term follow-up patients should have radiographs at 1 year, 2 years, 5 years, and every 5 years thereafter or sooner if symptoms arise. Standard antibiotic prophylaxis for invasive procedures is recommended for life. There are no weight-bearing restrictions 
Potential Pitfalls and Preventive Measures.
Potential pitfalls and appropriate preventative measures are listed in Table 37-19. Shoulder hemiarthroplasty requires accurate reconstruction of the proximal humerus for the rotator cuff to stabilize and power the shoulder for adequate function. Poor function after fracture hemiarthroplasty is often related to complications related to the tuberosities.39,89,269 
 
Table 37-19
Hemiarthroplasty
View Large
Table 37-19
Hemiarthroplasty
Potential Pitfalls and Preventions
Pitfall Preventions
Tuberosity malunion Establish correct stem insertion depth
Adequate tendon release
Stable suture fixation from tendon insertion around humeral stem
Avoid over-tightening of sutures
Tuberosity nonunion Stable suture fixation from tendon insertion around humeral stem
Bone grafting
Conservative progression of physical therapy
Instability Stable suture fixation of lesser tuberosity
Establish adequate stem retroversion
“Overstuffing” Establish correct stem insertion depth
Select appropriate head size
X
Tuberosity malunion leads to an inadequate head to tuberosity height, thereby altering the biomechanics of the shoulder. Placing the humeral head too proud leads to a tuberosity that is too distal with regard to the humeral head. The rotator cuff is thereby placed under increased tension and may subsequently rupture. Furthermore, increased stresses may occur between the prosthetic head and glenoid surface, potentially leading to early glenoid erosion. Too deep humeral stem placement will lead to a tuberosity that is too high with regard to the humeral head. This will lead to subacromial impingement and shoulder dysfunction. Carefully determining the correct depth of insertion of the humeral stem is therefore critical to avoid tuberosity malposition. 
Long-term function depends on achieving healing of the tuberosities to the shaft. Stable fixation of the tuberosities should therefore be obtained with the addition of bone graft around the proximal aspect of the humeral stem. Furthermore, while physical therapy is important to regain motion, exercises should be progressed cautiously so as to not overstress the construct and risk failure of fixation with subsequent tuberosity migration or nonunion. Finally, selection of too large a humeral head component should be avoided as this will lead to a limited range of motion and may also result in early glenoid erosion. Careful matching of the prosthetic component with the size of the native head should be done, with a tendency to err toward the smaller prosthetic head. 
Treatment-Specific Outcomes.
Hemiarthroplasty continues to be the preferred option for the operative treatment of unreconstructable proximal humeral fractures. The results of a number of studies of hemiarthroplasty are given in Tables 37-20 and 37-21. Reliable pain control is achieved as reported by studies with up to 10 years of follow-up.89,212,214,269,274,335 Although several studies show good-to-excellent results in up to 90% of patients, others show that a large subset of patients, while achieving adequate pain control, have only fair functional results.212,214,269,274,335 Forward elevation after hemiarthroplasty for proximal humeral fractures averages 110 degrees, ranging from 20 to 180 degrees.9,89 Despite a large variability in function, prosthetic revision rates are low, with survival reported as high as 97% at 1 year, 95% at 5 years, and 94% at 10 years.9,335 However functional outcomes at an average follow-up of 10 years show unsatisfactory results in over half of patients.9 
Table 37-20
Published Results of the Treatment of Proximal Humeral Fractures with Hemiarthroplasty. Where Possible the Fracture Types are Defined by the Neer Classification with Two-, Three-, and Four-Part Fractures and Fracture Dislocation (FD) and Head-Splitting (HS) Fractures
Authors Fracture Type (Neer parts) Age (years) Follow-up (months) Outcome Scores Results
2 3 4 FD HS Mean (Range) Mean (Range)
Moeckel et al.274 0 5 13 4 70 (49–87) 36 (29–46) HSS 91% Ex/Good
Robinson et al.335 66 (30–90) 76 (24–156) Constant Fair (average)
Mighell et al.269 1 22 41 28 8 66 (39–89) 36 (12–89) ASES Fair (average)
Demirhan et al.89 0 2 15 15 58 (37–83) 35 (8–80) Constant 47% Ex/Good
Antuña et al.9 0 3 32 13 5 66 (23–89) 124 (60–264) Neer 47% Ex/Good
Gallinet et al.126 0 8 13 74 (49–95) 17 (6–55) Constant 39 (average)
Esen et al.106 0 7 25 6 4 70 (59–81) 79 (48–118) Constant/Neer 86% Ex/Good
Bastian and Hertel21 66 (38–87) 60 (40–88) Constant 70 (median)
Pijls et al.315 0 4 25 1 72 (55–91) 37 (13–62) Constant 68 (average)
Olerud et al.298 0 0 27 76 (58–90) 27 Constant 48 (average)
Noyes et al.293 100% 3 or 4 part 61 (31–79) 49 (5–100) Constant 50 (average)
Boyle et al.45 72 (27–96) 60 Oxford 32 (average)
Spross et al.383 8 14 76 (55–92) 36 (12–83) Constant 54 (average)
Boons et al.42 0 0 25 76 12 Constant 65 (average)
X
Table 37-21
The Complications Published in the Papers Detailed in Table 37-20
%
Authors Revision Surgery HO Implant Loosening Joint Penetration Infection Nerve Injury Nonunion Fracture Dislocation Malunion Subacromial Impingement
Deep Super
Moeckel et al.274 9 41 5 5
Robinson et al.335 8 0 3 1 3 21
Mighell et al.269 6 25 3 6 3
Demirhan et al.89 0 17
Antuña et al.9 0 0 10 3 10 14
Gallinet et al.126 0 0 5 5 5
Esen et al.106 7 0 5 5
Bastian and Hertel21 20 0 6
Pijls et al.315 3 0 3
Olerud et al.298 11 0 19
Noyes et al.293
Boyle et al.45
Spross et al.383 5 5
Boons et al.42 4 0 5
X
Comparative studies between ORIF and hemiarthroplasty have shown conflicting results with regard to functional outcome. One study showed that similar functional outcomes can be expected after locked plate fixation of proximal humeral fractures with nonischemic humeral heads and hemiarthroplasty, when intraoperative head vascularity is absent.21 Other studies have shown that ORIF achieves significantly better functional outcomes than hemiarthroplasty. Solberg et al. found significantly higher Constant scores after locked-plate fixation (68.6 points) than after hemiarthroplasty (60.6 points). Interestingly, while AVN of the humeral head, lead to functional scores that were significantly lower than internally fixed fractures without AVN, the results were similar to those after hemiarthroplasty.378 
Complications associated with hemiarthroplasty include nonunion of the tuberosities in 18% of patients.212,378 Infection occurs in 0.6% to 1.6% of cases, with some studies reporting infection in up to 8% of cases.212,378 While heterotopic ossification occurs in up to 8.8% of cases, it does not limit function.212 

Reverse Total Shoulder Arthroplasty

While it is possible to obtain clinical results that are similar to those of a normal shoulder with hemiarthroplasty the literature indicates that functional results are frequently disappointing.9,39 For this reason many surgeons now use reverse total shoulder arthroplasty, rather than hemiarthroplasty, for the treatment of proximal humeral fractures. Reverse total shoulder arthroplasty has become the implant of choice for the management of several conditions associated with significant rotator cuff dysfunction such as cuff tear arthropathy, massive irreparable rotator cuff tears with painful pseudoparesis and glenohumeral joint arthritis with advanced rotator cuff pathology.38,411,414 Because of concerns about possible tuberosity malposition and nonunion, reverse total shoulder arthroplasty has therefore been proposed as an alternative for the management of acute complex proximal humeral fractures.53,61,126,137,237,241,323,402,424 
By placing a hemisphere onto the glenoid surface and a concave tray onto the humeral stem, reverse shoulder arthroplasty allows for rotation to occur at the glenohumeral joint through activation of the deltoid, without the need for a functional rotator cuff/tuberosity unit. Furthermore medialization of the center of glenohumeral rotation improves the lever arm of the deltoid, thereby theoretically optimizing its biomechanics for shoulder elevation. Reverse total shoulder arthroplasty therefore not only offers an alternative for the management of complex acute proximal humeral fractures, but also for the management of proximal humerus malunion or nonunion where the normal anatomy of the tuberosities cannot be reliably restored.251,258,259,401,418 It has been suggested that rehabilitation after reverse total shoulder arthroplasty is quicker than after hemiarthroplasty, since the inherent implant stability and the fact that tuberosity healing is not important allows patients to regain an earlier active range of motion.146 
Shoulder elevation and abduction can be achieved in the absence of a functional rotator cuff, but glenohumeral rotation may be limited. While the anterior and the posterior deltoid allow for some rotation of the native glenohumeral joint, this ability is lost in reverse total shoulder arthroplasty due to medialization of the center of rotation. It is therefore recommended that the tuberosities be incorporated into reverse total shoulder arthroplasty construct for internal and external rotations of the shoulder to occur by action of the subscapularis and teres minor muscles, respectively.146,367,369,414 
Preoperative Planning.
A preoperative planning checklist for reverse shoulder arthroplasty is shown in Table 37-22. The preoperative planning for reverse total shoulder arthroplasty involves the same principles outlined for hemiarthroplasty. However because of the requirement for a glenoid component, a more focused assessment of the glenoid is required. One of the most frequent complications of reverse total shoulder arthroplasty is glenoid notching, which occurs when chronic medial impingement between the humeral component and the glenoid neck leads to progressive bone loss that can result in loosening of the glenoid component.61,53,290,368 Placement of the glenoid baseplate should therefore be aimed at maximizing inferomedial clearance by achieving some inferior overhang between the glenosphere and the glenoid neck. Furthermore, inferior tilt of the baseplate has been associated with improved biomechanical loading of the implant-bone interface and favorable clinical outcomes.155,368 Finally, the use of a lateral offset glenosphere can reduce the amount of medial glenohumeral impingement.154 While the normal glenoid is usually unaffected by a proximal humerus fracture, a clear understanding of the patient’s glenoid anatomy is key to achieving adequate implant positioning. In most instances, glenoid reaming will be performed parallel to the glenoid surface in the axial plane and with slight inferior inclination in the frontal plane. Pre-existing posterior or anterosuperior wear should be carefully assessed on radiographs and CT scans to allow intraoperative adjustment thereby ensuring central seating of the central peg of the baseplate in the glenoid vault. 
 
Table 37-22
Reverse Shoulder Arthroplasty
View Large
Table 37-22
Reverse Shoulder Arthroplasty
Preoperative Planning Checklist (in Addition to Items Described for Hemiarthroplasty)
  •  
    Equipment
  •  
    Glenoid retractors
  •  
    Reverse total shoulder arthroplasty system
X
Positioning.
Patient positioning is the same as detailed for hemiarthroplasty. 
Surgical Approaches.
Reverse shoulder arthroplasty can be performed either through a deltopectoral approach or through a superolateral deltoid-splitting approach. If there is cuff tear arthropathy, the superolateral approach has the advantage of being associated with less instability compared to the deltopectoral approach, as the subscapularis tendon is left intact.276 This advantage is however not present in proximal humeral fractures requiring arthroplasty, since access to the humeral canal is allowed by the displaced tuberosities. The deltopectoral approach has been shown to provide more reliable glenoid component positioning, with lower rates of glenoid loosening and glenoid notching.275 The deltopectoral approach is therefore recommended for proximal humeral fractures. 
Technique.
The technique of using a reverse shoulder arthroplasty to treat a proximal humeral fracture is outlined in Table 37-23. Implantation of a reverse total shoulder arthroplasty is initially similar to hemiarthroplasty. Once the tuberosities have been tagged, the humeral head extracted and the long head of the biceps cut, the glenoid is exposed with the use of two glenoid retractors. The labrum is then circumferentially released from the glenoid. Exposure of the glenoid in proximal humeral fractures is usually straightforward, due to absence of the humeral head and separation of the tuberosities. Care should be taken to fully expose the inferior border of the glenoid to allow as inferior placement of the baseplate as possible. Partial release of the triceps insertion from the infraglenoid tubercle is usually required. 
 
Table 37-23
Reverse Shoulder Arthroplasty
View Large
Table 37-23
Reverse Shoulder Arthroplasty
Surgical Technique
  •  
    Expose proximal humerus
  •  
    Find long head of the biceps distally and follow proximally to intertubercular groove for fracture fragment identification
  •  
    Transect long head of biceps at the level of surgical neck and tag distal segment for later tenodesis
  •  
    Identify and tag lesser tuberosity
  •  
    Release rotator interval
  •  
    Identify and extract humeral head and prepare for bone graft
  •  
    Place four braided nonabsorbable sutures around greater tuberosity through rotator cuff tendon
  •  
    Prepare glenoid
    •  
      Use proximal biceps stump to circumferentially resect glenoid labrum
    •  
      Identify inferior border of glenoid by releasing origin of triceps
    •  
      Ream glenoid to place baseplate in 10 degrees of inferior tilt
    •  
      Place and fix baseplate
    •  
      Place and fix glenosphere
  •  
    Prepare humeral canal
    •  
      Ream
    •  
      Place trial stem with tray and reduce onto glenosphere
    •  
      Apply traction onto arm while pushing tray and stem against glenosphere
    •  
      Measure depth of insertion
    •  
      Drill two 2-mm holes on anterior aspect of humerus shaft 1 cm apart and 1 cm distal to proximal fracture edge and pass two braided nonabsorbable sutures
    •  
      Place cement restrictor 1 cm distal to expected stem tip position
    •  
      Retrograde insert cement
    •  
      Introduce stem in 30 degrees of retroversion to pre-established depth
    •  
      After cement hardening place tray and reduce onto glenosphere
    •  
      Select final tray according to desired tension
    •  
      Place greater tuberosity sutures around humeral stem
    •  
      Pass two greater tuberosity sutures through subscapularis around lesser tuberosity
    •  
      Place definitive tray and reduce joint
    •  
      Place bone graft around proximal stem
    •  
      Reduce and tie greater tuberosity around stem
    •  
      Reduce and tie lesser tuberosity around stem
    •  
      Pass transosseous humeral shaft sutures through anterior and posterosuperior rotator cuff, respectively
    •  
      Incorporate long head of the biceps for tenodesis
  •  
    Confirm stability and range of motion
  •  
    Place drain
  •  
    Close wound
  •  
    Immobilize in sling
X
A central guide pin is placed in such a manner that the baseplate will be positioned centrally in the AP plane, caudally in the frontal plane and with 10 degrees of inferior tilt. After reaming and fixation of the baseplate, the glenosphere is placed. 
Humeral preparation is then completed as for hemiarthroplasty and the proposed trial stem is inserted in 10 to 30 degrees of retroversion with the thinest humeral tray. The humeral component is then reduced onto the glenoid and the distal humerus pulled, while pushing the humeral stem onto the glenosphere allowing the humeral shaft to telescope around the stem. Unlike hemiarthroplasty, final stem insertion is not aimed at reconstituting an adequate head to tuberosity height, but rather to obtaining adequate tension of the deltoid to avoid instability. Once maximum tension of the soft tissues is achieved the depth of insertion of the humeral stem is determined and marked. The definitive stem is then cemented to the set depth using standard cementing techniques and maintaining retroversion. Once the cement has hardened, the components are again reduced using the smallest trial insert. Final insert thickness is then increased until adequate soft tissue tension is obtained as determined by tightness of the conjoined tendon and deltoid muscle. Tuberosity fixation is then prepared as described for hemiarthroplasty. The definitive tray and insert are then placed and the components reduced. The tuberosities are then tied as described for hemiarthroplasty. Because of the geometry of reverse shoulder arthroplasty and changes in the alignment of the shoulder, anatomic reduction of the tuberosities is not always possible, or required. However, contact between the tuberosities and shaft should be established and the area bone grafted to achieve union (Fig. 37-42). 
Figure 37-42
 
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
View Original | Slide (.ppt)
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
View Original | Slide (.ppt)
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
View Original | Slide (.ppt)
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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Figure 37-42
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
View Original | Slide (.ppt)
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
View Original | Slide (.ppt)
A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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A–F: Reverse total shoulder arthroplasty. Four-part head split proximal humerus fracture in an 80-year-old female. G: Intraoperative image showing extraction of the humeral head fragment. H: Tagging of the greater tuberosity. I: Reaming of the humeral canal. J: Reaming of the glenoid. K and L: Placement of the baseplate and glenosphere. M and N: Assessment of humeral length and depth of stem cementation. While the elbow is pulled distally, the proximal humeral trial component is pushed against the implanted glenosphere. The resulting stem depth is marked. (Part N: Courtesy of Juan Pablo Simone, MD.) O: Depth of insertion marked on trial stem and corresponding cement restrictor. P: Cement in place. Note the use of methylene blue and placement of two diaphyseal sutures. Q: Cementation of final stem in 30 degrees of retroversion using the axis of the forearm as a reference (note the proximal guide pin). R: Bone graft is obtained from the resected humeral head. S: Proximal humeral polyethylene insert in place. T: Preliminary tuberosity reduction. U: Grafting between stem and tuberosities. V: Final reduction of tuberosities. W and X: Radiographic follow-up 5 months after surgery.
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X
Postoperative Care.
Patients routinely stay in hospital for at least one night. A similar postoperative protocol as described for hemiarthroplasty is used. Some authors advocate early active-assisted range of motion as pain allows.146 Due to the importance of obtaining tuberosity healing for rotation, it is however recommended that surgeons use a more conservative approach of passive range of motion for the first 6 weeks after surgery, followed by subsequent active-assisted range-of-motion exercises for 6 weeks and strengthening exercises at 3 months if required. Weight bearing is limited to less than 20 lb for life. 
Potential Pitfalls and Preventive Measures.
A list of potential pitfalls and their prevention is given in Table 37-24. The three main complications associated with reverse total shoulder arthroplasty are wound hematoma and instability in the short-term and glenoid notching, with glenoid component loosening, in the mid to long term.53,61,323,414 
 
Table 37-24
Reverse Total Shoulder Arthroplasty
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Table 37-24
Reverse Total Shoulder Arthroplasty
Potential Pitfalls and Preventions
Pitfall Preventions
Glenoid notching Adequate inferior exposure of the glenoid to allow inferior glenoid baseplate and glenosphere placement
Use of a lateralized glenosphere
Wound hematoma Careful hemostasis
Drain placement
Avoid anticoagulation
Instability Obtain adequate soft tissue tension
Use of large glenosphere
X
The incidence of glenoid notching in proximal humeral fractures ranges from 10% to 53%.53,61 As described, glenoid notching is best avoided with inferior placement of the glenosphere to allow inferomedial clearance of the proximal humerus during adduction. This can be achieved by positioning the baseplate inferiorly on the glenoid. Some systems allow for eccentric positioning of the glenosphere onto the baseplate, thereby permitting a more inferior glenosphere placement.88 The use of lateralized glenospheres, especially those with a circumference larger than half a sphere, can allow increased medial clearance.154 
Wound hematoma is the most frequent early postoperative complication after reverse total shoulder arthroplasty.414 It is therefore recommended to use careful hemostasis during the procedure. A postoperative drain is used for the early postoperative period. 
Instability has been shown to be a frequent complication after reverse total shoulder arthroplasty for proximal humeral fractures.323 Adequate soft tissue tension is required to achieve inherent stability between the humeral concavity and the glenosphere. Theoretically, larger glenospheres should be more stable but these are frequently not implantable in this predominantly smaller elderly female population. 
Treatment-Specific Outcomes.
Results after reverse total shoulder arthroplasty have been found to frequently be similar to those of hemiarthroplasty, especially during the first 6 postoperative months.45,126,424 As with hemiarthroplasty, functional scores and range of motion are frequently unpredictable.237,241 However decline in function over time appears to be more marked after hemiarthroplasty with reverse total shoulder arthroplasty showing improved function 5 years after surgery.45,137
In a comparative study of 40 patients with proximal humeral fractures treated with either hemiarthroplasty or reverse total shoulder arthroplasty, those in the hemiarthroplasty group reported better internal and external rotations. Those in the total shoulder group demonstrated better shoulder abduction, forward elevation, and functional scores. Tuberosity malunion was found in three patients with hemiarthroplasties, whereas 15 patients with reverse arthroplasty developed scapular notching.126 In a different comparative study of 10 patients with a mean age of 76 years similar functional scores were found between patients undergoing reverse total shoulder arthroplasty and those undergoing hemiarthroplasty. Similar forward elevation and external rotation were found in both the groups.424 
Cazeneuve et al. reported on 36 patients who had undergone reverse total shoulder arthroplasty. The average age was 75 years with a range of 58 to 92 years. After 7 years of follow-up function of the replaced shoulder was 67% of that of the contralateral shoulder. The complications included four dislocations, one infection, and two cases of complex regional pain syndrome. A total of three components (two glenoid components and one humeral stem) were found to be loose. The most frequent radiographic complications were scapular notching which occurred in 19 patients (53%).61 Bufquin et al. reported on 43 patients with reverse total shoulder arthroplasty for proximal humeral fractures in patients ranging from 65 to 97 years of age. After a mean follow-up of 2 years, forward elevation and external rotation averaged 97 degrees and 30 degrees, respectively. However a large variation in results was reported with values ranging from 35 to 160 degrees for elevation and 0 to 80 degrees for external rotation. At final follow-up 10 cases (25%) showed scapular notching.53 
Support for reverse total shoulder arthroplasty for the treatment of acute proximal humeral fractures continues to be scarce in the literature. While some studies show promising results, cautious use of reverse total shoulder arthroplasty should be advised because of the high rate of complications that has been reported. The ideal candidate for reverse total shoulder arthroplasty in a patient with a complex proximal humerus fracture is a low demand elderly patient with pre-existing rotator cuff pathology and glenoid pathology. 

Management of Adverse Outcome and Complications

There are numerous complications of proximal humeral fractures that have been described, but most are rare. Complications may occur as an inevitable consequence of a more severe injury or as a result of treatment. The latter may be because of errors in treatment selection or in the surgery that was undertaken. Implant-specific operative complications have been described in the previous sections and will not be discussed further here. 
Boileau et al. retrospectively analyzed 203 patients who presented with sequelae of proximal humeral fractures and were subsequently treated with an unconstrained modular prosthesis.37 They identified 137 (67.5%) cases of humeral head collapse or necrosis, 25 (12.3%) cases of irreducible dislocations or fracture dislocations, 22 (10.8%) cases of nonunion and 19 (9.4%) severe tuberosity malunions. The study did not include all complications of proximal humeral fractures but it highlighted the problems associated with osteonecrosis of the humeral head, nonunion, and tuberosity malunion in particular. These three complications are considered in detail together with an overview of other complications and their treatment. 

Osteonecrosis

Humeral Head

Osteonecrosis of the humeral head occurs as a consequence of impaired blood supply of the articular surface and subchondral bone, which undergo involutional change, leading to articular collapse and fibrosis. This condition may or may not be symptomatic,415 and the head may collapse completely, or there may be partial involvement, with or without articular collapse.20,170 
This complication may be an inevitable complication of the injury, because of the severe damage to the blood supply of the humeral head. Three- and four-part fractures and fracture dislocations are therefore at higher risk than are one- and two-part fractures. It may also occur as a consequence of operative treatment, because of excessive fracture manipulation and stripping of soft tissues, which contain the residual vascularity to the articular segment. Some individuals may also be predisposed to this complication, either because of their poor physiologic state secondary to their medical comorbidities and drug treatment, or through smoking and alcohol abuse. The pathophysiology of this condition is incompletely understood at present and other unknown factors may also be important. It does not invariably develop even if the head is completely denuded of blood supply,20,145,170 whereas some cases appear to occur after a relatively innocuous injury. 
The presentation is usually with pain, stiffness, and loss of function, typically after a latent period, where function has been satisfactory. Radiologically, the changes vary from patchy humeral head sclerosis, to complete humeral head resorption and collapse. The differential diagnosis is from post-traumatic osteoarthrosis, in which the degree of collapse is usually less severe, and from chronic joint sepsis, which, if clinically suspected, should be excluded by bacteriologic examination of a joint aspirate. CT and especially MRI are useful in the evaluation of the extent and severity of head involvement. 
In some cases, the osteonecrosis may not be associated with severe symptoms, and nonoperative treatment is advisable.415 Core decompression may occasionally be indicated for patients who have early radiologic changes,278 but most patients have advanced collapse and are symptomatic by the time they present.144 Hemiarthroplasty is indicated where symptoms are debilitating and function is poor.93,40 This technique is much more likely to be successful if there is no associated malunion that requires treatment.144 If there are reciprocal glenoid changes, a total joint arthroplasty may be more successful in relieving pain and restoring motion.93 Where there is a severe associated tuberosity malunion or cuff tear, reverse shoulder arthroplasty may provide better function, although comparative studies have not yet been performed to evaluate this.259,418 

Tuberosity

Osteonecrosis may also occur in one or both tuberosities after fracture, regardless of the viability of the humeral head. Resorption, sclerosis and collapse may be seen after fracture of the greater tuberosity (the “disappearing tuberosity”) and may also occur in the lesser tuberosity. It may occur after two-, three-, or four-part fractures and may follow nonoperative treatment, internal fixation, or arthroplasty. This complication is predictable, because until a fractured tuberosity unites, it only receives blood supply through residual periosteal attachments and its cuff attachments, which are often relatively avascular in elderly patients. The patient usually has debilitating shoulder pain and loss of function, with clinical signs of rotator cuff weakness and dysfunction. Subclinical forms probably occur frequently, and the precise pathology has not yet been fully elucidated. At present, there is no known treatment for this complication. 

Nonunion

Nonunion of the head to the shaft of the proximal humerus is a rare but debilitating complication.79 The normal time for clinical union of a proximal humeral fracture is typically 4 to 8 weeks. It is therefore logical to define nonunion to be present if a fracture site is still mobile 16 weeks postinjury, although 6 months has been used in some studies. In the only study to have evaluated the epidemiology of this complication, the overall reported incidence was 1.1%, although this rose to 8% if metaphyseal comminution was present and 10% if there was significant translation of the surgical neck.79 Nonunion was shown to very rare in varus-impacted proximal humeral fractures. Nonunion of one or both tuberosities to the head is less common and is considered together with tuberosity malunions later in the chapter. 
Although nonunion may occur for no obvious reason, in most instances there are identifiable patient-, fracture-, or treatment-related risk factors: Common patient-related factors include osteoporosis, poor physiologic state, medical comorbidities and drug treatment, heavy smoking, and alcohol abuse.163,352,408 Inflammatory or degenerative shoulder conditions associated with preinjury shoulder stiffness, may also predispose to nonunion.171 The fractures most at risk of nonunion are two-, three-, or four-part displaced fractures, where there is minimal residual cortical contact between the humeral head and shaft, and in those where there is marked metaphyseal comminution.79 The complete disruption of the periosteal sleeve leads to mechanical instability, and soft tissue interposition of periosteum, muscle, and the tendinous portion of the long head of biceps may also inhibit callus formation.124,125,283 It has been suggested that nonoperative treatment with hanging casts, which distract the fracture, and overzealous shoulder mobilization may predispose to nonunion.286 Poor surgical technique with extensive soft tissue stripping and a mechanically unstable fracture reduction and fixation may also cause nonunion. 
In clinical practice the diagnosis of a nonunion is seldom a problem. Pain, stiffness, and loss of function in the arm are the most constant complaints. The pain tends to be severe and debilitating and is aggravated by use of the arm and shoulder, because most movement occurs at the site of the nonunion. This is not amenable to splinting, and the use of a sling further compromises shoulder function. On examination, the patient often has a “pseudoparalysis” of the deltoid, rotator cuff, and periscapular muscles, with a flail arm. Attempted movement of the shoulder is painful and any motion occurs at the fracture site rather than the glenohumeral joint. Radiologically, there is resorption and widening of the fracture line, often with massive bone resorption. 
Further investigation should include CT to confirm the nonunion and assess the state of the humeral head articular cartilage, the degree of separation, union of any associated tuberosity fractures, and the feasibility of reduction and fixation of the fracture. If surgical reconstruction has been previously performed, infection should be excluded at the site of the nonunion by culture of an aspirate performed under ultrasound control.93 
Sustained pain relief and restoration of function after the development of this complication can only be provided by operative treatment. This is technically challenging, because of capsular contractures and scarring from previous surgery, bone loss, distorted anatomy, and osteopenia of the humeral head.124,125 Unfortunately, many patients with established nonunions are too elderly, frail, or medically unfit to undergo this type of surgery and the prolonged shoulder rehabilitation program thereafter. Pain management and activity modification are all that can be offered to these patients. 
All medically fit patients should be offered a surgical reconstruction. Attempts have been made to classify these according to their anatomic site and the degree of bone loss.63 In practice, the principal decision is whether the nonunion is amenable to ORIF or whether a humeral head replacement is required. The decision as to which form of treatment is most appropriate is individualized, but absence of infection, adequate humeral head bone stock, lack of severe tuberosity malunion, and absence of degenerative change or collapse of the articular surface are mandatory if ORIF is undertaken. 

Open Reduction and Internal Fixation

The exposure is similar to that used for primary ORIF. The nonunion is exposed and taken down by excision of the fibrous union and pseudocapsule and removal of any devitalized bone fragments. Arthrolysis of a stiff joint may be required, which aids in subsequent rehabilitation and limits force transmission at the nonunion site.163 However, care must be taken to avoid devitalization by excessive soft tissue stripping to expose the nonunion. It is essential to ensure that the bone ends are bleeding and the medullary canal is clear of fibrous debris. 
If there is minimal bone loss, the bone ends may be reduced in a relatively anatomic fashion. This is unusual, and more commonly there is extensive metaphyseal bone loss because of the “windscreen-wiper” effect of the shaft at the site of the mobile synovial nonunion. Satisfactory viable bone contact can usually only be achieved by impaling the relatively narrow bayonet of the shaft into the sheath of the wide humeral head metaphysis. The nonunion site is typically grafted with either corticocancellous strips of iliac crest bone graft, an IM bone plug, or a fibular strut graft.410 This may result in significant humeral shortening, but this is usually well tolerated. If maintenance of length is deemed to be important in a younger patient, this requires more extensive grafting of the metaphyseal defect, using autograft augmented with fibular strut grafting. 
Provisional fixation is achieved with K-wires and definitive plate fixation is then performed. A locking proximal humeral plate is the ideal implant in this situation, given the relatively poor proximal humeral bone stock. Postoperative rehabilitation follows the guidelines given for primary fixation. 
The treatment of any associated tuberosity fractures depends on whether they are healed and their degree of displacement. Ununited fragments may be amenable to reduction and stabilization using the osteosuturing techniques previously described, whereas healed, minimally displaced tuberosity fragments do not require adjuvant treatment. Tuberosity osteotomy may occasionally be used if there is a severe malunion, but this should be avoided if at all possible because of the risk of subsequent nonunion of the fragment. 
Most series that have reported on head-conserving reconstruction of established nonunions have reported a high success rate in achieving union, often with a good eventual functional outcome. However, a high rate of postoperative complications is to be expected, which may require further surgery, and the functional recovery time is usually prolonged. 

Humeral Head Arthroplasty

This technique is preferred if there is poor humeral head and metaphyseal bone stock and cavitation, severe tuberosity malunion or displaced nonunion, or collapse and degenerative change of the humeral articular surface. The main aim of the treatment is pain relief, and the eventual poor functional recovery is often worse than for a primary arthroplasty. Although hemiarthoplasty is most commonly used, total shoulder replacement may be indicated if there is glenoid articular surface wear or defects. The functional outcome is poor when osteotomy of the tuberosities is performed, and this should be avoided if possible.37,39 It has been suggested that reverse shoulder arthroplasty may improve the shoulder function in patients with nonunions associated with severe tuberosity malunions,37 although comparative studies have not yet been reported. 
Most studies that have reported on the use of arthroplasty to treat nonunion suggest that the procedure may be effective in reducing or eliminating pain but there is a high rate of complications which often require further surgery and are associated with a disappointing functional recovery.10,37,163,283 It remains to be seen in future clinical studies whether the use of reverse shoulder arthroplasty will improve the outcomes obtained with conventional arthroplasty in the treatment of this challenging complication.41 At present, an arthroplasty should only be considered for patients who have poorly controlled pain and have nonunions that are not amenable to reduction and internal fixation. 

Malunion

Some degree of malunion is inevitable in displaced proximal humeral fractures that are treated nonoperatively. It may occur after surgery through intraoperative malreduction or through inadequate fixation that allows secondary redisplacement. Two types of malunion are distinguishable and often coexist. Malunion of the head on the shaft either through impaction, translation, rotation, or angulatory deformity is common and is well tolerated in most patients. Malunion of one of both tuberosities is also common and well tolerated in older patients with limited functional expectations. However, in physiologically younger patients, the altered shoulder mechanics produced by the defunctioning and tearing of the rotator cuff tendons and mechanical impingement of the displaced tuberosity fragments often produces an unacceptable degree of pain and functional compromise. Where the two conditions coexist, it is therefore most often the tuberosity malunion that is symptomatic. 
A symptomatic malunion will typically give rise to shoulder pain, which is usually localized over the anterior deltoid. The pain is usually aggravated by use of the arm and particularly by forward flexion, abduction, and internal rotation. This frequently results in impairment of the patient’s ability to perform normal daily activities and leisure pursuits. It is important to try to distinguish the cause of symptoms on physical examination, because rotator cuff impingement and tears, post-traumatic shoulder stiffness, acromioclavicular joint dysfunction, biceps tendinopathy, and complex region pain syndromes may all contribute to the symptoms. In addition to specific clinical testing of these structures, a good response to subacromial local anesthetic tends to localize symptoms to the subacromial space. If infection is suspected, appropriate hematologic studies and bacteriologic examination of a joint aspirate are warranted. 
The complex anatomy of most malunions is best appreciated using CT with 3D reconstructions. MRI may be useful in evaluating the state of the rotator cuff and capsule, but interpretation of images is frequently hampered by the distorted anatomy. It may be useful in detecting radiologically occult early osteonecrosis. As with nonunion, attempts have been made to classify this complication27,37 but most often treatment is individualized on the basis of the patient’s physiologic status and level of symptoms, the anatomy of the injury, and the likelihood of success from a surgical reconstructive procedure. 
The results of corrective surgery are unpredictable, and for older patients a trial of nonoperative treatment is advisable. A shoulder rehabilitation program, pain management, and activity modification may reduce the symptoms to acceptable levels and improve function. The patients who remain symptomatic despite this treatment and request surgery should be carefully counseled about the likely limited gains from surgery, as well as the significant risk of complications. The technical details of the operative treatment according to the anatomic pattern of malunion are discussed below. 

Two-Part Greater Tuberosity Malunion or Displaced Nonunion

Isolated malunions and nonunions of the greater tuberosity are relatively common but are usually debilitating only in younger, physically active patients. The deforming forces of the attached cuff muscles cause the tuberosity to retract posterosuperomedially but the articular surface is unaffected. The posterior displacement may produce a bony block to external rotation, while superior displacement may block abduction and lead to subacromial impingement. Tuberosity malposition can also produce cuff dysfunction, attrition, and tears.364 Arthroscopic assessment may provide useful information and the condition may occasionally be amenable to arthroscopic mobilization and fixation if there is a relatively mobile nonunion.138 
Surgical reconstruction is usually performed using a deltoid-splitting approach to gain access to the displaced tuberosity, which is usually fixed and immobile. The fragment is mobilized by excision of the fibrous nonunion or osteotomy of a malunion. An extensive posterior capsular release or excision and a rotator interval dissection are often required to mobilize the fragment sufficient for it to be reduced to its decorticated native bed. Fixation is achieved using either interosseous sutures or screw fixation, as for an acute fracture. It is important to test the repair by fully internally rotating the arm, to ensure the repair is not unduly tight. An acromioplasty and subacromial decompression should be performed if the subacromial space is narrowed, to reduce the risk of later impingement. If the repair is tight, the arm is immobilized for 4 weeks in neutral or slight external rotation, to reduce the risk of failure of the repair. The postoperative treatment protocol is otherwise identical to the treatment of an acute fracture. There are a few reports of the results of treatment of greater tuberosity malunions,27 which report substantial pain relief and functional improvement but with prolonged recovery times. 

Two-Part Lesser Tuberosity Malunion or Displaced Nonunion

Two-part lesser tuberosity fractures are frequently diagnosed late or missed at initial presentation.98,240,294,297 The displaced fragment may block internal rotation or cause subscapularis weakness, and occasionally this may be amenable to arthroscopic treatment.175 The fragment is exposed through a deltopectoral approach and mobilized with capsular releases as for malunion of the greater tuberosity. Reduction and fixation of an associated articular fracture can be performed with heavy interosseous sutures or screws, dependent on the fragment size. 

Two-Part Surgical Neck Malunion

An isolated surgical neck malunion is seldom a cause of severe disability unless the humeral head heals with a varus deformity sufficient to cause secondary cuff impingement or dysfunction.25,93,364,365,379 The deformity is characteristically a complex angulatory (varus or rarely valgus) and internal rotational malunion, with translation of the shaft anteromedially.28,93,364,365 
Operative treatment is seldom indicated except in younger patients who are still symptomatic after a prolonged shoulder rehabilitation program. If clinically indicated, osteotomy to correct the deformity and locking plate fixation are performed.25,379 Open capsular release is usually performed if there is significant associated post-traumatic stiffness and the osteotomy is usually bone grafted. The results from this technique are satisfactory in most reported series.25,379 

Three- and Four-Part Malunions

In a minority of cases where there is no osteonecrosis and the deformity is less severe, soft tissue release and an osteotomy of the fracture fragments, followed by internal fixation, may be attempted. A successful outcome can only be achieved if there is a good correction of both osseous and soft tissue abnormalities.27,28 However, most symptomatic malunions are complex 3D deformities, which can usually only be treated by prosthetic replacement. The integrity of the glenoid articular surface determines whether humeral hemiarthroplasty or total shoulder arthroplasty is performed. The chief indication is for pain relief and the functional gains are often minimal. Extensive capsular excision is usually required, and any associated rotator cuff tears should be repaired. 
In some cases of tuberosity malposition, a greater tuberosity osteotomy can be avoided by using a small stem that is shifted in the medullary canal to compensate for the tuberosity malposition or by the use of an eccentric modular humeral head. If the normal relationship between the tuberosities and the humeral head cannot be achieved, either a tuberosity osteotomy and conventional arthroplasty, or a reverse shoulder arthroplasty should be performed. There may also be a role for the use of a resurfacing humeral hemiarthroplasty in selected cases, as this does not require the use of an IM stem for fixation. Three quarters of the humeral head must remain after reaming for this technique to be used, to allow secure fixation and prosthetic bone ingrowth. 
The available case series literature for treatment of complex multipart malunions is scarce, but the results of arthroplasty are inferior to those of prosthetic treatment of similar acute fractures. In particular, the requirement for tuberosity osteotomy is associated with a poor prognosis.37 Pain relief is usually achieved, but shoulder range of motion and strength are often limited.10,27,28,37,44,93,120,255,394 The results of the use of reverse shoulder arthroplasty for the treatment of severe malunion are still largely unknown in the longer term, although this is a promising new technique and the results of comparative outcome studies are awaited.41 

Other Complications

Post-Traumatic Shoulder Stiffness

The causes of post-traumatic shoulder stiffness are often multifactorial. Although capsular contracture is usually the main cause of refractory stiffness, other factors may include fracture malunion, complex regional pain syndrome, thoracic outlet syndrome, mechanical impingement of implants, and rotator cuff dysfunction from impingement or tears. These factors are poorly described in the contemporary literature but may nevertheless be contributory to persistent stiffness after fracture. 
The most characteristic finding is of restriction of movement in a “capsular pattern,” with generalized stiffness but selectively greater loss of shoulder abduction and external rotation. The initial treatment is nonoperative with shoulder rehabilitation to attempt to regain movement by selective stretching exercises. Most patients improve to a degree on this regime, and recovery of movement is often protracted over the first year after injury. A plateau in recovery is usually heralded by the presence of a firm “woody” feel on terminal stretching exercises, suggesting a mechanical block to movement. Distension arthrography is useful in stretching and rupturing the capsule in idiopathic adhesive capsulitis, but it is the authors’ experience that this procedure is less effective in the post-traumatic shoulder. 
In malunited fractures, it is important to distinguish whether the stiffness is because of soft tissue contracture or the malunion itself. An examination under anesthesia under fluoroscopy followed by an arthroscopic examination of the shoulder is often required to distinguish these conditions. If the malunion is considered to be the cause of the stiffness, it is unlikely that a soft tissue release will be effective and consideration must be given to corrective osteotomy as described previously. 
In patients with refractory post-traumatic stiffness without malunion, a manipulation under anesthesia is usually performed. This procedure is contraindicated in patients with uncertain fracture healing and in patients with severe osteoporosis, where there is a substantial risk of humeral shaft fracture during manipulation. If manipulation is unsuccessful in regaining sufficient movement, it should be followed by arthroscopic release of capsular tissue from the rotator interval, circumferential intra-articular capsular releases, subacromial decompression, and removal of impinging metal work.54,180,242 It is important to check for restoration of movement at each stage of the release and to measure the final on-table range of movement at the end of the procedure. The use of a continuous passive movement machine with regional anesthesia may be useful in retaining movement in the early postoperative period. Prolonged physiotherapy is often required thereafter to consolidate the improved range of movement. 

Infection

Infection is relatively rare in the shoulder even after surgical repair using open methods. This is because of the rich vascularity of the region and the good soft tissue cover.72,189 The precise prevalence of this complication is difficult to evaluate, because most reported case series of operative treatment are retrospective. Although infection is usually a postsurgical complication, it may occasionally develop after nonoperative treatment. This is more likely in thin, debilitated patients, either from infection of the fracture hematoma, or in those with displaced surgical neck fractures from pressure on the anterior soft tissues. 
Most infections are encountered after surgery and the risk is likely to be increased in thin and debilitated patients, in those patients with a more severe soft tissue injury and a more severe grade of fracture or if there is prolonged surgical time, poor surgical technique, or operator inexperience. It is important to distinguish superficial from deep infections. Superficial infections are common, confined to the skin and subcutaneous layer, and do not form a purulent collection. Superficial pin track infections are a particularly common complication of percutaneous pinning of fractures.186,207 In contrast, deep infections often form a sinus with a deep purulent collection that extends to the implant. These fail to resolve without further surgical treatment. Ultrasound and MRI may be useful in assessing for the presence of a deep collection. 
Superficial infections with a bacteriologically proven growth of pathogenic organisms invariably resolve with antibiotic therapy. It is often difficult to distinguish between a superficial infection and a wound hematoma, especially if cultures are equivocal. Broad-spectrum antibiotic therapy and topical dressings are frequently given empirically following discharge from hospital, and most superficial infections resolve on this regimen. More severe superficial infections should be treated with parenteral antibiotics, guided by wound cultures. An ultrasound guided aspirate is useful in distinguishing a deep purulent infection from a sterile wound hematoma. Large sterile wound hematomas require surgical drainage, as wound dehiscence may otherwise occur, with the risk of subsequent bacterial colonization and deep infection. 
Deep infections may occur either early or as a delayed complication, as with any implant-related infection. Early sepsis with a stable implant should be treated with a protocol of repeated surgical irrigation and debridement and with prolonged parenteral and then oral antibiotic therapy. The sepsis may be refractory to this treatment protocol, and in these circumstances a radical debridement with implant removal may be required to eradicate the infection, thereby allowing later revision surgery. 
Late deep infection may occur several years after a humeral head arthroplasty. It may follow a transient bacteremia, and the organism may be of low virulence or be antibiotic resistant.242,382 Debridement, metal work removal, spacer insertion, and antibiotic therapy may help to suppress or eradicate infection. Delayed reimplantation may be possible if the infection can be eradicated.242,382 

Authors’ Preferred Method

 
 
General Treatment Philosophy of Proximal Humerus Fractures
 

The great majority of proximal humeral fractures are treated nonoperatively. This includes essentially all nondisplaced fractures as well as most valgus-impacted fractures, especially in patients with lower functional expectations. In patients with higher baseline shoulder function and intrinsically higher expectations, surgical treatment may be recommended for most displaced fractures.30,157,270 Finally, patients with severely displaced and complex proximal humeral fractures are encouraged in most instances to undergo surgery.

 

In the subset of patients undergoing surgical treatment, we believe that fracture reduction and fixation should be performed in the great majority of cases. In the ideal setting anatomic reduction, with adequate fixation will lead to reestablishing the normal biomechanical relationship between the rotator cuff and a viable humeral head, potentially yielding a close to preinjury level of function. While humeral head necrosis will in most instances adversely affect outcome, partial necrosis may provide an acceptable outcome that is comparable to that of head replacement. We do not feel that based on the current literature, an accurate prediction can be made on what fractures will result in severe humeral head collapse. Results after shoulder hemiarthroplasty have been shown to be highly unpredictable and data on reverse total shoulder arthroplasty is still limited. We therefore consider that every effort should be made to reconstruct the proximal humerus with emphasis being placed on achieving anatomic reduction and stable fixation of the tuberosities. Shoulder arthroplasty is considered in fractures in which a high suspicion of head nonviability is suspected because of severe displacement of the fracture through the anatomical neck without metaphyseal extension, disruption of the medial hinge and frank dislocation from the glenoid. We believe that in technically unreconstructable fractures with fragmentation of the articular surface, arthroplasty should also be considered. In younger patients, hemiarthroplasty is the chosen treatment method. However, in elderly patients, reverse shoulder arthroplasty has become our treatment of choice.

 

Except for two-part surgical neck fractures, which may be treated with IM nailing, the authors’ preferred method of head preserving reconstruction of the proximal humerus is open reduction internal fixation with a locking screw construct. A deltopectoral approach is used for most open reconstructions, especially arthroplasties. A deltoid split is occasionally used for two-part greater tuberosity fractures and three-part greater tuberosity fractures and is the routine approach when IM nail fixation is planned.

 
Treatment of Individual Injury Patterns of Proximal Humerus Fracture
 
Nondisplaced or Minimally Displaced One-Part Fractures
 

These injuries are almost invariably treated nonoperatively with initial immobilization in a sling. Weekly radiographs and clinical assessment are performed for the first 3 weeks. Elbow, wrist, and hand mobilization begins immediately. Passive range-of-motion exercises are begun at 3 weeks if no change in fracture position has been confirmed. Active-assisted range-of-motion exercises are begun at 6 weeks and strengthening is started at 3 months when bony healing has been confirmed radiologically.

 
Greater Tuberosity Fractures
 

Neer’s criteria of displacement being defined as 1cm of translation or 45 degrees of angulation284,287 have guided surgeons in their management of proximal humeral fractures for many years and historically these were the criteria that many surgeons applied to the treatment of greater tuberosity fractures.116,284 However more recently the currently accepted threshold for surgical treatment of greater tuberosity fractures in active patients has become 5 mm with some authors suggesting that greater tuberosity fractures with 3 mm of displacement should be treated surgically in younger patients who have to undertake heavy overhead activity, such as athletes and laborers.196,245,306,364

 

Displacement of the greater tuberosity is poorly tolerated because of its key role in shoulder function.39,184 In two-part greater tuberosity fractures the greater tuberosity is displaced posteromedially by the pull of supraspinatus, infraspinatus, and teres minor. Displacement of more than 5 mm has been shown to cause symptomatic malunion364 and to limit abduction and external rotation. As the tuberosity displaces medially it leads to subacromial impingement, which limits abduction, and with posterior displacement abutment of the greater tuberosity against the posterior glenoid will result in limited external rotation. It is in fact likely that shortening of the rotator cuff muscles and altered muscle pull occurs with only minimal greater tuberosity displacement.

 

Favorable outcomes can be expected when displaced two-part greater tuberosity fractures heal without residual displacement after operative fixation. Flatow et al.116 reported the results of 12 displaced two-part greater tuberosity fractures that were treated by heavy suture fixation and rotator cuff repair through an anterolateral deltoid-splitting approach. All fractures healed without displacement and the authors reported 100% excellent or good results. Similar results have been reported by other authors.92,311 We therefore advocate operative fixation of greater tuberosity fractures which are displaced by more than 5 mm in active patients.

 
Two-Part Greater Tuberosity Fractures and Fracture Dislocations
 

In older, frail patients (usually older than 80 years) with limited functional expectations, a substantial degree of displacement can be accepted without recourse to operative treatment. These patients often have a poor outcome from surgical reduction and fixation, because of their poor bone quality and pre-existing cuff dysfunction, which precludes stable fixation. Although they will often have signs of continued cuff dysfunction from the tuberosity nonunion or malunion, their functional outcome will usually be adequate for their needs.

 

Operative treatment is advised for physiologically younger patients, who are typically younger than 65 years, active patients with fractures, which are either primarily displaced by more than 5 mm or become displaced by this amount within the first 2 weeks after injury. Selected older patients, usually aged between 65 and 80 years, with fragment displacement of 1 cm or more are offered operative reconstruction. When there is a tuberosity fragment of greater than 2.5 cm open reduction through a limited deltoid-splitting approach and internal fixation using partially threaded cancellous 3.5-mm screws is performed. It is important to insert screws to transfix the fragment to both the humeral head and the medial cortex of the metaphysis. Meticulous repair of any associated rotator cuff injury is also performed.

 

When the fragment is smaller than 2.5 cm or if it is heavily comminuted, the injury is treated in the same manner as a rotator cuff avulsion. The injury may be treated either with an arthroscopic technique or an open approach. Fixation is obtained either with suture anchors in a double row pattern or by the use of transosseous sutures.116,245 Alternatively, a small T-plate may be fixed laterally onto the proximal humerus with three screws and the horizontal component of the plate used to anchor sutures for tuberosity fixation. This may be of particular use in very osteopenic bone.

 

Associated Bankart lesions are rare and most frequently occur in younger patients.334 If after tuberosity fixation, the shoulder is found to be unstable when tested intraoperatively, the bony or labral glenoid rim avulsion is repaired.

 
Two-Part Lesser Tuberosity Fractures and Fracture Dislocations
 

Isolated lesser tuberosity fractures typically occur in younger or middle-aged patients and are displaced. Nonoperative treatment of these injuries risks later functional incapacity, because of subscapularis dysfunction. It is the authors’ policy to treat all these fractures operatively in medically fit patients. ORIF is performed through a standard deltopectoral approach. If there is a single large fragment, definitive internal fixation is performed using partially threaded 3.5-mm cancellous screws, inserted through the lesser tuberosity.336 Judging accurate screw length (typically between 40 and 50 mm) is an important technical aspect of the procedure, to gain bicortical purchase. If there is comminution associated with a fragment which is 2.5 cm or less screw fixation risks secondary comminution and may not provide sufficient stability. For these patients, the reduction is maintained by transosseous sutures, placed through the bone–tendon junction and through the metaphysis located deep to the fracture bed and lateral to it.336 Frequently, the long head of the biceps is found to be medially dislocated and injured by the fracture fragment. A biceps tenodesis may therefore be considered.

 

In the minority of patients where the lesser tuberosity fracture is associated with a locked posterior dislocation, an attempt is initially made to obtain closed reduction of the dislocation under anesthesia. Where this is not possible, an open reduction is performed through an extended deltoid-splitting approach. After reduction of the shoulder has been obtained, the stability of the shoulder is assessed throughout a full range of internal and external rotations with the arm at the side and in 90 degrees of abduction. If the shoulder is acutely unstable because of reengagement of a reverse Hill–Sachs lesion on the posterior glenoid beyond neutral rotation, the reverse Hill–Sachs lesion is either elevated and bone-grafted or, if there is a larger defect, filled with piece of shaped femoral head allograft, which is secured with two countersunk 3.5-mm partially threaded cancellous screws or headless compression screws. The lesser tuberosity is then reattached anatomically, using the same techniques as for other isolated two-part fractures, using either two 3.5-mm partially threaded cancellous screws or transosseous sutures.

 
Two-Part Surgical Neck Fractures
 

Almost all fractures in which the shaft is impacted into the surgical neck are treated nonoperatively. A substantial degree of translation of these two fragments is usually tolerated, as long as there is residual cortical contact and impaction. Occasionally, if there is severe varus angulation of the head fragment in a physiologically younger individual (typically younger than 65 years), operative disimpaction, anatomic reduction, and plate fixation will be performed to reduce the risk of later impingement of the greater tuberosity in the narrowed subacromial space and dysfunction of the rotator cuff from its shortened lever arm. In physiologically younger patients, displaced and comminuted surgical neck fractures are managed with ORIF using a locking plate.

 

An attempt is made to reduce the fracture anatomically whenever possible. It is important to restore continuity of the medial calcar support to prevent acute fixation failure using either structural graft or a low inferomedial screw, which is inserted through the plate. Occasionally, if there is extensive metaphyseal comminution in an older patient, the risk of metaphyseal nonunion is high. If there is extensive metaphyseal comminution shortening and impaction of the shaft fragment within the head is performed to produce a more stable configuration before the plate application. If the bone quality of the humeral head is very poor, a short proximal humeral locked IM nail will often provide more secure fixation than a plate. However, if possible, a locking plate is preferred for definitive fixation to minimize the risk of later rotator cuff dysfunction which is associated with nailing.

 
Three- and Four-Part Fractures
 

Fractures that occur in physiologically older patients should be treated nonoperatively if there is residual cortical continuity of the humeral head fragment on the shaft, the tuberosities are not too widely displaced, and the humeral head appears viable. Although the outcome is often imperfect, after union these patients will usually have a pain-free shoulder, which has sufficient function for their everyday needs.

 

Operative treatment is offered to physiologically younger patients, where it is thought that the risk of nonunion, cuff dysfunction, or osteonecrosis is high or where operative treatment is likely to provide a significant improvement in shoulder function over nonoperative treatment. In practice, this means that surgery to prevent nonunion or cuff dysfunction is often offered to patients with fractures in which the humeral shaft and tuberosities have significantly displaced from the humeral head. The risk of osteonecrosis is determined by the fracture configuration, with wide displacement of the head from the shaft with probable loss of the medial periosteal and capsular hinge, and the absence of a medial metaphyseal spike particularly associated with a higher risk of this complication. There are substantial functional gains from internal fixation for fractures in which the humeral head has displaced from its normal 130-degree head-shaft orientation to occupy an extreme position of varus (90-degree head–shaft angle) or valgus (180-degree head-shaft angle) or where there is marked humeral head articular surface incongruity from displaced marginal articular fragments attached to the tuberosities.

 

ORIF is performed whenever possible, and preoperative CT can provide an indication of the likelihood that this will be feasible. The goal is to attempt anatomic or near-anatomic reconstruction. Definitive internal fixation is performed, using a proximal humeral locking plate.

 

The patient is always preoperatively counseled that if the fracture is deemed to be unreconstructable, an arthroplasty will be performed. In young patients a cemented humeral head replacement will be performed, while a reverse total shoulder arthroplasty will be performed in the older patients.

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