Preoperative shoulder radiographs

Figure 1 Preoperative shoulder radiographs

Figure 2 CT scan images

Figure 2 CT scan images

Case Presentation

38 year old right hand dominant female with a history of anorexia nervosa, seizure disorder, and multiple falls presents to the emergency room with a left hip fracture and a right proximal humerus fracture.  She is known to be very osteoporotic due to her underlying medical issues in spite of her young age.  The work up of her proximal humerus fracture consisted of a series of radiographs (figure 1) and a CT scan (figure 2).

Figure 3 Proximal humerus plate placed lateral to the biceps.  The plate is provisionally held with k-                   wires into the head and the 3.5mm compression screw is placed into the shaft.

Figure 3 Proximal humerus plate placed lateral to the biceps. The plate is provisionally held with k- wires into the head and the 3.5mm compression screw is placed into the shaft.

Treatment

An interscalene block was administered along with general anesthesia to allow for complete muscle paralysis to aid in the reduction of the fracture.  She was placed in a low beach chair position with the back at 20 degrees of elevation and a standard deltopectoral incision was used.  Fracture reduction was accomplished by utilizing heavy nonabsorbable sutures at the bone-tendon interface of the rotator cuff, longitudinal traction on the arm, and an elevator placed medially to restore the head to the medial calcar.  The proximal humerus locking plate was placed just lateral to the biceps tendon and a 3.5 compression screw was placed in the oblong hole to reduce the shaft to the plate (figure 3).

Figure 4 Locking divergent screws are now placed into the head.

Figure 4 Locking divergent screws are now placed into the head.

C-arm was utilized to confirm the correct position of the plate relative to the greater tuberosity.  Locking divergent screws were then placed into the humeral head and their position and length was confirmed under c-arm (figure 4).

 

Figure 5 Figure 5 The medial calcar screws are placed and the sutures to the tuberosities are secured to the plate. Figure 6  Intraoperative confirmation of reduction and screw placement.

Figure 5 The medial calcar screws are placed and the sutures to the tuberosities are secured to the plate.
Figure 6 Intraoperative confirmation of reduction and screw placement.

The kickstand screw to buttress the humeral head to the medial calcar was placed and the remaining shaft screws were placed (figures 5 and 6).

Discussion

Proximal humerus fractures are the third most common fragility fractures in the elderly, behind distal radius and hip fractures.1 They account for 4-5% of all fractures. 2  Seventy –one percent of all proximal humerus fractures occur in individuals over the age of 60 as a result of low energy trauma and 75% of these fracture occur in women.3,4  The majority of these fractures are nondisplaced or minimally displaced and can be treated nonoperatively.  Of those fractures which may be amenable to surgical fixation, several options are available depending on the fracture pattern, the bone quality, and the age and activity level of the patient.  Treatment options include the following:  closed or open reduction and percutaneous pin fixation, open reduction and internal fixation (ORIF) with a proximal humerus locking plate and screws, blade plate, intramedullary nail, fracture hemiarthroplasty, and reverse shoulder arthroplasty.  Most displaced two, three and four part proximal humerus fractures are amenable to locked plating.

The work up of a proximal humerus fracture should include a standard series of xrays:  anteroposterior (AP), grashey, axillary, and scapular Y.  Computed tomography (CT) with 3-dimensional reconstruction can further elucidate the fracture pattern and aid in the determination of the need for surgery.  With the advent of proximal humerus locking plates in the early 2000s, many more proximal humerus fractures have been fixed surgically.5  The goal of surgical reconstruction is to restore the native anatomy and allow for early motion and use of the affected extremity.

The introduction of the proximal humerus locking plate has changed how orthopaedic surgeons treat displaced or unstable proximal humerus fractures over the last 10 years.  Prior to the advent of locked plating, fracture hemiarthroplasty was the treatment of choice for three and four part displaced proximal humerus fractures.  Poor functional results, high complication rates, and high pain scores have been demonstrated with the use of hemiarthroplasty for fracture.6  Advantages of the locking plates include the ability to fix fractures in osteoporotic bone in the elderly and the fixation of head splitting fractures and higher energy fractures in the younger patients thereby preserving the patient’s native joint.  Locked plates achieve this by providing multiple screws directed into the humeral head and locking them in different orientations.  This construct increases the strength of the implant and increases the pull-out strength. 7

Many studies have been performed looking at the functional outcomes of locked plating.8,9,10,11  While these studies show benefits, such as improved constant scores12 and better quality of life compared to nonoperative treatment13 and hemiarthroplasty14, they are not without complications.  The most common complications are screw perforation into the joint (13.7-23%), osteonecrosis (3.1-16.4%)11, 12, 15, and varus collapse (16.3%) 16 due to inadequate medial calcar support.  The revision rate has been reported to be as high as 30% in some studies. 13

Locked plating has been major advance in the treatment of proximal humerus fractures.  The technology is continuing to evolve and is a topic of active research.  Patient selection and surgeon training and technique are important considerations for improved outcomes and limiting complications leading to further surgery.

Caroline Chebli M.D.

Clinical Assistant Professor

Kennedy-White Orthopaedic Center

Florida State University College of Medicine

References

  1. Court-Brown CM, Caesar B.  Epidemiology of adult fractures:  a review.    2006; 37:691-697.
  2. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humerus fractures.  Acta Orthop Scand. 2001;72:365-71.
  3. Lind T, Kroner K, Jensen J. The epidemiology of fractures of the proximal humerus.  Arch Orthop trauma Surg. 1989;108:285-7.
  4. Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus.  Clin Orthop Relat Res. 1975;(112):250-3.
  5. Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson AN. Trends and variation and incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly.  J Bone Joint Surg Am.  2011;93:121-31.
  6. Noyes MP, Kleinhenz B, Markert RJ, Crosby LA. Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humerus fractures.  J Shoulder Elbow Surg.  2011;20: 372-7.
  7. Weinstein DM, Bratton DR, Ciccone WJ II, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures.  J Shoul Elbow Surg.  2006;15:239-43.
  8. Ockert B, Siebenburger G, Kettler M, Braunstein V, Mutschler W. Long term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus.  J Shoulder Elbow Surg.  pii: S1058-2746 (13)00569-7.
  9. Shulman BS, Ong CC, Lee JH, Karia R, Zuckerman JD, Egol KA. Outcomes after fixation of proximal humerus (OTA Type II) fractures in the elderly patients using modern techniques.  Geriatric Orthopaedic Surgery and Rehabilitation.  4;21-25.
  10. Konrad G, Bayer J, Hepp P, Voigt C, oestern H, Kaab M, Luo C, Plecko M, Wendt K, Kostler W, and Sudkamp N. Open reduction and interal fixation of proximal humeral fractures with use of the locking proximal humerus plate. J Bone Joint Surg Am. 2010;92 Suppl 1(Part 1):85-95.
  11. Sudkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kaab M, Luo C, Plecko M, Wendt K, Kostler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humeral plate: results of a prospective, multicenter, observational study.  J Bone Joint Surg Am.  2009;91:1320-8.
  12. Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audige L, Babst R. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis.   J Orthop Trauma. 2009;23:163-72.
  13. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial.  J Shoulder Elbow Surg.  2011;20: 747-55.
  14. Wild JR, DeMers A, French R, Shipps MR, Bergin PF, Musapatika D, Jelen BA. Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures.   2011;34:e629-33.
  15. Yang H, Li Z, Zhou F, Wang D, Zhong B. A prospective clinical study of proximal humerus fractures treated with a locked proximal humerus plate.  J Orthop Trauma.  2011;25:11-17.
  16. Sproul RC, Lyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. 2011;42:408-13.

 

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