From the Guidelines
Yes, a comminuted fracture involving the humeral head, neck, greater and lesser tuberosities with a dislocated humeral head is typically indicated for reverse shoulder arthroplasty (RSA).
Recommendation
Proceed with reverse shoulder arthroplasty for this complex proximal humerus fracture, as it provides better stability and function compared to other surgical options, such as hemiarthroplasty, especially in cases with severe fracture-dislocations and rotator cuff deficiency 1. The procedure involves:
- Removing the fractured humeral head
- Implanting a metal ball (glenosphere) onto the glenoid
- Placing a stem with a concave polyethylene cup into the humerus Post-operative care typically includes:
- Immobilization in a sling for 4-6 weeks
- Gradual physical therapy starting around 2-4 weeks post-op
- Full recovery may take 3-6 months RSA is preferred in this case because:
- It provides better stability and function compared to hemiarthroplasty for complex fractures
- It's particularly beneficial for older patients or those with poor rotator cuff function
- It allows for better pain relief and range of motion in cases of severe fracture-dislocations The reverse design compensates for rotator cuff deficiency by changing the center of rotation, allowing the deltoid muscle to elevate the arm more effectively, as suggested by limited recommendations in favor of reverse total shoulder arthroplasty over conventional total shoulder replacement and hemiarthroplasty in cases of metastatic bone disease to the proximal humerus 1. Key benefits of RSA in this context include improved range of motion and decreased instability compared to other constructs, making it an ideal choice for complex proximal humeral fractures, especially in older patients or those with significant rotator cuff damage.
From the Research
Indications for Reverse Shoulder Arthroplasty (RSA)
- A comminuted fracture involving the humeral head, neck, greater and lesser tuberosities with a dislocated humeral head may be an indication for Reverse Shoulder Arthroplasty (RSA) in elderly patients, as suggested by studies 2, 3, 4, 5, 6.
- The decision to perform RSA should be based on the complexity of the fracture, the patient's age, and their overall health status.
Fracture Patterns and RSA
- RSA may be indicated for 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures in patients ≥65 years old 4.
- Comminuted proximal humeral fractures with severe comminution of the greater tuberosity may also be an indication for RSA 5.
Outcomes of RSA
- RSA has been shown to result in better clinical outcomes and a similar complication rate compared to hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly 5.
- Anatomic healing of the greater tuberosity has been associated with better functional outcomes, less humeral-sided complications, and fewer re-operations 6.
- Tuberosity reconstruction and healing in RSA for fractures improves active forward elevation, external rotation, and patient satisfaction 2.