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). RSA is recommended in this case because:
- The extensive fracture pattern involves multiple critical components of the proximal humerus.
- The humeral head dislocation adds complexity to the injury.
- Traditional fixation methods may not provide adequate stability or function, as noted in the 2017 study published in the Annals of the Rheumatic Diseases 1, which highlights the potential complications of open reduction and locking plate osteosynthesis. The procedure involves replacing the damaged humeral head with a concave component and the glenoid with a convex component, reversing the normal ball-and-socket anatomy of the shoulder. This design allows for better function in cases where the rotator cuff is compromised or when there is significant bone loss, as seen in this type of comminuted fracture. Post-operative care typically includes:
- Immobilization in a sling for 4-6 weeks
- Gradual passive range of motion exercises starting at 2-4 weeks
- Active range of motion exercises beginning around 6 weeks
- Strengthening exercises initiated at 12 weeks Patients should be aware that recovery can take several months, and full function may not be achieved for up to a year. However, RSA can provide significant pain relief and improved shoulder function in complex cases like this, particularly in geriatric patients with pre-existing rotator cuff dysfunction or after the failure of first-line treatment, as suggested by the study 1.
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 can be an indication for Reverse Shoulder Arthroplasty (RSA) 2, 3, 4, 5, 6
- RSA is often indicated in elderly patients with displaced proximal humerus fractures (PHF), particularly those with complex fracture patterns such as 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures 4
- The procedure can provide early pain relief and return of shoulder function, as well as predictable elevation above shoulder level in the forward plane 4
Benefits and Outcomes of RSA
- Anatomical reduction and consolidation of both tuberosities is beneficial for functional recovery, with a cumulative effect on improving functional results and active motion 2
- Healing of both greater and lesser tuberosities can lead to better functional outcomes after RSA for fracture, with improved Constant scores and motion in anterior elevation and external rotation 2
- However, RSA performed for acute 3- and 4-part proximal humeral fractures may yield overall worse clinical outcomes and active range of motion compared to RSA performed for elective indications 6
Considerations and Complications
- Tuberosity management and healing are critical factors in determining the outcome of RSA for proximal humeral fractures, with tuberosity complications occurring at a higher rate in RSA for fracture patients compared to elective indications 6
- Intraoperative resection of the humeral head fragment and the tuberosities can increase the risk of dislocation after RSA, highlighting the importance of preserving the tuberosities and attached rotator cuff whenever possible 5