What are the treatment options for a fracture of the proximal humerus (upper arm bone)?

From the Guidelines

Most proximal humeral fractures can be treated non-operatively with good functional outcomes. When considering the management of fractures of the proximal humerus, it's essential to take into account the fracture pattern, displacement, and patient factors, including age and pre-existing conditions such as rotator cuff dysfunction 1. For patients older than 50 years, the management of these fractures is critical not only for the immediate outcome but also for the prevention of subsequent fractures.

Non-Operative Management

For minimally displaced fractures, conservative treatment is often recommended, which includes the use of a sling for immobilization for a period of 2-3 weeks, followed by early gentle range of motion exercises starting at 1-2 weeks. Pain management is also crucial and can include medications such as acetaminophen and NSAIDs for a short period as needed.

Operative Management

However, for significantly displaced fractures, such as three-part and four-part fractures, the treatment remains controversial. Open reduction and locking plate osteosynthesis is associated with considerable complication, and the outcome of hemiarthroplasty is closely related to tuberosity healing 1. In geriatric patients, especially those with pre-existing rotator cuff dysfunction or after the failure of first-line treatment, reverse shoulder arthroplasty may provide satisfactory shoulder function.

Rehabilitation and Complications

Physical therapy plays a crucial role in the recovery of all patients with proximal humerus fractures, starting with pendulum exercises and progressing to active-assisted range of motion by 6 weeks. It's also important to monitor for potential complications such as malunion, avascular necrosis, and adhesive capsulitis. Given the high incidence of osteoporosis in elderly patients with these fractures, measures to prevent subsequent fractures, as outlined in recommendations such as those from EULAR/EFORT 1, should be considered.

From the Research

Overview of Proximal Humerus Fractures

• Proximal humerus fractures are a common injury, particularly in the elderly population, often resulting from low-energy trauma in the presence of osteoporosis 2.
• The incidence of these fractures has increased over the decades but is expected to remain stagnant according to recent epidemiological studies 2.
• Treatment options vary and include non-operative therapy, minimal-invasive osteosynthesis, open reduction and plate fixation, intramedullary nailing, and primary arthroplasty 2.

Classification and Diagnosis

• The diversity of fracture types complicates the reliability of available classification systems, but predictive morphologic criteria can enable prognostic assessments 2.
• A short or absent metaphyseal head extension and disruption of the medial periosteal hinge can predict ischemia of the humeral head fragment 2.
• Initial imaging should involve orthogonal X-rays in three planes, and computed tomography (CT) imaging is the gold standard for determining fracture management 3.

Treatment Approaches

• Most proximal humeral fractures in the elderly are stable and can be successfully treated with non-operative means 2.
• Operative treatment for displaced, unstable fractures should use the least invasive procedure that provides adequate reduction and fixation stability 2.
• Open reduction and locking plate osteosynthesis is the standard operative procedure for displaced three- and four-part fractures, but innovation in fixation techniques is expanding indications for operative fracture treatment 2.
• Hemiarthroplasty and reverse shoulder arthroplasty are options when there's a high risk of avascular necrosis or in older patients with osteoporotic bone, with reverse shoulder arthroplasty preferred for better functional results 3.

Outcomes and Complications

• The outcome of hemiarthroplasty is closely related to anatomical tuberosity healing and restoration of rotator cuff function 2.
• Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients, rotator cuff dysfunction, or failure of first-line treatment 2.
• Complication rates vary depending on the fracture configuration and the course of management undertaken, with factors such as low local bone mineral density and residual varus displacement of the humeral head potentially promoting fixation failure or impairing functional outcome 2.

Trends in Treatment

• There has been an increase in the use of arthroplasty for complex fractures and poor bone quality, with reverse total shoulder arthroplasty (RTSA) becoming increasingly utilized 4.
• RTSA has been shown to have no or minimal between-group differences in self-reported shoulder function at one year or at two to three years' follow-up compared to hemiarthroplasty, but with a lower risk of complications 5.
• The choice of treatment should be individualized, based on careful evaluation of patient-specific, fracture-specific, and surgeon-specific aspects 2.