Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Treatment

Many treatment methods have been described through the years. In general, the choice of the treatment for a proximal humerus fracture should be based on the type of the fracture, presence of concurrent injuries, age and activity level of the patient, the presence and nature of comorbid medical conditions, and potential outcomes of specific treatment strategy.

Over 80% of the proximal humerus fractures are non-displaced or minimally displaced and can be treated non-operatively. Initially, the shoulder is immobilized in a sling at the side or in Velpaeu position. After pain is diminished and the fracture is stable (usually 7 to 10 days after injury), gentle pendulum exercises can be started. It is important to establish that the fracture is stable and moves as a unit prior to starting exercises.

The exercises should be performed 3 to 4 times a day under supervision of the therapist, or at home after appropriate instruction by a physical therapist. The patient should be advised that overly aggressive exercise can lead to malunion or nonunion. Initial, immobilization and early motion have a high degree of success as documented by numerous studies.

Some dislocated two-part surgical neck fractures can also be treated conservatively. They may require closed reduction in conscious sedation or general anesthesia. In this type of injury, the shaft is usually displaced medially and anteriorly by the pull of the pectoralis major muscle, while the tuberosities remain in a neutral position.

After adequate relaxation is achieved, it is possible to reduce the shaft and impact it under the head using gentle traction with flexion and adduction of the arm. Repeated and/or forceful closed reduction is not recommended. If a closed reduction is not possible, it is likely that there is an interposition of soft tissue, most commonly long head of the biceps, in the fracture site.

Whenever possible, fluoroscopic C arm visualization should be employed. This allows not only visualizing the reduction, but also assessing the stability of the fracture. If the fracture is unstable, percutaneous pinning of the anterior and greater tuberosity with terminally threaded K-wires can be used to further stabilize the fracture.

The greater tuberosity pins should be placed into the proximal humerus with the shoulder externally rotated and should engage the cortex at least 2 cm from most distal aspect of the humeral head. Be sure to pay close attention so that the humeral head is not penetrated.

Multipart proximal humerus fractures or isolated fractures of the greater or lesser tuberosities that are displaced more than 5 mm should be treated with open reduction and internal fixation. Many surgical modalities have been described in the literature. These include plates, screws, intramedullary devices, and various combinations. In general, it is important to avoid extensive exposure and soft tissue dissection because this may further compromise an already altered blood supply.

As per recent literature, blade plate with interfragmentary screws or newly designed contoured proximal humerus locking compression plates seem to be most commonly used techniques for open treatment of proximal humerus fractures. The majority of orthopedists use one of the two basic surgical approaches to proximal humerus: superior deltoid approach or long deltopectoral approach.

In an attempt to minimize surgical trauma to the soft tissue envelope, a new minimally invasive plating technique has been described. This plating technique preserves the soft tissue envelope and periosteum, maintains arterial vascularity and therefore minimizes the surgical trauma to the zone of injury.

In addition, early biomechanic studies demonstrated that locking plates are less likely to fail in osteoporotic bone. These results are promising, but further studies are needed to demonstrate relative merit of these new techniques.

In cases of comminuted four-part fractures, humeral head splitting injuries, or humeral head defects >40% of the articular surface, open reduction and internal fixation yields unsatisfactory results. Due to the high incidence of AVN, post injury early humeral head hemiarthroplasty is favored. In addition, results of late arthroplasty are inferior to those treated acutely with humeral head replacement.

The studies reviewing outcomes of hemiarthroplasty for proximal humerus fractures suggest that early surgical intervention within 2 weeks of injury and accurate tuberosity reconstruction are two factors that have the greatest impact on functional outcome.

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