Contents>Expert Panel
This editorial was written for the 2006 National Knowledge Week on Osteoporosis & Fragility Fractures. The following members of the Expert Panel contributed to this section: Professor Damian Griffin, Mr Matthew Costa and Mr Craig White
This article has been updated in 2007 by Mr M Costa and Mr C White for the Osteoporosis Annual Evidence Update.
Fractures of the proximal humerus are common accounting for 4-5 percent of fractures in the orthopaedic outpatients; this is about half as common as fractures of the proximal femur. Their incidence increases with age and they are more common in women. Many patients who sustain a proximal humeral fracture are osteoporotic. A recent series of over 1000 patients (Court, Garg et al. 2001) found that 73 percent of patients were women and the average age was 70. They are mostly the result of low energy falls, 87 percent being due to a fall from a standing height. With an increasing prevalence of osteoporosis in an ageing population, the numbers are set to rise over the coming years.
The original classification of proximal humeral fractures (Neer 1970) is still widely used in practice and research. Court’s prospective series in 2001 found that 49 percent of fractures were undisplaced by the criteria specified by Neer (less than one centimetre of displacement or less than 45 degrees of angulation of the fracture) It is generally accepted that this sub-group of fractures should be treated non-operatively. However, the rehabilitation regimes for these patients vary. In 2003, Hodgson looked at the timing of commencement of rehabilitation, comparing patients initiating physiotherapy at 1 and 3 weeks. The early group required less physiotherapy sessions to reach independent shoulder function and had less early pain. The benefits of early physiotherapy were also reported in the Kristiansen (Kristiansen and Kofoed 1988) trial. In this study, patients who received early physiotherapy had significantly better Constant Murley scores at 8 and 16 weeks than those who had delayed therapy, although the difference was not significant at a year.
For patients with displaced fractures (more than 1cm of displacement or more than 45 degrees of angulation) there is a great deal of debate regarding the use of operative versus non-operative treatment. The decision making process must take into account the fracture pattern, the perceived benefit of surgery, the general condition and motivation of the patient as well as the ability of the surgeon to carry out more complex procedures. Despite the large number of patients sustaining a proximal humerus fracture, the management of these injuries varies widely across the country. As implants and techniques have improved the ability to reduce and fix more and more complex fractures has come about. Kristiansen in 1988 studied surgical intervention in the form of percutaneous wire reduction versus closed manipulation of the fracture, in 31 displaced proximal humeral fractures. The surgical group had better outcomes in terms of function at one year, but the numbers were small. Zyto, Ahrengart et al. 1997, compared open reduction and wiring with conservative treatment. They found no difference between the two groups in the outcome scores at 4 years. However the only major complications occurred in the surgical group. Stableforth (Stableforth 1984) looked at the most complicated fractures (4-part displaced fractures). This study compared replacement of the humeral head with non-operative treatment. Their outcomes suggested that patients in the operated group did better functionally and had less pain at night than the non operative group. This conflicting evidence has led to a lack of consensus regarding the optimal management of displaced fractures of the proximal humerus. The interpretation of the trials is confounded by the small numbers of patients involved and the heterogeneous mix of fracture patterns within each study group.
If the decision has been taken to operate on a displaced fracture, then the surgeon still has to decide which implant to use. There is a vast array of implants available on the market, all with varying fixation principles and claims of efficacy. The decision is often dependent on the expertise of the surgeon and their experience. There are many case series in the literature of various techniques but to date only one randomised trial has been performed, (Hoellen, Bauer et al. 1997) This group looked at the outcome of endoprosthetic replacement versus minimal internal fixation with tension band wiring. They found no difference between the two groups but a lower complication rate in the replacement group. Historically, many surgeons would not consider fixing the more complex fractures due to the risk of avascular necrosis (failure of the blood supply) to the humeral head. The alternative is to replace the head with an endoprosthesis. A series of 163 patients (Robinson, Page et al. 2003) showed a survivorship of such prostheses of 93.9% at ten years. Recent trials have suggested that early mobilisation in patients with endoprosthetic replacement does not improve the function in the way it does with conservative management, and it may lead to more migration of the tuberosity fragments (Agorastides, Sinopidis et al. 2007). However, with the more modern implants such as intermedullary nails and minimally invasive locking plates, the ability to fix more complex fractures with less risk to the blood supply now exists; at least in theory. The incidence of avascular necrosis varies within reported series. It has been found to be as high as 37 % (Wijgman, Roolker et al. 2002; Gerber, Werner et al. 2004). These patients were all treated with internal fixation of three and four part fractures and fracture dislocations. However despite the high rate of avascular necrosis, 77% of these patients had a good or excellent Constant-Murley functional outcome. Biomechanical investigation of plate fixation has shown that the locked construct available in modern devices provides greater stability, reduced fixation failure and the possibility of earlier motion (Sanders, Bullington et al. 2007; Seide, Triebe et al. 2007). It seems that as techniques improve we will be able to fix fractures with less disruption to the soft tissues and earlier rehabilitation which will ultimately be of benefit for patients. However more quality randomised controlled trials are needed before current treatment can become evidence-based.
Key questions to address:
- Is surgical intervention better than conservative treatment in displaced proximal humeral fractures?
- Is fixation any better than head replacement in complex humeral head fractures?
- Do intramedullary nails perform any better than plate fixation?
- Are minimally invasive locking plates any better than conventional plate fixation?
- Are minimally invasive locking plates any better than intramedullary devices?
Bibliography:
Agorastides, I., C. Sinopidis, et al. (2007). "Early versus late mobilization after hemiarthroplasty for proximal humeral fractures." Journal of Shoulder and Elbow Surgery 2007;16(3, Supplement 1): S33-S38. (Link to PubMed abstract)
Court, B. C. M., A. Garg, et al. (2001). "The epidemiology of proximal humeral fractures." Acta orthopaedica Scandinavica; 72(4):365-71.
Gerber, C., C. M. L. Werner, et al. (2004). "Internal fixation of complex fractures of the proximal humerus." The Journal of bone and joint surgery. British volume; 86(6):848-55. (Link to abstract) (Link to full-text - Athens password requqired)
Hodgson, S. A., S. J. Mawson, et al. (2007). "Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up)." Journal of Shoulder and Elbow Surgery 2007; 16(2): 143-145. (Link to PubMed abstract)
Hoellen, I. P., G. Bauer, et al. (1997). "Prosthetic humeral head replacement in dislocated humerus multi- fragment fracture in the elderly--an alternative to minimal osteosynthesis?" Zentralblatt für Chirurgie;122(11): 994-1001.
Kristiansen, B. and H. Kofoed (1988). "Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus A controlled clinical trial." The Journal of bone and joint surgery. British volume; 70(5): 821-4. (Link to full-text, PDF format)
Neer, C. S., 2nd (1970). "Displaced proximal humeral fractures I Classification and evaluation." The Journal of bone and joint surgery. American volume; 52(6): 1077-89.
Robinson, C. M., R. S. Page, et al. (2003). "Primary hemiarthroplasty for treatment of proximal humeral fractures." The Journal of bone and joint surgery. American volume; 85(7): 1215-23. (Link to abstract) (Link to full-text - PDF format, Athens password required) (Link to full-text - Athens passwod required)
Stableforth, P. G. (1984). "Four-part fractures of the neck of the humerus." The Journal of bone and joint surgery. British volume; 66(1): 104-8.
Sanders, B. S., A. B. Bullington, et al. (2007). "Biomechanical evaluation of locked plating in proximal humeral fractures." Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons 2007;16(2): 229-34. (Link to PubMed abstract)
Seide, K., J. Triebe, et al. (2007). "Locked vs. unlocked plate osteosynthesis of the proximal humerus - A biomechanical study." Clinical Biomechanics 2007; 22(2): 176-182. (Link to PubMed abstract)
Wijgman, A. J., W. Roolker, et al. (2002). "Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus." The Journal of bone and joint surgery. American volume; 84(11): 1919-25. (Link to abstract) (Link to full-text - Athens password required)
Zyto, K., L. Ahrengart, et al. (1997). "Treatment of displaced proximal humeral fractures in elderly patients." The Journal of bone and joint surgery. British volume; 79(3): 412-7. (Link to abstract) (Link to full-text)
