Whether or not to operate is just one question

Proximal humeral fractures, notes Joseph D. Zuckerman, MD, have a higher rate of incidence than hip fractures, and increase exponentially in patients older than 50 years of age. Although most are nondisplaced fractures and are treated nonsurgically, the surgical treatment of complex fractures remains an issue.

According to Dr. Zuckerman, treatment decisions must consider not only the fracture, but also the patient and the surgeon (see Table 1). “Treating a displaced fracture nonsurgically does not generally provide good results,” he says. But a decision to treat the fracture surgically opens several options, including a closed reduction with internal fixation (CRIF), an open reduction with internal fixation (ORIF), reduction with intramedullary (IM) fixation, a prosthetic replacement, hemiarthroplasty or reverse total shoulder replacement.

CRIF vs. ORIF
Closed reduction and percutaneous fixation can be more technically demanding than alternative techniques, and the level of difficulty increases when moving from two-part to three- or four-part fractures. Percutaneous pins just beneath the skin can lead to skin problems and can interfere with early rehabilitation. For that reason, percutaneous screw fixation may be preferred.

Dr. Zuckerman considers that the development of the locking plate has made a major difference in the treatment and outcomes of proximal humeral fractures and has extended the indications for nonprosthetic treatment.

“The reality is,” he says, “that the design and structure of a locking plate provide enhanced fixation for proximal humerus fractures that have, by definition, poor quality bone.”

Although complications when using the locking plate have been reported, Dr. Zuckerman thinks that these will be addressed as the technique becomes more familiar to and used by surgeons.

Intramedullary fixation may be considered a hybrid procedure between closed reduction and open reduction.

“The problem here,” he says, “has been and always will be inserting [the IM device] through the subacromial space and the rotator cuff. My sense is that shoulder surgeons, who have a lot of respect for the rotator cuff and the subacromial space, tend to shy away from using IM fixation. Trauma surgeons, however, look at it a little differently and have more enthusiasm for the procedure.”

For this reason, he suggests that surgeons review not just shoulder literature, but trauma literature as well.

Recommendations
“When considering the options of open reduction, closed reduction, or a combination of the two,” he concludes, “I think ORIF—whether with locking plates or another device—should be used with two-, three-, and four-part fractures. Patient and surgeon considerations will determine which fractures to use it on.

“Percutaneous techniques are probably best used for two- and three-part fractures. The exception may be a valgus-impacted, four-part fracture. There’s a learning curve, as I pointed out. Make sure your results are comparable to doing an open reduction. The intramedullary device, I think, has a role in two-part fractures primarily, and three-part fractures maybe, but it has to be done by a surgeon who is comfortable with the technique.”

Disclosure information for Joseph D. Zuckerman, MD, is available on the AAOS Web site at www.aaos.org/disclosure. Peter Pollack is a staff writer for AAOS Now.