Arthroplasty for Proximal Humerus Fractures, Nonunions, and Malunions

Abstract

Treatment of complex fractures and fracture-dislocations of the proximal humerus in both the acute and late settings represent some of the most difficult injuries to assess and treat in the shoulder girdle. While the vast majority of proximal humerus fractures (more than 85%) are nondisplaced and amenable to nonoperative treatment, the remaining minority may involve multiple fragments or parts, comminution, and articular surface damage and represent a significant therapeutic challenge.Based on Codman's anatomical description of fractures about the proximal humerus [1], Neer [2] published a comprehensive four-part classification scheme of these complex injuries in 1970. Wide use of this system has allowed for more uniformity in evaluation and has directed treatment in this area for the last three decades.In conjunction with adequate evaluation of the proximal humeral anatomy, whether it is an acute fracture or the sequelae of an old injury, the therapeutic course should be guided by the surgical goal of anatomic restoration of the proximal humerus and patient-determined factors, such as age, function, and quality of remaining bone. With respect to acute fractures, all two-part, most three-part, and some fourpart fractures are well treated by closed reduction or open reduction and internal fixation techniques. When soft bone, impaired head vascularity, or articular damage make fixation difficult or ill-advised, prosthetic arthroplasty is a reasonable option.Use of a humeral head prosthesis for proximal humerus fractures was first reported in the 1950s. Multiple designs were emerging [3-7], but Neer's metal prosthesis became the most commonly used. In 1953, Neer [7] reported the first use of his prosthetic humeral head in a complex fracture-dislocation of the proximal humerus. In 1955 and 1970, he reported his series of 27 and 43 patients, respectively, with fracture-dislocations treated with prosthetic replacement [7,8].Advances in design since Neer's first-generation monoblock prosthesis and his subsequent redesign in 1973 have included the use of modular head and stem components. Restoration of soft tissue ten-

Diagnosing displaced four-part fractures of the proximal humerus: a review of observer studies

“…However, the systematic review found no association between high methodological quality and level of agreement regardless of explorative sensitivity analyses [16]. A re-analysis of quality assessment data (on a scale from 0 to 9) from the systematic review reveals no difference in methodological quality between the five studies reporting agreement on four-part fractures and the other seven studies (mean quality score 6.0 [range, [3][4][5][6][7][8][9] as compared to 4.9 [range, [2][3][4][5][6][7]). …”

“…2) and four-part 'fracture-dislocations' (Fig. 3) in elderly patients with poor bone quality, and open reduction and internal fixation in younger patients and in 'valgus impacted' fractures [4][5][6].…”

Management of Proximal Humeral Fractures in the Nineteenth Century: An Historical Review of Preradiographic Sources

“…Various techniques for open reduction and internal fixation have been suggested [35,38], and joint replacement has been recommended for comminuted fractures [3,20,28]. However, randomized trials are scarce, and systematic reviews [2,17,24] have been unable to document that surgical interventions produce better long-term outcomes than nonsurgical treatments.…”