Surgical management

 

SNOH ORIFSNOH Hemi 1SNOH

 

Indications

 

Displaced proximal humerus fractures

Young patients

 

Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP

Displaced 2 part SNOH fractures in young patient

 

Options

 

ORIF with locking plate

IM nail

Hemiarthroplasty

Reverse TSA

 

ORIF with locking plate

 

SNOHSNOHSNOH

 

Technique

 

Beach chair / deltopectoral approach

- extensile approach - release CA ligament / release proximal pectoralis major

- can release anterior deltoid insertion from lateral clavicle if needed (intra-osseous repair later)

- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

- reduce head onto shaft (head is displaced posteriorly) and avoid varus

- +/- fibular strut allograft

- provisionally fix with 2 mm k wires

- check provisonal fixation with fluoroscopy

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check fluoroscopy - avoid having plate too high

- keep head out of varus to avoid cutout

- long inferomedial screws / kickstand screws

- locking screws

 

SNOH ORIFsnoh

 

Plates

 

SNOHSNOHPlate

Synthes 3.5 mm LCP Proximal humeral plate surgical technique PDF

 

SNOH CT 4 Part YoungProximal humerus ORIF 1Proximal humerus ORIF 2

Long proximal humerus plates

 

SNOHSNOHP plate

Synthes 3.5 mm LCP Periarticular proximal humerus plate surgical technique PDF

 

Results

 

Deltoid split versus deltopectoral approach

 

Rouleau et al JSES 2020

- RCT of deltoid split versus deltopectoral approach

- 85 patients mean age 62

- better clinical outcomes with deltopectoral approach

 

Xie et al Orthop Trauma Surg 2019

- systematic review of 3 RCTs and 3 prospective studies

- shorter OR times and less AVN in deltoid split

- no difference functional outcomes or complication rates

 

Fibular strut allograft

 

fibular strutfibular strutfibular strut

 

Wang et al JBSJ Am 2023

- 80 patients RCT ORIF +/- fibular strut allograft

- no significant differences

 

Nie et al J Orthop Surg Res 2022

- systematic review of fibular strut allograft for augmentation SNOH ORIF

- 8 studies and 600 patients

- fibula strut associated lower complications and better outcomes

 

Complications

 

Kavuri et al Indian J Orthop 2018

- systematic review of locking plate fixation proximal humerus fractures

- 57 studies and 3400 patients

Intraarticular screw penetration 10%

- varus collapse 7%

- subacromial impingement 5%

- avascular necrosis 5%

- adhesive capsulitis 4%

- nonunion 2%

- deep infection 1%

- reoperation 14%.

 

Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral

 

SNOH ORIF AVNTSR Post OA

 

Hemiarthroplasty

 

Indications

 

Unreconstructable fracture - 4 part, comminuted, head spltting fracture

Insufficient glenoid

Young patients

 

Proximal Humerus 4 Part Fracture In ElderlyProximal Humerus UnreconstructableSNOH Hemi 2

 

Technique

 

Beach chair / deltopectoral approach

- need to be able to extend humerus to insert stem

- extensile approach - release CA ligament / release proximal pectoralis major

- can release anterior deltoid insertion from lateral clavicle if needed (intra-osseous repair later)

- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

 

Remove and size anatomical neck

- identify diameter and thickness

- ream humerus and trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities

- cement stem with retroversion of 30o

- repair tuberosities to the humeral stem

 

Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2hemi failed

 

Reverse total shoulder arthroplasty

 

Indications

 

Unreconstructable fracture - 4 part, comminuted, head spltting fracture, off ended

Elderly

 

SNOHSNOHSNOH

 

SNOHSNOHSNOH

 

Results

 

rTSA for proximal humerus fracture versus rotator cuff arthropathy

 

Paras et al JSES 2022

- systematic review of rTSA for fracture v arthropathy

- worse clinical outcomes and ROM for fracture

 

Cemented versus uncemented

 

Kao et al Eur J Orthop Traumatol 2023

- systematic review of 34 studies cemented v uncemented rTSA for SNOH #

- improved Constant score with cemented rTSA

- no difference in complications

 

Rossi et al JSES 2022

- systematic review of 45 studies cemented v uncemented rTSA for SNOH #

- no difference in outcomes

- high complication rate uncemented rTSA 10% v cemented 6%

 

Tuberosity fixation / healing

 

Vaccaro et al JSES 2025

- rTSA for SNOH #

- improved functional outcomes with tuberosity healing

 

Complications

 

Bents et al JSES Rev Rep 2024

- systematic review of complications after rTSA for fracture

- 100 studies and 10,000 cases

- overall complication 7%

- instability 2%

- infection 1%

- periprosthetic fracture 1%

- revision rate 3%