Indications
Displaced proximal humerus fractures
Young patients
Displaced 2 part SNOH fractures in young patient
Options
ORIF with locking plate
IM nail
Hemiarthroplasty
Reverse TSA
ORIF with locking plate
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
Plates
Synthes 3.5 mm LCP Proximal humeral plate surgical technique PDF
Long proximal humerus plates
Synthes 3.5 mm LCP Periarticular proximal humerus plate surgical technique PDF
Results
Deltoid split versus deltopectoral approach
- 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
- 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%.
Hemiarthroplasty
Indications
Unreconstructable fracture - 4 part, comminuted, head spltting fracture
Insufficient glenoid
Young patients
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
Reverse total shoulder arthroplasty
Indications
Unreconstructable fracture - 4 part, comminuted, head spltting fracture, off ended
Elderly
Results
rTSA for proximal humerus fracture versus rotator cuff arthropathy
- 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
- 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
- rTSA for SNOH #
- improved functional outcomes with tuberosity healing
Complications
- 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%