Proximal Humerus Fracture - Plating vs Hemiarthroplasty

Step 1: Preoperative Planning and Classification

Preoperative Planning and Classification: Review AP shoulder, scapular Y, and axillary lateral radiographs. CT scan with 3D reconstruction for complex fractures - essential for understanding fracture personality, displacement, head-split component, tuberosity displacement. NEER CLASSIFICATION: 1-part (undisplaced or <1cm, <45°), 2-part (surgical neck OR greater tuberosity OR lesser tuberosity OR anatomical neck), 3-part (surgical neck + one tuberosity), 4-part (surgical neck + both tuberosities). DISPLACEMENT criteria needed for count as part is more than 1cm or more than 45° angulation. Assess for head-split (intra-articular), valgus-impacted (medial periosteum intact equals blood supply preserved). Consider fracture-dislocation. Template plate size and screw trajectories.

Step 2: Patient Positioning - Beach Chair

Patient Positioning - Beach Chair: BEACH CHAIR position: patient semi-recumbent 30-45 degrees. Head secured with headrest. Affected arm draped free to allow manipulation. Mayo stand or arm holder for arm support. Ensure ability to extend, rotate, and manipulate arm without fighting drapes. Entire shoulder, lateral neck, chest to midline prepped. Radiolucent beach chair attachment allows intraoperative fluoroscopy (AP, scapular Y, axillary). Anesthesia: general with interscalene block (excellent postop analgesia, allows awake PT day 1).

Step 3: Deltopectoral Approach and Exposure

Deltopectoral Approach and Exposure: Incision from coracoid to deltoid insertion (10-12cm), in line with deltopectoral groove. Identify and preserve (or ligate) CEPHALIC VEIN - usually lies in fat stripe marking interval between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves). Retract deltoid laterally, pectoralis medially. Identify CORACOACROMIAL LIGAMENT (palpate coracoid, CA lig extends to acromion) - provides superior landmark. Deep layer: CLAVIPECTORAL FASCIA enveloping conjoined tendon (short head biceps + coracobrachialis). Divide clavipectoral fascia lateral to conjoined tendon. Identify SUBSCAPULARIS inferior border (rotator interval superiorly, subscap lower border inferiorly). Axillary nerve runs along subscap inferior border - PROTECT.

Step 4: Fracture Exposure and Hematoma Evacuation

Fracture Exposure and Hematoma Evacuation: Identify LONG HEAD BICEPS TENDON (LHB) in bicipital groove - serves as anatomical landmark (lesser tuberosity medial, greater tuberosity lateral). Evacuate hematoma. Identify fracture fragments: HUMERAL HEAD, SHAFT, GREATER TUBEROSITY (GT - supraspinatus, infraspinatus, teres minor insertions), LESSER TUBEROSITY (LT - subscapularis insertion). Tag tuberosities with STAY SUTURES (#2 Ethibond through rotator cuff tendons, not bone - allows manipulation). Assess head: viability (bleeding bone is good sign), impaction, head-split component. Identify MEDIAL CALCAR (medial periosteal hinge) - if intact, suggests preserved blood supply.

Step 5: Reduction of Humeral Head and Shaft

Reduction of Humeral Head and Shaft: Reduce HUMERAL HEAD to SHAFT first (before addressing tuberosities). Techniques: 1) Traction on arm with joystick K-wire into head fragment for manipulation, 2) Elevator or periosteal elevator medially to lever head onto shaft, 3) Provisional K-wire or heavy sutures for temporary fixation. Restore HEIGHT (avoid varus malreduction - causes inferior subluxation), ROTATION (use bicipital groove as landmark), VERSION (check with fluoroscopy). Varus is most common malreduction - ensure medial calcar supported. Fluoroscopy AP, scapular Y, axillary to confirm reduction.

Step 6: Proximal Humerus Locking Plate Application

Proximal Humerus Locking Plate Application: Select PROXIMAL HUMERUS LOCKING PLATE (PHILOS, Synthes; or equivalent). Plate positioned on LATERAL humeral shaft, 5-10mm distal to greater tuberosity (allows GT to sit anatomically, avoids subacromial impingement). Proximal plate has multiple locking screw holes targeting humeral head in various trajectories (support head in multiple planes). Plate secured to shaft first with NON-LOCKING cortical screws (allows adjustment). Then LOCKING screws into head (3-6 screws typically, divergent trajectories create cage supporting head). Screw length critical - must be subchondral (support head) but not penetrate articular surface. Inferomedial screw (calcar screw) provides critical medial support preventing varus collapse.

Step 7: Tuberosity Reduction and Fixation

Tuberosity Reduction and Fixation: After head-shaft construct stable, address TUBEROSITIES. Reduce GT and LT to head and shaft. Use stay sutures for manipulation. Ensure anatomical position - GT lateral to bicipital groove, LT medial. Reduction maintained with: 1) Heavy sutures (#2 or #5 Ethibond) through rotator cuff tendons, around plate, or through bone tunnels - suture fixation is PRIMARY for tuberosities (bone often too osteoporotic for screws). 2) Additional screws through tuberosities into head if bone quality adequate. Tuberosity position critical: height (restores rotator cuff length tension), rotation (GT posterolateral, LT anteromedial). Fluoroscopy to confirm no prominent bone causing impingement.

Step 8: Bone Grafting for Medial Column Support

Bone Grafting for Medial Column Support: Assess MEDIAL COLUMN (calcar region). If void or deficiency after reduction (common in comminuted fractures or when reducing impacted head), bone graft provides support and prevents varus collapse. AUTOGRAFT options: morselized from humeral head impaction (if have extra), iliac crest. ALLOGRAFT: morselized cancellous chips or structural allograft strut for large defects. Pack graft medially beneath head, supporting calcar. Inferomedial calcar screw then secures graft. CALCIUM PHOSPHATE cement alternative - injectable, hardens, provides structural support (some surgeons use routinely in elderly osteoporotic bone).

Step 9: Fixation Assessment and Range of Motion Check

Fixation Assessment and Range of Motion Check: Remove provisional fixation. Gently manipulate shoulder through range of motion - forward flexion, abduction, rotation. No crepitus or pain should be elicited. Tuberosities should move with head as unit (indicates stable fixation). Fluoroscopy FINAL images: AP (assess reduction, varus or valgus, screw position), SCAPULAR Y (assess reduction, version), AXILLARY (assess reduction, articular screw penetration, glenohumeral relationship). Confirm: 1) Anatomical reduction head-shaft-tuberosities, 2) No varus collapse, 3) Screws subchondral but not intra-articular, 4) No subacromial impingement of plate or GT, 5) Tuberosities anatomically positioned.

Step 10: Closure and Postoperative Protocol Setup

Closure and Postoperative Protocol Setup: Irrigate wound copiously. Repair ROTATOR INTERVAL if opened (superior border subscap to anterior supraspinatus) - restores anterior stability. Repair SUBSCAPULARIS if taken down (usually not necessary with deltopectoral). Close CLAVIPECTORAL FASCIA with absorbable suture (2-0 Vicryl). DELTOPECTORAL INTERVAL falls together (don't suture deltoid to pec - causes stiffness). Subcutaneous layer (3-0 Vicryl). Skin (subcuticular 4-0 Monocryl or staples). Apply SLING with small abduction pillow (positions arm in slight abduction reducing tension on repair). NO drain typically needed.

Step 11: Postoperative Rehabilitation Protocol - Critical for Outcome

Postoperative Rehabilitation Protocol - Critical for Outcome: PHASE 1 (0-6 weeks): SLING immobilization with abduction pillow. PASSIVE ROM only - pendulum exercises immediate, passive forward flexion and ER to tolerance with PT supervision (start days 1-3 post-op with interscalene block). Goal: prevent stiffness without stressing tuberosity fixation. PHASE 2 (6-12 weeks): Active-assisted ROM. Wean sling. Radiographs at 6 weeks to assess tuberosity healing - if healing progresses, advance PT. PHASE 3 (after 12 weeks): Active ROM and progressive strengthening. RADIOGRAPHS: 2 weeks (wound check), 6 weeks (tuberosity healing check), 12 weeks (further healing), 6 months, 1 year (AVN surveillance).

Step 12: Alternative - Hemiarthroplasty Technique

Alternative: Hemiarthroplasty - Indications and Technique: INDICATIONS for HEMIARTHROPLASTY over ORIF: 1) 4-part fractures in elderly osteoporotic bone (older than 65-70 years, poor bone quality), 2) Fracture-dislocations with head-split, 3) Articular surface comminution (head-split fractures), 4) Chronic fractures (older than 3-4 weeks) with retracted soft tissues. TECHNIQUE: deltopectoral approach as above. Remove humeral head (save for sizing). Prepare shaft (ream to appropriate size). CRITICAL: tuberosity management - tag GT and LT with stay sutures, preserve rotator cuff attachments, reduce around stem, fix with heavy sutures through stem holes and cerclage around stem and through bone. Height and version matched to native (use opposite side and saved head for templating). Trial, check stability, then final components. Cement vs press-fit based on bone quality.

Step 13: Complications Recognition and Early Management

Complications Recognition and Management: AVASCULAR NECROSIS (AVN): Incidence 15-75% depending on fracture (4-part highest, 3-part intermediate, valgus-impacted lowest). Risk factors: 4-part, fracture-dislocation, disrupted medial periosteum. Monitor radiographs 6 months-2 years. Early AVN may be asymptomatic - treat with activity modification. Late AVN with collapse - consider arthroplasty. TUBEROSITY COMPLICATIONS: nonunion (10-20%), malposition, pulloff. If nonunion: revision fixation with bone graft if good head, consider reverse if head AVN. STIFFNESS: adhesive capsulitis (30-40%). Prevent with early PT. Treat with aggressive PT, manipulation under anesthesia, arthroscopic capsular release if severe and longer than 6 months. VARUS COLLAPSE: fixation failure, loss of reduction. Prevent with medial support (calcar screw, bone graft). If occurs: may require revision or arthroplasty.

Immediate Postoperative (0-2 weeks):

• Sling with abduction pillow (20-30° abduction reduces GT tension)
• Pain control: Interscalene catheter 48-72 hours, then oral opioids plus NSAIDs
• Wound check day 1-2 (drain if placed, neurovascular status)
• Pendulum exercises start day 1 (passive shoulder circumduction, gravity-assisted)
• Radiographs at 2 weeks (wound check visit, assess reduction maintenance)

Phase 1 - Passive Motion (2-6 weeks):

• Continue sling between exercises (wean gradually after 4 weeks)
• PT supervised PASSIVE ROM only: Forward flexion, external rotation (arm at side), internal rotation to tolerance
• Goals by 6 weeks: 90-120° passive forward flexion, 30-40° passive ER, IR to abdomen
• NO active motion (protect tuberosity fixation from rotator cuff pull)
• Radiographs at 6 weeks: Assess tuberosity healing, hardware position, reduction maintenance

Phase 2 - Active-Assisted Motion (6-12 weeks):

• IF tuberosity healing progresses on 6-week radiographs, advance to active-assisted
• Wean sling (may use at night for comfort)
• Active-assisted ROM: Pulley exercises, wand exercises, table slides
• Gentle isometrics (deltoid, rotator cuff) if well-healed
• Goals by 12 weeks: 120-140° active-assisted flexion, 40-60° ER, IR to L3-L4
• Radiographs at 12 weeks: Confirm tuberosity union, assess for AVN early signs

Phase 3 - Active Strengthening (12+ weeks):

• Begin active ROM without assistance
• Progressive resistance: Theraband, light weights (start 0.5-1 kg, increase gradually)
• Rotator cuff strengthening protocol (external rotators, internal rotators, scaption)
• Goals by 6 months: Near-full active ROM (140-160° flexion, 40-60° ER, IR to T12), functional strength
• Radiographs at 6 months: AVN surveillance, assess tuberosity incorporation, hardware integrity

Long-term Follow-up:

• Radiographs at 1 year: AVN surveillance (may not appear until 12-24 months), tuberosity status
• Return to activities: Unrestricted daily activities 4-6 months, return to sport 6-12 months (based on healing, strength)
• Warn patient: Motion recovery slow (may take 12-18 months for maximal improvement), stiffness common (30-40%), AVN risk (monitor radiographically)

References

1. Neer CS 2nd. Displaced proximal humeral fractures. J Bone Joint Surg Am. 1970;52(6):1077-1089.

   • Original description of Neer classification system (1-part, 2-part, 3-part, 4-part based on displacement >1cm or >45°). Foundational paper establishing treatment algorithms based on fracture pattern. Described blood supply to humeral head and AVN risk with different patterns.

2. Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11:CD000434.

   • Comprehensive systematic review and meta-analysis comparing surgical vs nonoperative treatment. Found insufficient evidence to determine superiority of surgery over conservative care for displaced fractures. Highlighted high complication rates with surgery (35% reoperation for ORIF).

3. PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047.

   • Landmark RCT comparing operative (ORIF or hemiarthroplasty) vs nonoperative treatment in 250 patients. Found NO significant difference in patient-reported outcome measures (Oxford Shoulder Score) at 2 years. Suggests nonoperative treatment may be adequate for many displaced fractures.

4. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21(3):185-191.

   • Biomechanical study demonstrating the critical importance of medial column support in preventing varus collapse. Showed inferomedial calcar screw provides greatest resistance to varus collapse. Established concept that medial support (screw + bone graft if deficient) essential for construct stability.

5. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427-433.

   • Anatomical study of humeral head blood supply. Described arcuate artery (from anterior humeral circumflex) as primary blood supply entering medially at calcar. Identified predictors of AVN: disruption of medial periosteum, length of metaphyseal head extension <8mm, disruption of medial hinge. Explained why valgus-impacted fractures have lower AVN rate.

6. Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86(6):848-855.

   • Large series of proximal humerus ORIF with locking plates. Reported 25% complication rate including AVN (14%), screw perforation (11%), tuberosity complications (8%). Emphasized importance of anatomical reduction, secure tuberosity fixation with sutures, and early passive motion to prevent stiffness.

7. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):401-412.

   • Study of hemiarthroplasty outcomes demonstrating that tuberosity healing determines functional result. Found tuberosity nonunion or malposition in 27%, leading to poor outcomes. Emphasized critical importance of secure tuberosity fixation with heavy sutures through stem holes and around stem, anatomical positioning, and protected early mobilization.

8. Gracitelli ME, Malavolta EA, Assunção JH, et al. Locking intramedullary nails versus locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg. 2016;25(5):695-703.

   • RCT comparing locking plates vs intramedullary nails for 2 and 3-part fractures. Found no significant difference in functional outcomes but higher complication rate with nails (especially screw perforation). Supported use of locking plates as standard treatment for proximal humerus ORIF.

9. Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective series with short-term follow-up. J Orthop Trauma. 2014;28(3):157-163.

   • Prospective study comparing reverse shoulder arthroplasty vs nonoperative treatment in elderly patients with complex proximal humerus fractures. Found significantly better functional outcomes with reverse arthroplasty (Constant score 72 vs 54). Established reverse shoulder as superior option to conservative treatment in active elderly patients with 3 or 4-part fractures.

10. Olerud P, Ahrengart L, Ponzer S, et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20(5):747-755.

    • RCT of 3-part fractures in elderly comparing locking plate ORIF vs nonoperative treatment. Found no significant difference in functional outcomes but 30% complication rate in surgical group (including reoperation, AVN, tuberosity problems). Suggests nonoperative treatment may be adequate in elderly even for displaced 3-part fractures.