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Closed fracture proximal humerus, neck — Clinical Guidelines

Overview

Proximal humerus fractures involving the neck region are common in elderly individuals, often associated with osteoporosis and rotator cuff injuries, impacting shoulder function and recovery significantly. 1 5 9

Diagnosis

Radiographic Evaluation: Use X-rays and CT scans to classify fractures according to Neer or AO classification systems. 1 5

MRI for Rotator Cuff: Magnetic resonance imaging to assess concomitant rotator cuff tears, crucial for functional outcome prediction. 7 9

Clinical Assessment: Evaluate displacement of tuberosities and humeral head inclination for surgical planning. 7

Management

Surgical Options:

- ORIF with Plates: Open reduction and internal fixation using locking compression plates is common for displaced fractures. 3 - Intramedullary Nailing: Curvilinear nails show lower rotator cuff symptoms compared to straight nails, though outcomes vary. 6 - Fibular Allografts: Used as augmentation with locking compression plates, showing improved clinical and radiological outcomes. 2

Conservative Management:

- Immobilization: Initial immobilization with braces for non-operative candidates, especially elderly patients refusing surgery. 4

Arthroplasty: Hemiarthroplasty for severely comminuted fractures, though functional outcomes are generally moderate. 8

Special Populations

Elderly Patients: Often require conservative or arthroplasty approaches due to comorbidities and lower functional demands. 4 8

Rotator Cuff Tears: More prevalent in older patients, influencing treatment decisions and outcomes significantly. 5 7 9

Key Recommendations

Assess Rotator Cuff Integrity: Routinely evaluate rotator cuff tears via MRI to guide treatment and predict functional outcomes. (Evidence: Moderate) 7 9

Consider Patient Age and Comorbidities: Tailor treatment between surgical fixation (ORIF, intramedullary nailing) and arthroplasty based on patient age and overall health status. (Evidence: Moderate) 4 8

Use Fibular Allografts for Augmentation: In cases requiring surgical fixation, consider fibular allografts to enhance stability and improve clinical outcomes. (Evidence: Weak) 2

References

1 Lenz M, Kahmann S, Behbahani M, Pennig L, Hackl M, Leschinger T et al.. Influence of rotator cuff preload on fracture configuration in proximal humerus fractures: a proof of concept for fracture simulation. Archives of orthopaedic and trauma surgery 2023. link 2 Segarra B, Molina M, Aguilella L. Role of Fibular Allograft in Proximal Humerus Fractures: A Systematic Review. Journal of orthopaedic trauma 2022. link 3 Pavone V, Vescio A, Denaro R, Costa D, Condorelli G, Caruso VF et al.. Use of different devices for surgical treatment of proximal humerus fractures in adults: a systematic review. Acta bio-medica : Atenei Parmensis 2021. link 4 Brindisino F, Maselli F, Giovannico G, Dunning J, Mourad F. Conservative management in an elderly woman with proximal humeral head fracture and massive rotator cuff tear who refused surgery: A case report. Journal of bodywork and movement therapies 2020. link 5 Choo A, Sobol G, Maltenfort M, Getz C, Abboud J. Prevalence of rotator cuff tears in operative proximal humerus fractures. Orthopedics 2014. link 6 Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails. Journal of shoulder and elbow surgery 2014. link 7 Fjalestad T, Hole MØ, Blücher J, Hovden IA, Stiris MG, Strømsøe K. Rotator cuff tears in proximal humeral fractures: an MRI cohort study in 76 patients. Archives of orthopaedic and trauma surgery 2010. link 8 Grönhagen CM, Abbaszadegan H, Révay SA, Adolphson PY. Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years. Journal of shoulder and elbow surgery 2007. link 9 Gallo RA, Sciulli R, Daffner RH, Altman DT, Altman GT. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clinical orthopaedics and related research 2007. link

Closed fracture proximal humerus, neck