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Open fracture proximal humerus, greater tuberosity — Clinical Guidelines

Overview

Proximal humeral fractures (PHFs) involving the greater tuberosity are common injuries, particularly among elderly individuals with osteoporosis. These fractures often result in significant functional impairment due to their proximity to critical shoulder structures. Surgical intervention, including open reduction and internal fixation (ORIF) and arthroplasty procedures like reverse shoulder arthroplasty (RSA), is frequently required for displaced or unstable fractures. Despite advances in surgical techniques, complications such as nonunion, malunion, and intraarticular screw penetration remain prevalent, especially in osteoporotic bone. Effective management is crucial in day-to-day practice to restore function and minimize long-term disability 1 2.

Pathophysiology

Proximal humeral fractures, particularly those involving the greater tuberosity, typically result from high-energy trauma or low-energy injuries in osteoporotic bone. The complex anatomy of the proximal humerus, with its multiple articulating surfaces and supporting structures like the rotator cuff and deltoid muscle, complicates healing and functional recovery. In osteoporotic patients, the weakened bone structure predisposes to comminution and displacement, making anatomical reduction challenging. Failed internal fixation often leads to complications such as nonunion, malunion, and osteonecrosis, which can severely impact shoulder mechanics and function. Deltoid muscle forces can displace the fracture fragments further, exacerbating these issues 1 3 4.

Epidemiology

Proximal humeral fractures account for approximately 5% of all fractures and are the third most common fractures in patients older than 65 years, following hip and distal radius fractures 1 2. The incidence increases with age, reflecting the higher prevalence of osteoporosis in elderly populations. Surgical intervention is more frequently required in displaced or unstable fractures, with surgical treatment rates growing over recent years, reaching approximately 30% in some regions by 2010 2. Geographic variations exist, but overall trends indicate a rising need for surgical management, particularly in elderly and osteoporotic patients 2.

Clinical Presentation

Patients with proximal humeral fractures involving the greater tuberosity typically present with acute shoulder pain, swelling, and limited range of motion. Common symptoms include inability to lift the arm due to pain and weakness, visible deformity, and crepitus. Red-flag features include neurovascular compromise, significant skin tenting, or signs of systemic distress, which necessitate urgent evaluation and management. Atraumatic fractures in elderly individuals should raise suspicion for underlying osteoporosis 1 2.

Diagnosis

The diagnostic approach for proximal humeral fractures involves a combination of clinical assessment and imaging studies. Specific Criteria and Tests:

Clinical Assessment: Detailed history and physical examination focusing on pain localization, range of motion, and neurovascular status.

Imaging:

- X-rays: Essential for initial diagnosis, identifying fracture lines, displacement, and involvement of the greater tuberosity. - CT Scan: Provides detailed anatomical information, crucial for complex fractures and planning surgical interventions. - MRI: Useful for assessing soft tissue injuries, rotator cuff integrity, and assessing for occult fractures or edema 1 2.

Differential Diagnosis:

- Rotator Cuff Tears: Often coexist but can be distinguished by specific physical tests (e.g., Hawkins-Kennedy test, Patte test) and imaging findings. - Shoulder Dislocation: Presents with a markedly deformed shoulder and often history of trauma without typical humeral fracture patterns. - Osteoarthritis: May present with chronic shoulder pain but lacks acute trauma history and characteristic fracture lines on imaging 1 2.

Management

First-Line Treatment

Open Reduction and Internal Fixation (ORIF):

Indications: Displaced fractures requiring anatomical reduction and stabilization.

Techniques: Use of locking plates and intramedullary nails to enhance fixation in osteoporotic bone.

Complications to Monitor: Nonunion, malunion, screw penetration into the joint, and osteonecrosis.

Contraindications: Severe osteoporosis, significant soft tissue damage, or patient factors precluding surgery 1 3 4.

Second-Line Treatment

Arthroplasty Procedures:

Hemiarthroplasty:

- Indications: Comminuted fractures, elderly patients with poor bone quality. - Considerations: Higher complication rates if tuberosity nonunion occurs.

Reverse Shoulder Arthroplasty (RSA):

- Indications: Complex fractures, failed previous fixation, significant rotator cuff deficiency. - Advantages: Provides stable shoulder function regardless of tuberosity union. - Complications: Higher revision rates compared to primary arthroplasty, particularly in younger patients 1 2 19 20.

Refractory or Specialist Escalation

Salvage Procedures: Complex cases may require revision arthroplasty or specialized reconstructive techniques.

Referral: Orthopedic trauma specialists or shoulder arthroplasty experts for complex or recurrent failures.

Multidisciplinary Approach: Collaboration with geriatricians for osteoporosis management and physical therapists for rehabilitation 1 2 11.

Complications

Common Complications:

Nonunion and Malunion: Resulting in shoulder stiffness and pain.

Screw Penetration: Intraarticular screw migration leading to joint stiffness and pain.

Osteonecrosis: Particularly in osteoporotic bone, leading to further functional impairment.

Deltoid Tension: Displacement of fracture fragments due to deltoid muscle forces.

Management Triggers: Persistent pain, loss of function, or radiographic evidence of complications warrant further intervention or referral to a specialist 1 3 4.

Prognosis & Follow-Up

Expected Course:

ORIF: Good outcomes with proper anatomical reduction and stable fixation, though complications can affect long-term function.

Arthroplasty: RSA generally yields satisfactory outcomes, especially in complex cases, but long-term follow-up is essential to monitor for implant-related issues.

Prognostic Indicators: Initial fracture displacement, bone quality, and patient age significantly influence outcomes.

Follow-Up Intervals: Initial follow-up at 6-8 weeks post-surgery, then every 3-6 months for the first year, tapering to annually thereafter. Radiographic assessments and functional evaluations are crucial 1 2 26.

Special Populations

Elderly Patients:

Considerations: Higher risk of osteoporosis, comorbidities, and poorer bone healing.

Management: Emphasis on stable fixation techniques and careful consideration of arthroplasty options.

Comorbidities: Management of concurrent conditions like cardiovascular disease and diabetes to optimize surgical outcomes 1 2 17.

Key Recommendations

Surgical Intervention for Displaced Fractures: Consider open reduction and internal fixation (ORIF) for anatomically reducible fractures in younger patients with good bone quality; reserve reverse shoulder arthroplasty (RSA) for complex cases or those with failed fixation (Evidence: Strong 1 2).

Use of Advanced Fixation Techniques: Employ locking plates and intramedullary nails in osteoporotic patients to enhance stability (Evidence: Moderate 3 4).

Early Arthroplasty for Complex Cases: Opt for RSA as a primary procedure in elderly patients with complex fractures or significant rotator cuff deficiency to avoid complications of delayed fixation (Evidence: Moderate 19 20).

Comprehensive Follow-Up: Schedule regular follow-up visits with radiographic assessments to monitor for complications such as nonunion, malunion, and implant-related issues (Evidence: Moderate 26).

Multidisciplinary Care: Integrate geriatric care and physical therapy to address osteoporosis and optimize functional recovery (Evidence: Expert opinion 1 2).

Risk Stratification: Evaluate patient-specific factors including bone quality, fracture complexity, and comorbidities to guide treatment decisions (Evidence: Moderate 1 2).

Avoid Delayed Referral: Prompt referral to orthopedic trauma specialists for complex or recurrent failures to minimize long-term disability (Evidence: Expert opinion 11).

Consider Medicaid Status: Be aware of increased complication rates in patients with Medicaid insurance and tailor management strategies accordingly (Evidence: Moderate 17).

Patient-Specific Treatment Algorithms: Utilize evidence-based algorithms to tailor treatment based on risk factors and fracture characteristics (Evidence: Moderate 12).

Monitor for Osteolysis: Regularly assess patients post-RSA for signs of humeral osteolysis, especially with cemented stems, to guide timely interventions (Evidence: Moderate 13 14).

References

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Artificial intelligence-generated patient information on shoulder instability remains suboptimal: DeepSeek outperforms ChatGPT in completeness of content while ChatGPT is more readable. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2026. link 6 Do DH, Thapaliya A, Sambandam S. Predictors of inpatient mortality following reverse shoulder arthroplasty. Archives of orthopaedic and trauma surgery 2024. link 7 Bolam SM, Wells Z, Tay ML, Frampton CMA, Coleman B, Dalgleish A. Reverse total shoulder arthroplasty for acute proximal humeral fracture has comparable 10-year outcomes to elective indications: results from the New Zealand Joint Registry. Journal of shoulder and elbow surgery 2024. link 8 Kew ME, Mathew JI, Moran J, Fu MC, Taylor SA, Dines JS et al.. Factors associated with humeral stem revision in anatomic to reverse total shoulder arthroplasty revision. Journal of shoulder and elbow surgery 2023. link 9 Budge MD, Orvets N. Stemless total shoulder arthroplasty using a novel multiplanar osteotomy and elliptical humeral head results in both improved early range of motion and radiographic center of rotation compared with standard total shoulder arthroplasty. Journal of shoulder and elbow surgery 2023. link 10 Levin JM, Rodriguez K, Polascik BA, Zeng S, Warren E, Rechenmacher A et al.. Simple preoperative radiographic and computed tomography measurements predict adequate bone quality for stemless total shoulder arthroplasty. Journal of shoulder and elbow surgery 2022. link 11 Lin CC, Karlin E, Boin MA, Dankert JF, Larose G, Zuckerman JD et al.. Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review. JBJS reviews 2022. link 12 Spross C, Zdravkovic V, Manser M, Farei-Campagna JM, Jacxsens M, Jost B. Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms. The Journal of bone and joint surgery. American volume 2021. link 13 Mazaleyrat M, Favard L, Boileau P, Berhouet J. Humeral osteolysis after reverse shoulder arthroplasty using cemented or cementless stems comparative retrospective study with a mean follow-up of 9 years. Orthopaedics & traumatology, surgery & research : OTSR 2021. link 14 Lo EY, Rizkalla J, Montemaggi P, Majekodunmi T, Krishnan SG. Clinical and radiographic outcomes of cementless reverse total shoulder arthroplasty for proximal humeral fractures. Journal of shoulder and elbow surgery 2021. link 15 Holschen M, Berg D, Schulte T, Bockmann MB, Witt KA, Steinbeck J. Arthroscopic and open partial arthroplasty for the treatment of focal grade IV cartilage defects of the humeral head. Archives of orthopaedic and trauma surgery 2021. link 16 Humphrey CS, Gale AL. Spherical versus elliptical prosthetic humeral heads: a comparison of anatomic fit. Journal of shoulder and elbow surgery 2018. link 17 Sabesan VJ, Petersen-Fitts G, Lombardo D, Briggs D, Whaley J. Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures. Journal of shoulder and elbow surgery 2017. link 18 Collados-Maestre I, Lizaur-Utrilla A, Gonzalez-Navarro B, Miralles-Muñoz FA, Marco-Gomez L, Lopez-Prats FA et al.. Better functional outcome after single-radius TKA compared with multi-radius TKA. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2017. link 19 Shannon SF, Wagner ER, Houdek MT, Cross WW, Sánchez-Sotelo J. Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis. Journal of shoulder and elbow surgery 2016. link 20 Dezfuli B, King JJ, Farmer KW, Struk AM, Wright TW. Outcomes of reverse total shoulder arthroplasty as primary versus revision procedure for proximal humerus fractures. Journal of shoulder and elbow surgery 2016. link 21 Razfar N, Reeves JM, Langohr DG, Willing R, Athwal GS, Johnson JA. Comparison of proximal humeral bone stresses between stemless, short stem, and standard stem length: a finite element analysis. Journal of shoulder and elbow surgery 2016. link 22 Killen MC, Lane S, Charalambous CP. Shoulder Hemiarthroplasty for Trauma: does a Tuberosity Friendly Prosthesis Improve Outcome?. Ortopedia, traumatologia, rehabilitacja 2015. link 23 Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. Journal of shoulder and elbow surgery 2010. link 24 Polster JM, Subhas N, Scalise JJ, Bryan JA, Lieber ML, Schickendantz MS. Three-dimensional volume-rendering computed tomography for measuring humeral version. Journal of shoulder and elbow surgery 2010. link 25 Buzzell JE, Lutton DM, Shyr Y, Neviaser RJ, Lee DH. Reliability and accuracy of templating the proximal humeral component for shoulder arthroplasty. Journal of shoulder and elbow surgery 2009. link 26 Padua R, Bondì R, Ceccarelli E, Campi A, Padua L. Health-related quality of life and subjective outcome after shoulder replacement for proximal humeral fractures. Journal of shoulder and elbow surgery 2008. link 27 Reuther F, Müller S, Wahl D. Management of humeral head fractures with a trauma shoulder prosthesis: correlation between joint function and healing of the tuberosities. Acta orthopaedica Belgica 2007. link 28 Lin JS, Klepps S, Miller S, Cleeman E, Flatow EL. Effectiveness of replacement arthroplasty with calcar grafting and avoidance of greater tuberosity osteotomy for the treatment of humeral surgical neck nonunions. Journal of shoulder and elbow surgery 2006. link 29 Brauer CA, Rosen AB, Olchanski NV, Neumann PJ. Cost-utility analyses in orthopaedic surgery. The Journal of bone and joint surgery. American volume 2005. link 30 Pugh DM, McKee MD. Advances in the management of humeral nonunion. The Journal of the American Academy of Orthopaedic Surgeons 2003. link 31 Farrokh D, Fabeck L, Descamps PY, Hardy D, Delince P. Computed tomography measurement of humeral head retroversion: influence of patient positioning. Journal of shoulder and elbow surgery 2001. link

Open fracture proximal humerus, greater tuberosity