Advances in Proximal Humerus Fracture Fixation
For the Elderly

Interest in fixation of proximal humerus fractures is increasing, particularly for elderly patients, the expanding cohort most susceptible to this injury. "Modern methods of imaging and fixation have allowed surgery for this condition to become much more reliable and offer a viable alternative to humeral head replacement (HHR) for select complex fracture cases in the elderly," explains Michael E. Torchia, M.D., an orthopedic surgeon at Mayo Clinic in Rochester, Minn.

CT scan of humerus

Enlarge

X-ray of surgical repair of humeral fracture

Enlarge

Beyond Humeral Head Replacement

Fractures of the proximal humerus were classified by Charles Neer in a classic 1970 paper. These injuries range from minimally displaced 1-part fractures to more complex 3- and 4-part injuries.

It is generally accepted that 1-part fractures are treated nonoperatively and 2-part fractures are treated with internal fixation. Optimal treatment for 3- and 4-part fractures remains controversial. Traditionally, most of these complex fractures in elderly patients have been treated with HHR. The results, however, have been disappointing in terms of function at or above the shoulder level.

Mayo Clinic experience shows that selected 3- and 4-part fractures in elderly patients can now be treated successfully with open reduction and internal fixation by experienced teams supported with state-of-the-art imaging and implants. "It is really gratifying to see elderly patients come back to the clinic having regained their ability to perform activities of daily living independently," says Dr. Torchia.

Five Key Advances

Five recent advances have been pivotal in achieving success.

Better preoperative imaging
Three-dimensional CT reveals the exact geometry of the fracture and allows accurate preoperative planning and less surgical dissection.

Better intraoperative imaging
Improvements in fluoroscopy allow the surgeon to assess reduction and position of the implants in real time. High-quality imaging is critical to avoid screw penetration through the humeral head, a frequent but preventable complication reported in all major series.

Better implants (precontoured locking plates)
These new implants provide improved fixation in osteoporotic bone. The construct is strengthened by adding strategically placed tension band sutures, which neutralize the deforming forces of the rotator cuff. Dr. Torchia has coined the term "hybrid fixation" to describe the locking plate and suture composite.

Recognition of the importance of humeral head support
Published series report frequent problems with screw cutout. Mayo Clinic experience shows the problem can almost always be avoided by supporting the humeral head before application of the hardware.

Recognition of the value of postoperative protection
Mayo Clinic developed a postoperative protocol for geriatric patients to prevent fixation failure from early aggressive physical therapy. Bone and soft tissue repairs are protected by sling immobilization for 3 months with assisted motion exercises at 6 weeks and active motion at 3 months. No strengthening exercises are prescribed.

Evidence of success

Evidence for Change

Data from Mayo Clinic's series supports the hybrid fixation technique and a brief period of postoperative immobilization in elderly patients. From 2002 to 2007, Mayo Clinic's multidisciplinary orthopedic surgery team treated 23 patients with a mean age of 84 years (range, 75-94 years) for multipart fractures and impacted patterns using the hybrid technique. Patient follow-up averaged 28 months (range, 12-36 months). All fractures healed and all patients recovered enough motion to perform daily activities independently. There were no complications or reoperations in this series.

Two principal findings are especially noteworthy, says Dr. Torchia's Mayo Clinic colleague, Bernard F. Morrey, M.D., also an orthopedic surgeon. "The first is that the findings support the concept that advanced age is not a contraindication to open reduction with this technique. Selected elderly patients do well with open reduction. The second is that, contrary to conventional wisdom, immobilization does not seem to cause disabling stiffness in the elderly."