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Hemiarthroplasty for Three- andFour-part Proximal HumerusFractures

Abstract

Displaced three- and four-part proximal humerus fractures areamong the most challenging shoulder conditions to manage.Because of the risk of symptomatic malunion, nonunion, andhumeral head osteonecrosis, surgical management is preferred.Locking plate technology has provided an alternative tohemiarthroplasty for certain three- and four-part fracture patterns,even in the setting of osteopenic bone. Prosthetic humeral headreplacement has been advocated for head-splitting fractures andfracture-dislocations as well as four-part fractures with significantinitial varus displacement (>20°). Technical challenges, includingobtaining proper humeral head height, retroversion, and optimalpositioning and fixation of the tuberosities, have a substantial effecton patient outcomes.

Proximal humerus fractures ac-count for approximately 4% to

5% of all fractures.1,2 Three- andfour-part proximal humerus frac-tures and fracture-dislocations areamong the most severe and accountfor only 5% of all proximal humerusfractures.3

Fracture patterns vary based on themechanism of injury and bone den-sity at the time of injury. In older pa-tients (aged >60 years), three- andfour-part proximal humerus frac-tures are usually the result of low-energy trauma.4 These fractures areoften considered fragility fractures,and they serve as a clinical indicationof existing osteopenia or osteoporo-sis. When warranted, the patientshould be evaluated and treated forosteoporosis as part of fracture man-agement. In younger patients, proxi-mal humerus fractures can be the re-sult of high-energy trauma. Greaterconsideration is given to humeral

head preservation with fracture oste-osynthesis in this patient population.

Anatomy

The proximal humerus can be di-vided into four anatomic areas: hu-meral head, greater tuberosity, lessertuberosity, and surgical neck.5,6 Theaverage humeral neck-shaft anglemeasures approximately 140°.7 Hu-meral head version is quite variabledepending on which anatomic land-marks are used.8,9 Historically, 30° ofhumeral head retroversion has beenconsidered normal. In a study of 120cadaveric humeri, Hernigou et al9

used CT to measure humeral retro-version and reported that the averagehumeral head retroversion was 28.8°with reference to the forearm axis.However, Boileau et al8 determinedthat average retroversion was 17.9°with respect to the transepicondylaraxis and 21.5° with respect to the

Edwin R. Cadet, MD

Christopher S. Ahmad, MD

From Columbia Orthopaedics,Columbia University Medical Center,New York, NY.

Dr. Cadet or an immediate familymember has received research orinstitutional support from Smith &Nephew. Dr. Ahmad or animmediate family member serves asa paid consultant to Acumed andArthrex and has received researchor institutional support from Arthrex,Major League Baseball, and Stryker.

J Am Acad Orthop Surg 2012;20:17-27

Copyright 2012 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

January 2012, Vol 20, No 1 17

trochlear tangent axis in 65 cadav-eric humeri. They also noted an 8.9°difference between humeral head ret-roversion of the right and left hu-meri.

The supraspinatus, infraspinatus,and teres minor muscles insert on thegreater tuberosity; the subscapularismuscle inserts on the lesser tuberos-ity. In the setting of proximal hu-merus fracture, the direction of tu-berosity displacement is affected bythe tendons attached to the individ-ual fragments. Greater tuberosityfracture fragments migrate superi-orly and posteriorly, following thevector of the superior and posteriorrotator cuff. The lesser tuberositytranslates anteriorly and mediallyalong the vector of the subscapularis.The superior and posterior rotatorcuff is responsible for varus mal-alignment of the proximal humerusin the setting of displaced fractures.

The long head of the biceps travelswithin the intertubercular groove ofthe anterior humeral shaft, extendstoward the rotator interval, and in-serts onto the supraglenoid tubercleand superior labrum.10 The tendon isan extrasynovial structure in the gle-nohumeral joint and serves as a criti-cal landmark in tuberosity recon-struction in patients with three- andfour-part proximal humerus frac-tures. The long head of the bicepsmay be incarcerated within the frac-ture fragments and may impede frac-ture reduction. The bicipital grooveis another reliable anatomic land-mark that can be used to determinehumeral head retroversion.8

The pectoralis major tendon canalso create a deforming force in thesetting of proximal humerus frac-tures. The pull of the tendon acts toadduct and translate the humeralshaft anteriorly. The superior marginof the pectoralis major tendon insertsapproximately 5.6 cm distal to thetop of the humeral head11 or 4.2 cmdistal to the superomedial corner of

the greater tuberosity.12 These ana-tomic landmarks are useful in esti-mating humeral height for hemiar-throplasty of proximal humerusfractures.

Vascularity of the proximal hu-merus is an important factor in as-sessing fracture pattern severity;thus, a thorough knowledge of thevascular anatomy is important. His-torically, the anterior circumflex hu-meral artery and its terminal branch,the arcuate artery, have been notedas the preeminent source of perfu-sion to the proximal humerus.13 In acadaver study, Brooks et al14 investi-gated the vascularity of the humeralhead using a four-part fracturemodel. The authors noted that theprimary source of perfusion to theproximal humerus was via the ante-rior circumflex humeral and arcuatearteries, with significant intraosseousanastamoses existing between the ar-cuate artery and the posterior cir-cumflex humeral artery, metaphysealarteries, and the vessels of the greaterand lesser tuberosities. The authorsalso reported that, in most cases,four-part proximal humerus fracturedisrupted perfusion to the humeralhead. They also noted that the pos-teromedial vessels play a vital role inmaintaining proximal humerus per-fusion in certain fracture patterns.

However, debate continues regard-ing whether the anterior circumflexhumeral artery is the dominantsource of perfusion to the humeralhead. Recent studies have demon-strated that the posterior circumflexhumeral artery plays a greater rolethan does the anterior circumflex ar-tery in supplying blood to the proxi-mal humerus.15,16 Duparc et al15 ar-gued that the posterior and anteriorcircumflex humeral arteries areequally important in humeral headperfusion. Interestingly, the authorsnoted that the posterior circumflexhumeral artery was consistentlylarger in diameter than the anterior

circumflex humeral artery. In a ca-daver study, Hettrich et al16 quantita-tively assessed the vascularity of theproximal humerus and found thatthe posterior circumflex humeral ar-tery contributes 64% of the bloodsupplied to the proximal humerus,whereas the anterior circumflex hu-meral artery contributes just 36%.

Preservation of proximal humerusvascularity is important when distin-guishing between valgus impactedand varus angulated three- and four-part proximal humerus fractures.The valgus impacted fracture is char-acterized by intact medial soft tis-sues, which can potentially preservethe blood supply to the humeralhead.17 Acceptable results have beenachieved with reduction and percuta-neous pinning or plate osteosynthesisin patients with these fractures.4,17-21

In the markedly displaced four-partproximal humerus fracture with sig-nificant varus malalignment, disrup-tion of the medial soft-tissue enve-lope can potentially compromiseperfusion to the humeral head.

Classification

In 1934, Codman6 classified proxi-mal humerus fractures based on theanatomic location of the fracture. Hedivided the proximal humerus intofour parts (ie, head, greater tuberos-ity, lesser tuberosity, surgical neck)based on epiphyseal lines5,6 (Figure1). Neer5 expanded this classificationscheme to include fracture displace-ment and angulation to define the se-verity of the fracture pattern (Figure2). He defined a fracture part as afragment displaced >1 cm or angula-tion >45°. The probability of hu-meral head necrosis increases withthe severity of the fracture. The AOclassification, which is less fre-quently used than the Neer and Cod-man classification systems, empha-sizes determination of whether

Hemiarthroplasty for Three- and Four-part Proximal Humerus Fractures

18 Journal of the American Academy of Orthopaedic Surgeons

vascularity to the articular fragmentis significantly compromised. Type Ais an extra-articular unifocal fracturethat involves one of the tuberositieswith or without a concomitant meta-physeal fracture (Figure 3). Type B isan extra-articular bifocal fracture orfracture-dislocation with tuberosityand metaphyseal involvement. TypeC is a fracture or fracture-dislocationof the articular surface; this type isconsidered the most severe becausethe vascular supply is thought to beat the greatest risk of injury, therebymaking the humeral head susceptibleto the development of osteonecrosis.

Fracture classification can be per-formed using plain radiographs, ad-vanced imaging, or a combination ofboth. Several studies have assessedthe interobserver and intraobserverreliability of plain radiographs and

CT in defining proximal humerusfractures using the Neer and AOclassification systems22-25 (Figure 4).Although additional imaging is rou-tinely used to further characterizethese fractures, Sjödén et al26 demon-strated that the addition of CT andthree-dimensional imaging did notimprove interobserver reproducibil-ity of either the Neer or AO classifi-cation system.26 Bernstein et al22

found that the interobserver repro-ducibility of the Neer classificationhad a mean kappa coefficient of 0.52

with plain radiographs alone and0.50 with radiographs and CT scans.The authors noted a slight increasein intraobserver reliability when CTwas added to plain radiographic in-terpretation (0.64 versus 0.72); how-ever, no increase in interobserver re-producibility was observed with theaddition of CT. In general, we rec-ommend CT when the delineation offracture parts and patterns are un-clear to the surgeon; however, CT isnot absolutely required to classify allproximal humerus fractures.

The Neer classification of proximal humerus fractures is based on fragmentdisplacement and angulation. (Reproduced with permission from Neer CS II:Displaced proximal humeral fractures: I. Classification and evaluation. J BoneJoint Surg Am 1970:52[6]:1079.)

Figure 2

Codman classification of proximalhumerus fracture. (Reproducedwith permission from Green A,Norris TR: Part II: Proximalhumeral fractures and fracturedislocations, in Browner BD, JupiterJB, Levine AM, Trafton PG, eds:Skeletal Trauma: Basic Science,Management, and Reconstruction,ed 3. Philadelphia, PA, Saunders,2002, p 1514.)

Figure 1

Edwin R. Cadet, MD, and Christopher S. Ahmad, MD


Management Options

Neer27 reported poor results withnonsurgical management and osteo-synthesis of displaced three- andfour-part proximal humerus frac-tures compared with prosthetic hu-meral head replacement. He reportedhigh rates of symptomatic nonunion,malunion, tuberosity resorption, andosteonecrosis of the humeral head insignificantly displaced four-part frac-tures managed without proximal hu-meral head replacement. Neer27

found that patients had better out-comes with humeral head replace-ment than with open reduction andinternal fixation. He concluded thathumeral head replacement was thetreatment of choice for displacedfour-part proximal humerus frac-tures, thus shaping treatment algo-rithms that are still used today.

Locked PlatingLocked plating can be used to man-age Neer three- and four-part frac-tures. Successful open reduction andinternal fixation of displaced three-and four-part proximal humerusfractures requires medial support viaan anatomic reduction of the me-taphysis, inferomedial screw place-ment along the calcar of the proxi-mal humerus, or augmented supportof the medial column with a struc-tural endosteal implant28,29 (Figure5). Solberg et al18 compared themean Constant scores of patientsaged ≥55 years with three- or four-part proximal humerus fracturestreated with locked plating or hemi-arthroplasty. At a mean 36-monthfollow-up, the authors found signifi-cantly higher mean Constant shoul-der scores in the locked plate group(P < 0.001). Despite the higher com-plication rate in this group, betteroutcomes were achieved with lockedplating than with hemiarthroplasty,especially in patients with three-part

fractures. Of 38 patients in thelocked plate group, 6 developed os-teonecrosis following surgery, 6 hadevidence of screw perforation of thehumeral head, 4 had loss of fixation,and 3 developed wound infection. Incontrast, 7 of 48 patients in the

hemiarthroplasty group had non-union of the tuberosity fragments,and 3 patients developed wound in-fection. The authors noted that lossof fixation in the locked plate groupwas seen only in patients with initialvarus malalignment of the humeral

The AO classification of proximal humerus fractures emphasizes thevascularity of the articular fragment. Type A fractures are unifocal and extra-articular, whereas type B fractures are bifocal and extra-articular. Type Cfractures are articular and are considered the most severe due to potentialdisruption of the vascular supply, which can lead to osteonecrosis. (Redrawnwith permission from AO Foundation: Müller classification of fractures: Longbones. Available at: www.aofoundation.org/Documents/mueller_ao_class.pdf.Accessed September 12, 2011.)

Figure 3



head of >20°.In a series of 70 patients aged ≥55

years with Neer three- or four-partfractures treated with locked plating,Solberg et al4 found that patientswith valgus impacted fractures witha metaphyseal segment length >2mm experienced better clinical out-comes than did patients with fracturepatterns with initial varus malalign-ment. In addition, the authors notedthat humeral head angulation hadthe greatest effect on final clinicaloutcomes. Metaphyseal segmentlength <2 mm was predictive of de-veloping osteonecrosis.

HemiarthroplastyBesch et al30 assessed the clinical out-comes of 34 patients with four-partfractures treated with hemiarthro-plasty in primary and revision set-tings. Eighteen patients were treatedwith primary hemiarthroplasty, and16 underwent hemiarthroplasty fol-lowing failed initial osteosynthesis.The authors noted better clinical out-comes and a lower incidence of tu-berosity malalignment with associ-ated severe loss of function inpatients treated with primary hemi-arthroplasty.

We recommend hemiarthroplastyin medically stable patients who areable to protect the shoulder in a slingafter surgery to allow healing of thetuberosities. Based on the current lit-erature and our clinical experience,we reserve hemiarthroplasty for pa-tients with proximal humerus frac-tures with initial varus malalignment>20° in whom anatomic reductioncannot be achieved intraoperatively;

patients with moderate or severe os-teopenia that can compromise osteo-synthesis fixation techniques; pa-tients aged >55 years with Neerthree- or four-part fracture-disloca-tions; and patients with malunion,nonunion, hardware failure, or os-teonecrosis of the humeral head fol-lowing osteosynthesis (Figure 6). Pa-tients with valgus impacted fracturesand adequate bone quality are excel-

A, AP radiograph demonstrating a four-part fracture of the proximal humerus.B, Axial CT scan of a four-part proximal humerus fracture showing adisplaced fragment of the lesser tuberosity and a head-splitting fracture ofthe humeral head. (Courtesy of Columbia University, Center for Shoulder,Elbow and Sports Medicine, New York, NY.)

Figure 4

A and B, Preoperative AP radiographs demonstrating a three-part proximal humerus fracture with significant varusmalalignment in an 81-year-old woman. Note the displacement of the greater tuberosity fracture (arrow). PostoperativeAP (C) and axillary (D) radiographs of the proximal humerus following open reduction and internal fixation with aproximal humerus locking plate. Medial calcar support was achieved with anatomic reduction of the medial metaphysis,a medial calcar screw (solid arrow) and a cortical strut graft (dashed arrow). (Courtesy of Columbia University, Centerfor Shoulder, Elbow and Sports Medicine, New York, NY.)

Figure 5



lent candidates for osteosynthesiswith locked plating or percutaneouspinning techniques; these techniquesare especially recommended foryounger patients (aged <55 years).Hemiarthroplasty or reverse totalshoulder arthroplasty (RTSA) maybe more appropriate in lower de-mand patients and in older patients(aged >70 years) with poor bonequality and an inability to participatein a supervised physical therapy pro-gram.

Critical Components ofSuccessful Hemiarthroplasty

Tuberosity Position and HealingSuccessful hemiarthroplasty forthree- and four-part proximal frac-tures requires union and proper posi-

tioning of the tuberosity. Recently,experienced surgeons have foundthat surgical technique and pros-thetic design influence tuberosity po-sition and healing, which in turn af-fects overall patient outcome.Boileau et al31 assessed clinical andradiologic parameters in a study of66 patients who underwent hemiar-throplasty for displaced proximalhumerus fracture. Initial tuberositymalposition was present in 18 pa-tients (27%), and tuberosity dis-placement occurred in 15 patients(23%). Tuberosity migration was ob-served after initial malpositioningand after initial anatomic position-ing. Overall, final tuberosity malpo-sition occurred in 33 patients (50%).Factors significantly associated with

failure of tuberosity healing werepoor initial positioning of the pros-thesis (ie, excessive height and/or ret-roversion), poor positioning of thegreater tuberosity, and female sexwith advanced age (>75 years). Tu-berosity displacement and malposi-tion may help to explain less thanexemplary results. With regard tosubjective outcomes, 29 patientswere very satisfied, 9 were satisfied,and 28 were unsatisfied. Postopera-tive active elevation averaged only101° ± 33°, external rotation aver-aged 18° ± 15°, and internal rotationaveraged to the level of L3. The aver-age absolute Constant score was 56of 100 points (range, 20 to 95points).

Loebenberg et al32 demonstratedthat active range of motion (ROM)following hemiarthroplasty for four-part humerus fracture is affected bythe placement of the greater tuberos-ity fragment relative to the superiormargin of the prosthetic head. Theauthors concluded that tuberosityplacement 10 to 16 mm distal to thesuperior margin of the prosthetichead resulted in significantly im-proved active forward elevation andexternal and internal rotation com-pared with tuberosities positionedtoo proximal (3 to 9 mm) or too dis-tal (17 to 28 mm). A recent studyfound a significant correlation be-tween fatty infiltration of the su-praspinatus and infraspinatus mus-cles and greater tuberositymalposition and between fatty infil-tration of the subscapularis andlesser tuberosity malposition.33 Theauthors noted that fatty infiltrationof the cuff was significantly associ-ated with lower clinical scores, rein-forcing the importance of muscularintegrity in the setting of rotator cufffunction.

The tuberosities should be reap-proximated to the prosthesis and theshaft with horizontal sutures aroundthe stem and vertical sutures from

AP (A) and axillary (B) radiographs demonstrating screw perforation of thehumeral head several months after open reduction and internal fixation(ORIF) of a three-part proximal humerus fracture sustained by a 51-year-oldpedestrian struck by a motor vehicle. The patient had persistent pain andpoor function following ORIF. Postoperative AP (C) and axillary (D) radio-graphs following hemiarthroplasty for failed proximal humerus osteo-synthesis. (Courtesy of Columbia University, Center for Shoulder, Elbow andSports Medicine, New York, NY.)

Figure 6



the shaft. Frankle et al34 have shownthat adding a medial cerclage suturearound the prosthesis is critical todecrease interfragmentary strain andmotion, thereby maximizing fracturestability. This construct neutralizesthe complex forces acting on the tu-berosities.

Reduction of the tuberositiesshould begin by placing horizontalsutures that connect the greater andlesser tuberosities to avoid over-reduction inferiorly. Four suturestrands (two each in the posteriorand anterior rotator cuff) should bepassed through a hole commonlyfound near the lateral fin of the hu-meral prosthesis. Use of different col-ored sutures may facilitate suturemanagement at the time of final ten-sioning. Sutures originally placed atthe greater tuberosity are passedaround the the humeral prosthesis

and are then passed through the sub-scapularis tendon-bone junction ofthe lesser tuberosity. Fluoroscopycan be used to confirm proper tuber-osity positioning. Two humeral corti-cal sutures placed both anterior andposterior to the intertuberculargroove before stem insertion arepassed through the supraspinatustendon and subscapularis tendon-bone junction, respectively (Figure7). Final tensioning of the suturesshould occur with the arm slightlyflexed and in neutral to slight exter-nal rotation.

Wire fixation can be used as an al-ternative or as a complement to su-ture fixation and may providegreater fixation strength and com-pression. A fine balance exists be-tween application of appropriatetension, which facilitates tuberosityhealing, and overcompression, which

can compromise bone that may al-ready be comminuted and os-teopenic. Bone graft from the hu-meral head is strategically placed atthe interface between the tuberosityand the stem and between the hu-meral shaft and stem before finaltensioning of the sutures. Finally, therotator interval is closed with thearm in neutral to slight external rota-tion to prevent significant loss of ex-ternal rotation.

Humeral HeightDetermining proper prosthetic heightis critical to the success of prosthesishumeral replacement and is challeng-ing due to frequent fracture disrup-tion of the medial metaphyseal cal-car. Placing the prosthesis too low orhigh can cause improper tensioningof the deltoid and supraspinatus.Stem height position is extremely im-portant. Boileau et al31 reported thathumeral lengthening >10 mm causedby a proud prosthesis significantlycorrelated with tuberosity detach-ment and proximal migration of theprosthesis under the acromial arch,resulting in limited function. Hu-meral lengthening created excessivetension on the supraspinatus. Short-ening of the humerus was better tol-erated clinically. Functional resultswere not significantly altered untilhumeral shortening reached or ex-ceeded 15 mm.31,35

Intraoperatively, humeral heightcan be estimated based on the posi-tion of the prosthesis in the superior-inferior position where the greaterand lesser tuberosity fragments re-duce anatomically and under mini-mal tension at the prosthetic inter-face. Cement fixation helps maintainproper humeral height. An anatomicapproach to determining proper hu-meral height is performed by placingthe top of the prosthetic humeralhead approximately 5.6 cm proximalto the superior border of the pectora-lis major tendon.11 When the pecto-

A, Intraoperative photograph demonstrating exposed fracture fragments in adisplaced four-part proximal humerus fracture. Traction sutures are placed atthe rotator cuff tendon-bone junction to avoid comminution of the bonefragments. B, Intraoperative photograph demonstrating suture configurationof tuberosity reconstruction following final tensioning. Horizontal sutures(arrows) compress the greater and lesser tuberosities together. Verticalsutures connect the tuberosities (asterisks) to the proximal humeral shaft.(Courtesy of Columbia University, Center for Shoulder, Elbow and SportsMedicine, New York, NY.)

Figure 7



ralis major tendon is used as a guide,it is important to tag the superiorborder of the tendon humeral inser-tion with an identifiable suture thatcan be referenced.

Humeral Head VersionAchieving optimal humeral version isanother technical challenge associ-ated with hemiarthroplasty; the mostcommon error is placing the compo-nent in excessive retroversion. Exces-sive retroversion can force malposi-tioning of the greater tuberosity inthe horizontal plane, thereby creat-ing excessive tension on the tuberos-ity repair with the arm in internal ro-tation. Normal humeral retroversioncan range from 15° to 30°.8,9

We recommend placing the hu-meral component between 20° and30° of retroversion. Improper ver-sion may result in anterior or poste-rior instability.36 The transepicondy-lar axis and bicipital groove canserve as consistent anatomic land-marks when determining humeralhead retroversion.9,37 Kummer et al37

demonstrated that 30° of retrover-sion can be consistently reproducedby placing the lateral fin of the hu-meral prosthesis 30° posterior to the

posterior margin of the bicipitalgroove.

Stem Design and MaterialRecently, humeral stems have beendesigned for more accurate tuberos-ity placement and optimal bonegrafting. One design has a windowwithin a low-profile stem for place-ment of bone graft to enhance tuber-osity healing.38 A coating has alsobeen added to some stems to pro-mote bone healing to the stem. Onedesign has a rough hydroxyapatite-coated surface at the metaphysealportion of the prosthesis to enhanceearly bonding with bone. Anotherdesign has a microsurface of poroustantalum, which helps to stimulatebone healing and may be conduciveto direct bone apposition.39,40 Studiesare needed to determine whetherthese modifications improve out-comes. Regardless of stem design,surgical technique is the most impor-tant factor in a successful outcome.

The so-called unhappy shouldertriad, in which the prosthesis is tooproud and too retroverted with agreater tuberosity positioned toolow, is the worst outcome associatedwith hemiarthroplasty.31 The triad

inevitably leads to posterior migra-tion of the greater tuberosity, with apoor functional result. Careful surgi-cal technique and adherence to theaforementioned principles can resultin successful outcomes (Figure 8).

Postoperative RehabilitationImmediately postoperatively, the af-fected extremity is placed in a slingin slight external or neutral rotationto relieve stress on the greater tuber-osity. In general, rehabilitation be-gins on the first postoperative day.Pendulum and passive ROM exer-cises to 90° of forward elevation inthe scapular plane and gentle exter-nal rotation to neutral are performedwith the patient supine. The decisionto initiate passive ROM exerciseshould be individualized to the pa-tient and is dependent on the sur-geon’s confidence in the strength oftuberosity fixation. With tenuous tu-berosity fixation, ROM exercises canbe delayed for 2 to 3 weeks to mini-mize stress on the repair. Gentle ac-tive motion of the wrist and elbow isencouraged immediately postopera-tively. Active forward elevation andexternal rotation exercises are de-layed until radiographic evidence of

A, AP radiograph demonstraing head-split proximal humerus fracture in a 70-year-old woman with right-handdominance. Note the fragmented articular surfaces (dotted arcs). Postoperative AP (B) and axial (C) radiographs of theproximal humerus 3 months after hemiarthroplasty. Note the healed and properly positioned fragment of the tuberosity(arrow). (Courtesy of Columbia University, Center for Shoulder, Elbow and Sports Medicine, New York, NY.)

Figure 8



tuberosity healing is present. Oncetuberosity healing is confirmed ra-diographically, gentle isometric rota-tor cuff and scapular strengtheningcan begin, typically at 6 to 8 weeksfollowing surgery. The estimatedmaximum level of improvement canbe achieved 9 to 12 months postop-eratively. In addition, medical man-agement of osteopenia should be in-stituted.

Complications

Tuberosity nonunion is the mostcommon and devastating cause ofpoor outcomes following hemiar-throplasty for displaced four-partproximal humerus fracture. Biglianiet al41 identified tuberosity nonunionas the most common cause of failurein a series of 29 failed shoulderhemiarthroplasties performed tomanage acutely displaced proximalhumerus fractures. In a meta-analysisof 810 hemiarthroplasties, complica-tions included superficial and deepinfection (estimated incidence 1.6%and 0.6%, respectively), heterotopicossification (8.8%), and proximalmigration of the humeral head(6.8%).42

Outcomes

Hemiarthroplasty serves as a viableoption for pain relief in persons withdisplaced four-part proximal hu-merus fracture; however, the affectedshoulder rarely returns to its baselinelevel of function, specifically baselineROM. Kontakis et al42 reported theoutcomes of early management ofproximal humerus fractures withhemiarthroplasty in a total of 808patients (810 hemiarthroplasties). Ata mean follow-up of 3.7 years, meanactive forward elevation was 105.7°,mean abduction was 92.4°, and ex-ternal rotation was 30.4°. These re-sults are similar to those of otherreports.42-44 Kontakis et al42 identifiedthe Constant score for a total of 560patients in eight studies; the meanConstant score in patients who un-derwent replacement of a proximalhumerus prosthesis was 56.6 out of100 (range, 11 to 98).

Reverse Total ShoulderArthroplasty

The potential risk of tuberosity non-union has given rise to the increasinguse of RTSA for management of dis-

placed comminuted four-part frac-tures (Figure 9). RTSA was intro-duced to manage rotator cuffarthropathy.45 In contrast to the ben-efits of prosthetic humeral head re-placement, the main benefits associ-ated with RTSA are nonessentialtuberosity union to achieve activeforward elevation and the additionof glenoid resurfacing. Resurfacingthe glenoid with the glenospherecomponent can potentially preventthe painful sequelae of glenoid ero-sion and medialization that can oc-cur with resurfacing the humeralhead in isolation.

Bufquin et al46 prospectively stud-ied a cohort of 43 patients withthree- or four-part proximal humerusfractures treated with RTSA. At anaverage 22-month follow-up, meanactive forward elevation and exter-nal rotation with the arm in abduc-tion were 97° and 30°, respectively.The mean Constant score was 44.Complications included neuraprax-ias (5 patients), most of which re-solved; reflex sympathetic dystrophy(3 patients); anterior dislocation ofthe implant (1 patient); displacementof the tuberosities (19 patients); andscapular notching (10 patients). Theauthors concluded that adequateclinical results could be achievedwith RTSA in patients with three- orfour part fractures, despite loss of re-duction of the tuberosities.

Gallinet et al47 retrospectively stud-ied a series of 40 patients with com-plex three- or four-part proximal hu-merus fractures who underwenteither hemiarthroplasty or RTSA.Twenty-one patients underwenthemiarthroplasty with a standard ce-mented stem, and 19 underwentRTSA using a reverse prosthesis witha cemented stem. Mean follow-upfor the hemiarthroplasty and RTSAgroups was 16.5 and 12.4 months,respectively. Constant scores, activeabduction, and forward elevationwere higher in the RTSA group com-

Preoperative (A) and postoperative (B) AP radiographs of a displaced four-part proximal humerus fracture in an 82-year-old woman who underwentreverse total shoulder arthroplasty. (Courtesy of Columbia University, Centerfor Shoulder, Elbow and Sports Medicine, New York, NY.)

Figure 9



pared with the hemiarthroplastygroup (53, 91°, 97.5° and 39, 60°,53.5°, respectively). However, exter-nal rotation was greater in the hemi-arthroplasty group (13.5° versus 9°).Thirty-three patients were availablefor follow-up. In the hemiarthro-plasty group, radiographs showedfailed tuberosity healing in 3 of 17patients (18%). In the RTSA group,15 of 16 patients (94%) demon-strated radiographic evidence ofscapular notching; however, no casesof glenosphere loosening were re-ported.

Summary

Although it is challenging, surgicalmanagement is the preferred treat-ment method of displaced three- andfour-part proximal humerus frac-tures due to concerns regarding thedevelopment of symptomatic mal-union, nonunion, and osteonecrosisof the humeral head in fracture pat-terns with significant varus malalign-ment and displacement. Lockingplate technology is a viable option ifanatomic reduction or proper medialcolumn support can be achieved.Locked plating has proved to be par-ticularly successful for managementof three-and four-part fractures withvalgus impacted fracture patterns.

Prosthetic humeral head replace-ment has been shown to be effectivein providing good pain relief; how-ever, the affected extremity will notreach preinjury levels of function.Tuberosity union and positioning aswell as the establishment of properhumeral height and retroversion aresome of the challenges that must beconquered to achieve successful out-comes following hemiarthroplasty.

RTSA is a viable option in elderlypatients who are physically unable tosustain the rigors of prolonged physi-cal therapy and in patients with se-vere comminution of the tuberosities,

preexisting glenohumeral arthritis,or a history of failed osteosynthesisor hemiarthroplasty.

References

References printed in bold type arethose published within the past 5years.

1. Stimson BB: A Manual of Fractures andDislocations, ed 2. Philadelphia, PA, Lea& Febiger, 1947.

2. Green A, Norris T: Part II: Proximalhumeral fractures and fracturedislocations, in Browner BD, Jupiter JB,Levine AM, Trafton PG, eds: SkeletalTrauma: Basic Science, Management,and Reconstruction, ed 2. Philadelphia,PA, Saunders, 2002.

3. Bhandari M, Matthys G, McKee MD,Evidence-Based Orthopaedic TraumaWorking Group: Four part fractures ofthe proximal humerus. J Orthop Trauma2004;18(2):126-127.

4. Solberg BD, Moon CN, Franco DP,Paiement GD: Locked plating of 3- and4-part proximal humerus fractures inolder patients: The effect of initialfracture pattern on outcome. J OrthopTrauma 2009;23(2):113-119.

5. Neer CS II: Displaced proximal humeralfractures: I. Classification andevaluation. J Bone Joint Surg Am 1970;52(6):1077-1089.

6. Codman E: The Shoulder: Rupture of theSupraspinatus Tendon and OtherLesions In or About the SubacromialBursa. Boston, MA, privately printed,1934.

7. Takase K, Yamamoto K, Imakiire A,Burkhead WZ Jr: The radiographic studyin the relationship of the glenohumeraljoint. J Orthop Res 2004;22(2):298-305.

8. Boileau P, Bicknell RT, Mazzoleni N,Walch G, Urien JP: CT scan methodaccurately assesses humeral headretroversion. Clin Orthop Relat Res2008;466(3):661-669.

9. Hernigou P, Duparc F, Hernigou A:Determining humeral retroversion withcomputed tomography. J Bone Joint SurgAm 2002;84(10):1753-1762.

10. Nho SJ, Strauss EJ, Lenart BA, et al:Long head of the biceps tendinopathy:Diagnosis and management. J Am AcadOrthop Surg 2010;18(11):645-656.

11. Murachovsky J, Ikemoto RY,Nascimento LG, Fujiki EN, Milani C,Warner JJ: Pectoralis major tendonreference (PMT): A new method foraccurate restoration of humeral length

with hemiarthroplasty for fracture.J Shoulder Elbow Surg 2006;15(6):675-678.

12. Carey P, Owens BD: Insertionalfootprint anatomy of the pectoralismajor tendon. Orthopedics 2010;33(1):23.

13. Gerber C, Schneeberger AG, Vinh TS:The arterial vascularization of thehumeral head: An anatomical study.J Bone Joint Surg Am 1990;72(10):1486-1494.

14. Brooks CH, Revell WJ, Heatley FW:Vascularity of the humeral head afterproximal humeral fractures: Ananatomical cadaver study. J Bone JointSurg Br 1993;75(1):132-136.

15. Duparc F, Muller JM, Fréger P: Arterialblood supply of the proximal humeralepiphysis. Surg Radiol Anat 2001;23(3):185-190.

16. Hettrich CM, Boraiah S, Dyke JP,Neviaser A, Helfet DL, Lorich DG:Quantitative assessment of thevascularity of the proximal part of thehumerus. J Bone Joint Surg Am 2010;92(4):943-948.

17. Jakob RP, Miniaci A, Anson PS, JabergH, Osterwalder A, Ganz R: Four-partvalgus impacted fractures of theproximal humerus. J Bone Joint Surg Br1991;73(2):295-298.

18. Solberg BD, Moon CN, Franco DP,Paiement GD: Surgical treatment of threeand four-part proximal humeralfractures. J Bone Joint Surg Am 2009;91(7):1689-1697.

19. Jaberg H, Warner JJ, Jakob RP:Percutaneous stabilization of unstablefractures of the humerus. J Bone JointSurg Am 1992;74(4):508-515.

20. Südkamp N, Bayer J, Hepp P, et al:Open reduction and internal fixation ofproximal humeral fractures with use ofthe locking proximal humerus plate:Results of a prospective, multicenter,observational study. J Bone Joint SurgAm 2009;91(6):1320-1328.

21. Brunner F, Sommer C, Bahrs C, et al:Open reduction and internal fixation ofproximal humerus fractures using aproximal humeral locked plate: Aprospective multicenter analysis.J Orthop Trauma 2009;23(3):163-172.

22. Bernstein J, Adler LM, Blank JE, DalseyRM, Williams GR, Iannotti JP:Evaluation of the Neer system ofclassification of proximal humeralfractures with computerizedtomographic scans and plainradiographs. J Bone Joint Surg Am 1996;78(9):1371-1375.

23. Brunner A, Honigmann P, Treumann T,Babst R: The impact of stereo-visualisation of three-dimensional CT



datasets on the inter- and intraobserverreliability of the AO/OTA and Neerclassifications in the assessment offractures of the proximal humerus.J Bone Joint Surg Br 2009;91(6):766-771.

24. Sidor ML, Zuckerman JD, Lyon T,Koval K, Cuomo F, Schoenberg N: TheNeer classification system for proximalhumeral fractures: An assessment ofinterobserver reliability andintraobserver reproducibility. J BoneJoint Surg Am 1993;75(12):1745-1750.

25. Sjödén GO, Movin T, Güntner P, et al:Poor reproducibility of classification ofproximal humeral fractures: AdditionalCT of minor value. Acta Orthop Scand1997;68(3):239-242.

26. Sjödén GO, Movin T, Aspelin P,Güntner P, Shalabi A: 3D-radiographicanalysis does not improve the Neer andAO classifications of proximal humeralfractures. Acta Orthop Scand 1999;70(4):325-328.

27. Neer CS II: Displaced proximal humeralfractures: II. Treatment of three-part andfour-part displacement. J Bone Joint SurgAm 1970;52(6):1090-1103.

28. Gardner MJ, Boraiah S, Helfet DL,Lorich DG: Indirect medial reductionand strut support of proximal humerusfractures using an endosteal implant.J Orthop Trauma 2008;22(3):195-200.

29. Gardner MJ, Weil Y, Barker JU, KellyBT, Helfet DL, Lorich DG: Theimportance of medial support in lockedplating of proximal humerus fractures.J Orthop Trauma 2007;21(3):185-191.

30. Besch L, Daniels-Wredenhagen M,Mueller M, Varoga D, Hilgert RE,Seekamp A: Hemiarthroplasty of theshoulder after four-part fracture of thehumeral head: A long-term analysis of34 cases. J Trauma 2009;66(1):211-214.

31. Boileau P, Krishnan SG, Tinsi L, WalchG, Coste JS, Molé D: Tuberosity

malposition and migration: Reasons forpoor outcomes after hemiarthroplastyfor displaced fractures of the proximalhumerus. J Shoulder Elbow Surg 2002;11(5):401-412.

32. Loebenberg MI, Jones DA, ZuckermanJD: The effect of greater tuberosityplacement on active range of motionafter hemiarthroplasty for acute fracturesof the proximal humerus. Bull Hosp JtDis 2005;62(3-4):90-93.

33. Greiner SH, Diederichs G, Kröning I,Scheibel M, Perka C: Tuberosity positioncorrelates with fatty infiltration of therotator cuff after hemiarthroplasty forproximal humeral fractures. J ShoulderElbow Surg 2009;18(3):431-436.

34. Frankle MA, Ondrovic LE, Markee BA,Harris ML, Lee WE III: Stability oftuberosity reattachment in proximalhumeral hemiarthroplasty. J ShoulderElbow Surg 2002;11(5):413-420.

35. Neer CS II, Kirby RM: Revision ofhumeral head and total shoulderarthroplasties. Clin Orthop Relat Res1982;(170):189-195.

36. Murthi A, Bigliani L: Four-part proximalhumerus fractures, in Levine WN, MarraG, Bigliani L: Fractures of the ShoulderGirdle. New York, NY, Marcel Dekker,2003, pp 113-130.

37. Kummer FJ, Perkins R, Zuckerman JD:The use of the bicipital groove foralignment of the humeral stem inshoulder arthroplasty. J Shoulder ElbowSurg 1998;7(2):144-146.

38. Kontakis GM, Tosounidis TI,Christoforakis Z, Hadjipavlou AG: Earlymanagement of complex proximalhumeral fractures using the Aequalisfracture prosthesis: A two- to five-yearfollow-up report. J Bone Joint Surg Br2009;91(10):1335-1340.

39. Cohen R: A porous tantalum trabecularmetal: Basic science. Am J Orthop (BelleMead NJ) 2002;31(4):216-217.

40. Levine B, Della Valle CJ, Jacobs JJ:Applications of porous tantalum in totalhip arthroplasty. J Am Acad OrthopSurg 2006;14(12):646-655.

41. Bigliani LU, Flatow EL, McCluskey,Fischer RA: Failed prostheticreplacement for displaced proximalhumerus fractures. Orthop Trans 1991;15:747-748.

42. Kontakis G, Koutras C, Tosounidis T,Giannoudis P: Early management ofproximal humeral fractures withhemiarthroplasty: A systematic review.J Bone Joint Surg Br 2008;90(11):1407-1413.

43. Naranja RJ Jr, Iannotti JP: Displacedthree- and four-part proximal humerusfractures: Evaluation and management.J Am Acad Orthop Surg 2000;8(6):373-382.

44. Goldman RT, Koval KJ, Cuomo F,Gallagher MA, Zuckerman JD:Functional outcome after humeral headreplacement for acute three- and four-part proximal humeral fractures.J Shoulder Elbow Surg 1995;4(2):81-86.

45. Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy. J Bone Joint Surg Am1983;65(9):1232-1244.

46. Bufquin T, Hersan A, Hubert L, MassinP: Reverse shoulder arthroplasty for thetreatment of three- and four-partfractures of the proximal humerus in theelderly: A prospective review of 43 caseswith a short-term follow-up. J Bone JointSurg Br 2007;89(4):516-520.

47. Gallinet D, Clappaz P, Garbuio P,Tropet Y, Obert L: Three or four partscomplex proximal humerus fractures:Hemiarthroplasty versus reverseprosthesis. A comparative study of 40cases. Orthop Traumatol Surg Res 2009;95(1):48-55.

