Review Question - QID 214842

Figures A and B demonstrate a 4-part proximal humerus fracture dislocation in an elderly patient with osteopenia. Given her age, bone quality, and fracture pattern, she would best be managed with reverse total shoulder arthroplasty (RSA).

Proximal humerus fractures in the elderly, osteopenic patient population are difficult to treat due to comminution and poor bone quality. Treatment options commonly used in younger patients have a higher propensity for failure including ORIF and hemiarthroplasty with tuberosity repair. AVN is common, especially if <8mm of calcar is attached to the articular segment. RSA provides great pain relief and early functional recovery in elderly patients with 3 and 4-part proximal humerus fractures, especially in the setting of dislocation.

Bufquin et al. reviewed the use of RSA for patients with 3 and 4-part proximal humerus fractures. They report satisfactory forward elevation, external rotation in abduction, constant scores, and modified constant scores in this population. They conclude that reverse shoulder arthroplasty is a procedure that provides pain relief and an easier functional recovery regardless of tuberosity healing.

Jobin et al. reviewed RSA for the management of 3 and 4-part proximal humerus fractures. They report that worse outcomes in these patients are seen with ORIF due to head osteonecrosis, loss of fixation, and screw penetration. Similarly, hemiarthroplasty results in high rates of tuberosity resorption, malunion, or nonunion resulting in pseudoparalysis. They conclude that satisfactory results can be obtained with reverse shoulder arthroplasty for 3 and 4-part proximal humerus fractures in elderly patients with careful preoperative planning and attention to technical details.

Figure A and B are the AP and scapular Y radiographs of the right shoulder demonstrating a comminuted 4-part proximal humerus fracture.

Incorrect Answers:
Answer 1: Nonoperative management would lead to nonunion or malunion with unacceptable functional results with this fracture pattern.
Answer 2: ORIF for 4-part proximal humerus fractures in elderly osteopenic patients has a higher incidence of screw penetration and head osteonecrosis.
Answer 3: Hemiarthropalsty with tuberosity repair requires a longer period of immobilization and results in worse functional outcomes when compared to reverse shoulder arthroplasty.
Answer 5: Anatomic total shoulder arthroplasty is not used in the treatment of proximal humerus fractures.