Review Question - QID 220003

The patient is an octogenarian with a chronic fracture dislocation of the shoulder involving a segmental humeral shaft component. Given the complexity of her injury, a thorough pre-operative workup including a CT scan with a plan for a reverse total shoulder arthroplasty using revision components and supplementary fixation would be most appropriate in this scenario (Answer choice 3).

In elderly patients, ORIF may not be possible due to impaired bone quality and increased risk of conversion to arthroplasty due to avascular necrosis and implant failure; thus, in an elderly patient with poor bone quality, reverse shoulder arthroplasty may provide a more predictable outcome than ORIF. Other options such as hemiarthroplasty have historically been used in the treatment of proximal humerus fracture; however, recent literature as shown that reverse total shoulder arthroplasty has demonstrated improved patient and functional outcomes for proximal humerus fracture management when compared to hemiarthroplasty alone. Non-operative treatment for an injury this severe would only be indicated in a severely compromised, low-demand patient in whom the risks of surgery and anesthesia outweigh the benefits.

Miltenberg et al. reviewed fracture dislocations of the proximal humerus treated with open reduction and internal fixation. The authors included 294 patients across 12 studies with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations treated with ORIF and found at a mean follow up of 2.9 years that conversion to arthroplasty was observed in 10.7% and an all-cause reoperation rate was observed in 35.6%. They concluded that patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates.

Samborski et al. compared the outcomes associated with non-operative treatment, locked plate fixation (ORIF), and reverse shoulder arthroplasty (RSA) for type C proximal humerus fractures in the adult population. The authors included a total of 88 patients (41 non-operative, 23 ORIF, and 24 RSA) and found at the 6-month follow-up that ORIF and RSA had better ROM and PROMIS PF scores than non-operative treatment, but there was also a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups. They concluded that proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to non-operative management at the expense of a higher complication rate in the ORIF group.

Shukla et al. performed a meta-analysis reviewing hemiarthroplasty versus reverse shoulder arthroplasty for the treatment of proximal humeral fractures. The authors included 7 studies and found that reverse shoulder arthroplasty was more favorable than hemiarthroplasty in terms of forward elevation, abduction, tuberosity healing, Constant score, American Shoulder and Elbow Surgeons score, and Disabilities of the Arm, Shoulder and Hand score. They concluded that the available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication.

Figures A and B are AP and velpeau views of a right shoulder with a head-split variant proximal humerus fracture dislocation. Figure C is an AP of the humerus showing an additional segmental humeral shaft component of the fracture.

Incorrect Answers:
Answer 1: Non-operative management of this fracture would only be acceptable for a low-demand patient in whom the risks of surgery and anesthesia outweigh the benefits.
Answer 2: A closed reduction attempt three weeks after the injury without obtaining advanced imaging would not be advised and would be unlikely to result in a successful reduction.
Answer 4: Isolated ORIF in an octogenarian with poor bone quality is more likely to fail than a reverse shoulder replacement based on the current literature.
Answer 5: Proceeding with an RSA in an urgent fashion is not necessary prior to complete pre-operative workup.