Review Question - QID 220103

The patient is an octogenarian with a fracture-dislocation of the proximal humerus. High-level data has shown that reverse total shoulder arthroplasty is superior to both plate fixation and hemiarthroplasty in terms of patient outcomes in this patient population.

Proximal humerus fractures are commonly seen in older patients with osteoporotic bone following a ground-level fall onto an outstretched arm. In general, many proximal humerus fractures in elderly, low-demand patients can be treated non-operatively. Those with complex fracture dislocations and those who fail non-operative management or whose activity levels demand improved functional outcomes can be treated with reverse total shoulder arthroplasty. Reverse total shoulder arthroplasty in this patient population has been shown to result in better clinical outcomes with similar complication rates when compared with hemiarthroplasty and proximal humerus locking plate fixation given the generally decreased bone quality for tuberosity healing and screw fixation.

Fraser et al. performed a multicenter randomized controlled trial, the DelPhi (Delta prosthesis-PHILOS plate) trial, comparing reverse total shoulder arthroplasty and plate fixation for the treatment of proximal humerus fractures, with the hypothesis that reverse total shoulder arthroplasty yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate. The authors included 124 patients with 2-year follow-up, and found that the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. They concluded that there is an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.

Cuff et al. published a comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. The authors reviewed 53 consecutive elderly patients (average age, 74.4 years) who underwent an arthroplasty for a complex proximal humeral fracture, with indications for arthroplasty being four-part fractures, three-part fractures with severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral head. Of the 47 patients available for follow-up at a minimum of two years, the authors found that final average outcome scores and patient-reported satisfaction were lower in the hemiarthroplasty group than in the RSA group. They concluded that reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly.

Figures A and B are AP and scapular Y radiographs of a right shoulder, respectively, depicting a complex 4-part proximal humerus fracture-dislocation.

Incorrect Answers:
Answers 1-3: Reverse total shoulder arthroplasty in this patient population has been shown to result in better clinical outcomes with similar complication rates when compared with hemiarthroplasty and plate fixation.
Answer 4: Nonsurgical management of a fracture-dislocation is not appropriate in this situation unless the patient is too ill to undergo surgery.