Comprehensive Guide to Proximal Humeral Fractures: Surgical Indications, Anatomy & Biomechanics

Introduction & Epidemiology

Proximal humeral fractures (PHFs) represent a significant portion of all fractures, accounting for approximately 5-6% of all adult fractures and are the third most common fracture in older adults after hip and distal radius fractures. Their incidence is rising due to an aging population and increased prevalence of osteoporosis. While most PHFs are minimally displaced and managed non-operatively, a substantial subset, particularly those involving the articular segment or significant displacement, necessitates surgical intervention.

The treatment of PHFs remains a complex and often debated topic, largely due to the diverse patient demographics, fracture patterns, and inherent challenges in achieving stable fixation and predictable functional outcomes, especially in the osteoporotic elderly population. Fractures involving the articular surface or those significantly compromising the vascular supply to the humeral head carry a higher risk of complications such as avascular necrosis (AVN), non-union, and malunion, often leading to debilitating pain and functional limitations.

Classification systems, primarily Neer and AO/OTA, are instrumental in guiding treatment decisions by describing fracture morphology, displacement, and articular involvement. Neer's classification categorizes fractures into 2-, 3-, or 4-part based on displacement of the articular segment, greater tuberosity, lesser tuberosity, and surgical neck. AO/OTA further refines this with alphanumeric codes detailing extra-articular (Type A), partial articular (Type B), and complete articular (Type C) involvement. The management spectrum ranges from non-operative care for stable, minimally displaced fractures to open reduction internal fixation (ORIF), hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) for more complex patterns. The focus of this review is on surgical indications for articular part involvement, particularly where the integrity or viability of the articular surface is compromised, leading to consideration of reconstructive or replacement strategies.

Surgical Anatomy & Biomechanics

A thorough understanding of the proximal humeral anatomy, its intricate vascular supply, and the surrounding soft tissue envelope is paramount for effective surgical planning and execution in PHFs.

Surgical Anatomy

• Proximal Humerus: Comprises the humeral head (articular segment), anatomical neck, surgical neck, greater tuberosity, and lesser tuberosity.

  • Humeral Head: Approximately one-third of a sphere, articulating with the glenoid. Its articular cartilage is critical for smooth, low-friction motion. Fractures directly involving the articular surface (e.g., head-splitting fractures) or compromising its blood supply are a major concern.
  • Anatomical Neck: Lies at the base of the articular cartilage. Fractures here often disrupt the primary blood supply to the head.
  • Surgical Neck: Distal to the tuberosities, a common site for fractures, especially 2-part patterns. Displacement here can significantly affect alignment and stability.
  • Greater Tuberosity: Insertion site for the supraspinatus, infraspinatus, and teres minor tendons (posterior and superior rotator cuff). Fractures here can lead to retraction and compromise rotator cuff function.
  • Lesser Tuberosity: Insertion site for the subscapularis tendon (anterior rotator cuff). Fractures here can lead to internal rotation deformity.
  • Bicipital Groove: Houses the long head of the biceps tendon, running between the tuberosities.

• Vascularity of the Humeral Head: The blood supply to the humeral head is precarious and largely relies on two main sources:

  • Anterior Humeral Circumflex Artery (AHCA): Gives rise to the ascending branch (arcuate artery), which penetrates the bone through the bicipital groove and supplies the majority (60-80%) of the humeral head.
  • Posterior Humeral Circumflex Artery (PHCA): Supplies the posterior aspect of the humeral head and contributes to the tuberosity vascularity.
  • Metaphyseal Vessels: Derived from the axillary artery branches, contributing to the surgical neck and tuberosities.
    Displacement of Neer 3- and 4-part fractures, particularly those involving the anatomical neck or severe comminution of the tuberosities, significantly disrupts these vessels, elevating the risk of avascular necrosis (AVN) of the humeral head. Factors such as a medial hinge disruption, displacement of >1 cm, or angulation >45 degrees are associated with increased AVN risk.

• Soft Tissues:

  • Rotator Cuff: The four tendons (supraspinatus, infraspinatus, teres minor, subscapularis) are crucial for dynamic stability and motion. Their insertions onto the tuberosities are often fragmented in complex fractures, making anatomical reduction and healing essential for functional recovery after ORIF or HA. In RSA, while tuberosity healing is beneficial, satisfactory function is less dependent on it due to the deltoid acting as the primary motor.
  • Deltoid Muscle: Primary abductor of the shoulder, critical for RSA function. Its integrity and innervation (axillary nerve) are paramount.
  • Neurovascular Structures: The axillary nerve wraps around the surgical neck, approximately 5-7 cm distal to the acromial edge. It is vulnerable to iatrogenic injury during plating or open reduction. The axillary artery and brachial plexus are also nearby.

Biomechanics

The glenohumeral joint is a ball-and-socket joint designed for high mobility at the expense of inherent stability.
* Stability: Primarily provided by the rotator cuff muscles, glenohumeral ligaments, joint capsule, and negative intra-articular pressure.
* Fracture Impact: PHFs disrupt the normal biomechanics by:
* Displacing the articular segment: Leading to incongruity, pain, and arthritis.
* Disrupting rotator cuff insertions: Impairing force couples and active motion.
* Altering humeral head version and inclination: Affecting glenohumeral kinematics.
* Surgical Goals:
* ORIF: Restore anatomical alignment, particularly of the articular surface and tuberosities, to allow for rotator cuff healing and preserve humeral head viability. Achieve stable fixation to permit early rehabilitation.
* Hemiarthroplasty (HA): Replace the humeral head while preserving the tuberosities for rotator cuff reattachment, aiming for a pain-free, stable, and mobile joint. Success is highly dependent on tuberosity healing.
* Reverse Shoulder Arthroplasty (RSA): Lateralize the center of rotation, tension the deltoid, and bypass a non-functional or severely damaged rotator cuff, providing predictable pain relief and deltoid-driven active elevation. Tuberosity healing is less critical, making it advantageous in complex fracture patterns with compromised tuberosities.

Indications & Contraindications

The decision-making algorithm for PHFs, particularly those involving the articular segment, is complex and hinges on patient factors, fracture characteristics, and surgeon experience.

Non-Operative Indications

• Minimally displaced fractures (e.g., Neer 1-part, stable 2-part surgical neck with minimal angulation <45° and displacement <1 cm).
• Impacted valgus fractures with stable articular surface.
• Patients with significant medical comorbidities precluding surgery.
• Low-demand, frail elderly patients where surgical risks outweigh potential benefits.
• Non-displaced or minimally displaced greater tuberosity fractures (<3-5 mm).

Operative Indications for Articular Part Fractures

The primary goal of operative treatment is to restore function, achieve pain relief, and prevent or treat complications associated with the fracture or non-operative management. When the articular part is involved or at risk, surgical options become critical.

Open Reduction Internal Fixation (ORIF)

• Displaced 2-, 3-, and select 4-part fractures in younger, active patients with good bone quality.
• Head-splitting fractures where the articular fragments are large enough and reducible, allowing for stable screw fixation.
• Displaced anatomical neck fractures if vascularity to the head is deemed adequate and fixation is achievable.
• Displaced greater tuberosity fractures (>3-5 mm) resulting in rotator cuff dysfunction, especially in active individuals.
• Valgus-impacted fractures with significant articular depression or instability.
• Fracture-dislocations where closed reduction is unsuccessful or unstable, often requiring internal fixation after reduction.

Hemiarthroplasty (HA)

HA involves replacing the humeral head while preserving the tuberosities for rotator cuff reattachment. Its indications have narrowed considerably with the advent of RSA.

• Severe comminution of the humeral head/articular surface that precludes ORIF, especially with high risk of AVN (e.g., Neer 4-part fractures, head-splitting fractures with irreparable articular damage).
• Younger, active patients with an irreparable humeral head where RSA is considered less desirable due to long-term glenoid wear and impingement concerns, assuming a healthy rotator cuff.
• Failed ORIF with AVN or severe malunion/non-union in younger patients.
• Contraindications to RSA (e.g., active deltoid palsy).

Reverse Shoulder Arthroplasty (RSA)

RSA is increasingly utilized for complex proximal humeral fractures, particularly in the elderly. Its design bypasses the need for functional rotator cuff healing for active elevation, making it ideal in certain scenarios.

• Main Indications (adapted from seed content):

  • Displaced 3- and 4-part fractures in elderly patients (>70-75 years old) , where bone quality is often poor, and the risk of AVN, non-union, or failure of ORIF is high. This is particularly true for fracture patterns that compromise articular segment vascularity or make stable ORIF challenging.
  • Comminuted fractures of the tuberosities and/or small fragments of the tuberosities, such as avulsion or impression fractures: In these cases, anatomical reduction and stable healing of the tuberosities are often impossible or highly unreliable with ORIF or HA. RSA provides a reliable outcome despite poor tuberosity healing.
  • Proximal humeral fractures with a pre-existing rotator cuff tear: RSA is advantageous as it does not rely on rotator cuff integrity for function, offering predictable pain relief and active elevation.
  • Head-splitting fractures with severe articular comminution or displacement precluding anatomical reduction and stable fixation, especially in the elderly.
  • Fracture-dislocations with extensive humeral head damage in elderly patients.
  • Failed ORIF resulting in non-union, malunion, AVN, or implant failure, particularly in older patients with irreparable rotator cuff or poor bone stock.
  • Severe osteoporosis that precludes stable ORIF.

• Advantages of RSA (from seed content):

  • Shoulder function less dependent on healing of the tuberosities.
  • Predictable satisfactory outcome in relation to pain relief and shoulder function.
  • One-step procedure (avoiding multiple surgeries).

Contraindications to Surgical Intervention (General and Specific)

• Absolute Contraindications:
  • Active infection (local or systemic).
  • Acute medical comorbidities that preclude safe anesthesia or surgery (e.g., uncontrolled cardiac disease, recent myocardial infarction).
  • Non-functional or paralyzed deltoid muscle (absolute for RSA).
  • Irreparable axillary nerve injury (absolute for RSA).
• Relative Contraindications:
  • Severe bone loss of the glenoid (for RSA).
  • Younger, active patients (HA or ORIF often preferred over RSA due to longevity concerns and glenoid wear).
  • Unrealistic patient expectations.
  • Non-compliance with post-operative rehabilitation.

Table: Operative vs. Non-Operative Indications for Proximal Humeral Fractures

Pre-Operative Planning & Patient Positioning

Meticulous pre-operative planning is critical to anticipate challenges, select appropriate implants, and optimize surgical outcomes.

Pre-Operative Planning

1. Clinical Assessment:
   • Patient History: Age, hand dominance, occupation, activity level, medical comorbidities (e.g., diabetes, osteoporosis, cardiovascular disease), prior shoulder pathology (e.g., rotator cuff tear, arthritis, previous surgery).
   • Physical Examination: Neurovascular status (axillary nerve function, radial pulse), skin integrity, deltoid function, pre-existing range of motion (if possible).
2. Imaging:
   • Radiographs: Standard trauma series (AP of glenohumeral joint, scapular Y view, axillary view) are essential to characterize the fracture pattern, displacement, and articular involvement. True AP, Grashey, and Velpeau views may provide additional detail.
   • Computed Tomography (CT) Scan: Indispensable for complex PHFs, especially those involving the articular surface (head-splitting) or significant comminution (3- and 4-part).
     • 3D Reconstructions: Provide invaluable insights into fragment size, displacement, articular step-off, presence of impaction, tuberosity integrity, and glenoid morphology (critical for RSA).
     • Assessment of Humeral Head Perfusion: Can sometimes infer vascular compromise based on fracture lines, but is not definitive.
   • Magnetic Resonance Imaging (MRI): Typically not routinely indicated in acute fractures, but may be considered in younger patients or when a pre-existing rotator cuff tear is suspected and would significantly alter the treatment plan (e.g., conversion from ORIF to HA/RSA).
3. Classification:
   • Apply Neer and/or AO/OTA classification systems to precisely describe the fracture pattern, which directly influences treatment decisions.
4. Implant Selection:
   • ORIF: Locking plates (e.g., PHILOS, Afx, Perimed) are commonly used for metaphyseal comminution, often with suture augmentation for tuberosity fragments. Consider various screw lengths and types (locking, non-locking, cancellous, cortical).
   • HA/RSA:
     • Stem Design: Cemented vs. uncemented, short vs. standard length, modularity.
     • Humeral Head (HA): Various sizes, offset, and neck-shaft angles.
     • Glenosphere (RSA): Different diameters, lateralization options, eccentric vs. concentric.
     • Humeral Tray/Polyethylene Insert (RSA): Different sizes and liners.
   • Ancillary Materials: High-strength sutures, cables, bone graft (autograft/allograft) for comminution or defect filling.
5. Surgical Strategy & Contingency Planning:
   • Identify the most appropriate surgical approach.
   • Plan the sequence of reduction maneuvers and provisional fixation.
   • Anticipate potential difficulties (e.g., poor bone quality, fragment comminution, neurovascular compromise).
   • Have backup implants or alternative strategies available (e.g., if ORIF fails intraoperatively, consider conversion to HA/RSA if appropriate).
   • Discuss the planned procedure, risks, benefits, and expected outcomes with the patient and their family.

Patient Positioning

The most common position for proximal humeral fracture surgery is the beach chair position , though some surgeons prefer supine with a bolster.

1. Anesthesia: General endotracheal anesthesia is typically employed. A regional nerve block (e.g., interscalene block) can be highly beneficial for post-operative pain management.
2. Beach Chair Position:
   • Patient is semi-recumbent at 45-70 degrees, with the head supported in a padded headrest.
   • Torso elevated, hips flexed, knees flexed with foot support.
   • The operative arm is draped free, allowing for full range of motion, traction, and manipulation. This is crucial for reduction maneuvers and implant placement.
   • Padding of all pressure points (sacrum, heels, opposite elbow, etc.) to prevent nerve compression or skin breakdown.
   • Ensure easy access for the C-arm image intensifier for intraoperative fluoroscopy in multiple planes (AP, Y-view, axillary).
3. Supine Position with Bolster:
   • Less commonly used for PHFs, but preferred by some surgeons, especially for arthroplasty.
   • Patient lies supine on the operating table. A bolster or beanbag is often placed under the scapula to elevate the operative shoulder and provide stability.
   • The operative arm is draped free.
   • May offer better stability for glenoid preparation in arthroplasty but can make traction and certain reduction maneuvers more challenging.
4. Sterile Preparation and Draping:
   • Wide preparation of the shoulder, chest, and arm (from chin to iliac crest, and past elbow) to allow for extensile exposure if needed.
   • Sterile draping to isolate the surgical field and allow full access to the shoulder and arm for manipulation.

Detailed Surgical Approach / Technique

The choice of surgical technique depends heavily on the fracture pattern, patient characteristics, and chosen treatment modality (ORIF, HA, or RSA). The deltopectoral approach is the workhorse for most proximal humeral fracture surgeries.

Common Surgical Approach: Deltopectoral

1. Incision: A curvilinear incision starting from the coracoid process, extending distally along the deltopectoral groove for 8-15 cm, depending on exposure requirements.
2. Deltopectoral Interval: Identify the interval between the deltoid muscle laterally and the pectoralis major muscle medially. The cephalic vein typically runs within this groove; it is usually retracted laterally with the deltoid to preserve it.
3. Clavipectoral Fascia: Incise the clavipectoral fascia to expose the underlying conjoined tendon (coracobrachialis and short head of biceps) and pectoralis minor. Retract these medially.
4. Axillary Nerve: The axillary nerve is a critical structure, coursing circumferentially around the surgical neck, approximately 5-7 cm distal to the acromion. Protect it throughout the procedure, especially during subperiosteal dissection and screw placement.
5. Deep Dissection:
   • For ORIF/HA : Incise the deltoid insertion on the anterior acromion if necessary for superior exposure, but typically avoided. Mobilize the interval anteriorly to expose the subscapularis tendon.
   • For RSA : Wider exposure may be needed, often requiring tenotomy of the subscapularis (lesser tuberosity remains attached if fragmented).

Open Reduction Internal Fixation (ORIF) - Plating

ORIF aims to restore anatomical alignment and achieve stable fixation to facilitate healing.

1. Exposure and Hematoma Evacuation: Once the deltopectoral interval is developed, carefully evacuate the fracture hematoma to visualize all fragments. Avoid excessive soft tissue stripping to preserve vascularity.
2. Reduction Techniques:
   • Traction and External Rotation: Applied to the arm to disimpact fragments.
   • Indirect Reduction: Using joysticks (K-wires), bone hooks, or percutaneous clamps to manipulate fragments.
   • Direct Reduction: Careful manipulation of the humeral head fragment, often with sutures passed through the rotator cuff tendons (supraspinatus, subscapularis, infraspinatus) for control and later reattachment.
   • Reduction Aids: Provisional K-wires or reduction clamps.
   • Anatomical Reduction: Crucially, restore the proper length, alignment, and rotation of the humeral head and tuberosities. The tuberosities, especially the greater tuberosity, must be anatomically reduced and held in place to allow for optimal rotator cuff function.
3. Plate Application (e.g., Locking Plate Systems like PHILOS):
   • Plate Positioning: The plate is typically placed on the lateral aspect of the humerus, distally enough to capture adequate diaphyseal bone but proximally enough to support the head. Ensure the plate is placed just distal to the bicipital groove and approximately 5-7 cm from the lateral acromion to avoid damaging the axillary nerve.
   • Distal Fixation: Initially secure the plate to the humeral shaft with cortical or locking screws.
   • Proximal Fixation: Insert locking screws into the humeral head fragment(s). Aim for divergent trajectories to maximize purchase in the osteopenic bone. Ensure screws do not penetrate the articular surface (verify with fluoroscopy in multiple planes).
   • Tuberosity Fixation: Suture augmentation is often used to pull tuberosity fragments towards the plate and secure them to the humeral head. High-strength sutures passed through the rotator cuff tendons are then tied around the plate. This is vital for rotator cuff healing and functional recovery.
   • Medial Column Support: Consider placing a medial calcar screw or bone graft to prevent varus collapse, especially in osteoporotic bone.
4. Stability Assessment: Assess fixation stability through range of motion. Confirm reduction and implant position with fluoroscopy.

Hemiarthroplasty (HA)

HA is chosen when the humeral head is irreparable but the glenoid is healthy and rotator cuff function can be restored.

1. Approach: Deltopectoral approach. Subscapularis tenotomy and repair are typically performed. Protect the inferior joint capsule.
2. Humeral Head Resection: Osteotomize the humeral head at the anatomical neck, carefully preserving the tuberosities with their rotator cuff attachments. Assess the tuberosities for comminution and viability.
3. Humeral Preparation:
   • Prepare the humeral canal by reaming and broaching to accept the selected humeral stem.
   • Maintain the correct version (typically 20-30° retroversion relative to the epicondylar axis) and neck-shaft angle to prevent impingement.
   • Insert the trial stem and head.
4. Tuberosity Reattachment: This is the most critical step for HA success.
   • Use high-strength non-absorbable sutures or cables to encircle and securely reattach the greater and lesser tuberosities to the humeral shaft and the prosthetic neck.
   • Achieve an anatomical position of the tuberosities to restore rotator cuff tension and allow healing.
   • Often, holes are drilled in the humeral shaft and stem for suture passage.
5. Trial Reduction and Stability: Reduce the shoulder joint, assess stability, range of motion, and soft tissue tension. Adjust neck length or head size if needed.
6. Definitive Implantation: Insert the final components (cemented or uncemented stem, final humeral head). Re-tension tuberosities.
7. Closure: Repair the subscapularis tendon. Layered closure.

Reverse Shoulder Arthroplasty (RSA) for Fracture

RSA is increasingly preferred for complex PHFs in the elderly, especially with comminuted tuberosities or pre-existing rotator cuff dysfunction, as it provides predictable deltoid-driven function.

1. Approach: Deltopectoral approach is standard. Subscapularis tenotomy and repair of the lesser tuberosity fragment (if salvageable) are performed. Assess the greater tuberosity fragments.
2. Humeral Head Osteotomy: Resect the humeral head at the anatomical neck. Manage any tuberosity fragments.
3. Glenoid Preparation:
   • Expose the glenoid. Remove remaining articular cartilage and prepare the glenoid bone.
   • Ream the glenoid surface to create a flat or slightly concave base for the glenoid baseplate.
   • Drill a central hole for the glenoid central peg/screw and peripheral holes for fixation screws.
   • Baseplate Fixation: Impact the glenoid baseplate. Insert locking screws. Ensure solid fixation, typically with a slight inferior tilt (e.g., 10-20°) to minimize scapular notching.
   • Glenosphere Implantation: Select and implant the glenosphere (e.g., 36mm, 38mm, 42mm, 44mm diameter), impacting it securely onto the baseplate. Various sizes and lateralization options are available.
4. Humeral Preparation:
   • Ream and broach the humeral canal for the selected humeral stem.
   • Maintain appropriate retroversion (e.g., 20° retroversion) and establish the correct humeral length.
   • Insert the trial humeral stem, humeral tray, and polyethylene liner.
5. Tuberosity Management (Crucial for Fracture RSA):
   • While RSA function is less dependent on tuberosity healing, an attempt to anatomically reduce and repair them with high-strength sutures around the prosthetic components is generally recommended if fragments are large enough and viable.
   • This can improve external rotation and provide some load-sharing, potentially reducing stress on the glenoid. However, satisfactory outcomes are still achieved even with tuberosity non-union in RSA.
   • As per seed content: "Shoulder function less dependent on healing of the tuberosities." This is a key advantage.
6. Trial Reduction and Stability: Reduce the trial components. Assess stability, deltoid tension, and range of motion. Ensure no impingement or dislocation. Adjust neck length, offset, or glenosphere size if necessary.
7. Definitive Implantation: Insert the final humeral stem (cemented or uncemented), humeral tray, and polyethylene liner. Finalize tuberosity repair.
8. Closure: Reattach the subscapularis if tenotomized (unless it's part of the comminuted lesser tuberosity). Layered closure.

Complications & Management

Proximal humeral fractures, particularly those treated surgically, are associated with a range of potential complications, which can significantly impact patient outcomes. Prevention, early recognition, and appropriate management are paramount.

Table: Common Complications, Incidence, and Salvage Strategies

General Management Principles

• Prevention: Meticulous surgical technique, appropriate implant selection, strict adherence to post-operative protocols.
• Early Detection: Regular clinical follow-up, appropriate imaging (X-rays, CT).
• Conservative Management: For minor or asymptomatic complications (e.g., asymptomatic scapular notching, mild nerve palsies).
• Surgical Revision: Indicated for symptomatic or progressive complications that significantly impair function or threaten implant longevity. This often involves more complex procedures with higher risks.

Post-Operative Rehabilitation Protocols

Post-operative rehabilitation is crucial for optimizing outcomes and varies significantly depending on the surgical procedure performed and the quality of fixation or tuberosity repair. Early motion is generally desirable, but protection of the repair is paramount.

General Principles

• Pain Management: Essential for early participation in therapy.
• Sling Immobilization: Duration varies based on fracture stability, bone quality, and procedure.
• Gradual Progression: From passive to active-assisted to active range of motion (ROM), followed by strengthening.
• Patient Education: Crucial for adherence to restrictions and exercises.
• Surgeon Communication with Therapist: Essential to tailor the protocol to the specific surgical findings.

Open Reduction Internal Fixation (ORIF)

The rehabilitation for ORIF aims to protect the fracture fixation while allowing for soft tissue healing and gradual restoration of motion.

• Phase 1: Protection and Early Motion (Weeks 0-6)
  • Immobilization: Sling for 4-6 weeks (some protocols allow earlier removal for showering/hygiene).
  • Activity: Elbow, wrist, and hand ROM exercises. Pendulum exercises.
  • Passive Range of Motion (PROM): Initiated around 2-3 weeks post-op, or later (4-6 weeks) if fixation is tenuous or tuberosity comminution is significant.
    • Focus on gentle forward flexion (up to 90-120°) and external rotation (0-30°). Avoid internal rotation beyond neutral in early stages if lesser tuberosity was involved.
    • No active contraction of the deltoid or rotator cuff muscles.
• Phase 2: Active-Assisted & Active Range of Motion (Weeks 6-12)
  • Sling: Discontinued as tolerated, typically by 6 weeks.
  • AAROM: Progress to active-assisted exercises (e.g., pulley exercises, cane exercises).
  • AROM: Initiate active ROM, gradually increasing as pain allows and radiographic healing progresses.
  • Gentle Isometric Strengthening: Start with submaximal isometric contractions of rotator cuff and deltoid.
  • Avoid Lifting: No lifting of objects with the affected arm.
• Phase 3: Strengthening and Advanced Motion (Weeks 12-24)
  • Progressive Strengthening: Introduce resistance exercises using bands, light weights.
  • Rotator Cuff and Scapular Stabilization: Focus on restoring strength and coordination.
  • Proprioception and Neuromuscular Control: Exercises to improve joint awareness and stability.
• Phase 4: Return to Activity (Months 6+)
  • Gradual return to sport-specific or work-specific activities, depending on patient goals and fracture healing.
  • Full strength and endurance continue to improve over 12-18 months.

Hemiarthroplasty (HA)

HA protocols are similar to ORIF, with a strong emphasis on protecting tuberosity repair.

• Phase 1: Protection and Gentle PROM (Weeks 0-6)
  • Immobilization: Sling for 4-6 weeks. Strict adherence is critical due to reliance on tuberosity healing.
  • PROM: Initiated around 2-3 weeks. Limit forward flexion (e.g., 90-120°) and external rotation (e.g., 0-30°). Avoid internal rotation.
  • No Active Movement: Absolutely no active motion of the shoulder to protect the tuberosity repairs.
• Phase 2: AAROM and Gentle Strengthening (Weeks 6-12)
  • Sling: Weaned as tolerated.
  • AAROM: Gradually introduce, but continue to protect the tuberosities.
  • Gentle Isometrics: Start submaximal rotator cuff isometrics if tuberosity healing appears adequate (radiographic signs).
• Phase 3: Progressive Strengthening (Weeks 12-24)
  • Similar to ORIF, focusing on rotator cuff and deltoid strengthening.
  • Delayed progression if tuberosity healing is not progressing well.
• Phase 4: Return to Activity (Months 6+)
  • Highly dependent on tuberosity healing and overall functional recovery. Often slower than ORIF due to reliance on soft tissue healing in potentially poor bone.

Reverse Shoulder Arthroplasty (RSA) for Fracture

RSA protocols can often progress more quickly than ORIF or HA, especially if tuberosity repair is deemed unreliable or not performed, as function relies on the deltoid.

• Phase 1: Protection and Early Motion (Weeks 0-4)
  • Immobilization: Sling for 3-4 weeks. Some surgeons advocate for immediate, gentle passive/active-assisted motion. If tuberosities were well-repaired, a slightly longer protection phase may be warranted.
  • PROM/AAROM: Initiate early (within the first week) gentle passive and active-assisted elevation and external rotation.
  • Active Deltoid Activation: Encourage gentle isometric deltoid contractions.
  • Avoid: No hyperextension, adduction, or combined internal rotation/adduction (especially if tuberosities not repaired) to prevent dislocation.
• Phase 2: Active ROM and Gentle Strengthening (Weeks 4-12)
  • Sling: Weaned.
  • AROM: Focus on active elevation (deltoid-driven motion) and external rotation.
  • Gentle Strengthening: Initiate resistance exercises for deltoid and periscapular muscles using light weights or bands.
  • No Lifting: Limit lifting to light objects for several months.
• Phase 3: Progressive Strengthening and Functional Activities (Weeks 12-24)
  • Increased Resistance: Gradually increase weights and resistance.
  • Functional Training: Incorporate activities of daily living and work-specific tasks.
  • Focus: Continue to emphasize deltoid strength and coordinated shoulder movement.
• Phase 4: Return to Activity (Months 6+)
  • Gradual return to desired activities, with permanent restrictions on heavy lifting or impact sports.

Summary of Key Literature / Guidelines

The landscape of proximal humeral fracture management, especially for articular involvement, is dynamic, with ongoing research refining treatment algorithms. Several key themes and guidelines have emerged.

1. Non-Operative vs. Operative Management:

   • Minimally Displaced Fractures: A meta-analysis by Handoll and Brorson (2015) in the Cochrane Database of Systematic Reviews confirmed that for minimally displaced fractures, non-operative treatment with early mobilization generally yields comparable functional outcomes to surgical intervention, with fewer complications. The UK-based PROXIMAL trial (2015) also supported non-operative management for most Neer 3- and 4-part fractures in the elderly, noting no significant difference in patient-reported outcomes compared to surgery, but with a higher complication rate in the surgical group. This emphasizes careful patient selection for surgery.
   • Displaced Fractures: For significantly displaced fractures, particularly those involving the articular surface or severe angulation, operative intervention is generally favored, especially in younger, active patients, to restore anatomy and improve function.

2. ORIF vs. Arthroplasty for Complex Fractures in the Elderly:

   • Rising Role of Arthroplasty: For complex 3- and 4-part PHFs in older adults, the consensus has shifted from predominantly ORIF or HA towards increasing utilization of RSA.
   • HA vs. RSA: Multiple studies, including randomized controlled trials and meta-analyses, have demonstrated superior or at least comparable functional outcomes and pain relief for RSA compared to HA in the treatment of complex PHFs in the elderly.
     • Meta-analysis by Shi et al. (2017) and Wang et al. (2018): Generally found that RSA provides better functional scores (e.g., Constant score) and active range of motion, particularly active elevation, than HA for displaced 3- and 4-part fractures in the elderly. RSA also has a lower rate of tuberosity non-union related complications compared to HA, which significantly impacts HA outcomes.
     • Advantages of RSA: Its ability to restore predictable deltoid-driven function independent of rotator cuff and tuberosity healing makes it highly attractive in osteoporotic bone where tuberosity fixation and healing are notoriously difficult. Pain relief is consistently good with RSA.
     • Disadvantages of HA: High rates of tuberosity non-union (up to 30-60%), glenoid erosion, and unpredictable functional outcomes have diminished its primary role for elderly fracture patients, though it remains an option for younger, active patients with irreparable humeral heads and healthy rotator cuffs.
   • ORIF vs. RSA in the Elderly: While ORIF can achieve good results in select elderly patients with good bone quality and reducible fractures, its failure rates (AVN, non-union, screw cutout) can be substantial in osteoporotic bone. For those with high comminution, particularly of the tuberosities, or pre-existing rotator cuff pathology, RSA generally offers more reliable pain relief and functional restoration.

3. Outcomes of RSA in Fracture Settings:

   • Studies consistently report good to excellent pain relief following RSA for fractures.
   • Active elevation typically ranges from 100-140 degrees, with external rotation often more limited (20-40 degrees), especially if tuberosities do not heal.
   • Patient satisfaction rates are high.
   • Complication rates for RSA, while present (e.g., scapular notching, infection, dislocation), are generally acceptable given the complexity of the treated fractures.

4. AAOS and Specialty Society Guidelines:

   • American Academy of Orthopaedic Surgeons (AAOS): Guidelines often emphasize shared decision-making, patient-specific factors, and the use of current evidence. While not providing strict algorithms for every fracture pattern, they support individualized treatment based on fracture characteristics, patient age, activity level, and comorbidities.
   • Specialty Societies (e.g., American Shoulder and Elbow Surgeons - ASES, European Society for Surgery of the Shoulder and Elbow - SECEC): These groups regularly publish consensus statements and research focusing on the evolving role of arthroplasty for complex fractures. The trend clearly indicates an increasing recommendation for RSA in the elderly population with comminuted fractures or pre-existing rotator cuff deficiency.

5. Evolving Trends:

   • Short Stems and Stemless Implants: Increasingly explored for RSA in fractures to preserve bone stock, though their long-term efficacy and indications are still being defined.
   • Improved Implants: Better locking plate designs for ORIF, more modular arthroplasty systems.
   • Focus on Tuberosity Healing in RSA: While RSA function is less dependent on tuberosity healing, efforts to improve tuberosity reattachment and union in fracture RSA are ongoing, as successful healing can lead to even better external rotation and overall function.

In conclusion, the decision to operate on proximal humeral fractures with articular involvement is a nuanced one. While ORIF remains a viable option for younger patients with reducible fractures and good bone quality, for the elderly, especially with severe comminution, osteopenia, or pre-existing rotator cuff pathology, reverse shoulder arthroplasty has emerged as the preferred surgical option due to its predictable outcomes, reliable pain relief, and ability to circumvent the challenges of tuberosity healing. Continued research will further refine patient selection and surgical techniques to optimize long-term functional results.