Open Reconstruction of Complex Proximal Metadiaphyseal Fragility Fractures of the Humerus

Abstract

Purpose:

A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications.

Methods:

From 2008 to 2012, 21 such operations were performed; 18 were considered “fragility” fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative.

Results:

The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15).

Conclusion:

Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.

Introduction

Isolated proximal humerus fractures are the third most common fracture in the elderly patients and account for approximately 4% of all fractures. ¹ Open reduction and internal fixation (ORIF) has become a popular option for treatment in an effort to limit short-term dysfunction and improve long-term functionality. However, proximal humerus fractures, which also involve the shaft, are much rarer and potentially more difficult to treat, particularly in the geriatric population.

Although geriatric complex proximal humeral fracture with diaphyseal extension is relatively rare injury, it can bring about a dramatic change in a patient’s function and subsequent quality of life. Because of the potential surgical morbidity in the aged population, conservative management has traditionally been the treatment of choice. However, prolonged short-term disability and increased risk of long-term impairment make this treatment paradigm less appealing. ²

The purpose of this report is to describe the advantages of a surgical paradigm using direct reduction and locked plating in the aged population to treat complex metadiaphyseal proximal humeral fractures. We hypothesize that rigid skeletal fixation will promote fracture union with optimal alignment. Further, we submit that early physiotherapy after ORIF can promote optimized functionality in the geriatric patient.

Materials and Methods

After institutional review board approval, 24 patients with complex fractures involving both the proximal humerus and the humeral shaft were identified from our orthopedic trauma database (study period 2008-2012). Eighteen were considered “fragility” fractures and included in the study. Fragility fracture was defined according the National Osteoporosis Foundation based on low energy mechanism of injury and/or advanced patient age. Furthermore, this cohort was defined based on previous medical history of metabolic bone disease (including usage of disease-modifying drugs for osteopenia or osteoporosis; Figure 1).

Figure 1.

A, Complex metadiaphyseal proximal humeral fracture in geriatric host with known osteoporosis after a simple fall. B, Fixation with lag screws and long periarticular locking plate after direct anatomic reduction. Immediate use of arm prescribed postoperatively with 10-pound weight restriction.

All operations were performed acutely by a fellowship trained orthopedic trauma surgeon. A formal extraperiosteal approach, as described by Henry, was used to expose the proximal humerus and humeral shaft (Figure 2). Absolute stability was the goal via direct anatomic reduction and lag screw fixation complemented by usage of a long periarticular locking plate as the neutralization device. Patients were placed in a sling for 2 weeks for surgical wound healing then began physiotherapy and usage of the affected arm. Additionally, patients were instructed to use their arm for activities of daily living with a 10-pound weight restriction for the first 6 weeks.

Figure 2.

Surgical exposure to combined proximal humerus and shaft fractures using extraperiosteal dissection as described by Henry.

Outcomes data collected included fracture union, alignment, and evidence of postoperative complications. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess long-term functional outcome at a greater than 1-year postoperative time point.

Results

Eighteen patients treated with ORIF for complex metadiaphyseal humeral fragility fracture comprised the study cohort. The group consisted primarily of elderly females (83% with mean age at time of repair of 70). The most common mechanism of injury was simple fall (78%). Uneventful union occurred in all cases. Union, however, could not be assessed in 1 patient as death from unrelated causes occurred before fracture healing could be objectively measured.

Complications included 1 case of incomplete radial nerve palsy, which had resolved by the 1-year follow-up appointment. Another patient had a documented radial nerve palsy, which was present prior to injury. No other neurologic deficits were noted, and no other complications, such as infection, malalignment, or avascular necrosis, occurred.

Of the 18 patients in the study sample, 13 (72%) were available for administration of the DASH. In all, 1 patient died and 4 were lost to follow-up. The mean age of the DASH responders at time of injury was 69 years. In all, 2 patients were men and 11 were women. The 85% sustained the injury by falling on the affected shoulder. Three had rotator cuff pathology, which was either preexisting or induced by the injury.

Long-term return to functionality was evident based on a median DASH score of 12 (mean 21, standard deviation [SD] = 20) at an average follow-up time of 31 months postoperatively (range: 12-42 months). In all, 75% of patients reported no pain (DASH question [Q] 24) at this time, while the remaining 25% reported no more than moderate pain. Seventy five percent had also achieved return to overhead functionality as measured by DASH Q6, 12, and 15 (Figure 3).

Figure 3.

Patient with optimized Disabilities of the Arm, Shoulder, and Hand (DASH) scores demonstrates overhead functionality after formal open reconstruction of fragility fractures involving the humeral proximal end and shaft.

Discussion

Complex metadiaphyseal fracture of the proximal humerus in the fragile geriatric host has the potential to cause both temporary and long-term disability, which can profoundly impact quality of life including independent living. In our study, we have demonstrated that open reconstruction emphasizing anatomic reduction and rigid internal fixation is optimally suited to restore functionality in the elderly patient as evidenced by our patient’s DASH scores. Despite the more complex nature of the metadiaphyseal fractures treated in our case series, DASH outcomes were at least equivalent to those seen for ORIF of isolated proximal humerus fractures. ^{3 -7} Further, Hunsaker et al ⁸ report the mean DASH score of the general population at 10.1 (SD 14.7), and the Institute for Work & Health reports the minimal clinically detectable change (MDC95) in the DASH as 8 to 17 points. As such, the average DASH score of 21 (median 12) observed in our sample could be considered clinically indistinguishable from scores in the general population.

A number of disadvantages have traditionally been cited for ORIF in the context of proximal humerus fractures including possible disruption of blood supply to the proximal humerus, insult to the radial nerve, reduced overhead function due to the proximity of the plate to the acromion, risk of screw perforation, and secondary displacement necessitating reoperation. Studies of outcomes in isolated proximal humerus fractures have reported overall complication rates with ORIF ranging from 17% to 35%. ^{9 -12} Specific rates of osteonecrosis and nonunion have been reported ranging from 1% to 5% and 0% to 6%, respectively. ^{13 -19} Brunner et al ⁹ report that elderly patients have a 2- to 3-fold higher risk of complication when compared to younger individuals.

Fortunately, surgical expertise with osteoporotic fractures and locked periarticular implants has improved since the introduction of this technology. In our case series, only 1 patient experienced a postoperative complication, namely transient radial nerve palsy. None of the 18 patients in our sample experienced avascular necrosis, nonunion, malunion, or required reoperation. Further, plate impingement was not an issue as 75% of our patients reported return of overhead functionality.

As an alternative to direct reduction and open fixed angle plating, treatment alternatives for complex geriatric metadiaphyseal proximal humerus fractures include functional bracing, intramedullary nailing, or minimally invasive bridge plating (minimally invasive plate osteosynthesis [MIPO]). Although surgical risks are obviated with fracture bracing, short-term disability is noteworthy as well as the increased incidence of malunion, adjacent joint stiffness, and overall extremity dysfunction. ²⁰ With regard to intramedullary nailing and minimally invasive bridge plating strategies, flexible fixation and indirect reduction may not be as reliable of a treatment strategy in the geriatric host versus the younger patient. ²¹

Garnavos et al ²² specifically studied closed nailing for complex metadiaphyseal fractures of the proximal humerus. The authors concluded that nailing was “satisfactory” for these complex injuries but their study included a heterogenous patient population. Specifically analyzing their patients older than 65 years of age reveals a complication rate of 60%. They had 1 postoperative loss of reduction at 1 week requiring conversion to plate fixation. Furthermore, they report technical difficulties intraoperatively including need for open nailing/cerclage after failed closed reduction as well as difficulties with distal cross locking. Finally, persistent shoulder pain was reported in over 40% of their cases, which is consistent with the known risk of iatrogenic injury to the rotator cuff when humeral nailing is performed. ²²

Minimally invasive plate osteosynthesis is a viable technique for the geriatric population with proximal humeral fracture with shaft extension, and good results have been reported. ²³ However, MIPO for this indication is very operator dependent. Lau et al ²⁴ managed 10 older patients with minimally invasive plating with 5 complications including 2 radial nerve injuries, delayed union, and plate impingement. Laflamme et al ²⁵ studied 34 cases of isolated proximal humerus fractures and 16 cases were older than 60 years of age. Residual deformity was recorded in over 25% of cases in these more simple fracture patterns, highlighting the difficulties with indirect reduction and plate application through limited exposures.

Although, there are multiple treatment options for complex metadiaphyseal proximal humeral fractures in the elderly patients, our results would suggest that selected cases amenable to open reconstruction with direct reduction and rigid locked plate fixation is efficacious and safe in this fragile patient population. Our study has distinct strengths as we critically examined a rare yet disabling injury pattern in a uniform patient population with a single operative and rehabilitation protocol. Despite our promising results, this study does have specific limitations. This was a retrospective study without a control group and selection bias. The sample size of 18 patients is small, yet these injuries are rare as compared to isolated proximal humeral fractures. Furthermore, our long-term DASH data were limited to 13 of our 18 patients, despite all patients followed to radiographic and/or clinical union.

Conclusion

The ORIF using long periarticular locking plates is a viable option for complex metadiaphyseal proximal humeral fractures in the geriatric host with optimal union rates and overall functionality.