Introduction

The management of shoulder trauma, especially with regards to fractures of the clavicle and proximal humerus, has evolved significantly in recent years. With emerging surgical techniques, medical device innovations, and improved understanding of the natural history of these injuries, orthopedic surgeons are better equipped to address the unique challenges these fractures present. This article provides a comprehensive update on the current concepts and treatment modalities in shoulder trauma based on recent literature and editorial insights.

Keywords

1. Shoulder trauma management
2. Proximal humerus fractures
3. Clavicle fracture treatment
4. Locking plate fixation
5. Reverse shoulder arthroplasty

Advances in Proximal Humerus Fractures

One of the most common injuries encountered in orthopedic practice is the fracture of the proximal humerus, particularly among elderly patients. The complexity of treating these fractures stems from the intricate anatomy of the shoulder and its importance in upper limb function. Schumaier and Grawe have detailed the evaluation and management of proximal humerus fractures in the elderly, highlighting the need for a pragmatic approach based on the patient’s functional demands, bone quality, and fracture pattern (Schumaier, A., & Grawe, B., 2018).

Recent articles have provided outcome analyses of non-operative management for these injuries (Khoriati, A.A., 2019), advocating for conservative treatments in cases that are amenable to such an approach. On the other hand, surgical interventions have seen notable improvements, with innovative techniques such as intramedullary nail fixation via the Neviaser portal being evaluated for effectiveness and safety (Tanaka, Y., et al., 2019).

Locking plate fixation has become a cornerstone in the surgical management of proximal humerus fractures, thanks to advances in design and technique (Laux, C.J., et al., 2017). These locking plates provide stable fixation, especially in osteoporotic bone, and allow for early mobilization, which is crucial for optimal recovery.

The Emergence of Reverse Shoulder Arthroplasty

For cases where the proximal humerus fracture is associated with severe arthritis or previous implant failures, reverse shoulder arthroplasty (RSA) has emerged as a viable salvage operation (Chauhan, V.S., et al., 2019). While traditionally used for complex joint pathology and rotator cuff arthropathy, RSA has been showing promising results in the context of trauma as well.

The effectiveness of RSA as a secondary option after failed megaprosthesis for osteosarcoma of the proximal humerus has been detailed in the recent literature, showing that this technique can provide pain relief and functional improvement even in challenging clinical scenarios (Vaishya, R., et al., 2019).

Management of Clavicle Fractures

Clavicle fractures constitute another major component of shoulder trauma. These injuries can occur through various mechanisms, from sports-related impacts to simple falls, and their incidence and patterns have been explored through large databases such as the National Electronic Injury Surveillance System (NEISS) (DeFroda, S.F., et al., 2019; Hoogervorst, P., et al., 2018).

Although traditional non-operative management is still prevalent for midshaft clavicle fractures, surgical options like locking plate fixation have gained favor in certain cases, offering better alignment and potentially reducing the risk of malunion and nonunion (Vaishya, R., et al., 2017).

Radial Nerve Management in Humeral Shaft Fractures

The radial nerve is vulnerable in humeral shaft fractures and can significantly impact patient outcomes if not managed appropriately. In their work, Vaishya and colleagues debated the timing of radial nerve exploration with such injuries, concluding that early exploration is not always justifiable and that a tailored approach is essential depending on the clinical context (Vaishya, R., et al., 2018).

Furthermore, comprehensive clinical guidelines for the management of proximal humeral fractures are crucial to streamline care and improve patient outcomes (Misra, S., 2019). These guidelines offer a step-by-step approach to both conservative and surgical management options, emphasizing the importance of individualizing treatment protocols.

Conclusion

Shoulder trauma management continues to advance, with the introduction of novel surgical techniques, refinements in fixation technology, and evolving approaches to rehabilitation. These updates are critical for orthopedic surgeons and healthcare professionals aiming to optimize the care of patients with clavicle and proximal humerus fractures.

The field is also seeing an increase in the use of reverse shoulder arthroplasty as a salvage operation for complex cases, providing hope for improved functionality in previously challenging situations. Amidst these advancements, it is the comprehensive assessment of each patient, considering their specific needs and circumstances, that dictates optimum management strategies for shoulder trauma.

References

Chauhan, V.S., Vaish, A., & Vaishya, R. (2019). Reverse shoulder arthroplasty after failed megaprosthesis for osteosarcoma of the proximal humerus: a case report and review of the literature. J Clin Orthop Trauma. doi: 10.1016/j.jcot.2019.03.015. PMC6491923 31061583.

DeFroda, S.F., Lemme, N., Kleiner, J., Gil, J., & Owens, B.D. (2019). Incidence and mechanism of injury of clavicle fractures in the NEISS database: athletic and non-athletic injuries. J Clin Orthop Trauma. doi: 10.1016/j.jcot.2019.01.019. PMC6738494 31528074.

Hogaervorst, P., van Schie, P., & van den Bekerom, M.P.J. (2018). Midshaft clavicle fractures: current concepts. EFORT Open Rev. 3, 374-380. PMC6026885 30034818.

Khoriati, A.A. (2019). Outcomes following non-operative management for proximal humerus fractures. J Clin Orthop Trauma. 10(3), 462-467. doi: 10.1016/j.jcot.2019.01.029. PMC6491913 31061570.

Laux, C.J., Grubhofer, F., Werner, C.M.L., Simmen, H.P., & Osterhoff, G. (2017). Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res. 12, 137. PMC5613450 28946902.

Misra, S. (2019). Clinical guidelines for the management of proximal humeral fractures. J Clin Orthop Trauma. 10(3), 615-616. PMC6494746 31061604.

Schumaier, A., & Grawe, B. (2018). Proximal humerus fractures: evaluation and management in the elderly patient. Geriatr Orthop Surg Rehabil. 9, 2151458517750516. PMC5788098 29399372.

Tanaka, Y., Gotani, H., Sasaki, K., Yoshimura, T., Yagi, H. (2019). Evaluation of intramedullary nail fixation via the Neviaser portal for proximal humerus fracture. J Clin Orthop Trauma. doi: 10.1016/j.jcot.2019.02.007. PMC6491907 31061572.

Vaishya, R., & Khandel, I.K., Agarwal, A.K., & Vijay, V. (2018). Early exploration of radial nerve with secondary injuries in humeral shaft fractures is not justifiable. J Clin Orthop Trauma. doi: 10.1016/j.jcot.2018.11.002. 10.1016/j.jcot.2018.11.002.

Vaishya, R., Vijay, V., Khanna, V. (2017). Outcome of distal end clavicle fractures treated with locking plates. Chin J Traumatol. 20(1), 45-48. PMC5343094 28233729.

DOI
10.1016/j.jcot.2019.04.004

This comprehensive review of recent advances in shoulder trauma management offers insights into current treatment modalities for proximal humerus and clavicle fractures, as well as the emerging role of reverse shoulder arthroplasty and the decision-making process behind radial nerve exploration in humeral shaft fractures.