Proximal humeral fractures represent a significant challenge in modern trauma practice, not only in the context of patient care but also in terms of the socioeconomic impact on healthcare systems. With a heightened incidence rate in an aging population, these injuries necessitate both a nuanced understanding and an up-to-date approach to surgical management. In this comprehensive review, we’ll delve into the surgical techniques utilized for proximal humeral fracture fixation and the variable outcomes associated with these methods.

Epidemiology and Socioeconomic Burden of Proximal Humeral Fractures

Fractures of the proximal humerus are among the most frequent occurrences in orthopedic trauma, particularly in elderly populations. The injury often results from low-energy falls and has been linked to osteoporosis—adding to the complexity of treatment (Palvanen et al., 2006; Court-Brown & Caesar, 2006). According to Maravic et al. (2014), the burden on healthcare resources is considerable, as these fractures not only account for hospital admissions but often lead to extensive follow-up care and rehabilitation requirements.

Surgical Approaches and Techniques

Surgical intervention for proximal humeral fractures has evolved considerably over the years. From the percutaneous fixation with Schanz screws (Eid et al., 2011) to more complex methodologies involving locking plates and intramedullary nails, the quest for optimal stabilization and recovery outcomes continues (Hertel et al., 2004).

Locking Plate Fixation

Locking plates have become a mainstay in the management of complex proximal humeral fractures. Studies have conveyed the importance of both proper surgical technique and plate positioning to ensure stability and minimize complications such as avascular necrosis and malunion (Gardner et al., 2007; Zhang et al., 2011). Ensuring medial support, as suggested by Gardner and colleagues, plays a pivotal role in favorable outcomes.

Intramedullary Nail Fixation

Nail fixation offers an alternative to locking plates, especially in specific fracture patterns. Several studies underpin the viability and biomechanical superiority of nail fixation in two-part surgical neck fractures (Hatzidakis et al., 2011; Nolan et al., 2011). Deciding upon the appropriate intervention often comes down to individual patient factors and specific fracture characteristics.

Minimally Invasive and Percutaneous Techniques

Minimally invasive and percutaneous techniques aim to decrease soft tissue disruption, potentially leading to quicker rehabilitation and lower rates of complications (Vundelinckx et al., 2012; Innocenti et al., 2013). Yet, there remains debate over their efficacy compared to more established open procedures, especially for more complex fracture patterns.

Role of Augmentation and Additional Techniques

The use of fibular strut grafts and calcium sulphate augmentation has been documented to provide additional stability to the typical fixation methods (Bae et al., 2011; Somasundaram et al., 2013). These adjunct measures are particularly intriguing for cases where bone quality or fragment stability may pose a challenge.

Patient Outcomes

Despite advances in surgical techniques, patient outcomes remain variable. Rangan et al. (2015) highlighted that surgical treatment might not always confer a benefit over non-surgical management for certain proximal humeral fractures, although this remains contentious and highly dependent on individual patient factors and fracture patterns.

Factors Influencing Outcomes

Multiple factors can impact the success of surgical fixation, including but not limited to:
1. Bone quality, particularly in osteopenic or osteoporotic patients
2. The precise nature and complexity of the fracture
3. The expertise and decisions made by the operating surgeon
4. Timeliness and type of postoperative rehabilitation

Functional Outcomes and Complications

Several studies, such as those by Schulte et al. (2011) and Neviaser et al. (2011), have examined the nuances of functional recovery and complication rates. These studies underline the need for meticulous preoperative planning and patient-centered care approaches to optimize the balance between stability, healing, and the restoration of function.

Consensus and Clinical Guidelines

Current clinical practice demonstrates a lack of uniform consensus on the optimal approach for treating proximal humerus fractures. Meta-analyses and large-scale reviews advocate for a fracture-specific, patient-specific approach, adapting surgical choices to the individual’s needs and the fracture’s characteristics (Sabharwal et al., 2016; LaMartina et al., 2018).

The Economic Perspective

The economic considerations of proximal humeral fracture management underscore the need for cost-effective, outcome-driven approaches. The choice between surgical intervention, the type of implant, and the necessity for adjunct techniques must all be weighed against the financial implications for healthcare systems and patients alike.

Conclusions and Future Directions

Effective management of proximal humerus fractures remains a dynamic area in orthopaedics, with ongoing research seeking to refine surgical techniques and improve patient outcomes. Continued advancements in implant design, augmented reality in surgical planning, and an emphasis on evidence-based practices will facilitate further improvements in the care of patients with these challenging injuries.

References

1. Court-Brown, C.M., & Caesar, B. (2006). Epidemiology of adult fractures: A review. Injury, 37(8), 691-697. DOI: 10.1016/j.injury.2006.04.130
2. Gardner, M.J., Weil, Y., Barker, J.U., et al. (2007). The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma, 21(3), 185-191. DOI: 10.1097/BOT.0b013e318033309f
3. Hatzidakis, A.M., Shevlin, M.J., Fenton, D.L., et al. (2011). Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus: A multicenter retrospective observational study. J Bone Joint Surg Am, 93(24), 2172-2179. DOI: 10.2106/JBJS.J.01531
4. Maravic, M., Briot, K., Roux, C. (2014). Burden of proximal humerus fractures in the French national hospital database. Orthop Traumatol Surg Res., 100(8), 931-934. DOI: 10.1016/j.otsr.2014.08.008
5. Rangan, A., Handoll, H., Brealey, S., et al. (2015). Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: The PROFHER randomized clinical trial. JAMA, 313(10), 1037-1047. DOI: 10.1001/jama.2015.1629

Keywords

1. Proximal Humerus Fracture Fixation
2. Orthopedic Trauma Surgery
3. Humeral Fracture Outcomes
4. Shoulder Fracture Treatment
5. Locking Plate Fixation Humerus