Surgical management of proximal humeral fractures

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Abstract

BACKGROUND: Current clinical guidelines for the treatment of proximal humeral fractures standardize each case based solely on the type of injury. However, there is no systemic approach to the choice between performing humeral osteosynthesis or shoulder arthroplasty, based on a comprehensive assessment of objective diagnostic criteria.

AIM: The work aimed to develop a diagnostic algorithm with the aim of enabling a differentiated approach to the surgical treatment of proximal humeral fractures.

METHODS: This pilot, single-center, cohort, retrospective, observational study with a complete sample compared quantitative and qualitative data from two groups of patients. Outcomes of 50 patients with proximal metaepiphyseal humeral fractures treated surgically between 2019 and 2022 were analyzed. All patients underwent multislice computed tomography of the shoulder joint. Computed tomography data were used to calculate Hounsfield units of the humeral fracture fragments. Prognostically, Hounsfield units values below 65, corresponding to significant reduction in bone density due to regional or systemic osteoporosis, indicated a poor outlook for osteosynthesis, with elevated risks of implant instability, secondary fragment displacement, and nonunion of the fracture site. In cases with satisfactory bone density values, osteosynthesis techniques for humeral fractures were applied. Reverse shoulder arthroplasty was performed in patients with fractures unsuitable for reconstruction. Functional, clinical, and radiological outcomes of surgical treatment were assessed in both groups. Functional and clinical outcomes were evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS: Retrospective follow-up showed no adverse osteosynthesis outcomes such as nonunion or avascular necrosis of the fragments. No purulent-inflammatory complications occurred. Fracture consolidation was achieved, and favorable functional outcomes were observed in all patients treated with either osteosynthesis or shoulder joint arthroplasty.

CONCLUSION: Measurement of Hounsfield units of bone fragments represents an objective quantitative criterion for assessing bone tissue density and predicting the feasibility of humeral fracture osteosynthesis.

About the authors

Gurgen A. Kesyan

Priorov National Medical Research Center of Traumatology and Orthopedics

Email: kesyan.gurgen@yandex.ru
ORCID iD: 0000-0003-1933-1822
SPIN-code: 8960-7440

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

Grigoriy S. Karapetyan

Priorov National Medical Research Center of Traumatology and Orthopedics

Email: dr.karapetian@mail.ru
ORCID iD: 0000-0002-3172-0161
SPIN-code: 6025-2377

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

Artyom A. Shuyskiy

Priorov National Medical Research Center of Traumatology and Orthopedics

Author for correspondence.
Email: shuj-artyom@mail.ru
ORCID iD: 0000-0002-9028-3969
SPIN-code: 6125-1792

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

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Supplementary files

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2. Fig. 1. Post-traumatic aseptic necrosis of the humeral head after osteosynthesis (author’s material).

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3. Fig. 2. Hounsfield unit calculation based on computed tomography in a patient with normal and reduced bone fragment density of the humerus (author’s material).

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4. Fig. 3. Plate osteosynthesis of a humeral fracture (author’s material).

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5. Fig. 4. Osteosynthesis of a humeral neck fracture using gamma pins (source: Lazarev A.F., Solod E.I. Osteosynthesis in fractures of the neck of the humerus in elderly patients. N.N. Priorov Journal of Traumatology and Orthopedics. 2003;10(3):57–61. doi: 10.17816/vto200310357-61. EDN: OITEEP).

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6. Fig. 5. Plate osteosynthesis of a humeral fracture (author’s material).

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7. Fig. 6. Reverse shoulder arthroplasty in a patient with a humeral fracture unsuitable for osteosynthesis (author’s material).

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