Humeral head split in the elderly - Is shoulder prosthetic replacement always necessary?

There is a consensus among orthopaedic surgeons that elderly patients who present with a head split after a proximal humerus fracture will require either reverse shoulder replacement or hemi-arthroplasty. An alternative to surgery is always non operative treatment. Open reduction and internal fixation using a plate should be avoided. The reason lies on the disrupted blood supply to the humeral head that will lead to avascular necrosis, possible failure of fixation and prominence of humeral screws with subsequent erosion to the glenoid cartilage and posttraumatic glenohumeral arthritis. While most cases of humeral head split lead to avascular necrosis of the humeral head there is a small percentage of patients who are not candidates for prosthetic replacement after this severe injury to the proximal humerus. In patients who are frequent fallers as in the case reported below there is a concern of periprosthetic humeral fracture after a new fall. It is common to see periprosthetic fractures after reverse or hemi-arthroplasty if the balance problems of the patient are not addressed or can not be addressed. It is our practice to review the patient's reasons for falling. It is of great value to review medications that the patient is taking along with the concurrent medical conditions that lead to balance problems.

The following case demonstrates a head split after a fall. This is a 77 y/o F who has multiple falls due to balance problems. She lives alone and stays active doing work around the house. Ambulates with a cane and depends on her arms for daily living activities. After explaining risks and benefits of sling immobilization, non operative approach and operative approach (prosthetic replacement vs ORIF) the patient elected to proceed with osteosynthesis. We elected to use an intramedullary fibular graft to support the osteopenic bone of the humeral head and provide better blood flow to the compromised humeral head. 18 months after her surgery she has union of the proximal humerus and active FE to 110 on the injured side (opposite shoulder 160 degrees of FE). She is pleased with the outcome and has not pain. Radiographically there is still a small intra-articular step off. While this case demonstrates the value of the intramedullary fibular grafting we cannot conclude that routine use of this technique will lead to healing of the fracture. A larger study is required to evaluate the effectiveness of this method.

Injury films

Intraop fluroscopic image

18 months postop the fracture has healed.

R side is the operated side. ROM 18 months after surgery.

AO technique:
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?redfix_url=1302003581263&implantstype=&segment=Proximal&bone=Humerus&classification=11-C2.3&showPage=redfix&treatment=&method=Open%20reduction%3B%20plate%20fixation

Further reading:
http://boneandjoint.org.uk/highwire/filestream/39970/field_highwire_article_pdf/0/423.full-text.pdf

http://www.ncbi.nlm.nih.gov/pubmed/23823048