CORR Insights^®: Deltoid-split or Deltopectoral Approaches for the Treatment of Displaced Proximal Humeral Fractures?

Where Are We Now?

The number of proximal humeral fractures is increasing steadily along with the incidence of osteoporosis, and these fractures now represent the third most common fracture in the elderly [3]. Although 80% of these fractures can be adequately managed nonoperatively, displaced fractures require some type of reduction and fixation [5]. Surgical management is challenging due to both biologic and biomechanical factors. Several tendons attach to the proximal humerus, and their unopposed pull on individual fracture fragments leads to displacement that often defies closed management. The proximal humerus has a rich but vulnerable blood supply, which must be carefully protected during open reduction. Avascular necrosis of the humeral head represents a complication due to vascular damage either from the fracture itself or surgery to fix it. Osteoporosis often limits the success of devices to gain fixation in the proximal fragment in this region. Although there are a myriad of fixation devices available, recent studies have demonstrated good results with locking plates [1, 7, 9, 14], locking rods [17], various percutaneous pin techniques [10, 12], and even suture fixation [6]. The variety of hardware options and techniques suggests there is no single best approach for many proximal humerus fractures, and that we still have much to learn about how to manage patients with these injuries.

Where Do We Need To Go?

This article by Mohr and colleagues compares two approaches for the placement of a polyaxial locking plate for fixation of proximal humeral fractures. This single-center prospective study on 120 patients compared a standard deltopectoral approach to a “less invasive” deltoid-splitting approach. Although the variety of complications differed in the two groups, there was no difference with respect to total complication rate. Outcomes including pain, ROM, and function were also comparable in both groups, indicating that either approach is a viable option in the management of proximal humeral fractures. The authors found that the adequacy of reduction prior to fixation does affect the outcome significantly and may be more difficult through the limited deltoid split approach. Interestingly, there were no axillary nerve injuries with this approach.

Studies such as this, which pose a well-defined and limited question regarding one aspect of the management of proximal humeral fractures, are extremely helpful in advancing our knowledge and understanding in this area. Although this study answers the single question regarding approach options with this hardware, the authors gleaned information about other factors involved in the ultimate outcome of these patients, namely the ability to obtain an acceptable reduction in a stable configuration. Studies evaluating a certain orthopaedic device often focus more on the mechanical features of the device, and fail to emphasize the major principles of management of the fracture itself. Successful management of proximal humeral fractures requires a careful exposure that does not devascularize the proximal humerus. Successful management should also stabilize the reduction of the fracture, and apply a fixation device that adequately neutralizes all deforming forces.

The investigators did not bone graft the fracture site as recommended by other authors. Loosening of the implant requiring revision occurred nearly 10% of the time. Despite the fact that this number is lower than previous reports, it remains unacceptably high.

How Do We Get There?

There are a variety of methods to successfully manage proximal humeral fractures from a standpoint of fixation devices. Current challenges in the management of these fractures continue to include the incidence of humeral head avascular necrosis and management of medical calcar comminution which often leads to the complication of varus collapse. Because the results of humeral head replacement for proximal humeral fractures have been so unpredictable, it is critical that the results of osteosynthesis for these fractures be improved. Previous reports of locking plates used for proximal humeral fractures cite overall complications rates between 10% and 34% [2, 7, 8, 13, 15, 16]. Research initiatives must focus on lowering these complication rates. There are nuances with every orthopaedic device available. It is incumbent on researchers to develop not only adequate hardware, but to work out the technical factors associated with the entire procedure to create a reproducibly successful operation.

This study addressed one step of the technique necessary for polyaxial plate application. Observations by the authors touched on many other factors involved in the success of the surgery. Other technical aspects regarding the use of polyaxial plates include safe reduction technique, plate and screw configuration, optimal use of bone graft, biceps management, and rotator cuff issues. Similar unique technical issues exist with the use of locking rods, which face multiple technical challenges including the ability to adequately obtain a closed reduction, adequate rod placement to avoid impingement and significant rotator cuff damage, and dealing with the distracting forces of gravity on the humeral shaft. Multiple innovations have been recommended recently on the use of percutaneous pins, including external cages and cannulated screw placement over pins [4, 11, 12]. Each of these areas represents an opportunity for focused research to help optimize treatment of these complex fractures. Prospective studies of limited scope such as that of Mohr and colleagues are beneficial to the orthopaedic community to achieve these goals.