How Should 4-part Proximal Humerus Fractures Be Managed?

    Dr. Edwin Spencer and Dr. John Sperling debated the merits of 2 treatment options for these fractures at ICJR’s Pan Pacific Orthopaedic Congress. Below are the abstracts of their presentations.

    Orthopaedic surgeons have multiple options for managing proximal humerus fractures, including open reduction internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (TSA).

    The use of reverse TSA to repair proximal humerus fractures is relatively new, born out of the frustration orthopaedic surgeons had with disappointing long-term functional and pain relief results with some of these other options. Studies have shown that reverse TSA can be more reliable than hemiarthroplasty for managing proximal humerus fractures, although it can also have as many, if not more, complications as hemiarthroplasty. [1-4]

    At the International Congress for Joint Reconstruction’s recent Pan Pacific Congress, Edwin E. Spencer, Jr., MD, and John W. Sperling, MD, MBA, debated the use of reverse total shoulder arthroplasty (TSA) versus hemiarthroplasty in managing proximal humerus fractures. Below are the abstracts from their presentations.

    Reverse TSA for Proximal Humeral Fractures
    Edwin E. Spencer Jr., MD, Knoxville Orthopaedic Clinic, Knoxville, Tennessee

    The treatment of proximal humeral fractures has evolved significantly over the past decade. The most popular options include:

    • ORIF with various plate configurations
    • Percutaneous pinning
    • Prosthetic replacement

    The key is to choose the most predictable form of treatment with the fewest potential complications.

    The results of hemiathroplasty for fracture hinge on the healing of the tuberosities. With an approximate 50% rate of tuberosity malunion or non-union when using a hemiarthroplasty, the reverse TSA has become increasing popular.

    The reverse TSA is the most common revision option in a failed hemiarthroplasty for fracture, therefore many decide to use it in the primary situation in case the tuberosities fail to heal. However even with a reverse TSA, greater tuberosity healing yields a much better result with greater function and external rotation strength when compared with those in whom the tuberosities did not heal.

    In my presentation, I will discuss tips and tricks for performing a reverse TSA for fracture to maximize the results.

    Dr. Spencer’s can be found here.

    Hemiarthroplasty for Proximal Humerus Fractures
    John W. Sperling, MD, MBA, Mayo Clinic, Rochester, Minnesota

    While there has been increasing interest in the use of the reverse TSA for the treatment of 4-part proximal humerus fractures, there continues to be a role for hemiarthroplasty in select patients. This includes young active patients with fractures not amenable to fixation. Every effort is made to attempt to fix fractures in young patients to avoid placement of an arthroplasty.

    When hemiarthroplasty is selected, I favor the use of a convertible stem that can also be used with reverse TSA. This can considerably facilitate revision surgery in the future if the patient develops tuberosity resorption or glenoid wear. The stem can be retained in many patients, making the revision to reverse more straightforward without necessitating stem removal.

    For both reverse TSA and hemiarthroplasty, I prefer to use a short stem if possible. This helps manage potential complications, including periprosthetic fractures. In addition, I choose to avoid cement if possible. The stem can frequently become impacted in place with outstanding rotational and height stability.

    If excellent stability cannot be obtained, I use a small amount of cement proximally. Placement of the cement down the entire humeral shaft should be avoided, as it makes subsequent stem removal difficult.

    Secure fixation of the tuberosities is essential in encouraging healing and maximizing patient function. There are multiple published techniques on tuberosity repair. Each highlights the importance of fixation of the tuberosities to the humeral shaft, as well as to each other. Moreover, I have found it valuable to use intraoperative fluoroscopy to confirm that the tuberosities are in the right position at the conclusion of the procedure.

    Flouroscopy also confirms proper height of the humeral head. Over-stuffing the joint should be avoided. The surgeon needs to see 30% to 50% translation of the humeral head in an anterior and posterior direction with the head facing straight across from the glenoid with the arm in the neutral position.

    The security of the repair determines the specific postoperative rehabilitation program. There has been a tendency towards a less-aggressive rehabilitation program to try to encourage tuberosity healing.

    Dr. Sperling’s presentation can be found here.


    • Acevedo DC, Vanbeek C, Lazarus MD, Williams GR, Abboud JA.  Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results. J Shoulder Elbow Surg. 2014 Feb;23(2):279-89. doi: 10.1016/j.jse.2013.10.003.
    • Cuff DJ, Pupello DR.  Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients.  J Bone Joint Surg Am. 2013 Nov 20;95(22):2050-5. doi: 10.2106/JBJS.L.01637.
    • Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE.  Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review.  J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48.
    • Namdari S, Horneff JG, Baldwin K.  Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review.  J Bone Joint Surg Am. 2013 Sep 18;95(18):1701-8.