by Elizabeth Hofheinz, M.P.H., M.Ed.
When proximal humerus fractures don’t respond to nonoperative management, what happens to those patients who go on to have a nonunion with the accompanying pain and impairment in functioning?
A team from the Icahn School of Medicine at Mount Sinai in New York City recently delved into this question with their work, “Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review,” appears in the September 2020 edition of the Journal of Orthopaedic Trauma. 
Co-author Paul J. Cagle, M.D. is Assistant Professor of Shoulder and Elbow Surgery at the Icahn School of Medicine at Mount Sinai in New York, and told OSN, “As a shoulder surgeon, taking care of patients with shoulder fractures is one of my primary concerns, and in some cases, it means taking care of patients who had a fracture that did not heal. To ensure we are providing the highest level of care, we conducted a systematic review examining all available published data.”
Meticulous selection of studies
Initially examining 1,294 studies, the team selected 61 to proceed to full-text review, with 37 ultimately meeting the inclusion criteria (508 patients). Excluded studies were: case reports (n = 2), abstract only (n = 2), review article (n = 3), and failure to stratify outcomes by sequelae type (n = 12), nonunion site (n = 2), and treatment modality (n = 3).
The researchers looked at: (1) ORIF stratified by fixation construct (locked plate, nonlocked plate, T-plate, and intramedullary nail); n=246, (2) hemiarthroplasty (HA) or total shoulder arthroplasty; n=137 (TSA), and (3) reverse TSA (RTSA); n=125.
“Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty,” wrote the authors. “Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123–1448; external rotation: 42–468; Constant score: 75–84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.48 vs. 97.28) but less external rotation (16.58 vs. 36.88) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively.”
Dr. Cagle told OSN: “A careful review of the literature demonstrated that treatment of proximal humerus fractures with an open reduction and internal fixation or a reverse shoulder arthroplasty provided good results. A closer look at the groups demonstrated that patients who underwent a reverse shoulder replacement tended to be older. We were excited and surprised to see the union (healing) rate of fractures in the open reduction and internal fixation was 97%.”
“I believe this provides a concise summary of the available literature demonstrating that proximal fractures can be safely and reliably treated with either open reduction and internal fixation or a reverse total shoulder arthroplasty.”