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Surgeons Advice on Shoulder Fractures When Evidence is Lacking

Posted on: 12/20/2010
Medicine has taken a decided turn toward demanding evidence that a treatment technique or approach is the right one to choose for each problem. Evidence-based medicine also addresses the specific needs of each patient who happen to have that problem. But what should be done when there isn't enough evidence to know which way to go? And when there is more than one way to go?

That's the dilemma facing surgeons treating patients with complex shoulder fractures -- ones that break the bones into three or four pieces. The question is: which works better -- open reduction and internal fixation (ORIF) or shoulder replacement? And if a shoulder replacement is needed, should that be a hemiarthroplasty, a total joint replacement, or a reverse arthroplasty?

A hemiarthroplasty means only one part of the joint is replaced (either the round ball in the socket or the socket). And a reverse arthroplasty describes an implant with a ball-shaped head where the socket used to be and an artificial socket where the round head of the humerus (upper arm bone) was once located.

When selecting the right shoulder implant to use, the decision-making goes even one step further. In each of the replacement categories, there are many different designs (styles, materials) of implants to choose from. The same goes for hardware used in the ORIF. The surgeon must decide whether to use locking and nonlocking plates, pegs vs. screws, and rotator cuff sutures vs. no sutures.

Regardless of the treatment approach enlisted, there are many factors to consider such as patient age, health, blood supply to the shoulder, bone health, and joint mechanics. That's why there haven't been enough studies comparing each type of implant with patient characteristics and outcomes to guide the surgeon.

The authors of this study use the three-part shoulder fracture of an active 55-year-
old man to walk us through the decision of ORIF vs. arthroplasty. There was a three-part fracture of the upper humerus. The neck of the humerus was also displaced (the fracture separated and shifted apart). Fortunately, there was good bone quality and good blood supply. No nerve damage occurred as a result of the displacement of bone (jagged edges can sometimes cut into nearby tissues).

Open-reduction and internal fixation (ORIF) is preferred for younger, active, healthy patients. But the surgeon must be able to reduce the fracture (put it back together and hold it there). If the gap between the pieces of bone is too much for the body to fill in on its own, bone grafting may be used. Otherwise, it may be necessary to go to Plan B (replace instead of repair).

Anyone under the age of 60 should at least be considered for ORIF as part of Plan A (repair as the first line of treatment). Older adults (especially over age 80) and anyone with a degenerated or previously torn rotator cuff may be a better candidate for a reverse arthroplasty. Age isn't the only cut-off used when choosing between ORIF and arthroplasty. As mentioned, there are many potential patient factors that must be taken into consideration.

As it turned out for this patient, he had an ORIF with very good results. Two years later, he was back to work and play at full speed. There were no complications from loss of blood supply. Motion was slightly limited because of heterotopic-ossification (bone develops in the nearby muscles).

The authors concluded that evidence-based surgical treatment guidelines for three and four-part shoulder fractures is decidely limited (downright lacking)! It looks like open-reduction and internal fixation (ORIF) can be used most of the time. Anyone with more complex fractures, significant osteoporosis, and other shoulder (or health) problems may be a better candidate for a shoulder replacement instead.

References:
Kevin W. Farmer, MD, and Thomas W. Wright, MD. Three- and Four-Part Proximal Humerus Fractures: Open Reduction and Internal Fixation Versus Arthroplasty. In The Journal of Hand Surgery. November 2010. Vol. 35A. No. 11. Pp. 1881-1884.

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