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Derek S. Shia, MD
Proximal humerus fractures are a very common injury that occurs in all populations but is certainly more prevalent in the patient population over the age of 65. It is the third most common fragility fracture after distal radius and hip fractures. The majority of proximal humerus fractures can be treated non-operatively, however there are some fractures that can benefit from operative intervention. The extent of operative intervention can include percutaneous pinning, open reduction internal fixation, and joint replacement depending on various fracture and patient characteristics.
The proximal humeral anatomy consists of four main anatomic structures that are important in understanding xrays when you are interpreting the fracture configuration as well as how a given fracture will be treated.
The four parts include the humeral head, greater tuberosity, lesser tuberosity and humeral shaft. Fractures are classified according to which structures are fractured. The Neer classification is commonly used to describe these fractures and can be categorized into 2-part, 3-part, and 4-part fractures with further differentiation into head splitting fractures and fracture dislocations. The importance of this classification allows the selection of the optimum treatment and the ability to predict complications including fracture collapse, avascular necrosis and healing.
The vast majority of proximal humerus fractures can be successfully treated non-operatively particularly in older patients. The deformity can be well tolerated and the loss of function typically occurs with overhead activities. Most activities of daily living occur at waist level and therefor may be largely unaffected. There are a subset of fracture in younger patients and ones that have significant displacement that may be more amenable to surgery.
The need for the diagnosis and treatment of osteoporosis is an important facet of complete musculoskeletal health. Testing for osteoporosis is important but particularly in females over the age of 65 and vitally important in patients that have sustained a fragility fracture. A fragility fracture includes a fracture of the hip, distal radius, humerus or vertebral compression fracture from a low energy injury such as falling from standing height
Testing involves examining the density of various bones in the body and is called a DEXA scan (Dual Emission X-Ray Absorptiometry). This test is usually ordered by your primary care physician and evaluates a patient’s bone density. If you are tested and the bone density is greater than 2.5 standard deviations below normal than a patient is considered osteoporotic.
Treatment for osteoporosis should include the recommended daily doses of calcium and vitamin D but may also involve the need for additional pharmacologic intervention. These medications include bisphosphonates, hormone replacement therapy and calcitonin therapy and can be started in consultation with your primary medical care physician. The goal of these therapies is improve bone density and can reduce the incidence of fragility fracture by as much as 50%.
This step is very important to regaining functional use of the shoulder and arm and is used in conjuction with operative and non-operative intervention. I generally allow immediate elbow and wrist range of motion. Physical therapy in patients who are treated non-operatively is usually initiated within two weeks from the date of injury. Physical therapy will often begin with pendulum exercises and gentle passive range of motion. This slowly progresses to active and active assist range of motion. The length of time that physical therapy is performed, depend on many patient and fracture characteristics, but complete recovery usually takes 3-6 months.
For severely displaced fractures, surgery may be the most reliable way to restore anatomic relationships and allow optimal function of the shoulder. There are a myriad of different techniques for fixing proximal humerus fractures and can vary from percutaneous techniques involving wires to the other extreme involving the total replacement of the shoulder joint. This decision involves many patient factors including the severity of the fracture, age and function of the patient.
Isolated greater tuberosity fractures often occur in younger individuals after a traumatic injury. These fractures need to be closely monitored due to the involvement of the rotator cuff. While many fractures involving the proximal humerus can tolerate displacement, the greater tuberosity, due to the attachment of the rotator cuff, cannot. Displacement more than 5 mm is usually an indication for surgery and often can be accomplished arthroscopically with percutaneous techniques.
Many innovations over the past decade have allowed superior fixation of peri-articular fractures in osteoporotic bone involving the proximal humerus. One of the most important innovations involves the use of locking plate technology. This technology allows the use of a fixed angle construct to help support osteoporotic bone which has a tendency to collapse into a varus deformity. These implants are far superior to older implants that rely on an interference fit between the bone and screw. In patients with osteoporotic bone this interference fit is significantly effected and can lead to early failure of the construct.
Several new techniques have been available over the past few years that can really help patients that have severe fractures. These two techniques include the reverse total shoulder arthroplasty and the use of fibular strut allografts with locking plate technology for patients with severe fractures and osteoporotic bone.
The use of a fibular allograft allows immediate structural augmentation of a patient’s bone stock to allow a more robust and anatomic reconstruction of the proximal humerus. Many patients who have sustained a proximal humerus fracture have osteoporotic bone. When fractures occur in this type of bone even the use of locked plating devises can fail due to the lack of underlying bone support. The use of these allografts provides an immediate structural support and helps to prevent loss of fixation.
This is an example of a four part proximal humerus fracture in a patient with osteoporosis the pre-operative x-ray demonstrates a very typical fracture pattern with the articular surface of the humeral head pointing straight up.
Post-Operative x-rays demonstrate an anatomic reduction with the use of an intra-medullary fibular allograft.
The reverse total shoulder replacement is performed on severe fractures in patients generally over the age of 65. This has shown in several studies to be superior to reconstruction with a hemiarthroplasty particularly in older patients. Hemiarthroplasty has historically demonstrated good results in terms of pain relief but has been somewhat less predictable in terms of improving function. Most historical studies have only shown forward flexion to about 90 degrees. With newer ingrowth surfaces and attention to the repair and reconstruction of the tuberosities, which control rotator cuff function, these results have shown improvement. The importance of these tuberosities to a good functional outcome is critical.
The reverse total shoulder allows a reconstruction that demonstrates superior functional results to hemiarthroplasty with additional excellent relief of pain.
In summary, proximal humerus fractures are very common and can result in significant morbidity. The vast majority of these fractures can be treated non-operatively and patients can expect a return to normal function usually with some residual stiffness. In patients that have more severe fractures there are many available techniques and implants that can allow reconstruction of the shoulder and allow a good return to function without pain.
Reverse Total Shoulder
By Derek S. Shia, M.D.
The reverse total shoulder is a relatively new type of shoulder arthroplasty specifically developed for patients that have a combination of both arthritis and loss of rotator cuff function, also known as rotator cuff arthropathy. Prior to the advent of this prosthesis a good solution was not available for this debilitating shoulder problem. Historically patients with this problem were treated with various non-operative and operative modalities that did not completely address their underlying problem. Often times, treatment was able to achieve some pain relief but did not address the loss of the functional use of the shoulder. The reverse shoulder replacement offers a solution to a problem that prior to its development, was not available. This replacement allows good pain relief but also improves patient’s functionality by allowing restoration of a patient’s ability to raise their arm. Patients may be candidates for this procedure when they have a painful rotator cuff tear that is no longer repairable and have significant loss of shoulder function. The replacement has also been successfully used in severe fractures of the shoulder in older patients, where reconstruction utilizing plates and screws is not possible.
The rotator cuff is vitally important for normal shoulder function and is comprised of four different muscles. The muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles contribute to two major functions in the shoulder, one is compressing the humeral head on the socket, keeping the joint centered, and the second involves controlling shoulder positioning. The rotator cuff controls the forward elevation as well as internal and external rotation of the shoulder. The loss of rotator cuff function results in weakness, pain, development of arthritis and the inability to functionally use the shoulder. When the function of the rotator cuff is severely compromised the patient may develop a pseudoparalysis, which is an inability of a patient to lift their arm up to 90 degrees.
Rotator cuff tears occur in both young and old patients but are increasingly common as patients become older. Younger patients often report a history of a traumatic event but in older patients rotator cuff tears can occur without an inciting traumatic event. Recent studies have demonstrated an increasing prevalence of rotator cuff tears in patients over the age of 55 even in the absence of trauma. Patients frequently notice progressive shoulder pain and weakness. This often effects their sleep and use of the shoulder.
The typical patient presents with a long history of pain as well as a progressive impairment of their shoulder function. Patients are frequently able to perform activities at waist height but find it difficult to impossible to perform many activities above shoulder height.
While the rotator cuff cannot be directly visualized with plain radiographs, secondary changes can be seen. These changes include loss of the normal contour of the greater tuberosity, superior migration of the humeral head, gapping of the glenohumeral joint, and wearing of the acromion from the underlying humeral head.
The image on the left demonstrates a normal shoulder x-ray with the humeral head centered on the glenoid. The image on the right demonstrates superior migration of the humeral head. It has developed arthritis within the glenohumeral joint. In addition, the humeral head can be seen abrading the undersurface of the acromion.
MRI’s of the shoulder frequently demonstrate a massive rotator cuff tear usually involving three or more tendons. MRI’s also commonly demonstrate retraction of the rotator cuff to the level of the socket as well as significant fatty infiltration of the rotator cuff musculature. Fatty infiltration is a common occurrence in chronic rotator cuff tears and is the process where muscle transforms into fat. Unfortunately, this change is not reversible making diagnosis of acute rotator cuff tears that much more important.
Treatment of this condition depends on many factors including a patient’s functional level, functional disability, other medical comorbidities, and expectations. Treatments can include both operative and non-operative modalities. The non-operative modalities include physical therapy, pain management, corticosteroid injections, and activity modification. Operative intervention has historically been treated with a humeral head replacement with an enlarged head. This surgery resulted in satisfactory outcomes from patients in regards to some pain relief but offered little in improvement in overall shoulder function. This has lead to the design and implementation of the reverse total shoulder replacement.
The reverse total shoulder was FDA improved in 2004 in the United States but has been available for use in Europe for over 15 years. It provides both pain relief and improvement of shoulder function for patients that have a complete loss of their rotator cuff function. This loss of rotator cuff function often results in significant pain as well as an inability to raise one’s shoulder over 90 degrees. The reverse prosthesis works by exchanging the position of the ball and socket portions of the shoulder joint. This design improves two important biomechanical properties of the shoulder. The replacement centralizes and distally translates the center of rotation of the shoulder thereby improving the power that the deltoid muscle can provide and allowing patients to lift their arms again.
The image on the left demonstrates a reverse shoulder replacement, while the image on the right demonstrates an anatomic shoulder replacement.
The reverse total shoulder procedure requires surgery at the hospital and typically involves a two day hospitalization. The procedure typically takes two hours to complete and has a low complication rate in primary surgeries. The immediate post-operative regimen includes sling use for the first two weeks followed by night sling use for two weeks. This allows rapid mobilization and allows the patient to achieve early functional recovery.
The reverse shoulder replacement has also been used successfully in older patients with severe humerus fractures. Before the advent of the reverse shoulder replacement patients were treated with a hemi-replacement (only the humeral head is replaced). While good pain relief was achieved in these patient’s, this type of replacement required healing of the rotator cuff to the prosthesis in order for it to function properly. Unfortunately, the healing of the rotator cuff is unpredictable in this scenario and frequently leads to significant functional impairment in older patients. The reverse shoulder prosthesis allows reconstruction of severe fractures while improving the functional outcome of the patients that undergo the procedure. The rotator cuff muscles are repaired in a similar technique as used in the hemi-replacement but unlike the hemi-replacement rotator cuff healing is not necessary to regain ability to perform overhead activities.
The reverse total shoulder is a good option for certain patients with arthritis and underlying rotator cuff tears as well as severe fractures. This design allows for a better functional outcome in comparison to historical treatment options. Short term studies have demonstrated reliable functional recovery as well as reduction in pain. This surgery has provided many patients with difficult problems a good solution, and we await long term studies to further validate these findings.
© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
By Derek S. Shia, M.D.
Rotator cuff tears are one of the most common orthopedic problems and effect more than 17 million persons annually in the United States. The rotator cuff is an essential group of four muscles that control shoulder motion and contribute to the concentric reduction of the glenohumeral joint. Rotator cuff tears have a tremendous effect on a patients’ ability to perform athletic activities such as tennis, golf, and softball but can also affect simple activities of daily living such as sleeping, brushing teeth, and combing hair. Not all rotator cuff tears occur due to a traumatic incident and many patients may be living with a painful shoulder as a result of a rotator cuff tear without knowing it. There are various treatment options available to patients depending on their age, activity level, size of tear and the length of time that the tear has been present.
There are two principle populations that are effected by rotator cuff tears. The first is young patients that have experienced a significant traumatic event that causes the rotator cuff to tear. The event that causes this is usually a high energy injury and patients complain of an immediate change in their ability to use their arm. The second group of patients is an older population that typically cannot recall a traumatic event. These patients often have an insidious onset of shoulder pain and weakness. They complain of an inability to perform activities above shoulder height such as washing their hair or lifting dishes up to high shelves as well as pain reaching behind themselves. Night pain is also very common and patients commonly seek treatment because they have a difficult time sleeping.
While these two groups make up the majority of patients there is certainly an overlap between these patients groups. Patients that need to be closely evaluated include patients over the age of 45 with a shoulder dislocation as well as patients who fall without radiographic evidence of a fracture but with weakness.
The incidence of rotator cuff tears is very strongly correlated with a patients’ age. Several studies have been recently published investigating this relationship. One of these studies utilized ultrasound to determine the prevalence of rotator cuff tears in 237 asymptomatic individuals. They found that age was strongly correlated with the prevalence of a full thickness rotator cuff tear. None of the patients age 40-49 demonstrated rotator cuff tears, patients who were age 50-59 demonstrated a 10% prevalence of a full thickness rotator cuff tear, patients age 60-69 demonstrated a 20% prevalence and patients older than 70 had a 41% prevalence of a full thickness tear. The importance of this study demonstrated the relationship between age and the likelihood of the presence of a full thickness rotator cuff tear in patients with no complaints of shoulder pain or weakness. In a related study 588 patients who had unilateral shoulder pain had the opposite shoulder examined with ultrasound. This study demonstrated a high incidence of rotator cuff tears in older individuals with 50% of patients over the age of 65 demonstrating a full thickness rotator cuff tear in the opposite shoulder that was asymptomatic.
It is important to consider the specific patient in terms of their functional status and also the natural history of untreated rotator cuff tears when contemplating various treatment options. Unfortunately, there is no evidence that rotator cuff tears can spontaneously heal without surgical intervention but depending on the patient and the size of the tear it is possible to make a rotator cuff tear asymptomatic. In a recent study investigating the natural history of non-surgically treated rotator cuff tears that were followed for 5 years, no tears showed any evidence of healing. Of the patients that became symptomatic again after a trial of non-operative management 50% of those patients had an enlargement of the tear. Of the patients that remained asymptomatic over the 5 year period, 20% had an enlargement of their tear. Of the patients whose tear increased, the average increase in size of the tear was 30%.
When considering that rotator cuff tears do not heal without surgical intervention it is important to think about the implications for the patient. When a rotator cuff tear does occur, irreversible changes of the muscle can begin within the first three months after an injury. Without the proper length/tension relationship fatty infiltration will begin in torn rotator cuff muscles. This process results in the replacement of the normal muscle tissue with fat, causing a permanent change in the elastic properties of the muscle tendon unit. This change is irreversible and can affect both a patients’ outcome after surgery and result in a rotator cuff being irreparable at the time of surgery. Various studies have investigated fatty infiltration after a rotator cuff repair and they have found these changes do not reverse even after repair of the tendon.
The physical exam is one of the most important parts of the patient evaluation and is instrumental in obtaining the correct diagnosis. Inspection of the shoulder should include evaluation of any atrophy along the scapular spine which is often indicative of a chronic rotator cuff tear.
Evaluation of a patients shoulder range of motion is vitally important in determining the correct diagnosis. Shoulder motion comes both from the glenohumeral joint which is responsible for 2/3 of the overall motion and the scapulothoracic joint which is responsible for the remaining 1/3 of overall shoulder motion. It is important to separate these two motions to detect pathology in the shoulder joint. Scapular kinematics are often abnormal following rotator cuff injuries and can be seen when evaluating the scapula during shoulder range of motion. The assessment of active and passive range of motion is also critical. Loss of both active and passive range of motion is often indicative of an adhesive capsulitis while loss of only active range of motion is often suggestive of rotator cuff pathology.
While there are a multitude of described tests for evaluation of the rotator cuff I have included some of the most common and helpful ones for detecting rotator cuff pathology.
The empty can test helps to evaluate the supraspinatus, the most commonly involved muscle in rotator cuff pathology.
Test of external rotation strength with the shoulders in internal rotation will help evaluate the infraspinatus.
The lift off test will help evaluate the function of the subscapularis.
The hornblower test will help evaluate the teres minor and is often only positive in massive rotator cuff tears.
Evidence of massive rotator cuff tears include a positive drop arm sign, which is the inability for a patient to hold their shoulder in external rotation, a positive hornblower test, as well as a pseudoparalysis of the shoulder when a patient is unable to actively lift their shoulder to 90 degrees.
Radiographs are an important modality when examining pathology around the shoulder and can suggest rotator cuff pathology. This xray demonstrates chronic rounding of the greater tuberosity often seen in long standing rotator cuff tears. It also demonstrates superior translation of the humeral head relative to the glenoid and gapping of the glenohumeral joint. Other pathology that can be appreciated by radiographs include both arthritis and calcific tendonitis which can sometimes present similarly to a rotator cuff tear.
MRI is an integral modality in the evaluation of a rotator cuff tear and adds important information regarding the extent and treatment of the tear. Choices between open and closed MRI’s are a common discussion with patients and are often driven by patient choice, body habitus and difficulty with claustrophobia. While open MRI’s continue to improve, closed MRI’s utilize a larger magnet and provide a clearer picture of all the involved pathology and improves the ability to make an accurate diagnosis.
An MRI can help determine the size of the tear and which tendons are involved, it can demonstrate the amount of retraction of the tendon and the amount of fatty infiltration. All these factors are important for determining the likelihood that a tear is repairable and whether it will heal.
There are various non-operative treatment options including activity modification, NSAIDS, physical therapy, and corticosteroid injections. The goal of these treatments is to reduce pain, increase range of motion, and improve function. The goals of physical therapy are to strengthen the remaining rotator cuff, improve scapular kinematics that are often abnormal after a rotator cuff tear, and strengthen scapular stabilizers. Physical therapy also works to improve range of motion, and promote functional return to normal activities.
The use of corticosteroid injections for rotator cuff disease is commonly used. The use of corticosteroids has been extensively studied and through multiple studies and meta-analyses have demonstrated limited efficacy in the long term treatment of rotator cuff disease. One benefit that has been shown is an improvement in pain levels in patients in comparison to placebo over the short term.
There are downsides to repeated corticosteroid injections with a theoretical reduction of overall tendon strength. Basic science research have predominated these studies and have even demonstrated increased type III collagen expression after only a single injection. For this reason while a single corticosteroid is often considered, multiple injections should be judiciously utilized. Multiple injections over time are often reserved for patients with limited functional goals and inability to undergo surgical intervention.
Surgical intervention for a repairable tear can be treated arthroscopically in the vast majority of cases. The advantages of an arthroscope versus an open repair includes several things including the ability to fully evaluate and treat any additional intra -articular pathology, preserve the deltoid muscle, and allow full access to the shoulder. Controversy continues to exist regarding the optimal surgical construct for the treatment of rotator cuff tears and whether a single or a double row repair best treats the pathology. A double row repair provides a more anatomic reconstruction of the rotator cuff footprint and may lead to lower rerupture rates in comparison to single row repairs in larger tears. This is currently a hotly debated topic and while basic science studies demonstrate benefits, functional differences have not been demonstrated to be statistically significant between either repair type in clinical studies.
Arthroscopic rotator cuff repair is performed as an outpatient procedure and normally takes between 1- 2 hours depending on the size of the tear and any concomitant pathology that needs to be addressed. The post-operative regimen typically involves a sling for the first 4 weeks. For smaller tears immediate motion is begun and for larger tears there is a period of immobilization. Strengthening is started at 12 weeks with gradual return to normal function. There are very good reported outcomes in the literature following rotator cuff repair with good alleviation of pain and return to functional status.
For certain patients the size and chronicity of their tear may not allow a primary repair. For these patients depending on their age and functional status various treatment options are available. These include tendon transfers including latissiumus dorsi and pectoralis major transfers. These are primarily used in younger patients with painful large chronic tears but with good function. The second treatment option is the reverse total shoulder replacement.
This option is reserved for older patients with a chronic irreparable rotator cuff tear and poor shoulder function. This option through a replacement of the shoulder joint eliminates pain and improves shoulder function.
Several factors have been demonstrated in the literature to negatively affect the functional outcome of patients following rotator cuff repair, these include: smoking, diabetes, patient age, the size of the rotator cuff tear , whether the rotator cuff tear is full thickness or partial thickness, and the degree of fatty infiltration. Some of these factors cannot be controlled but early diagnosis and treatment can avoid some of these pitfalls.
While no treatment algorithm is without exceptions this is a generalized way to think about rotator cuff tears and their treatment. Partial thickness tears have some risk of enlarging but a trial of non-operative management is indicated to see if a patient will do well without surgery. The second class of patients is the young patient who has a full thickness tear or any patient with an acute tear. In this patient population there is more downside to delaying surgery in that the tear will not heal itself, it may enlarge, and that the rotator cuff may undergo irreversible fatty infiltration. In this patient population surgery is indicated. The third category is elderly patients with a chronic rotator cuff tear. This is another population when waiting will have little impact on the patients’ outcome and non-operative treatment should be attempted.
Rotator cuff tears are extremely prevalent and have a significant impact on the patients who have them. A careful physical exam, good imaging and understanding of rotator cuff pathology and its natural history are instrumental in obtaining the correct diagnosis and developing the appropriate treatment course for a patient with a rotator cuff tear. While non-operative treatments are commonly utilized initially there are many minimally invasive treatment options available if surgery is necessary and good to excellent results are common following intervention.
© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author