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Proximal Humerus Fracture with Metaphyseal Extension: Treatment and Outcomes
Mithun Neral, MD1; Xavier Simcock, MD2; Blaine Bafus, MD1; Harry Hoyen, MD3
1Case Western University Hospitals, Cleveland, OH, 2Cleveland Clinic Foundation, Cleveland, OH, 3Metro Health Medical Center, Cleveland, OH
Intro: The traditional classification of proximal humerus fractures is based on anatomical parts, however the extension to the proximal metaphysis was not included in this classification. In order to provide stable fixation of the humeral head, the medial calcar provides critical stability during fracture reduction. We hypothesize that a proximal humerus fracture with metaphyseal extension may result in different treatment considerations and outcomes than other proximal humerus fractures. The purpose of this study is to analyze our experience managing proximal humerus fractures with metaphyseal extension.
Materials and Methods: A retrospective chart review was performed of consecutive patients over a 5-year period (2010-2014) who underwent surgical treatment for proximal humerus fracture with metaphyseal extension. Patient demographic information including age, co-morbidities, hand dominance, and mechanism of injury were collected. All proximal humerus fractures with fracture extension at least 1cm distal to the humeral surgical neck were included in the study. Radiographs and operative reports were reviewed to determine fracture classification, fixation details, and time to healing. Clinic notes were used to determine final functional outcomes and complications.
Results: 47 patients with unilateral proximal humerus fractures with metaphyseal extension that underwent surgical treatment were included in the study. Mean patient age was 54±16 years old (range 18-86). 43 patients underwent primary open reduction internal fixation (ORIF) with a proximal humerus locking plate, 3 patients underwent delayed ORIF with a proximal humerus locking plate after failed non-operative management, and 1 patient underwent hemiarthroplasty with proximal humeral shaft plating. Utilizing an extended locking construct, the metaphyseal fracture extension was incorporated into the plate fixation in 44 of the 47 patients (94%). Two patients with extensive medial calcar comminution didn’t have fixation of the metaphyseal extension and 1 patient underwent hemiarthroplasty. Mean final shoulder range of motion was 121° in forward flexion, 106° in abduction, and 42° in external rotation. The mean time to healing was 2.7 months with all but one fracture healed by 4 months. 8 patients (17%) had complications including infection, AVN, and intraarticular screw penetration.
Conclusion: Previously, fractures of the proximal humerus with metaphyseal extension have not been critically analyzed. In our experience, ORIF using proximal humeral locked plating with incorporation of the metaphyseal extension is an effective treatment strategy. Although the medial calcar is a critical structure for proximal humerus stability, in the majority of fracture settings, this can be incorporated into an elongated locking construct without the need for hemiarthroplasty.
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