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Current Techniques and Controversies in Proximal Humerus Fractures

Gardner, Michael J. MD

doi: 10.1097/BTO.0000000000000033

Department of Orthopaedic Surgery, Washington University, St. Louis, MO

Author is a consultant for Synthes, Stryker, DGIMed Ortho, and RTI Biologics, and receives research support from Synthes.

Address correspondence and reprint requests to Michael J. Gardner, MD, Washington University Orthopedics, St. Louis, MO 63110. E-mail:

Proximal humerus fractures continue to be a difficult problem for orthopedic surgeons. As the population ages, these fractures are becoming increasingly common. Although the majority of fractures are stable and would not benefit from surgery, the precise operative indications remain unclear. If surgery is indicated, the next difficult decision is what procedure to perform. The main decision tree branch point is internal fixation versus arthroplasty.

Operative fixation comes in many forms. The introduction of locked plating about a decade ago seemed to be a great solution, as the short-end segment with associated osteoporosis appeared to be the exact situation that locked plating was designed to address. We learned quickly that locked plating does not overcome poor surgery and inadequate reductions, and early series reported strikingly high failure rates. With improved understanding of failure mechanisms and the biology of the proximal humerus, newer techniques have been devised to improve fixation and minimize failures, and early reports are promising. For these reasons, the pendulum has continued to favor operative fixation with head salvage for the majority of unstable fractures. As far as arthroplasty, the recent popularity of reverse shoulder arthroplasty has presented another option for acute fracture treatment. Regardless of the operative treatment chosen, these procedures are among the most technically demanding fractures to treat, with little room for error.

This edition of TIO features some of the world’s experts in proximal humerus fracture treatment. These authors have devoted their careers to studying the natural history of these fractures and pioneering new techniques and surgical approaches to maximize patient outcomes. In this issue, you will find articles involving percutaneous techniques, using both pins and plates. Novel open surgical approaches are discussed, as well as augmentation with both cement and structural constructs, such as fibular allografts. Intramedullary nailing, arthroplasty, and proximal humeral nonunion treatment are also specifically addressed.

I hope you enjoy this issue, and find these cutting edge techniques useful for your practice.

Michael J. Gardner, MD

Washington University, St. Louis, MO

© 2013 by Lippincott Williams & Wilkins