Conservative Treatment of a Complex Humeral Shaft and Head Fracture
1Department of Orthopedic and Trauma Surgery, University Hospital Halle, Halle/Saale, Germany
2Center of Orthopedic and Trauma Surgery, Park-Clinic Leipzig, Leipzig, Germany
Acknowledgement: The authors would like to thank the Federal Statistical Office in Wiesbaden, Germany, for creating the custom diagnosis-related group (DRG) report, which was used in the data analysis of humeral fractures for this report. DGR represents a classification system for medical data (eg, primary and secondary diagnoses, procedure codes, demographic variables) regarding hospitalized patients. The Federal Statistical Office maintains general statistical information (http://www.destatis.de) and health data (http://www.gbe-bund.de) for patients in Germany.
Abstract: Complex humeral fractures often present a challenge, especially with regard to deciding between surgical intervention and a conservative approach to treatment. Making the best decision requires careful consideration of a variety of factors, including the extent of the injury, associated level of osseous destruction, and the patient’s physiologic reserves and resources, the latter of which takes into account the patient’s comorbidities, lifestyle, and level of demand with regard to joint function. In today’s society, people are staying increasingly active into old age; thus, more patients may desire surgical intervention when they sustain a complex fracture. In the case of patients with multimorbidity, however, surgery may not be the best strategy. Although the outcome after surgical treatment has shown excellent results, conservative treatment is a valid treatment option that has also shown good clinical and radiographic results. The authors report the case of a highly active, multimorbid patient who sustained a multifragmentary humeral shaft and humeral head fracture that was successfully treated using a conservative approach, thereby adding an additional case to the literature supporting the use of conservative treatment when a surgical approach poses too many risks.
Key words: Humeral head fracture, humeral shaft fracture, subcapital humerus fracture, conservative treatment, conservative fracture management.
As patients age, their propensity to sustain fractures, particularly more complex multifragmentary fractures, increases. A study assessing the epidemiology of fractures found that 75% of patients with proximal humeral fractures were aged 60 years or older, with 70% of these fractures being complex with multiple fragments.1 Most fractures were sustained following falls on level ground, with more elderly persons falling at home and more younger people falling in public areas.1 As this and other studies show, fractures can and often do occur after a seemingly trivial fall.1,2
A variety of factors can predispose patients to sustaining fractures. In the elderly, these factors include osteoporosis, low calcium intake, low physical activity levels, and lack of coordination, all of which contribute to a fracture risk that is five times higher than that found in younger people.3,4 Osteoporosis, which is considerably more prevalent in female patients, is one of the greatest risk factors for fractures; thus, it is not surprising that fractures occur three times more often in women than in men.1,3 Subsequently, appropriate management of osteoporosis is essential, as this can prevent bone loss and reduce fracture rates.5,6 Historically, calcium in combination with vitamin D supplementation has been recommended in people 50 years of age and older to prevent or help manage osteoporosis, with an oral vitamin D dosage of 700 IU to 800 IU daily reported to reduce the risk of hip and nonvertebral fractures7,8; however, these recommendations have recently changed. In February 2013, the US Preventive Services Task Force (USPSTF) issued a statement concluding that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with more than 400 IU of vitamin D3 and more than 1000 mg of calcium for the primary prevention of fractures in younger men and women (premenopausal) and in noninstitutionalized postmenopausal women.9 Based on its review of the currently available data, the USPSTF has recommended against daily use of these supplements for the primary prevention of fractures in noninstitutionalized postmenopausal women. In addition, the statement warned that even if used at lower doses, vitamin D and calcium supplements might increase the risk of kidney stones in older women; however, the USPSTF suggests that vitamin D supplementation can be used to mitigate falls risk in community-dwelling adults aged 65 years or older who are at increased risk for falls. Therefore, physicians need to use their best judgment when prescribing calcium and vitamin D supplements to their older patients. In addition, weight-bearing exercises, fall prevention, and bone-friendly medications remain essential components of an osteoporosis management plan and should be used.
When humeral head fractures occur, conservative or operative treatment can be undertaken. Proximal humerus fractures with minimal dislocation can be treated conservatively.10 Several reports indicate that approximately 60% to 80% of proximal humerus fractures and humeral head fractures can be successfully treated without surgery,11,12 but surgery is generally recommended when the fragment has migrated more than 1 cm, if angulation exceeds 45 degrees, and in cases of multifragmentary fractures.13,14 However, preexisting comorbidities and poor general health can contraindicate an operative approach. In this article, we report the case of an active older man whose multifragmentary humeral shaft and humeral head fracture was successfully treated using a conservative approach, and provide a quick overview of the currently available literature on this topic. Our experience and review of the literature show that surgery is not always necessary to obtain a good result following a complex injury.
A 69-year-old retired but active man presented to our clinic after falling approximately 10 feet from a ladder onto his right shoulder while gardening. He reported severe immobilizing pain and could not move his right arm. Using a 10-point visual analog scale (VAS), he rated his pain as a 9, indicating unbearable pain. Physical examination revealed soft tissue swelling, a large hematoma, crepitation of bone fragments, and abnormal mobility of his shoulder despite no skin defects or vascular or nerve injuries.
The patient’s medical history was significant for tachyarrhythmia, arterial hypertension, coronary artery disease, aortic valve insufficiency in the setting of New York Heart Association functional class IV heart failure, diabetes mellitus, hyperlipidemia, and stage 3 chronic kidney disease. In addition to a complex medication regimen to manage these conditions, he was taking phenprocoumon following a venous thromboembolism sustained 8 months before presenting to our clinic.
Plain radiographs (Figure 1) and computed tomography scans (Figure 2) of the patient’s right shoulder showed a multifragmentary displaced spiral fracture of the humeral shaft with a fracture gap of more than 8 mm; this finding classified the fracture as 12-C3 using the AO Classification System for proximal humeral fractures. A humeral head fracture with fragment dislocation of more than 8 mm and a subcapital humerus fracture were also observed, leading to a fracture classification of 11-C3.3 using the AO system and a 4-part fracture using the Neer Classification System.
Figure 1. Initial plain radiographs of the right shoulder. Both the anterior-posterior view (A) and the axial view (B) show a multifragmentary displaced spiral fracture of the humerus shaft, a subcapital humerus fracture, and a dislocated humeral head fracture.
Figure 2. Initial computed tomography of the right shoulder (coronary view) showing a complex humeral shaft and head fracture with a fracture gap of more than 8 mm and damage of the articular surface.
In addition to having a complex fracture pattern and poor general health, the patient displayed symptoms of shock, including significant anemia, worsening renal insufficiency, and a state of health conducive to the development of sepsis. Using the American Society of Anesthesiology (ASA) classification system, the patient was given an ASA IV status, indicating that surgery conferred a high risk of mortality. He was subsequently admitted to the intensive care unit (ICU), and we decided to follow a conservative treatment plan.
During his 5-day stay in the ICU, adequate analgesia was achieved by using interscalene brachial plexus anesthesia, and his shoulder was immobilized using a special cast that provided constant traction of 1 kg to the longitudinal axis of the upper arm. In addition, cryotherapy and lymphatic drainage were performed. The shoulder remained immobilized for a total of 3 weeks. Thereafter, the patient was discharged to his home and underwent outpatient passive motion therapy starting with pendulum exercises. After 4 weeks of this therapy, he advanced to guided movements that required up to 60 degrees of flexion and abduction, and to all levels of active assisted range of motion exercises. Moreover, he continued with his water-based kinesitherapy program, which had started after immobilization with the cast. Rotation movements were not allowed until 6 weeks after the accident.
Seven weeks after the accident, intensive active physical therapy was initiated with free range of motion exercises and weight-bearing exercises that used increasing loads; however, a load of more than 45 lb was not permitted until 12 weeks after the accident. As the treatment plan was being carried out, the patient’s injury was monitored via radiography at 3, 4, and 6 weeks post-injury.
Seven weeks after the initial physiotherapeutic treatment, there was no soft tissue swelling, immobilizing pain, or crepitation, and he rated his pain on the VAS as a 1 of 10. He also had good passive and active shoulder joint mobility (Figure 3). The active range of motion of his right glenohumeral joint was 150/0/20 degrees in horizontal abduction and adduction. The active forward flexion and backward flexion was 160/0/30 degrees. Six months after starting conservative therapy, radiological examinations showed complete bony fusion; there was no malunion, nonunion, or any further dislocation of the fragments (Figure 4). There was no neurovascular injury and the patient was symptom-free, with no pain while resting or during normal activity. Subsequently, he was able to return to living independently.
Figure 3. Plain radiographs of the right shoulder 6 months after conservative treatment. The anterior-posterior view (A) shows complete bony fusion with unchanged impaction of the stem. The axial view (B) also shows complete bony fusion and no malunion or nonunion.
Figure 4. Photographs showing the patient’s joint function 6 months after conservative treatment. Side (A) and abduction (B) positions are shown.
Conservative estimates have suggested that proximal humerus fractures account for 4% to 5% of all fractures, but the prevalence is expected to increase as the population base continues to age.11,15 Currently, approximately 70% of humeral head fractures occur in patients older than 60 years.11 In 2010, there were 61,583 patients with humeral head fractures receiving inpatient treatment in Germany, with 4770 (7.6%) of these patients aged 60 to 65 years and 9031 (14.6%) aged 70 to 75 years (this group had the greatest frequency of humeral head fractures).16 Humeral shaft lesions were present in 879 patients (1.4%). The adults aged 70 years and older tended to have diagnoses beyond that of a humeral fracture, with chronic kidney disease, osteoporosis, and coronary artery disease and other cardiovascular conditions being common. In addition, many patients were on anticoagulation regimens.
Because the majority of humeral fractures occur in older adults, deciding which therapies are most appropriate is always challenging, particularly as the number of comorbidities and medications being used increases. In addition, complex and dislocated fractures with multiple fragments pose a particular challenge in this patient population and further necessitate an individualized approach to treatment, which can be surgical or conservative.
Surgical treatment is invasive and can involve any number of approaches, including percutaneous K-wire fixation, plate fixation, intramedullary fixation, percutaneous external fixation, or total shoulder joint replacement.2 In contrast, conservative treatment entails repositioning and immobilization, followed by pendulum exercises of the shoulder joint and early functional therapy. In the elderly patient, bone quality is an essential factor in deciding which treatment route to take.17 In the case of complex fractures, there is no clear advantage to operative versus conservative management.18-23 Factors that favor a conservative approach include decreased bone strength, reduced bone mineral density, osteoporosis, pre-existing degenerative shoulder arthrosis, rotator cuff degeneration, and multimorbidity; however,it is also essential to think about the feasibility of immobilization and early functional therapy.2 Furthermore, it is important to consider that humeral fractures are especially problematic in elderly persons because they often limit their ability to maintain their own household, causing them to give up their independence. In addition, these upper extremity injuries impede their ability to walk and increase their fear of falling, causing them to become significantly restricted.24 As a result, it is assumed that outpatient physical therapy is difficult to perform, inadequate, and negatively affects treatment results; thus, in many cases, only a stable and modestly dislocated fracture is treated conservatively. As our case shows, however, this strategy can be successful even in patients with complex fractures.
The data and literature to guide evidence-based decision-making with regard to treating humeral fractures in elderly persons with multimorbidity are lacking.21 What follows is a brief overview of the available literature regarding surgical versus conservative management for proximal humerus fractures, with some of the described fractures being complex and involving older adults.
Surgery Versus Conservative Treatment: Examining the Literature
There are a few situations in which surgery is generally warranted. Surgery is necessary and recommended when there is a secondary dislocation.2,14 It should also be performed when a fragment has migrated 1 cm or more or if there is a tilt of more than 45 degrees.10,13,14 Moreover, emergency surgical intervention is essential when there is a vascular or nerve injury.14
Surgery has the advantage of providing an early functional therapy, enabling patients to return to their normal lives and resume their daily activities earlier25; however, this approach is associated with many potential complications, including hematomas, loss of ability to reposition; an implant breaking or loosening; perforation; infection; malunion (ie, fracture has healed in a suboptimal position) or nonunion (ie, fracture is unable to heal); adhesive capsulitis (ie, shoulder stiffness and pain caused by tightening of the joint capsule); iatrogenic neurovascular injury; osteonecrosis of the humeral head; and shoulder impingement syndrome (ie, impingement of tendons or bursa in the shoulder from the bones of the shoulder).2,10,26
Although conservative treatment is not invasive, there is still the potential for complications. Nonunion is of particular concern27,28; therefore, regular radiographic examinations are needed when using this approach. Despite a surgical approach being more common for complex humeral factures, numerous reports have described successful conservative treatment of these fractures.27-33
A prospective study by Young and Wallace27 examining injuries of the upper end of the humerus found that 68 of 72 patients (94%) receiving conservative treatment for minimally displaced fractures (n=32) or for two- or three-part fractures according to the Neer Classification (n=32) had good or satisfactory results 6 months after treatment. Of note, many of these patients were elderly. A study by Klestil and colleagues,28 which had a longer follow-up period of 18 months, clinically and radiographically evaluated healing of 63 traumatic humeral shaft fractures that were treated surgically (n=27) or conservatively (n=36). Analysis of the data suggested that conservative treatment of humeral shaft fractures is superior to surgery with regard to mobility of the shoulder and elbow, strength, incidence of neurological complications, pain, subjective rating, and cosmesis.28
A study by Dallek and colleagues29 assessed 79 patients with humeral shaft fractures treated using a hanging cast. Of these patients, 12 (15%) required surgery after 8 weeks because of nonunion, 62 (78%) demonstrated very good results with the hanging cast treatment at 1 and 5 years after the injury, and 5 (7%) had poor long-term results following the hanging cast treatment.29 Lill and colleagues30 assessed the results of conservative treatment of 52 patients (median age, 72 years) with proximal humeral fractures and found that this approach yielded good results in individuals with two- or three-part fractures and poor results in those with 4-part fractures. In those experiencing poor results, the most common problems were persistent painful impairment in range of motion and loss of strength. Based on their findings, the authors state that conservative treatment is a reasonable option for 2- or 3-part fractures, but that 4-part fractures are best managed surgically.30
Hanson and colleagues31 studied the outcome of conservative treatment of proximal humeral fractures in 124 of 160 patients who completed 1-year follow-up. A variety of fracture types were included in this study, from one- to four-part fractures to head-splitting fractures. The overall data showed good functional results using conservative treatment; however, like with other studies, clinical and radiographic findings showed poorer results for four-part fractures.31 In contrast, a study by Yüksel and colleagues32 showed satisfactory results using conservative treatment for both three- and four-part fractures, including in persons aged 65 years and older.
Finally, a systematic review of the literature performed by Iyengar and colleagues33 identified 12 studies assessing the long-term outcome of conservative treatment of proximal humerus fractures, including one- to four-part fractures. Cumulatively, these studies had a mean follow-up of 45.7 months (range, 12-120 months) and included 650 patients with a mean age of 65 years (range, 51-75 years). The rate of radiographic union was 98% and the complication rate was 13%, with varus malunion being the most common complication and avascular necrosis being the least common complication. Of the studies that reported patients’ range of motion (n=5), there was an average of 139 degrees of forward flexion, 48 degrees of external rotation, and 52 degrees of internal rotation. Based on these findings, the authors conclude that nonoperative treatment of proximal humeral fractures provides good joint function, shows a high rate of radiographic healing, and has only a modest complication rate.
Putting the Findings in Perspective
Although the literature shows that not all cases of complex and displaced humeral fractures have been treated successfully using a conservative approach, it also shows that surgery is not always superior. Our case report adds to the body of literature that shows that good outcomes are possible when treating complex fractures conservatively. Although our patient’s complex fracture pattern favored an operative approach, the conservative approach we took led to an excellent clinical outcome at the patient’s 6-month follow-up; there was no malunion or nonunion, the latter of which is of particular concern when treating a patient conservatively. In addition, the patient experienced no pain and was able to return to his normal activities of daily living. Koithan and Oestern2 define a good outcome following proximal humerus fracture treatment as a healed fracture without subsequent pain and an ability to return to normal, age-adapted activities of daily life, regardless of which treatment was provided. Our patient’s outcome clearly fits this definition.
Multifragmented and displaced humeral fractures in the elderly require an individualized treatment approach that optimizes safety and the possibility for good results. Because of our patient’s numerous comorbidities and poor overall clinical picture, the risks of an operative approach outweighed the potential benefits. As our case shows, although a treatment approach may seem clear when considering the fracture alone, once a patient’s state of health and comorbidities are factored into the equation, that approach may no longer be viable. In the case of patients with a complex clinical picture, as is commonly encountered when the patient is elderly, the risks of surgery, the possible complications, and the achievable clinical outcome have to be carefully considered to choose the best treatment strategy.
When proceeding with a conservative approach, it is imperative to closely monitor patients clinically and radiographically for complications during and after their treatment and adjust the approach accordingly. Only by performing such monitoring can a patient’s functional outcome be assessed correctly. Regardless of the treatment chosen, the goal should be to reestablish satisfactory shoulder function. If this is not achieved with a conservative approach, surgery can be considered in some cases. For example, when there is progressive degeneration or humeral head necrosis, provided the risks of surgery do not outweigh the potential benefits. Patients with good physiologic reserves are ideal candidates for surgery.
Deciding on an optimal treatment approach for complex humeral fractures is often challenging, especially when the patient is elderly and has a complex clinical picture. Although surgery is generally recommended as the preferred strategy in the setting of complex fractures, particularly 4-part fractures per the Neer classification, a patient’s comorbidities and overall clinical picture need to be considered. When these factors are taken into consideration, surgery may not be ideal. However, as our case shows, a conservative approach does not mean the results will necessarily be suboptimal. Despite our patient having a complex and displaced humeral fracture, the conservative approach we used yielded good results and enabled the patient to return to living independently and without pain.
As the population continues to age, falls and fractures are likely to become more prevalent. Instead of simply managing more complex fractures in an increasingly complex patient population, which will be extremely challenging, it behooves us as healthcare providers to help patients prevent such injuries from occurring in the first place. We can achieve this by preventing and managing osteoporosis in our patients, educating them on preventive strategies (eg, use of proper footwear and assistive devices), and encouraging physical activity, particularly strength training and balance exercises.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Sven Freche, MD, Department of Orthopedic and Trauma Surgery, University Hospital Halle, Halle/Saale, Germany; email@example.com