[Proximal humerus fractures]

[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.

[Indication for primary fracture prosthesis of the shoulder]

Although fractures of the proximal humerus are one of the most common osteoporotic fracture types, no generally accepted treatment algorithm exists in the current literature. For young patients with high functional demands and good rehabilitation potential, we recommend humeral head salvage therapy. If symptomatic humeral head necrosis occurs, the implantation of an anatomic endoprothesis is possible on a secondary basis. For patients with a biological age > 70 years suffering from a persisting defect of the rotator cuff along with a humeral head fracture or from a multiple fragment fracture of the humeral head, we increasingly prefer implantation of a reverse shoulder prosthesis due to good clinical results. However, because of technical aspects and a high complication rate, treatment using the reverse fracture prosthesis should be reserved for surgeons with expertise in this particular field. After analyzing the fracture- and patient-specific risk factors and performance expectations, the trauma surgeon can select the best individual therapy with the patient.