Proximal Humeral Fractures: Is Some Varus Acceptable? (2016)

Commentary While the overwhelming majority of proximal humeral fractures do well after nonoperative treatment, considerable clinical uncertainty remains, despite numerous techniques and studies, as to the best management of those with more complex fracture patterns. Further, when open reduction and internal fixation (ORIF)1 is elected, debate has raged as to how important anatomical reduction is to the final outcome, given that more aggressive exposure and fracture manipulation may cause soft-tissue damage and threaten bone vascularity. The current study is a welcome contribution to this conversation. This case series evaluated 98 consecutive type-C (OTA/AO classification) fractures treated by locking-plate ORIF at a single center. Surgeons exercised individual judgment as to whether to accept imperfect reduction rather than employ “harsh maneuvers of fracture reduction.” The major finding was that the cases in which anatomical or “acceptable” (close to anatomical) reduction was achieved did better. It has long been recognized that >5 mm of superior malunion of the greater tuberosity can compromise results (this study did not evaluate medial retraction), and that was confirmed in this report. More controversial were the findings related to varus position of the neck-shaft angle. Loss of the medial calcar through comminution can allow fracture collapse, and approaches to avoid this include bone-grafting, the use of medial support screws (so-called “kick-stand” screws reaching medially to support the calcar), and allowing mild varus to close down the medial fracture line for stability. This study showed better results after the use of medial support screws and that mild varus position did not adversely affect outcome. However, since individual surgeon preference determined the amount of varus employed and no controls were used, it is difficult to derive precise guidelines for reduction. Nevertheless, these results would suggest that surgeons need not default to more aggressive and invasive techniques if mild varus alignment is present and that medial support screws allow for a stable reduction. There was a high rate of complications (32.7%) and revisions (27.6%) in this series, and given the existence of randomized prospective studies that fail to show an advantage of surgery over nonoperative treatment even for severe injuries2, more work needs to be done to guide patient selection for operative intervention. It was interesting that age did not influence outcome, nor did OTA/AO fracture type, while the much-maligned Neer classification did influence outcome, with worse results seen with increasing fracture fragments. What are the lessons from this study and other recent reports for the clinician? First, consider nonoperative intervention for all but the most severe cases; functional results can be surprisingly good despite imperfect radiographs2. Second, reverse arthroplasty (and, in increasingly rare instances, hemiarthroplasty) is an option for especially comminuted fractures in elderly patients3. Finally, if ORIF is elected, efforts to achieve and maintain a good reduction are justified, although mild varus can be accepted when necessary to achieve a stable medial hinge, supported by medial support screws. This study did not examine the use of intramedullary or medial bone-grafting, also of potential value in achieving medial support, or the use of minimally invasive, percutaneous techniques, which can further reduce soft-tissue disruption in selected cases4.