Percutaneous pins versus ORIF, or is HHR Better?

Abstract

Displaced proximal humerus fractures that require surgical management challenge the orthopaedic surgeon and are a subject of continued debate. Treatment options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), and humeral head replacement (HHR). Closed reduction and percutaneous pinning is technically challenging and its success depends on surgeon experience and patient selection. Closed reduction and percutaneous pinning should be reserved for young motivated patients with two-part surgical neck fractures in the acute setting. Open reduction and internal fixation is suitable for most two-and three-part fractures and the choice of fixation-suture, plate, or intramedullary devices depends on surgeon preference. We favor suture fixation for two-part tuberosity fractures and rotationally stable surgical neck fractures. We treat three-part fractures in patients with good bone quality with suture fixation of the tuberosities and stabilization of the head to the shaft with modified Enders nails. Enders nails should also be added to rotationally unstable surgical neck fractures. Finally, HHR should be performed on all four-part fractures, fracture dislocations, and head-splitting injuries. We also prefer HHR for three-part fractures in elderly patients with osteoporotic bone.