Do you know the procedure for treating proximal humerus fractures?

Proximal humerus fractures are one of the most common fractures in trauma orthopedics, and most proximal humerus fractures are low-energy osteoporotic fractures in the elderly.

Although the majority of proximal humerus fractures can be treated conservatively, 10-15% of fractures still require surgical treatment, which includes incisional reduction plate fixation, closed reduction intramedullary nail internal fixation, and joint replacement.

The decision of treatment needs to be based on the patient's physical condition, his or her own perception, psychological expectations, and fracture type.

1. Resetting and fixation of emergency fractures

【Recommendation】For proximal humeral greater tuberosity (NEER type 2 partial fracture) fractures combined with shoulder dislocation, preoperative CT examination, except for fractures in the surgical neck region, repositioning and braking with traumatic shoulder brace under emergency anesthesia (expert recommendation rate: 100%; strong recommendation rate: 76.2%).

2. Preoperative acute pain control

【Recommendation】Patients with proximal humerus fracture have preference for preoperative analgesia with oral acetaminophen or NSAIDs, and oral opioids can be added if the effect is not good (expert recommendation rate: 100%; strong recommendation rate: 73.8%).

3. Preoperative missionary education

[Recommendation] Preoperative education should be carried out in a diversified and multi-modal manner. (Expert recommendation rate: 100%; strong recommendation rate: 83.8%)

4. Preoperative nutritional assessment and supportive treatment

【Recommendation】To complete nutritional screening of patients within 24 h of admission and to provide nutritional interventions for patients with nutritional risk. (Expert recommendation rate: 98.5%; strong recommendation rate: 55.9%)

5. Perioperative glucose assessment and regulation in diabetic patient

【Recommendation】The recommended glycemic control target for most diabetic patients undergoing elective surgery is 7.8 to 10.0 mmol/L.

6. Management of soft tissue swelling in the perioperative period

【Recommendation】For patients undergoing elective surgery for proximal humerus fracture, multiple physical methods are given to reduce swelling during the perioperative period. (Expert recommendation rate: 98.5%; strong recommendation rate: 80.9%)

7. Preoperative dietary management

【Recommendation】 Patients with elective surgery can eat clear beverages 2 h before surgery and starchy foods or dairy products 6 h before surgery. (Expert recommendation rate: 100%; strong recommendation rate: 76.5%)

8. Perioperative urinary catheter management

【Recommendation】Routine perioperative urinary catheterization is not recommended for proximal humerus fracture surgery (Expert recommendation rate: 100%; Strong recommendation rate: 78.6%)

9. Prophylactic application of perioperative antimicrobial drugs

【Recommendation】For patients with proximal humerus fractures requiring endoprosthesis or joint replacement, the prophylactic use of first- and second-generation cephalosporins is recommended for infection prevention in the perioperative period. (Expert recommendation rate: 97.1%; strong recommendation rate: 73.5%)

10. Choice of anesthesia

【Recommendation】Anesthesia is recommended to adopt the method of regional block compound general anesthesia, select drugs to avoid aggravating the systemic organ dysfunction of elderly patients, and pay attention to strengthen monitoring (expert recommendation rate: 100%; strong recommendation rate: 71.4%).

11. Intraoperative blood pressure contro

[Recommendation] Moderate reduction of blood pressure should be paid attention to reduce intraoperative blood loss for proximal humeral fractures, but elderly patients with multiple comorbidities should pay attention to maintaining hemodynamic stability to avoid inadequate perfusion of tissues and organs (expert recommendation rate: 100%; strong recommendation rate: 61.9%).

12. Intraoperative volume management

[Recommendation] Implement a goal-oriented fluid management strategy, and vasoactive drugs can be given prophylactically during general anesthesia to prevent fluid overload (expert recommendation rate: 100%; strong recommendation rate: 69.1%).

13. Intraoperative blood management

[Recommendations] Intraoperative controlled hypotension is not recommended for proximal humeral fractures, especially in elderly patients, and intraoperative blood transfusion and tranexamic acid can be applied. Intraoperative check of HGB <80g/L recommends transfusion of allogeneic blood (expert recommendation rate: 100%; strong recommendation rate: 73.8%).

14. Prevention of intraoperative hypothermia

[Recommendations] Patients with proximal humeral fractures should strengthen intraoperative temperature monitoring and take various measures to maintain core temperature above 36°C (expert recommendation rate: 100%; strong recommendation rate: 76.2%).

15. Choice of surgical approach

(1) Fracture staging of proximal humerus

[Recommendation] Neer's staging is recommended for proximal humerus fracture staging (expert recommendation rate: 100%; strong recommendation rate: 83.3%).

(2) Surgical approach

The surgical plan should be selected based on fracture morphology, bone quality, patient's physiological and psychological status and other relevant factors.

[Recommendation] The internal fixation material can be selected according to the fracture type and bone density, such as plate or intramedullary nail; for elderly patients with osteoporosis who are difficult to reset or fix, 4-part fracture (and fracture dislocation), 3-part fracture with severe osteoporosis, split fracture and anatomical neck fracture, artificial shoulder joint replacement is selected, and reverse shoulder joint replacement is recommended if combined with rotator cuff injury (expert recommendation rate: 100%. (Strong recommendation rate: 71.4%).

Figure 1 A 65-year-old female with a 4-part fracture of the proximal humeral adductor insertion and an allograft fibular implant plate fixation with incision and repositioning.

16. Placement of wound drainage tube

[Recommendations] Indications for not placing drainage tubes: ① Minimally invasive operation techniques (MIPPO and intramedullary nailing); ② Low bleeding. Indications for placement of drainage tube: ① via pectoral deltoid approach, locking plate fixation or shoulder joint replacement; ② significant bleeding from the wound surface (expert recommendation rate: 100%; strong recommendation rate: 71.4%).

17. Wound closure

【Recommendation】The surgical incision was closed by simple interrupted, layer-by-layer sutures (expert recommendation rate: 100%; strong recommendation rate: 76.2%).

18. Postoperative recovery diet

【Recommendation】Patients can ingest dregs-free drinks via mouth once they are awake after surgery, and resume normal diet after 1-2 h if there is no adverse reaction.

19. Postoperative position selection and early activity

【Recommendation】Patients do not need to lie flat on the pillow after surgery, they can adopt a semi-recumbent position and can move on the floor after waking up. The traumatic shoulder brace should be braked.

20. Postoperative analgesic measures

【Recommendation】Postoperative analgesia in patients with proximal humeral fractures is recommended to use regional blockade combined with regular "background doses" of NSAIDs, and if necessary, intravenous self-administered analgesia pumps or peripheral nerve block self-administered analgesia pumps (expert recommendation rate: 100%; strong recommendation rate: 78.6%).

21. Prevention of postoperative nausea and vomiting

[Recommendation] All patients should be given prophylactic antiemetic medication 30 min before the end of surgery. (Expert recommendation rate: 97%; strong recommendation rate: 47.8%)

22. Functional rehabilitation

【Recommendation】Patients with fixed and stable proximal humerus fractures should start rehabilitation exercises as early as possible after surgery. Rehabilitation exercises help to better restore the function of the upper limb (Expert recommendation rate: 100%; Strong recommendation rate: 92.9%).

23. Discharge criteria and follow-up

【Recommendation】Practical discharge criteria should be established, and patients should be followed up regularly for at least 6 months (expert recommendation rate: 100%; strong recommendation rate: 83.3%).

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