Figure. Anteroposterior radiograph of the right shoulder.
A 76-year-old woman presents to the emergency department (ED) with severe right shoulder pain after a fall. She states that she slipped on ice and landed on her right shoulder. She is unable to lift her right arm. An anteroposterior radiograph of the right shoulder, which shows a completely displaced anatomical neck fracture of the proximal humerus, is obtained (Figure).
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A completely displaced anatomical neck fracture of the proximal humerus disrupts the blood supply to the humeral head. The disrupted blood supply generally cannot be restored; this results in poor healing rates with conservative treatment or when fracture fixation is attempted. For this reason, conservative treatment and open reduction and internal fixation are not viable options unless patients are not candidates for surgery. 1
Surgical options include a hemiarthroplasty or a reverse total shoulder arthroplasty (RSA). Both options replace the humeral head with a metal prosthesis.1,2 A hemiarthroplasty was traditionally used for completely displaced proximal humerus fractures but poor outcomes were seen in elderly patients with rotator cuff disease, poor bone stock (osteopenia or osteoporosis), and a greater tuberosity fracture that is not reconstructable.2 The success of a hemiarthroplasty of the shoulder is largely dependent on the healing potential of the greater tuberosity, which decreases with age.
RSA relies on the deltoid muscle for forward flexion of the arm instead of the rotator cuff, which may be degenerated with age.2 RSA offers elderly patients better forward flexion, improved rates of greater tuberosity healing, and a lower rate of revision surgery compared with treatment with hemiarthroplasty.2
1. Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95(22):2050-2055.
2. Gallinet D, Ohl X, Decroocq L, et al. Is reverse total shoulder arthroplasty more effective than hemiarthroplasty for treating displaced proximal humerus fractures in older adults? A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2018;104(6):759-766.