A systematic review of proximal humerus fractures and associated vascular injuries

Objective

Proximal humerus fractures are common with a reported neurovascular injury incidence of 0.09% to 5%. This study aimed to synthesize the current evidence on the presentation and management of proximal humerus fractures with associated vascular injury to aid clinical decision-making.

Methods

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration: CRD42023393957) to identify articles reporting proximal humerus fractures with associated vascular injury in adults. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist. Outcomes included presentation, fracture classification, type of vascular injury, method of orthopedic and vascular repair, and complications.

Results

A total of 40 articles representing 55 individuals with a fracture were included. Injuries most commonly occurred after a low-energy mechanism such as a fall from a standing height (n = 32, 58%). The presentation of ischemia included cool limb (n = 29, 53%), pallor (n = 21, 38%), prolonged capillary refill (n = 7, 13%), and an absent or reduced pulse (n = 47, 85%). Concomitant neurological injury was reported in 30 cases (55%) and fracture dislocations were reported in 17 cases (32.7%). Fracture classification was variable; however, when all recorded fracture patterns were described in terms of 2-, 3-, or 4-part fractures, these represented 49% (n = 27), 24% (n = 13), and 18% (n = 10), respectively. Fracture management preceded vascular repair in 30 (55%). Orthopedic management was primarily performed by open reduction internal fixation or wire fixation (n = 33, 60%) and hemiarthroplasty (n = 11, 20%). Isolated arterial injury was the most common vascular injury (n = 52, 95%). Arterial injuries were primarily repaired by an interposition graft (n = 21, 38%), primary repair (n = 11, 20%), or conservative management (n = 9, 16%). Complications such as amputation, compartment syndrome, avascular necrosis, and metalwork failure were reported in 13 cases.

Conclusions

Proximal humerus fractures with associated vascular injuries occur most commonly in the older adults after low-energy mechanisms such as a fall from a standing height. A high index of suspicion is needed as not all injuries present with classical ischemic symptoms, and these injuries carry significant associated morbidity.