General considerations
Many of these injuries have one or more fractures splitting the humeral head. These articular surface splits need to be reduced anatomically and fixed securely for good results and to prevent later glenohumeral arthrosis. The reduction must be confirmed by intraoperative image intensification which is difficult. Obtaining and maintaining reduction of the head-splitting fracture lines is very demanding. In some cases, especially in case of significant osteoporosis or if a reconstruction is not achievable, primary arthroplasty will be the preferred treatment. Nevertheless, especially in younger patients, reconstruction should be attempted.
| Nonoperative | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Elderly infirm patient; excessive surgical risk |  |
 |
Supporting indications
- Risks of surgery outweigh benefits
Advantages
- No operative risks
- No anesthetic risks
Disadvantages
- Must accept fracture malalignment
- Risk of nonunion
- Risk of avascular necrosis
- Early use risks displacement
- Risk of poorer functional outcome
- Increased risk of posttraumatic arthrosis
- Closed reduction of glenohumeral dislocation probably impossible
| ORIF - Plate fixation | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Repairable proximal humerus fracture; acceptable surgical risk |  |
 |
Supporting indications
- Younger patient
- Unacceptable deformity, particularly articular surface
- Better bone quality; larger fracture fragment
Advantages
- Preservation of humeral head
- Possibility for delayed arthroplasty
- Exposure available from open glenohumeral reduction
Disadvantages
- Risk of fixation failure
- Risk of avascular necrosis
- Technically very demanding
| Hemiarthroplasty | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Inability to reconstruct the fracture; acceptable surgical risk | |
|
Indication for hemiarthroplasty increases with patient’s age and increases with head fragmentation. A hemiarthroplasty requires a repairable rotator cuff.
Supporting indications
- Poor bone quality
- Humeral head ischemia in the elderly patient
- Intraoperative failure of osteosynthesis
Advantages
- Provides a replacement for unreconstructable humeral head
- If failure of fixation and/or avascular necrosis (AVN) are highly likely, primary arthroplasty may avoid a second surgery
Disadvantages
- Resection of the humeral head
- Possible failure of tuberosity repair
- Possible pain and/or poor shoulder function
- Possible arthroplasty failure
- Risk of damage to the axillary nerve depending on the approach chosen
| Reverse arthroplasty | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Displaced fractures in elderly patients | |
|
Supporting indications
- Comminuted fractures of the tuberosities and/or small fragments of the tuberosities such as avulsion or impression fractures
- Proximal humeral fractures with a preexisting rotator cuff tear
Advantages
- Shoulder function less dependent on healing of the tuberosities
- Predictable satisfactory outcome in relation to pain relief and shoulder function
- One-step procedure
Disadvantages
- Special experience of the surgeon necessary
- Minimal revision options if surgery fails
| *Skill | |
|---|---|
|
Basic surgical experience, no specialized skills |
 |
Some specialized surgical experience |
|
Highly experienced and skilled surgeon |
| *Equipment | |
|---|---|
|
Basic equipment only |
 |
Simple surgical and imaging resources |
|
Full specialized surgical and imaging resources |