Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, dislocation, fragmentary metaphyseal +/- fragmentary articular

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Glossary

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 Basic surgical experience, no specialized skills Basic equipment only

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 Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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 Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2011-05-02