The dislocation needs to be reduced as soon as possible to preserve the viability of the humeral head and neurological integrity. Doing so, this procedure is usually combined with an osteosynthesis. A closed reduction may be attempted but it is often unsuccessful. Thus, the need for an open reduction and internal fixation must be remembered.
Operative fixation is the preferred treatment. However, the decision for surgery should also include the functional demands of the patients, the presence of comorbidities, and the ability to undergo operative treatment. All treatment options carry a high risk of avascular necrosis.
Indications for arthroplasty are inability to achieve satisfactory reduction and stable fixation, especially in elderly patients with osteoporotic bone.
|Elderly infirm patient; excessive surgical risk|
Although very rare, closed reduction of the glenohumeral joint may be successful. A patient may not be an acceptable candidate for surgical repair. In this case, nonoperative management of the anatomical neck fracture is appropriate, accepting risk of redislocation, nonunion, and/or avascular necrosis. Alternatively, in the very frail elderly patient, one might choose to accept the dislocation without even attempting a closed reduction. If the patient is a surgical candidate, unsuccessful closed reduction should be followed by prompt open reduction, almost always with fracture fixation.
- Successful closed glenohumeral reduction
- Patient not a candidate for surgery
- No operative risks
- No anesthetic risks
- Risk of redislocation
- Risk of nonunion
- Risk of avascular necrosis
|ORIF - Plate fixation|
|Displacement of neck and/or tuberosities; acceptable surgical risk|
Open reduction and plate osteosynthesis is the currently favored technique for these fractures. With poorer bone quality, prosthetic replacement might be considered.
- Unacceptable instability or deformity
- Bone quality suitable for internal fixation
- Preservation of humeral head
- Possibility for delayed arthroplasty
- Exposure available from open glenohumeral reduction
- Risk of fixation failure
- Risk of avascular necrosis
- Technically demanding
|Inability to reconstruct the fracture; acceptable surgical risk|
A hemiarthroplasty requires a repairable rotator cuff.
- Poor bone quality
- Humeral head ischemia in the elderly patient
- Intraoperative failure of osteosynthesis
- 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
- 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
|Displaced fractures in elderly patients|
- 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
- Shoulder function less dependent on healing of the tuberosities
- Predictable satisfactory outcome in relation to pain relief and shoulder function
- One-step procedure
- Special experience of the surgeon necessary
- Minimal revision options if surgery fails
|Basic surgical experience, no specialized skills|
|Some specialized surgical experience|
|Highly experienced and skilled surgeon|
|Basic equipment only|
|Simple surgical and imaging resources|
|Full specialized surgical and imaging resources|