Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, dislocation, simple metaphyseal, intact articular

back to skeleton

Glossary

General considerations

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.

Nonoperative
Main indication Skill Equipment
Elderly infirm patient; excessive surgical risk Basic surgical experience, no specialized skills Basic equipment only

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.

Supporting indications

  • Successful closed glenohumeral reduction
  • Patient not a candidate for surgery

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Risk of redislocation
  • Risk of nonunion
  • Risk of avascular necrosis
ORIF - Plate fixation
Main indication Skill Equipment
Displacement of neck and/or tuberosities; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Open reduction and plate osteosynthesis is the currently favored technique for these fractures. With poorer bone quality, prosthetic replacement might be considered.

Supporting indications

  • Unacceptable instability or deformity
  • Bone quality suitable for internal fixation

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 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

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