Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, marked displacement, fragmentary articular, varus malalignment

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Glossary

General considerations

Head-splitting fractures which involve both articular surface and tuberosities often have a significant portion of the head that remains with the greater tuberosity. They need to be properly reduced to achieve good results in terms of stability, function and pain relief. It is especially necessary to reduce any intraarticular gap or step-off. Typically, there is a double profile image of the head on an appropriately oriented x-ray, but the split in the humeral head articular surface is hidden inside the joint capsule, under the rotator cuff.

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.

Indications for arthroplasty are inability to achieve satisfactory reduction and stable fixation, especially in elderly patients with osteoporotic bone.

Given the articular surface deformity and varus malalignment, nonoperative treatment is likely to be followed by limited functional outcome and increased pain.

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

Supporting indications

  • Minimally displaced, stable fractures
  • Risks of surgery outweigh benefits

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Must accept fracture alignment including articular step-off
  • Early use risks displacement
  • Risk of poorer functional outcome
  • Higher risk of secondary posttraumatic arthrosis
ORIF - Plate fixation
Main indication Skill Equipment
Displacement involving articular surface and acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization

Advantages

  • Initially, the humeral head is preserved
  • More options of revision surgery
  • Comprehensive access to fracture zone which aids reduction

Disadvantages

  • Risk of secondary loss of reduction
  • Risk of persistent intraarticular step/gap
  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Inability to reconstruct the fracture, particularly articular surface 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