Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, marked displacement, intact articular, valgus malalignment

back to skeleton

Glossary

General considerations

These fractures often have an associated displaced greater tuberosity fracture.

They should be properly reduced to achieve good results in terms of stability, function and pain relief. These fractures are generally unstable after reduction (disimpaction), especially if the medial hinge is disrupted.

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 stable fixation, especially in elderly patients with osteoporotic bone.

Nonoperative
Main indication Skill Equipment
Less severe impaction and/or tuberosity displacement; elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • CCD angle less than 160°
  • Greater tuberosity displacement < 1 cm
  • Stable fracture
  • Risks of surgery outweigh benefits

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Must accept fracture alignment
  • Early use risks displacement
  • Risk of poorer functional outcome
ORIF - Plate fixation
Main indication Skill Equipment
Significant valgus and/or greater tuberosity displacement; 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.

Supporting indications

  • CCD angle > 160°
  • Greater tuberosity displacement > 5 mm
  • Young active patient

Advantages

  • Tension band suturing of the rotor cuff possible
  • Possibility to treat associated injuries

Disadvantages

  • Risk of damage to the axillary nerve depending on the approach chosen
  • Risk of secondary loss of reduction in cases of severe osteoporosis
  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Inability to obtain satisfactory reduction or fixation 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