Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, slight displacement, valgus malalignment

back to skeleton

Glossary

General considerations

These fractures should be properly reduced to achieve good results in terms of stability, function and pain relief. The anatomical neck fracture is fairly stable. The periosteum is typically not ruptured and the risk of avascular necrosis is reduced.

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.

Nonoperative treatment of minimally displaced fractures is largely satisfactory. Watch for significant prominence of the greater tuberosity which may produce painful limited motion through coraco-acromial impingement.

Nonoperative
Main indication Skill Equipment
Less angulation/displacement and/or limited functional expectations 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
  • Possibility of additional displacement
  • Risk of poorer functional outcome
MIO - Screw fixation
Main indication Skill Equipment
Acceptable closed reduction of fracture suitable for fixation with screws alone Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality; large bone fragments
  • Young patients
  • Unacceptable deformity

Advantages

  • Minimal soft-tissue damage

Disadvantages

  • Closed reduction may not be achievable
  • Limited stability
  • Risk of damage to the axillary nerve
MIO - Plate fixation
Main indication Skill Equipment
Satisfactory reduction achieved closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

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

Advantages

  • Less soft-tissue damage
  • Supplementary suture fixation possible (with increased proximal exposure)
  • Early mobilization may be possible

Disadvantages

  • Limited exposure may not permit satisfactory reduction
  • Limited exposure may compromise placement
  • Risk of damage to the axillary nerve
  • Technically demanding
ORIF - Plate fixation
Main indication Skill Equipment
Significant displacement or angulation that can not be corrected closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Surgeon’s desire for improved stability and earlier use

Advantages

  • Usually allows early mobilization and light use
  • Possibility of supplementary suture fixation of tuberosities
  • More stable than fixation with screws alone
  • Open exposure makes correct reduction easier

Disadvantages

  • Risk of inadequate reduction or fixation
  • Risk of axillary nerve injury (if transdeltoid approach is used)
  • Technically demanding
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