Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 4-Part, slight displacement, varus malalignment

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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 less stable than with valgus malalignment. This kind of fracture needs to be properly reduced to achieve good results in terms of stability, function and pain relief. In particular, the varus displacement needs to be restored in order to prevent a secondary varus dislocation or implant failure.

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. Early assisted motion should be encouraged.

Nonoperative
Main indication Skill Equipment
Minimal varus angulation or 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
  • Varus angulation may increase without reduction and fixation
  • Risk of poorer functional outcome
MIO - Screw fixation
Main indication Skill Equipment
Deformity that can be corrected with closed reduction, fracture pattern suitable for fixation with screws alone Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality
  • Young patients
  • Unacceptable deformity

Advantages

  • Minimal soft-tissue damage

Disadvantages

  • No exposure for reduction
  • Limited stability
  • Risk of damage to the axillary nerve
MIO - Plate fixation
Main indication Skill Equipment
Closed reduction is possible but plate is required for adequate stabilization 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

  • Small exposure for reduction
  • Risk of damage to the axillary nerve
  • Technically demanding
ORIF - Plate fixation
Main indication Skill Equipment
Open exposure required to obtain satisfactory reduction Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Unacceptable deformity
  • A fracture with greater displacement or instability
  • Surgeon’s desire for optimal stability and earlier use

Advantages

  • ORIF treatment offers higher likelihood of proper reduction
  • Possibility of supplementary suture fixation of tuberosities
  • Usually allows early mobilization and light use
  • More stable than fixation with screws alone

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