Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 2-part, surgical neck, no impaction

back to skeleton

Glossary

General considerations

These fractures are unstable. They typically occur in older patients. Signs of instability are a translation of the humeral shaft of more than 33% and/or a metaphyseal comminution. In these cases, the risk of a nonunion is increased up to 8-10%, so surgery may be recommended. If operative reduction and fixation are chosen, the technique will depend upon surgical skill, available implants and equipment. Fixation without open reduction may be attempted initially, but the surgeon should be prepared to open the fracture if the attempt is unsuccessful.

If fixation is chosen in multifragmentary fractures, nailing or angular stable plates might be preferable because they offer more stable fixation in a short or osteoporotic proximal humeral segment.

Nonoperative
Main indication Skill Equipment
Most fractures, even with significant translation Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Risks of surgery outweigh benefits

Advantages

  • Outcomes of nonoperative care are similar to those achieved with surgery
  • No operative risks
  • No anesthetic risks

Disadvantages

  • Early use risks increased displacement
  • Possible nonunion
MIO - Screw fixation
Main indication Skill Equipment
Reducible fracture with good bone quality and appropriate fracture pattern Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Cannulated screws are only applicable in fractures with angulation.

Supporting indications

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

Advantages

  • Minimal soft-tissue damage vs. plate fixation

Disadvantages

  • No exposure for reduction
  • Limited stability
  • Risk of damage to the axillary nerve
  • Not suitable for most transverse fractures
MIO - Plate fixation
Main indication Skill Equipment
Reducible fracture with poorer bone quality or transverse fracture pattern Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

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

Advantages

  • Earlier mobilization
  • No violation of the rotator cuff

Disadvantages

  • Risk of axillary nerve damage
  • Technically demanding
Nailing (straight nail)
Main indication Skill Equipment
Reducible fracture with a proximal segment suitable for nail fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

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

Advantages

  • Strong fixation in poor bone quality
  • Entrance point of the nail does not interfere with the footprint of the supraspinatus tendon
  • Less extensive exposure than ORIF
  • Possibility of earlier motion

Disadvantages

  • Possible increased shoulder pain, or rotator cuff disturbance
  • Reduction may be difficult
  • Risk of damage to the axillary nerve
  • Violation of the rotator cuff
Nailing (bent nail)
Main indication Skill Equipment
Reducible fracture with a proximal segment suitable for nail fixation 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 extensive exposure than ORIF
  • Possibility of earlier motion

Disadvantages

  • Possible increased shoulder pain, or rotator cuff disturbance
  • No hardware fixation of lesser tuberosity
  • Entry point of the nail may interfere with the footprint of the supraspinatus tendon and/or with the fracture line of the greater tuberosity if present
  • Reduction may be difficult
  • Risk of damage to the axillary nerve
  • Violation of the rotator cuff
ORIF - Plate fixation
Main indication Skill Equipment
Need for open reduction and optimal fixation stability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

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

Advantages

  • Earlier mobilization
  • No violation of the rotator cuff
  • Decreased risk of nonunion

Disadvantages

  • Technically demanding
  • Screws must be placed for excellent humeral head purchase while avoiding shoulder joint
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