Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 3-part, surgical neck and greater tuberosity, impaction

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Glossary

General considerations

Tuberosity malunion or nonunion, and secondary fracture displacement can be problematic for these injuries. However, the humeral head blood supply is seldom totally disrupted, thus avascular necrosis is unusual.

Surgical treatment for the greater tuberosity fragment must correct any displacement greater than 5 mm and provide stable fixation for early motion. Tuberosity fixation can be supplemented with a tension band suture through its rotator cuff insertion for increased stability. If surgery is done, fixation of the metaphyseal (surgical neck) component is typically included.

A significantly displaced greater tuberosity fracture will impinge on the coraco-acromial arch. This causes painful reduction of motion. Nonoperative treatment will not correct this and should be reserved for patients with unacceptably high surgical risk. If the greater tuberosity is not significantly displaced, conservative treatment may be considered, and can give good results.

Nonoperative
Main indication Skill Equipment
Minimal displacement and/or elderly, infirm patient Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Risks of surgery outweigh benefits

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Reduced comfort and function
  • Greater tuberosity impingement on coraco-acromial arch
  • Possibility of further displacement
MIO - Screw fixation
Main indication Skill Equipment
Satisfactory reduction and fixation can be 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

  • Minimal soft-tissue damage

Disadvantages

  • Reduction may be difficult
  • Limited stability
Nailing
Main indication Skill Equipment
Significant angulation plus tuberosity fracture not compromised by nail 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
MIO - Plate fixation
Main indication Skill Equipment
Both fracture components can be reduced closed 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
  • Less soft-tissue damage than ORIF

Disadvantages

  • Risk of axillary nerve damage
  • Limited exposure of the fracture
  • Technically demanding
  • Greater tuberosity reduction must be nearly anatomical, and preserved during plating
  • Disimpaction causes instability, which fixation must overcome
ORIF - Plate fixation
Main indication Skill Equipment
Open exposure required for satisfactory reduction and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Open reduction with plate fixation is the currently favored technique for these fractures.

Supporting indications

  • Greater tuberosity displacement greater 5 mm
  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization
  • Osteoporotic bone

Advantages

  • Best means of achieving satisfactory reduction and stable fixation
  • Earlier mobilization
  • No violation of the rotator cuff

Disadvantages

  • Technically demanding
  • Greater tuberosity reduction must be nearly anatomical, and preserved during plating
  • Disimpaction causes instability, which fixation must overcome
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