Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

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

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Glossary

General considerations

In these fractures the blood supply to the humeral head is seldom totally disrupted, however, tuberosity malunion or nonunion, and secondary displacement can be problematic. Lesser tuberosity fractures are unusual, and indications for surgical repair are not clear. A significant lesser tuberosity displacement suggests subscapularis tendon avulsion. Operative repair, including tension band sutures for the tendon, may be necessary to preserve internal rotation strength and possibly shoulder stability as well.

Conservative treatment may also be considered and may achieve good results and is most appropriate for low-demand patients, if the shoulder is stable and subscapularis function is satisfactory.

Nonoperative
Main indication Skill Equipment
Acceptable angulation with good internal rotation strength or frail elderly patient Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Risks of surgery outweigh benefits
  • Minimal metaphyseal angulation

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Subscapularis avulsion may not be recognized
  • Possibility of displacement
Nailing
Main indication Skill Equipment
Unacceptable metaphyseal angulation; satisfactory internal rotation strength 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
Unacceptable metaphyseal angulation; satisfactory internal rotation strength 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 extensive surgical wound

Disadvantages

  • Risk of axillary nerve damage
  • Limited exposure of the fracture
  • Limited control of the lesser tuberosity
  • Technically demanding
  • Disimpaction causes instability, which fixation must overcome
ORIF - Plate fixation
Main indication Skill Equipment
Unacceptable metaphyseal angulation and/or internal rotation weakness 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

  • Need to repair lesser tuberosity with subscapularis insertion
  • Need for more stability after disimpaction
  • Osteoporotic bone

Advantages

  • Permits subscapularis repair and stabilization of metaphyseal fracture
  • Good exposure of the fracture components

Disadvantages

  • Technically demanding
  • 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