Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 3-part, surgical neck and tuberosity, dislocation

back to skeleton

Glossary

General considerations

This dislocation should be reduced as soon as possible to preserve the viability of the humeral head and neurological integrity. Most often, this is done in the OR using open techniques and muscle relaxing anesthesia. Typically, this open reduction is combined with an osteosynthesis of the fracture. While closed reduction might be successful, anesthesia with muscle relaxation should be used, and the possibility of an immediate open reduction must be considered. If closed reduction is satisfactory and displacement is minimal, nonoperative management may prove successful.

These injuries may include rotator cuff tears. An early postreduction MRI, or arthroscopic evaluation can help avoid unnecessary delays before surgical repair.

Nonoperative
Main indication Skill Equipment
1) Successful closed glenohumeral reduction with satisfactory (minimally displaced) fracture alignment 2) Very frail elderly patient with minimal requirements for upper extremity use Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Risks of surgery outweigh benefits

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Possibly painful shoulder
  • Probably impaired function
  • Late revision is challenging
MIO - Screw fixation
Main indication Skill Equipment
Successful closed glenohumeral reduction with fracture suitable for closed reduction and screw fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Screw fixation may only be suitable insimple 2-part fractures.

Supporting indications

  • Good bone quality
  • Unacceptable deformity

Advantages

  • Minimal soft-tissue damage from fracture fixation
  • May permit earlier mobilization under favorable circumstances

Disadvantages

  • No exposure for reduction
  • Limited stability
  • Risk of damage to the axillary nerve
MIO - Plate fixation
Main indication Skill Equipment
Successful closed glenohumeral reduction with fracture suitable for closed reduction and plate fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Unacceptable deformity
  • Ability to achieve satisfactory reduction and fixation without open exposure

Advantages

  • Less soft-tissue damage from fracture fixation compared to ORIF
  • May permit earlier mobilization under favorable circumstances

Disadvantages

  • No exposure for reduction
  • Limited stability
  • Risk of damage to the axillary nerve
  • Technically demanding
ORIF - Plate fixation
Main indication Skill Equipment
Need for open fracture reduction and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Open glenohumeral reduction is typically required in these fractures, usually through a deltopectoral incision.

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

Supporting indications

  • Fracture displacement and instability
  • Osteoporotic bone

Advantages

  • Repairable fracture
  • Earlier mobilization
  • No violation of the rotator cuff
  • Good exposure of the fracture possible

Disadvantages

  • Risk of fixation failure
  • Possibility of shoulder stiffness and impaired function
  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Irreparable fracture or failure of primary Highly experienced and skilled surgeon Full specialized surgical and imaging resources

A hemiarthroplasty requires a repairable rotator cuff.

An arthroplasty is rarely if ever indicated in simple 2-part fractures.

Supporting indications

  • Poor bone quality
  • Salvage procedure for failed reduction and fixation

Advantages

  • Provides a replacement for unreconstructable humeral head
  • If failure of fixation and/or avascular necrosis (AVN) are highly likely, primary arthroplasty may avoid a second surgery

Disadvantages

  • Resection of the humeral head
  • Possible failure of tuberosity repair
  • Possible pain and/or poor shoulder function
  • Possible arthroplasty failure
Reverse arthroplasty
Main indication Skill Equipment
Displaced fractures in elderly patients Highly experienced and skilled surgeon Full specialized surgical and imaging resources

An arthroplasty is rarely if ever indicated in simple 2-part fractures.

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