Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 3-part, surgical neck and tuberosity, no impaction

back to skeleton

Glossary

General considerations

In these fractures either greater or lesser tuberosity may be involved. Displacement of the greater tuberosity (greater than 5 mm) that might produce impingement is important to correct.

Due to the instability and displacement of these fractures, operative treatment is commonly recommended. The fixation techniques of the tuberosities depends on the fracture pattern (single versus multifragmentary pattern), and the bone quality. Remember to include supplementary tension band sutures through the tendons inserting on avulsed tuberosities.

Fixation of comminuted metaphyseal fractures is more demanding. These fractures are associated with higher rates of complication (secondary displacement, malunion, implant failure). It is important to gain secure fixation in the short proximal humeral segment.

Nonoperative treatment should be reserved for patients with limited functional expectations.

Nonoperative
Main indication Skill Equipment
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

  • Risks of nonunion, malunion, or greater tuberosity impingement
  • Early use risks displacement
  • Risk of poor functional outcome
MIO - Screw fixation
Main indication Skill Equipment
Reducible fracture with suitable pattern for screw 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

Contraindications

  • Multifragmentary metaphyseal fractures (insufficient stability)
  • Fracture of lesser tuberosity

Advantages

  • Minimal soft-tissue damage
  • Earlier mobilization might be achievable under favorable circumstances

Disadvantages

  • No exposure for reduction
  • Limited stability
  • Risk of damage to the axillary nerve
Nailing
Main indication Skill Equipment
Fracture can be reduced closed and has pattern 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
MIO - Plate fixation
Main indication Skill Equipment
Significantly displaced fracture that can be reduced closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Need for more stability and/or earlier mobilization
  • Workable plan for tuberosity reduction and fixation

Advantages

  • Possibility of stabilizing fractures without extensive exposure

Disadvantages

  • Risk of axillary nerve damage
  • Exposure may be insufficient for reduction and fixation of fracture components
  • Technically demanding
ORIF - Plate fixation
Main indication Skill Equipment
Displacement and/or instability are unacceptable 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

  • Inability to obtain satisfactory reduction or fixation with closed reduction
  • Expectation that adequate stability can be obtained with ORIF

Advantages

  • Best available fixation
  • Best possible fracture exposure

Disadvantages

  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Extreme osteoporosis and/or comminution with severe displacement that is predictable of an unacceptable result; salvage after failure of alternative Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Usually, these fractures can be advantageously treated by osteosynthesis. Quite often, the pathology is located on the medial metaphyseal side and the humeral head itself is not involved in the pathology. Therefore, the risk of avascular necrosis with humeral head collapse is low. Furthermore, depending on fracture level, fixation of the prosthesis is challenging, since its distal support is limited.

A hemiarthroplasty requires a repairable rotator cuff.

Supporting indications

  • Poor bone quality
  • Humeral head ischemia in the elderly patient
  • Intraoperative failure of osteosynthesis

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

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