Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Isolated anatomical neck, dislocation

back to skeleton

Glossary

General considerations

The dislocation needs to be reduced as soon as possible to preserve the viability of the humeral head and neurological integrity. Typically, reduction should be done open with muscle relaxing anesthesia. This procedure is usually combined with an osteosynthesis. If attempted as a closed reduction, remember that this may be unsuccessful with need for an open procedure. All treatment options carry the high risk of avascular necrosis.

Operative fixation is the preferred treatment. However, the decision for surgery should also include the functional demands of the patients, the presence of comorbidities, and the ability to undergo operative treatment.

Nonoperative
Main indication Skill Equipment
Elderly infirm patient; excessive surgical risk Basic surgical experience, no specialized skills Basic equipment only

Although very rare, closed reduction of the glenohumeral joint may be successful. A patient may not be an acceptable candidate for surgical repair. In this case, nonoperative management of the anatomical neck fracture is appropriate, accepting risk of redislocation, nonunion, and/or avascular necrosis. Alternatively, in the very frail elderly patient, one might choose to accept the dislocation without even attempting a closed reduction. If the patient is a surgical candidate, unsuccessful closed reduction should be followed by prompt open reduction, almost always with fracture fixation.

Supporting indications

  • Successful closed glenohumeral reduction
  • Patient not a candidate for surgery

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Risk of redislocation
  • Risk of nonunion
  • Risk of avascular necrosis
ORIF - Plate or screw fixation
Main indication Skill Equipment
Acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources

In some cases, neurovascular compromise results from the dislocated humeral head. If this is the case, emergency treatment is necessary. If not, definitive reduction and fixation should not be long delayed, particularly if one wishes to salvage the humeral head.

Open reduction and angular stable plate osteosynthesis is the currently favored technique for these fractures.

Supporting indications

  • Fracture instability
  • Bone quality suitable for internal fixation

Advantages

  • Preservation of humeral head
  • Possibility for delayed arthroplasty
  • Exposure available from open glenohumeral reduction

Disadvantages

  • Risk of fixation failure
  • Risk of avascular necrosis
  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Inability to reconstruct the fracture; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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
  • Risk of damage to the axillary nerve depending on the approach chosen
*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