Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Isolated anatomical neck, slight displacement

back to skeleton

Glossary

General considerations

These fractures are rare and carry a risk of avascular necrosis.

Operative fixation is the preferred treatment. However, the functional demands of the patients, the presence of comorbidities and the ability to undergo nonoperative treatment should also be taken into considerations. Nonoperative treatment tends to have unsatisfactory results.

Primary or delayed hemiarthroplasty can be considered for elderly osteoporotic patients, for whom fixation would not be stable, for grossly displaced fractures, or after the development of avascular necrosis (AVN).

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

Supporting indications

  • Minimally displaced, stable fractures
  • Risks of surgery outweigh benefits

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Must accept fracture alignment and possibility of nonunion and/or AVN
  • Risk of poorer functional outcome
  • Risk of fracture displacement
MIO - Screw fixation
Main indication Skill Equipment
Closed reduction possible Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality
  • Young patients
  • Minimal displacement of the humeral head
  • Unacceptable deformity

Advantages

  • Minimal soft-tissue damage
  • Possibly reduced risk of AVN

Disadvantages

  • Limited options of reduction
  • Limited stability
  • Risk of damage to the axillary nerve
ORIF - Screw fixation
Main indication Skill Equipment
Open exposure required for reduction but well-suited fixation with multiple screws Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Osteoporotic bone in the elderly
  • Unacceptable deformity

Advantages

  • May provide greater stability

Disadvantages

  • May increase risk of AVN
  • Possibility of inadequate reduction or fixation
  • Risk of axillary nerve injury (if transdeltoid approach is used)
  • Technically demanding
ORIF - Plate fixation
Main indication Skill Equipment
Open reduction required; maximal mechanical stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Osteoporotic bone in the elderly
  • Unacceptable deformity

Advantages

  • May provide greater stability

Disadvantages

  • May increase risk of AVN
  • Possibility of inadequate reduction or fixation
  • Risk of axillary nerve injury (if transdeltoid approach is used)
  • Technically demanding
Hemiarthroplasty
Main indication Skill Equipment
Inability to obtain satisfactory reduction or fixation; salvage of failed reduction and fixation 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