Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus

back to skeleton

Glossary

Surgical procedures sorted by fracture type

Use this menu to jump directly into a specific classification (optional):
A1.1 A1.2 A1.3 A2 A3 B1.1/3 B1.2 B2 B3 C1.1 C1.2 C1.3 C2.1 C2.2 C2.3 C3.1 C3.2 C3.3
A1.1

Extraarticular unifocal fracture of greater tuberosity, not displaced

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Impacted greater tuberosity fractures Basic surgical experience, no specialized skills Basic equipment only
Screw fixation Nonimpacted greater tuberosity fracture Some specialized surgical experience Full specialized surgical and imaging resources
A1.2

Extraarticular unifocal fracture of greater tuberosity, displaced

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Frail elderly patient Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; screw fixation Fracture that can be reduced closed Some specialized surgical experience Full specialized surgical and imaging resources
Open reduction; screw or suture fixation Inability to reduce closed Some specialized surgical experience Simple surgical and imaging resources
A1.3

Extraarticular unifocal fracture with glenohumeral dislocation

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Satisfactory reduction of the greater tuberosity after the glenohumeral joint is reduced Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; screw fixation Persistent displacement of the greater tuberosity after reduction of the glenohumeral dislocation Some specialized surgical experience Full specialized surgical and imaging resources
Open reduction; screw or suture fixation Persistent or recurrent displacement of the greater tuberosity after reduction of the glenohumeral dislocation Some specialized surgical experience Simple surgical and imaging resources
A2

Extraarticular unifocal fracture, impacted metaphyseal

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Acceptable deformity Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; screw fixation Unacceptable deformity and/or risk of displacement Some specialized surgical experience Full specialized surgical and imaging resources
Closed reduction; plate fixation Unacceptable deformity and/or risk of displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; nail fixation Unacceptable deformity and/or risk of displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; screw fixation Unacceptable deformity and/or instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Unacceptable deformity and/or instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources
A3

Extraarticular unifocal fracture, nonimpacted metaphyseal

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Most A3 fractures (surgical neck), even with significant translation Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; screw fixation Reducible fracture with good bone quality and appropriate fracture pattern Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; plate fixation Reducible fracture with poorer bone quality or transverse fracture pattern Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Closed reduction; nail fixation Reducible fracture with a proximal segment suitable for nail fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Need for open reduction and optimal fixation stability Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1.1/3

Extraarticular bifocal fracture, with metaphyseal impaction, greater tuberosity is off

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Minimal displacement and/or elderly, infirm patient Basic surgical experience, no specialized skills Basic equipment only
Limited open reduction; screw fixation Satisfactory reduction and fixation can be achieved closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; nail fixation Significant angulation plus tuberosity fracture not compromised by nail Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Both fracture components can be reduced closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Open exposure required for satisfactory reduction and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1.2

Extraarticular bifocal fracture, with metaphyseal impaction, lesser tuberosity is off

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Acceptable angulation with good internal rotation strength or frail elderly patient Basic surgical experience, no specialized skills Basic equipment only
Limited open reduction; nail fixation Unacceptable metaphyseal angulation; satisfactory internal rotation strength Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Unacceptable metaphyseal angulation; satisfactory internal rotation strength Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Unacceptable metaphyseal angulation and/or internal rotation weakness Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B2

Extraarticular bifocal fracture, without metaphyseal impaction

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Limited open reduction; screw fixation Reducible fracture with suitable pattern for screw fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; nail fixation Fracture can be reduced closed and has pattern suitable for nail fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Significantly displaced fracture that can be reduced closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Displacement and/or instability are unacceptable Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Extreme osteoporosis and/or comminution with severe displacement that is predictable of an unacceptable result; salvage after failure of alternative treatment Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3

Extraarticular bifocal fracture, with glenohumeral dislocation

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment 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
Limited open reduction; screw fixation Successful closed glenohumeral reduction with fracture suitable for closed reduction and screw fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Successful closed glenohumeral reduction with fracture suitable for closed reduction and plate fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Need for open fracture reduction and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Irreparable fracture or failure of primary treatment Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1.1

Articular fracture with slight displacement, cephalotubercular, with valgus malalignment

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Less angulation/displacement and/or limited functional expectations Basic surgical experience, no specialized skills Basic equipment only
Limited open reduction; screw fixation Acceptable closed reduction of fracture suitable for fixation with screws alone Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Satisfactory reduction achieved closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Significant displacement or angulation that can not be corrected closed Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1.2

Articular fracture with slight displacement, cephalotubercular, with varus malalignment

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Minimal varus angulation or elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Limited open reduction; screw fixation Deformity that can be corrected with closed reduction, fracture pattern suitable for fixation with screws alone Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Limited open reduction; plate fixation Closed reduction is possible but plate is required for adequate stabilization Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Open exposure required to obtain satisfactory reduction Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1.3

Articular fracture with slight displacement, anatomical neck (non-displaced / displaced)

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Closed reduction; screw fixation Closed reduction possible Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; screw fixation Open exposure required for reduction but well-suited fixation with multiple screws Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Open reduction; plate fixation Open reduction required; maximal mechanical stability desired Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to obtain satisfactory reduction or fixation; salvage of failed reduction and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C2.1

Articular fracture, impacted with marked displacement, cephalotubercular, with valgus malalignment

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Less severe impaction and/or tuberosity displacement; elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Significant valgus and/or greater tuberosity displacement; acceptable surgical risk. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to obtain satisfactory reduction or fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C2.2

Articular fracture, impacted with marked displacement, cephalotubercular, with varus malalignment

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Significant displacement; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Elder patient with poor bone quality; salvage of previous failure Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C2.3

Articular fracture, impacted with marked displacement, transcephalic (double profile image on X-ray) and tubercular, with varus malalignment

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Displacement involving articular surface and acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to reconstruct the fracture, particularly articular surface Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3.1

Articular fracture, dislocated, anatomical neck (anterior / posterior)

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient; excessive surgical risk Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to reconstruct the fracture; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3.2

Articular fracture, dislocated , anatomical neck and tuberosities (head impacted / non-impacted)

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient; excessive surgical risk Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Displacement of neck and/or tuberosities; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to reconstruct the fracture; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3.3

Articular fracture, dislocated, cephalotubercular fragmentation (head intact / fragmented)

Please select a treatment option:
Treatment Main indication Skill Equipment
Nonoperative treatment Elderly infirm patient; excessive surgical risk Basic surgical experience, no specialized skills Basic equipment only
Open reduction; plate fixation Repairable proximal humerus fracture; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Hemiarthroplasty Inability to reconstruct the fracture; acceptable surgical risk Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Special considerations

Principles of management of open fractures
Complications
Infection
Compartment syndrome
*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