Diagnosis

Extraarticular 3-part fracture of surgical neck with impaction and involvement of a tuberosity

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These fractures are bifocal fractures, involving the surgical neck and one tuberosity. Neither fracture line involves the articular surface, and there is impaction of the metaphyseal (surgical neck) component.

The subgroups are distinguished by metaphyseal angulation and tuberosity fracture morphology.

Since the metaphyseal impacted fracture component is usually quite stable, the indication for surgery depends on the displacement of the tuberosity. Greater tuberosity displacement of more than 5 mm should be reduced and fixed. Also, if there is a severe displacement of the humeral head a reduction should be considered especially in the young.

Options
1.  Lateral impaction of surgical neck and involvement of greater tuberosity
2.  Medial impaction of surgical neck and involvement of lesser tuberosity
3.  Posterior impaction of surgical neck and involvement of greater tuberosity

1.  Lateral impaction of surgical neck and involvement of greater tuberosity

Lateral impaction of surgical neck and involvement of greater tuberosity

Lateral impaction of surgical neck and involvement of greater tuberosity

In this subgroup, the fracture of the metaphysis is impacted laterally and involves a fracture of the greater tuberosity. These fractures appear as valgus impacted 3-part fractures. Due to the direction of the lateral impaction they can be divided in a pure lateral impaction, a posterolateral impaction, and a anterolateral impaction.

Since the periosteum is typically not ruptured, they tend to be quite stable.

Lateral impaction of surgical neck and involvement of greater tuberosity

Lateral impaction of surgical neck and involvement of greater tuberosity

X-rays by courtesy of B Ockert, LMU Munich, Germany.

2.  Medial impaction of surgical neck and involvement of lesser tuberosity

Medial impaction of surgical neck and involvement of lesser tuberosity

Medial impaction of surgical neck and involvement of lesser tuberosity

In this subgroup, the fracture of the metaphysis is impacted medially and involves a fracture of the lesser tuberosity. These fractures appear as varus impacted 3-part fractures. Due to the direction of the lateral impaction they can be divided in a pure lateral impaction, a posterolateral impaction, and an anterolateral impaction.

Since the periosteum is typically not ruptured, they tend to be quite stable.

Be aware that there may be a pre-existing rupture of the supra-/infraspinatus tendon, especially, if there is no severe rotational component of the humeral head.

3.  Posterior impaction of surgical neck and involvement of greater tuberosity

Posterior impaction of surgical neck and involvement of greater tuberosity

Posterior impaction of surgical neck and involvement of greater tuberosity

In this subgroup, the fracture of the metaphysis is impacted posteriorly and involves a fracture of the greater tuberosity. These fractures appear as impacted 3-part fractures. 

Since the periosteum is typically not ruptured, they tend to be quite stable.

Note the inherent danger of missing its anterior angulation if only an AP x-ray is considered.

Posterior impaction of surgical neck and involvement of greater tuberosity

Posterior impaction of surgical neck and involvement of greater tuberosity

X-rays by courtesy of B Ockert, LMU Munich, Germany.