Diagnosis

Articular or 4-part fracture with slight displacement and intact articular surface

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These fractures are fractures of the anatomic neck with a slight displacement. They may involve both tuberosities. A truly isolated fracture of the anatomic neck without involvement of either tuberosity is very rare and somewhat theoretical.

Although these fractures do not pass through the articular surface, they are termed “articular fractures”; the articular surface is detached from both tuberosities.
Quite often, the blood supply of the humeral head is impaired and the risk of subsequent avascular necrosis (AVN) is high.

4-part fractures according to Codman and Neer separate the proximal humeral epiphysis from both tuberosities and the metaphysis.

Options
1.  4-Part fracture with valgus malalignment
2.  4-Part fracture with varus malalignment
3.  Isolated anatomical neck fracture with slight displacement

1.  4-Part fracture with valgus malalignment

4-Part fracture with valgus malalignment

4-Part fracture with valgus malalignment

These fractures are valgus impacted 4-part fractures with a slight displacement. Both tuberosities are involved. The periosteum, especially the medial hinge, is typically not ruptured. The fracture is often quite stable. If in doubt it is recommended to check the stability by image intensification. The indication for surgery depends on the degree of displacement and patient’s demands. 

4-Part fracture with valgus malalignment

4-Part fracture with valgus malalignment

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

2.  4-Part fracture with varus malalignment

4-Part fracture with varus malalignment

4-Part fracture with varus malalignment

These are varus impacted 4-part fractures with slight displacement. Both tuberosities are involved. The periosteum, especially the medial hinge, is typically not ruptured. They are less stable than valgus malaligned fractures. In the elderly, impaction of the osteoporotic humeral head onto the shaft medially is acceptable. If in doubt about the stability, it is recommended to check the stability under image intensification. The indication for surgery depends on the degree of displacement and patient’s demands.

3.  Isolated anatomical neck fracture with slight displacement

Isolated anatomical neck fracture with slight displacement

Isolated anatomical neck fracture with slight displacement

This fracture type is extremely rare and somewhat theoretical.

Isolated anatomical neck fracture with slight displacement

Isolated anatomical neck fracture with slight displacement

X-ray taken from Orozco R et al, (1998) Atlas of Internal Fixation. Used with kind permission.