Diagnosis

4-Part fracture with marked displacement

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These fractures are characterized by a marked displacement of the fragments and disruption of the periosteal sleeve. They are highly unstable. Due to the disrupted periosteal sleeve, especially on the medial side, the blood supply of the humeral head is severely affected. Prognostic factors of an ischemic humeral head are a) a fracture line located in the anatomic neck, b) a ruptured medial soft-tissue hinge, and c) a short posteromedial distal metaphyseal extension beyond the humeral head (less than 8 mm).

Although these fractures do not necessarily pass through the articular surface, they are termed “articular fractures”; the articular surface is detached from both tuberosities and/or fractured itself. 

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 intact articular surface and valgus malalignment
2.  4-Part fracture with intact articular surface and varus malalignment
3.  4-Part fracture with fragmentary articular surface and varus malalignment

1.  4-Part fracture with intact articular surface and valgus malalignment

4-Part fracture with intact articular surface and valgus malalignment

4-Part fracture with intact articular surface and valgus malalignment

In these fractures both tuberosities are displaced. The periosteum, especially the medial hinge, is quite often ruptured. The fracture is typically unstable. Due to the displacement and instability an operative treatment is recommended.

4-Part fracture with intact articular surface and valgus malalignment

4-Part fracture with intact articular surface and valgus malalignment

2.  4-Part fracture with intact articular surface and varus malalignment

4-Part fracture with intact articular surface and varus malalignment

4-Part fracture with intact articular surface and varus malalignment

In these fractures both tuberosities are displaced. This fracture type is highly unstable and typically requires operative treatment. Surgery is very demanding and associated with a high complication rate. Secondary varus collapse is often seen, especially in the elderly with osteoporotic bone, particularly if the varus malalignment is not properly reduced.

4-Part fracture with intact articular surface and varus malalignment

4-Part fracture with intact articular surface and varus malalignment

3.  4-Part fracture with fragmentary articular surface and varus malalignment

4-Part fracture with fragmentary articular surface and varus malalignment

4-Part fracture with fragmentary articular surface and varus malalignment

These fractures include a transcephalic (head-splitting) fracture line. This runs obliquely, somewhat parasagittally. A significant portion of the head remains attached to the greater tuberosity. A radiographic indication of a transcephalic fracture is a double profile of the convex subchondral bone of the humeral epiphysis. Optimal treatment is anatomical reduction and stable fixation. Arthroplasty may need to be considered in the elderly, osteoporotic patient.

4-Part fracture with fragmentary articular surface and varus malalignment

4-Part fracture with fragmentary articular surface and varus malalignment

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