Diagnosis

Articular or 4-part fracture with glenohumeral dislocation

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These fractures all involve a glenohumeral dislocation (head fragment displaced from glenoid fossa). An anterior dislocation is much more common than posterior. The risk of avascular necrosis is significantly increased by the combination of a dislocation with a fracture that devascularizes a small humeral head fragment or is comminuted.

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.  Isolated anatomical neck fracture with glenohumeral dislocation
2.  4-Part fracture, simple metaphyseal fracture with intact articular surface
3.  4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface
4.  Humeral head impaction

1.  Isolated anatomical neck fracture with glenohumeral dislocation

Isolated anatomical neck fracture with glenohumeral dislocation

Isolated anatomical neck fracture with glenohumeral dislocation

In these fractures the tuberosities are not involved. They require reduction as soon as possible. Open reduction is often necessary.

Isolated anatomical neck fracture with glenohumeral dislocation

Isolated anatomical neck fracture with glenohumeral dislocation

2.  4-Part fracture, simple metaphyseal fracture with intact articular surface

4-Part fracture, simple metaphyseal fracture with intact articular surface

4-Part fracture, simple metaphyseal fracture with intact articular surface

These are unusual injuries.

In these fractures the anatomical neck and the tuberosities are fractured, the articular surface remains intact. This “4-part fracture dislocation” requires a reduction as soon as possible. Open reduction is often necessary. In elderly osteoporotic patients arthroplasty needs to be considered.

4-Part fracture, simple metaphyseal fracture with intact articular surface

4-Part fracture, simple metaphyseal fracture with intact articular surface

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

3.  4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface

4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface

4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface

These fracture dislocations are particularly severe because of extensive proximal humeral comminution. The articular surface may or may not be intact but there are multiple metaphyseal fragments. These fractures are particularly challenging not just because of the glenohumeral dislocation but also because of the multiple fragments of the proximal humerus. While reconstruction should be attempted in young patients, elderly and osteoporotic patients are better served by arthroplasty.

4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface

4-Part fracture, fragmentary metaphyseal fracture +/- fragmentary articular surface

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

4.  Humeral head impaction

Impaction of the humeral head is a feature of some of these fractures. Impaction injuries should be identified and respected. Treatment protocols for these rare injuries remain to be developed.