x Proximal Humeral Fractures JB .docx
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Proximal Humeral Fractures
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Figure 1: The four osseous segments are humeral head and articular surface (1), greater tuberosity (2), lesser tuberosity (3) and humeral shaft (4). The so-called anatomic neck is shown in green; this represents the fused epiphyseal plate below the articular surface. The so-called surgical neck is shown in blue. This is the junction between the shaft and the tuberosities. The bicipital groove lies between the greater and lesser tuberosities.
Figure 2: An x-ray highlighting the articular surface (blue), greater tuberosity (red), lesser tuberosity (yellow) and humeral shaft (green).
There are multiple muscular insertions on the proximal humerus. These attachments typically work in tandem to produce balanced forces that stabilize the glenohumeral joint. With a fracture, though, they can be deforming.
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Figure 3: Various “two part” fractures
- Three-part fractures (
figFigure 4) have two main fracture lines: one of the surgical neck (making the shaft one of the “parts”) and another that usually displaces the greater tuberosity (the second “part”). The intact humeral head is then the third “part”. (The lesser tuberosity is only very rarely the second “part” in a3 part3-part fracture; the figure shows the typical configuration.)
Figure 4: A “three part” fracture.
- Four-part fractures (
figFigure 5) have displacement across fracture lines between all four parts
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Figure 5: A “four part” fracture
In addition, injuries can include fractures of the articular surface (head-splitting fractures and impaction fractures) and disruption of the gleno-humeral articular (fracture dislocation).
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Figure 6: Sshowing an x-ray (A) and clinical photo (B) of surgical fixation of a proximal humerus fracture. (courtesy of https://ars.els-cdn.com/content/image/1-s2.0-S2212628717300439-gr10_lrg.jpg )
Locking plates are especially desirable for fixing osteoporotic bone. Suture fixation avoids the potential complications associated with inserting a bulky plate. At times, a hybrid approach, using both a plate and sutures can provide the best fixation.
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Figure 7: A proximal humerus fracture treated with hemiarthroplasty. (courtesy Andrew F. Kuntz, MD)
Figure 8: A proximal humerus fracture treated with a reverse hemiathroplasty. (courtesy Andrew F. Kuntz, MD)
Even if non-operative management can be reliably expected to result in some degree of malunion or lost motion, but approach to treatment may be desirable in some patients. Non-operative management not only avoids the costs and potential complications associated with operative intervention, some malunion or lost motion may be well-tolerated by many low-demand patients.
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Figure 9: Ernest Amory Codman, M.D. (Wikipedia)
Key Terms
Greater tuberosity, Lesser tuberosity, Surgical neck, Anatomic neck, Axillary nerve, steonecrosis, Closed reduction, Total shoulder arthroplasty
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