eMedicine Specialties > Orthopedic Surgery > Shoulder

Proximal Humerus Fractures: Treatment

Author: Mark Frankle, MD, Director of Shoulder and Elbow Fellowship Program, Florida Orthopedic Institute; Chief, Clinical Associate Professor, Department of Surgery, University of South Florida College of Medicine
Contributor Information and Disclosures

Updated: Oct 16, 2009

Treatment

Medical Therapy

Proximal humerus fractures may be treated nonoperatively with an initial period of immobilization followed by early motion. Initial immobilization may be achieved with a sling, shoulder immobilizer, or a sling with an accompanying swathe. These devices provide varying degrees of constraint. Depending on the fracture type and the patient's body habitus, each of these devices may be helpful. Additionally, because the patient's axilla will be apposed for a prolonged period, a simple pad may be placed in the axilla to minimize skin chafing.¹¹

If the fracture is stable, gentle range-of-motion exercises may begin after 7-10 days. However, an unstable fracture may lead to early fracture displacement. In general, unstable fractures are much more painful and often require surgical stabilization to achieve adequate pain relief.

Physical therapy may be initiated after 3 weeks, and may allow a more expeditious return of upper extremity function. However, aggressive passive and active-assisted range of motion must not be performed until bony union has occurred.¹²

Surgical Therapy

Surgical management of proximal humerus fractures may be divided by fracture type (eg, Neer type, anatomic type, greater tuberosity, surgical neck, anatomic neck, articular surface, lesser tuberosity fragments) or by method of fixation (eg, closed reduction with no fixation, percutaneous fixation, open reduction with internal fixation, humeral head replacement associated with tuberosity fixation).^13,2

Greater tuberosity fractures, 2-part

Displacement of greater tuberosity fractures usually is posterior and superior. Attempts at closed reduction typically are unsuccessful, except in cases with an associated anterior dislocation, in which closed reduction of the fragment may be adequate. However, close scrutiny of the lateral y-view and the axillary view are needed to avoid persistent posterior displacement that can heal in a malunited position and lead to a mechanical block of motion. Up to 8% of greater tuberosity fractures are associated with an anterior dislocation; these fractures have the highest incidence of axillary nerve injury.

To optimize shoulder function, open treatment is recommended for greater tuberosity fractures displaced 5 mm or more. The type of greater tuberosity fracture influences surgical approach and fixation. Fragment sizes may vary from small to large. A small fragment that is displaced primarily superiorly is a result of an avulsion of the supraspinatus muscle. This fracture is approached anterosuperiorly, much like a rotator cuff repair, complete with an acromioplasty.

An alternative approach is a deltoid-splitting approach, but instead of taking the deltoid off the anterior acromion,¹⁴ it is peeled off the posterior acromion, which avoids the acromioplasty and minimizes weakening of the anterior deltoid. This approach is especially helpful if the fragment is displaced posteriorly. Fixation of smaller fractures can be accomplished with heavy sutures, wire, or, occasionally, screws. Associated rotator cuff tears should be closed.

Larger fractures with a spiral or oblique configuration can extend several centimeters into metaphyseal bone. A deltopectoral approach allows adequate exposure for reduction and proper fixation, which may require a distal exposure for drill holes for sutures or wires. The axillary nerve is in danger if a deltoid-splitting approach is used for this type of fracture pattern. Fixation with heavy suture, wire, and, possibly, screws may be considered for these fractures.

Lesser tuberosity fractures, 2-part

Displacement of the lesser tuberosity often is medial, and closed reduction with internal rotation often can place the tuberosity in satisfactory position. Therefore, open treatment of these fractures may not be necessary. However, posterior dislocation can result and should be suspected in the isolated lesser tuberosity fracture. For the unstable shoulder following posterior dislocation, with the arm in internal rotation, use a trial of closed reduction with an external rotation brace (eg, gunslinger type of brace). Attention to reduction of the lesser tuberosity is necessary to avoid nonunion and malunion.

Occasionally, a reverse Hill-Sachs lesion of the humeral head may be present. If less than 40% of the head is involved and the shoulder is unstable, with closed reduction, advancement of the lesser tuberosity into the head defect can be performed (McLaughlin procedure). Therefore, CT scans may be helpful to assess humeral head involvement in lesser tuberosity fractures.

Surgical neck fractures, 2-part

Displacement of surgical neck fractures typically produces an angulation with an anterior apex, and medial displacement of the shaft due to the pull of the pectoralis major. Reduction maneuvers include flexing and adducting the arm to relax the displacement forces. Occasionally, interposition of the long head of the biceps can block reduction. In cases in which closed reduction can be accomplished, treatment options include closed reduction alone (if reduction is stable), percutaneous fixation, and open reduction and internal fixation. Closed reduction alone under general anesthesia offers limited morbidity, but it may allow gradual loss of reduction, leading to malunion that will produce motion loss to a minimum of 1° per degree of deformity. For example, a 45° anterior angulation produces a 45° loss of anterior flexion.

Percutaneous pinning has been advocated with the use of 2.5-mm terminally threaded AO/ASIF pins. This technique can be challenging technically; in osteoporotic bone, it may have associated hardware problems. Frequent reoperations may be necessary for pin removal. Open reduction and internal fixation for surgical neck fractures in which closed reduction can be accomplished has the potential for increased operative morbidity when compared to the above-described closed techniques. However, this procedure may provide a more stable construct, allowing a more dependable functional outcome.

A method of limited open reduction with internal fixation utilizing intramedullary devices has been described. A variety of devices have been used with this technique. The authors' preferred technique is with a long, thin staple device, and is performed through an anterior superior approach. In cases in which closed reduction cannot be accomplished, an open deltopectoral approach allows a safe approach to the fracture.

Once satisfactory reduction is achieved, a variety of fixation techniques can be selected. The pattern of these fractures can vary; in unstable oblique or spiral fractures, plate fixation may be preferable. The use of a 90° blade plate that has been adapted for the proximal humerus provides an enhanced application in osteoporotic bone. Intramedullary devices or pin fixation can also be used, particularly if the fracture pattern is stable. Another popular technique uses a combination of modified Enders nails with a tension band suture or wire.

Anatomic head fractures, 2-part

This rare injury can occur in conjunction with humeral head dislocation. In general, it has a very guarded prognosis because of the compromised blood supply to the head segment. Open reduction and internal fixation can be difficult because of the limited bone available for fixation devices to be placed. Wire or suture tension band techniques have been utilized with attention to meticulous handling of soft tissue. Primary humeral head replacement also is performed for anatomic head fractures. This can be attractive, as the tuberosities can be left intact, and soft-tissue management is straightforward because contracture or scar has not developed. Additionally, if the metaphyseal bone stock is maintained, uncemented placement of the stem may be reasonable.

Three-part fractures

Three-part proximal humerus fractures usually are rotary fracture-dislocations in which one tuberosity is displaced and retracted by its attached rotator cuff musculature. The humeral head and the other tuberosity remain attached and are subluxated or dislocated, rotating according to the pull of the attached rotator cuff. Blood supply to the head may be preserved by the retained soft-tissue attachments. However, the risk of avascular necrosis remains approximately 14%. These fractures nearly always require open surgical management.

Preoperative planning should include a complete history and physical examination with a thorough neurovascular examination of the affected extremity. If vascular injury is suspected, obtain an angiogram and vascular surgery consultation immediately. Document any neurologic deficits. Radiographic studies should include AP, lateral, and axillary views, and CT scan of the affected shoulder. Routine preoperative laboratory studies should be obtained (CBC, BMP, coagulation studies, and type and cross-match). Obtain appropriate consultations prior to surgery.

Elderly patients with poor tissue quality and osteoporosis usually require primary hemiarthroplasty and, if necessary, rotator cuff repair. In younger patients, make every effort to retain the humeral head. Informed consent forms should include the possibility of hemiarthroplasty in case the decision is made intraoperatively that fixation is an inappropriate treatment.

Prior to surgery, fully inform patients of the intensive postoperative rehabilitation required, the possibility of residual stiffness, and the possibility of reoperation (for removal of painful hardware, for capsular release and lysis of adhesions, for treatment of nonunion, and for possible conversion to hemiarthroplasty or total shoulder arthroplasty should avascular necrosis or posttraumatic arthritis occur).

Four-part fractures

Four-part fractures have detachment of both tuberosities and dislocation of the humeral head from the glenoid. The tuberosities are retracted in the direction of the pull of their respective rotator cuff musculature.

No viable soft-tissue attachments remain to the humeral head, rendering it avascular. The incidence of avascular necrosis is approximately 34%. These fractures all require open surgical management if a viable shoulder is to be obtained.

Preoperative preparation is the same as described for 3-part fractures and includes obtaining complete history and physical examination, paying close attention to neurovascular examination of the affected extremity. Radiographic evaluation should include AP, lateral, and axillary views, and CT scan. Obtain appropriate laboratory studies and specialty consultations prior to surgery. Results are best if surgery is performed within 2 weeks of injury. Longer delays result in retraction of the tuberosities with concomitant atrophy of cuff musculature, thereby compromising outcome.

Intraoperative Details

Three-part fracture operative technique

The patient with a proximal humerus fracture is placed in the beach-chair position. Fluoroscopy is placed, and scout images are obtained prior to preparing and draping. Take care throughout the surgery not to apply excessive traction to the affected extremity as this can injure the brachial plexus. Intravenous antibiotics are administered prior to skin incision. Additionally, place proper padding where necessary to avoid compression of neurovascular structures (eg, by straps).

A deltopectoral approach is used. The authors preserve the cephalic vein and retract it medially with the pectoralis major following coagulation and division of the perforating veins from the deltoid. This is done to avoid damaging the vein during placement of retractors under the deltoid during operation. The clavipectoral fascia is divided, and the subacromial, subdeltoid, and subcoracoid spaces are carefully developed. The conjoint tendon only should be retracted medially to avoid injury to the musculocutaneous nerve. The axillary nerve then is localized in the subdeltoid and subcoracoid spaces by gently sweeping the finger in a proximal-to-distal fashion. Its position is confirmed by gently tugging on it in the subcoracoid space while palpating it in the subdeltoid space and vice versa. Intermittently apply this test throughout the operation to detect accidental fixation or entrapment of the nerve.

The long head of the biceps tendon is localized distally under the insertion of the pectoralis major muscle and followed proximally to locate the rotator interval, which then is opened. Care is taken to avoid excessive soft-tissue stripping to maintain the blood supply of the humeral head, particularly the arcuate branch of the anterior humeral circumflex artery. The displaced tuberosity is identified and 2 No. 5 nonabsorbable sutures are placed at the bone-tendon junction. These are used to apply traction and fixation of the fragment. Any adhesions are carefully lysed to mobilize the tuberosity. The authors also place 2 No. 5 nonabsorbable sutures through drill holes in the shaft straddling the bicipital groove 1 cm below the fracture site at the surgical neck. These are used to apply supplementary figure-of-eight fixation.

The head and its attached tuberosity then are reduced and fixed with the instrumentation of choice. The authors prefer the use of an Evans staple, although other devices (eg, intramedullary rod) may be used. If an AO/ASIF T plate is used, avoid excessive soft-tissue stripping. The fracture pattern at the surgical neck must be evaluated, as this dictates the type of instrumentation used. For example, in a transverse fracture, the use of an Evans staple is appropriate. An oblique fracture may require the use of a blade plate.^15,16

Obtain fluoroscopic images at this time to ensure proper reduction. The displaced tuberosity then is reduced and fixed with a combination of cerclage sutures, supplemented by the previously mentioned figure-of-eight sutures attached to the shaft. If bone quality is good and comminution is not present, cancellous screws also may be incorporated to fix the tuberosity to the head. The authors also add a cottony Dacron suture with a Krakow weave to supplement areas of comminution. Obtain fluoroscopic images during tuberosity fixation to avoid overreduction or underreduction. The graft substitute then is placed at the tuberosity-head interface. Range of motion that does not derange stability is documented intraoperatively. The operative site then is irrigated abundantly, and standard closure is performed. The authors rarely find drains necessary.

An immobilizer is applied to the extremity in the operating room. A thorough neurovascular examination is performed in the recovery room. Direct particular attention to examination of the axillary and musculocutaneous nerves. Document any deficits immediately. The patient generally is hospitalized 2-5 days postoperatively. Prophylactic intravenous antibiotics are administered for 48 hours.

The authors protect the extremity in a shoulder immobilizer for 3-4 weeks, during which time passive exercises are instituted in accordance with the stable range of motion noted intraoperatively. The immobilizer then is replaced with a sling for an additional 2-3 weeks, and active range of motion is instituted progressively. If intraoperative stability is considered tenuous, the authors may elect to use an abduction pillow and allow minimal range of motion for up to 6 weeks while fracture healing is obtained. The patient is monitored in the clinic via serial radiographs at 10 days, 3 weeks, 6 weeks, 3 months, 6 months, and thereafter as needed.

If hardware causes impingement or pain, it may be removed once fracture healing is complete. Stiffness may require operative capsular release. Nonunions usually necessitate reoperation with osteotomy, bone grafting, and possible conversion to hemiarthroplasty.¹⁷ Avascular necrosis may require conversion to total shoulder arthroplasty.

Four-part fracture operative technique

The patient is positioned in a beach-chair position and prepared and draped. Fluoroscopy usually is not necessary. Prophylactic antibiotics are administered prior to incision. A deltopectoral approach is taken, as described for 3-part fractures. The axillary nerve is identified and examined intermittently during the surgery¹⁸ .

The following basic steps then are taken:

1. The lesser tuberosity fragment is identified, which often is a small fragment. Therefore, the authors also perform additional osteotomy of the remaining lesser tuberosity at the bicipital groove.
2. Two No. 5 nonabsorbable sutures are placed at the bone-tendon junction to be used for traction and later fixation. Adhesions to the lesser tuberosity are lysed, allowing its mobilization.
3. The articular head segment is removed from the glenoid vault. This may require removal of a portion of inferior capsular attachment. The head segment then is used to gauge the diameter of the implant and is morselized for grafting.
4. The greater tuberosity fragment is identified, and 2 No. 5 nonabsorbable sutures are placed at the bone-tendon junction. Adhesions are lysed, and mobilization is performed.
5. The glenoid vault is inspected, and any remaining bone fragments are removed. A glenoid sizer is used to verify the radius of curvature, allowing an appropriate match of the glenoid and prosthetic head. It also is evaluated for the presence of arthritis, which, if advanced, may warrant glenoid replacement as well.
6. The humeral shaft is exposed by extending and adducting the arm. Two blunt Hohmann retractors may be placed subperiosteally to aid in exposure, and the humeral shaft is reamed to determine canal size. Take care to hold the arm loosely during this procedure, as the torque from reaming a rigidly held humerus can cause fracture.
7. A modular trial stem is placed to determine height and version. With the arm at neutral, the head component should face the glenoid. Version is approximately 30° of retroversion. An alignment rod attached to the trial aids in obtaining this.
8. The appropriate head trial is selected, and the tuberosities are temporarily reduced. Range of motion then is evaluated.
9. Two holes are drilled in the humeral shaft straddling the bicipital groove 1 cm distal to the fracture site at the surgical neck. Two No. 5 nonabsorbable sutures are placed so that they exit through the cortex of the shaft. These will be used later for figure-of-eight fixation.
10. A cement plug is placed in the shaft 1.5 cm distal to the stem. Prior to placing the stem, a 3-mm cottony Dacron suture is placed in the medial hole of the prosthesis. The stem then is cemented in place.
11. The trial head is placed. Proper head size and height should allow approximately 50% anterior-posterior translation and 25% inferior translation with respect to the glenoid. The trial is removed, and the prosthetic head is placed on the stem.
12. The cottony Dacron suture attached to the stem then is passed through the bone-tendon junction.
13. Graft from the humeral head is placed at the tuberosity-stem interface. The tuberosities are reduced and fixed by the previously placed sutures in a cerclage fashion and the shaft sutures in a figure-of-eight fixation. The rotator cuff interval then is closed over the long head of the biceps tendon.
14. The wound is irrigated and closed in a standard fashion. An immobilizer is placed in the operating room, and postoperative care is instituted as detailed previously for 3-part fractures.

Complications

Neurologic and brachial plexus injuries

Neurologic and brachial plexus injuries occur in up to 50% of proximal humerus fractures. Anterior fracture dislocations may injure the axillary nerve. Carefully document any deficits, and monitor them via electromyography. Explore injuries showing no improvement at 3 months. The risk of nerve injury is increased in elderly patients, fractures at the surgical neck, dislocation, blunt trauma with associated hematoma, and in failed open reduction and internal fixation.

Vascular injuries

Injury to the axillary artery may occur in displaced proximal humerus fractures, usually following severe blunt trauma or penetrating trauma. This injury may also be seen with minimally displaced fractures in the elderly patient with arteriosclerosis due to lack of elasticity of the vessel walls. Although it is always important to evaluate the radial pulse, its presence in a case of vascular injury can be misleading because of collateral circulation.

Maintain a high index of suspicion, and proceed to an angiogram when signs of vascular compromise are present. These include expanding hematoma, pallor, paresthesias, pulselessness, unexplained hypotension, bruits, and pulsatile external bleeding. Perform arterial repair emergently when indicated. Failure to recognize and treat these injuries can have catastrophic consequences, including amputation, gangrene, and neurologic compromise (due to compression from the hematoma).

Stiffness or frozen shoulder

Stiffness or frozen shoulder may occur with nonoperative and operative management of proximal humerus fractures. This emphasizes the need for a directed physiotherapy program to maintain mobility during the postfracture and postoperative period. Patients who do not respond to stretching exercises may require operative management, including arthroscopic and/or open release of adhesions. Manipulation under anesthesia should not be performed alone, as risk of refracture exists.

Avascular necrosis

Avascular necrosis is seen in up to 14% of 3-part fractures treated with closed reduction and in up to 34% of 4-part fractures. This complication leads to pain and stiffness in the shoulder and may ultimately require total shoulder arthroplasty.

Malunions

Greater tuberosity malunions occur as a result of the pull of the rotator cuff. Displacement is superior if only the supraspinatus is involved. Union at this site may result in impingement syndrome. Displacement is posterior if the pull is predominately infraspinatus. Union at this site may result in posterior impingement against the glenoid, resulting in decreased external rotation. Indications for surgery include pain and loss of function. Superior tuberosity malunion may be treated with acromioplasty if it is not severe, or tuberosity osteotomy and cuff mobilization. Acromioplasty offers no benefit in posterior malunions, which are treated by tuberosity osteotomy and capsular release. Isolated lesser tuberosity malunions are very rare and will not be discussed.

Surgical neck malunions and malunions of 3-part fractures may be multiplanar in nature with combinations of rotation, flexion/extension, and varus/valgus deformities. Significant angulation may be accepted at the surgical neck. However, there is a concomitant loss of elevation. Additionally, varus malunion places the greater tuberosity in the subacromial space with loss of lateral humeral offset.

Malunion and avascular necrosis of the humeral head in 3- and 4-part fractures usually requires prosthetic replacement. Frequently, posttraumatic arthritis is present on the glenoid surface, and a glenoid component also should be used.

Malunion of a fracture-dislocation may be difficult to treat. The head component may be dislocated anteriorly or posteriorly. Great care must be taken in its mobilization and removal, as there may be adhesion of the neurovascular bundle in the associated scar tissue. Prosthetic replacement usually is necessary.

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