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Nonprosthetic Management of Proximal Humeral Fractures

Iannotti, Joseph P. MDPhD; Ramsey, Matthew L. MD; Williams, Gerald R. MD; Warner, Jon J.P. MD

Journal of Bone & Joint Surgery - American Volume: August 2003 - Volume 85 - Issue 8 - p 1578–1593
Instructional Course Lecture

Joseph P. Iannotti, MD, PhD; Department of Orthopaedic Surgery A-41, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address:

Matthew L. Ramsey, MD; Gerald R. Williams, MD; Presbyterian Hospital, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA 19104

Jon J.P. Warner, MD; Harvard Shoulder Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 275 Cambridge Street, Fourth Floor, Boston, MA 02114

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Indications and Diagnosis

Most proximal humeral fractures are not sufficiently displaced or angulated to require surgical management. It is estimated that 20% of all proximal humeral fractures should be treated surgically 1, and humeral head replacement is the preferred method of treatment for many of those fractures. An indication for hemiarthroplasty is the classic four-part fracture or four-part fracture-dislocation, particularly when the articular segment of the humeral head is separated from the tuberosities and the humeral shaft, because of the expected high risk of osteonecrosis. Other indications for hemiarthroplasty are fragmentation of the articular surface and severe osteoporosis. On the other hand, reduction and internal fixation can be accomplished for displaced fractures associated with an intact humeral head with good-quality bone. The indications for open or closed reduction and internal fixation are related to the fracture pattern, the quality of the bone, the status of the rotator cuff, and the age and activity level of the patient. The goal of reduction and fixation of a proximal humeral fracture is to obtain nearly anatomic reduction and stable fixation to allow an early range of motion 2. Recently, there has been an emphasis on the use of less invasive open procedures for reduction and fixation, thereby minimizing periarticular scarring and decreasing the risk of vascular insult to the articular humeral head segment from the surgical exposure 3-5.

Accurate diagnosis and effective management of proximal humeral fractures require good-quality radiographs in at least two orthogonal planes. In general, basic radiographs include an anteroposterior view, an axillary view, and a scapular lateral (Y) view. Sometimes, in an emergency department setting, it is not easy to obtain all three of these views with sufficient quality to make a clear diagnosis and define the best treatment options. A computed tomography scan can be of value when the plain radiographs do not clearly define the size of the fragments or the degree of displacement. Although magnetic resonance imaging is rarely needed, it is indicated when the patient has symptoms suggestive of a preinjury shoulder disorder such as a rotator cuff tear. It can also be useful in the evaluation of the rotator cuff when the patient has persistent pain after the fracture has healed.

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Isolated Fracture of the Greater Tuberosity

Fractures of the greater tuberosity can be associated with an acute glenohumeral dislocation or a tear of the rotator cuff. When associated with a glenohumeral dislocation, the greater tuberosity fracture fragment is usually small and lies in a satisfactory position after reduction of the dislocation of the humeral head. In these cases, the size of the fragment, the amount of residual displacement, and the presence of a full-thickness rotator cuff tear determine the need for surgical management. In Neer's review of displaced proximal humeral fractures, ≥1 cm of displacement was considered an indication for surgical management 1,6. This general guideline may not apply to all cases of greater tuberosity fracture. Nonoperative treatment is usually recommended for such fractures that have <0.5 cm of superior displacement or <1 cm of posterior displacement. The difference between the amount of allowable superior displacement and the amount of allowable posterior displacement is due to the greater likelihood of symptoms associated with subacromial impingement when there is superior displacement. Patient age and activity level influence the decision to reduce and internally fix a displaced fracture of the greater tuberosity as nonoperatively treated fractures are likely to cause more pain in active individuals.

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Results of Surgery

Flatow et al. evaluated the results in twelve patients in whom an isolated acute fracture of the greater tuberosity had been treated with open reduction and internal fixation with use of a deltoid-splitting approach and suture fixation 7. The results were uniformly good or excellent. In that study, 0.5 cm of superior displacement was considered to be a sufficient indication for open reduction and internal fixation.

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Surgical Technique

The superior surgical approach—i.e., splitting of the deltoid—is ideal for smaller fracture fragments and for fractures associated with a rotator cuff tear. This approach allows direct exposure and repair of both the rotator cuff and the greater tuberosity ( Figs. 1-A and 1-B ). The innervation of the deltoid by the axillary nerve limits the distal extent of the superior approach to approximately 5 cm from the lateral aspect of the acromion. A large fracture fragment with diaphyseal extension is difficult to mobilize, reduce, and fix through the superior approach without undue risk to the axillary nerve and should be managed surgically through a deltopectoral approach. The deltopectoral approach enables distal placement of sutures, a plate, or screws into the fragment with less risk of injury to the axillary nerve. When a large fragment of the greater tuberosity is displaced posteriorly and is behind the humeral head, a bone hook can be used to pull the fragment into the surgical field. Then, placement of a traction suture into the rotator cuff to control and manipulate the fragment allows the fragment to be anatomically reduced to the proximal part of the humerus.

A fragment of the greater tuberosity is excised only when it is <1 cm in size. If the fragment is larger, excision makes rotator cuff repair very difficult, if not impossible. Therefore, most displaced fragments of the greater tuberosity should be saved and treated with open reduction and internal fixation. The method of fixation depends on several factors, including the size of the fragment, the quality of the bone, the degree of comminution, and the presence of an associated rotator cuff tear. Suture fixation with use of the rotator cuff for proximal fixation is preferable, particularly for smaller and comminuted fragments or for osteoporotic bone. Most fractures of the greater tuberosity are secured with a figure-of-eight suture as well as an intraosseous suture with number-5 or larger nonabsorbable suture material. Cancellous bone screws can be used for large noncomminuted fragments when the bone is of good quality. Bone screw fixation is often supplemented with a figure-of-eight suture ( Fig. 2 ).

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Persistent pain due to malunion of the greater tuberosity can occur with as little as 0.5 cm of superior displacement. The symptoms result from subacromial impingement. Such subacromial pain can be treated with subacromial decompression if the displacement is <1 cm. If the displacement is minimal and the fragment is ≤1 cm in size, excision of the osseous prominence that is causing impingement followed by rotator cuff repair can yield a satisfactory result. When the greater tuberosity is displaced >1 cm, an osteotomy of the fragment is the preferred treatment ( Figs. 3-A and 3-B ). The fragment is then mobilized by dissection and release of scar tissue and the underlying capsule associated with the torn and scarred rotator cuff. Mobilization of the retracted rotator cuff tissue is required to reduce the greater tuberosity fragment to an anatomic position. Mobilization of the rotator cuff requires release of the rotator interval and the underlying capsule at the site of the fracture.

Beredjiklian et al. evaluated the results at an average of forty-four months after surgical management of a proximal humeral malunion in thirty-nine patients, eleven of whom had an isolated malunion of a fracture of the greater tuberosity 8. These eleven malunions were treated with a combination of osteotomy and fixation of the tuberosity or subacromial decompression and excision of a portion of the impinging fracture fragment. When the tuberosity was osteotomized, capsular release was required to obtain a full passive arc of motion and to achieve cuff repair. Nine patients had a satisfactory result. The results of the surgical management of malunions of the greater tuberosity have been reported to be less favorable than the results of reduction and fixation of acute fractures 9. However, the results of surgical management of an isolated greater tuberosity malunion are generally more favorable than the results of surgical management of malunions that also involve the surgical neck or both tuberosities (three and four-part malunions).

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Surgical Neck Fractures

Surgical neck fractures are often undertreated and are associated with a relatively high risk of malunion or nonunion. Malunion can be fairly well tolerated if the relationship of the articular surface and the tuberosities is not distorted. Fracture classifications, although very good, tend to underestimate or overestimate the severity of the fractures because the quality of the bone or the health and understanding of the patient are not always considered 1,10,11. With this in mind, one can define two distinct patient groups who should be treated with different approaches, even when the fracture is the same 12.

One group consists of young patients, more often male, who sustain high-energy trauma. This sometimes causes fragments to be impacted, but more often than not there is comminution. Typically, the bone quality is good with thick cortices and dense cancellous structure. The patient is usually able to comply with postoperative therapy. This group can be treated with a variety of surgical methods, including open reduction and internal fixation.

The second group consists of elderly patients, more often female. Minor trauma, such as a fall, causes impaction or comminution of thin cortices and porous cancellous bone. An unstable configuration of thin bone fragments is the rule. Elderly patients sometimes have a poor understanding of the nature of the surgery or their role in the postoperative rehabilitation, may have comorbid medical conditions that adversely affect the outcome, and often are frail and have a limited social support system to aid in postoperative recovery. Rigid internal fixation devices often fail when applied to thin porous bone, so fixation options may be more limited in these patients. In some cases, it is better to perform a hemiarthroplasty because of poor-quality bone.

Indications for stabilization of a surgical neck fracture include a displaced unstable fracture, multiple trauma, association with other upper-extremity fractures, vascular injury, and a patient who will comply with a postoperative regimen.

Percutaneous internal fixation is an excellent option for a displaced two-part fracture that can be reduced with closed manipulation. While this technique can be difficult and tedious, it offers several advantages. There is almost no dissection of the soft tissues, which minimizes the risk of the articular segment becoming avascular.

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Surgical Technique

The technique of closed reduction and percutaneous fixation of proximal humeral fractures was originally described by Bohler 13 for the treatment of fractures in children, but it has become a standard treatment method for displaced two-part fractures when the patient has good-quality bone and minimal comminution.

There are several pitfalls with this treatment. The first is improper patient selection. The ideal indication is a displaced two-part fracture of the surgical neck that can be reduced by closed manipulation with the patient under anesthesia. Marked comminution or the inability to reduce the fracture are contraindications to this technique. Another pitfall is related to patient positioning, draping, and fluoroscope placement in the operating room. The patient should be positioned on the operating table so that the arm is free to be manipulated and biplanar fluoroscopic image intensification is possible. While use of a fluoroscopic operating table is preferred by some, we prefer to place the patient supine onto a long bean bag that can be contoured around the scapula, allowing the patient to be moved sufficiently laterally for c-arm visualization. The c-arm is brought in from a cranial direction, and a closed reduction, confirmed in two planes, is performed before preparation and draping of the shoulder for surgery ( Figs. 4-A and 4-B ).

A third pitfall is related to the reduction maneuver. Usually, two-part fractures have an apex anterior angulation. In such cases, some longitudinal traction is applied while posteriorly directed pressure on the humerus is used to correct the anterior angulation. It is helpful to have a sterile arm-positioner to hold the arm in place of an assistant. Once the reduction is confirmed, the arm is prepared in a sterile fashion and fixation pins are placed under image-intensification control. Two and a half-millimeter terminally threaded pins (AO; Synthes, Paoli, Pennsylvania) are preferred for the internal fixation. The terminal threads of these pins help to prevent migration. In some patients, cannulated 4.0-mm screws can be used to fix the fracture.

The pinning technique has been described in detail previously 14. Once the fracture has been reduced, a pin is held in front of the shoulder and an image in the anteroposterior plane confirms proper orientation. A small stab incision is then made, and a straight clamp is used to spread the soft tissue down to the lateral humeral cortex. Two pins are then inserted, from inferior and lateral up into the articular fragment, and biplanar confirmation of proper pin placement is performed. Next, a third pin is placed from a more anterior and distal orientation. In the case of a three-part fracture with an unstable greater tuberosity fragment, one or two additional pins can be placed through this fragment and down into the humeral shaft ( Fig. 5 ). The pins are trimmed so that they lie underneath the skin, and then all incisions are closed with sutures. The shoulder is placed in an immobilizer, which the patient wears for four to six weeks. Pendulum exercises are instituted immediately after treatment of two-part fractures. When a proximal pin was used to secure a greater tuberosity fragment, no motion is begun until three weeks after the surgery, at which time the proximal pins are removed and pendulum exercises are begun. The patient should be evaluated weekly in the physician's office for the first two postoperative weeks to ensure that the pins do not become prominent as the soft-tissue swelling around the pins subsides. Serial radiographs are made at each visit to monitor for movement of the pins. If the pins do become prominent, they should be trimmed back to a subcutaneous position. The pins are usually removed between four and six weeks after surgery, either in the physician's office or in an operating room. After the pins have been removed, active motion is commenced. In general, stiffness is not a problem as the joint was not violated by surgical dissection.

Intramedullary fixation with use of combinations of rods, wires, and sutures to treat two-part fractures of the surgical neck has also been described 15. Although this method has been successful when it has been performed properly by some surgeons, there are concerns about torsional rigidity and the risk of displacement. Furthermore, impingement by a prominent rod can be a problem ( Fig. 6 ).

An elderly patient with a two-part fracture of the surgical neck may have osteoporotic bone, precluding rigid fixation. To address this, Banco et al. described a method of fixation termed the parachute technique. 16 With this method, heavy sutures of 5-mm Dacron are placed through the rotator cuff tendons and then through drill holes in the humeral shaft distal to the fracture so that stability is achieved through impaction and compression of the fracture ( Figs. 7-A, 7-B, adn 7-C ).

A displaced comminuted surgical neck fracture associated with good-quality bone can be treated successfully with a special blade-plate ( Figs. 8-A , 8-B, and 8-C ). Preoperative planning is essential, especially when there is extensive comminution, so that length can be restored. Long arm radiographs of both humeri allow the surgeon to determine the proper length and to restore the fractured humerus to match the humerus on the contralateral side. An AO distractor can be used to restore length, and then the blade-plate can be applied. Since no dissection is required in the region of the medial soft tissues adjacent to the bicipital groove, the risk of devascularizing the humeral head fragment is reduced.

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Three-Part Fractures

The muscles that are attached to the fracture fragments create deforming forces. Awareness of the common patterns of three-part proximal humeral fractures and an understanding of the muscle forces that act on the fracture fragments allow one to adjust the treatment for each patient.

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Deforming Forces

In three-part fractures, fracture lines occur through the surgical neck and the greater or lesser tuberosity. Involvement of the greater tuberosity is much more common than involvement of the lesser tuberosity. The greater tuberosity is displaced superiorly and posteriorly by the pull of the attached supraspinatus, infraspinatus, and teres minor. The degree of displacement depends largely on the location of the fracture line with respect to the rotator cuff insertion. The humeral head fragment is pulled into internal rotation by the attached subscapularis, and the shaft is displaced anteriorly and medially by the pull of the pectoralis major. These forces, combined with the proximal pull of the deltoid, produce retroversion of the humeral head.

With a three-part fracture with a lesser tuberosity fragment, the lesser tuberosity is displaced medially by the attached subscapularis. The humeral head and the greater tuberosity fragment are pulled into adduction and external rotation. The shaft is pulled anteriorly and medially by the pectoralis major and proximally by the deltoid.

An understanding of the deforming forces is critical since these forces must be neutralized to achieve a satisfactory reduction of the fracture and the fixation devices must be capable of withstanding the continuous muscle forces. The options for internal fixation include interfragmentary fixation with sutures or wire, percutaneous pinning, plate-and-screw fixation, and intramedullary fixation with and without suture supplementation.

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Surgical Technique

Regardless of the method of fixation, adequate surgical exposure is critical. For most three-part fractures, an extended deltopectoral approach provides the exposure necessary to mobilize and fix the surgical neck and tuberosity components of the fracture. The fracture of the greater tuberosity is more easily managed through a superior deltoid-splitting approach, but fixation of the surgical neck portion of a three-part fracture through this approach is possible only with an intramedullary rod.

There are two goals in the surgical management of three-part proximal humeral fractures. The first is to obtain an anatomic reduction of the fracture fragments, and the second is to neutralize the deforming forces to prevent displacement of the fragments following fixation. Often these two goals can be achieved simultaneously within the fixation construct. However, several techniques achieve these goals independently.

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Interfragmentary Fixation

Interfragmentary fixation with suture or wires is an established method for fixing three-part fractures of the proximal part of the humerus 17,18. Neutralization of the forces about the humerus requires achievement of both horizontal and vertical stability across the fracture. To obtain adequate suture fixation in osteopenic bone or comminuted tuberosity fragments, the sutures must be passed at the tendon-bone junction of the tuberosity. Accurate placement of the sutures into the humeral head in the anterior-to-posterior and superior-to-inferior directions is imperative. When the sutures that have been passed through the tuberosity are then passed into the humeral head fragment, they must be placed at the margin of the fracture bed because, when they are placed in the fracture site, the tuberosity fragment tends to be displaced as the sutures are tied. The same is true for the sutures directed in the superior-to-inferior direction. Superior displacement of the tuberosity fragment should be avoided because it can cause subacromial impingement.

The sutures form a figure-of-eight tension-band configuration. Heavy nonabsorbable suture is recommended. We currently use number-2 fiberwire suture (Arthrex, Naples, Florida). Drill holes are made in the shaft fragment about 1 to 2 cm distal to the fracture site along the medial and lateral ridges of the bicipital groove. Then horizontal sutures are passed through the fractured tuberosity fragment at the bone-tendon junction and through the intact tuberosity of the humeral head fragment. Finally the sutures are crossed and passed through the drill holes in the shaft fragment, forming a figure-of-eight. As these sutures are tied, the major deforming forces across the fracture are neutralized ( Figs. 9-A and 9-B ).

A potential complication associated with use of the figure-of-eight tension-band technique as the only means of fixation is overlap of the fracture fragments as the sutures are tied. In order to maintain the fracture reduction as the sutures are tied, interfragmentary sutures can be placed through the fracture site 12. Drill holes are placed at the fracture margins, on corresponding sides of the fracture fragments, and a figure-of-eight suture is passed with the suture crossing at the fracture site. This prevents the fracture fragments from overlapping when the tension-band neutralization suture is tightened.

Hawkins et al. reported satisfactory results in twelve of fourteen patients treated with a wire tension-band construct 17. However, forward elevation was limited to approximately 120°, and avascular necrosis of the humeral head developed in two patients.

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Percutaneous Pinning

Percutaneous pinning of three-part proximal humeral fractures requires advanced skills; good bone stock; minimal comminution, particularly of the tuberosity fragment; and a patient who is able and willing to cooperate with treatment. A retrograde lateral pin, a retrograde anterior pin, or a retrograde anterolateral pin can be used. The retrograde anterolateral pin is most commonly employed to achieve percutaneous fixation of the shaft to the humeral head. A fourth option, an antegrade superolateral pin, can supplement the retrograde pin if instability is a problem, but it will slow rehabilitation because it will impinge on the acromion.

Necessary equipment includes a c-arm and image intensifier, 2.5-mm terminally threaded pins, a pin cutter, a small cannulated-screw system, a small to medium-sized periosteal elevator, and a reduction pick or hook. A knowledgeable assistant is always helpful, and a skillful radiology technician to operate the c-arm and image intensifier is mandatory.

The patient is placed in the beach-chair position with the back of the operating table elevated approximately 30°. The c-arm is positioned so that anteroposterior and axillary images can be made. Through a stab incision at the level of the surgical neck, the humeral head is elevated with a reduction tool, reestablishing the neck-shaft angle. The retrograde pins are placed to obtain fixation of the humeral head to the humeral shaft. The greater tuberosity fragment is reduced to the head-shaft composite with use of a reduction pick and is provisionally fixed with a guide-wire for the 4.0-mm cannulated-screw set. When the tuberosity has been reduced satisfactorily, a screw of appropriate length is placed.

Percutaneous pinning of three-part fractures of the proximal part of the humerus is technically demanding. A transitional step before performing the fully percutaneous technique is performing open reduction and internal fixation of the greater tuberosity fragment through a superior deltoid-splitting approach followed by percutaneous pinning of the surgical neck component of the fracture. The deltoid split is performed between the anterior and middle thirds of the deltoid, with the anterior third of the deltoid released in continuity with its periosteal sleeve from the acromion. The tuberosity fragment is then fixed to the head fragment with an interfragmentary suture technique. The surgical neck component can be anatomically reduced through the superior deltoid split. Under fluoroscopic guidance, the surgical neck component can then be fixed percutaneously. Once the surgeon has become comfortable with this technique, he or she can transition to a fully percutaneous technique.

Resch et al. reported good to very good functional results with percutaneous pinning of three-part proximal humeral fractures 5. At twenty-four months, no patient in their study demonstrated radiographic evidence of necrosis of the humeral head. The expertise required to obtain such outstanding results of the treatment of these difficult fractures cannot be overstated.

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Plate-and-Screw Fixation

The results of plate-and-screw fixation of three-part proximal humeral fractures have been mixed. Although some authors have reported excellent results 19,20, this approach has typically been associated with a high complication rate, particularly in elderly patients 21-25. Earlier implants were poorly designed, and placement of those implants required extensive soft-tissue stripping, which placed the vascular supply to the humeral head at risk. Currently, there is a renewed interest in plate-and-screw fixation with the development of better implants, including the fixed-angle blade-plate and the locking anatomic proximal humeral plates.

The indication for plate-and-screw fixation is a comminuted fracture, particularly one involving the tuberosity and the surgical neck and requiring rigid fixation. An extended deltopectoral incision is utilized to approach the fracture, and the tuberosity fragment is first reduced to the humeral head with interfragmentary sutures. If a blade-plate is utilized, a guide-wire is advanced into the humeral head under fluoroscopic guidance and a plate of appropriate length is selected. If an anatomic proximal humeral locking plate is chosen, it is placed along the greater tuberosity and diverging, locked screws are placed into the humeral head. Then, the head is anatomically reduced to the shaft, and bicortical shaft fixation is performed.

If bone quality is a concern, neutralization sutures can be placed at the bone-tendon junction and passed through one of the holes of the plate to counteract the pull of the rotator cuff on the head and tuberosity fragments.

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Intramedullary Fixation

There are two types of intramedullary fixation of three-part proximal humeral fractures: (1) intramedullary fixation as the sole means of fixation 2, and (2) intramedullary fixation with Ender rods supplementing a tension band. The second type is the preferred method of intramedullary fixation because it provides longitudinal and rotational stability to the fracture.

These methods are technically demanding. Since the fracture line in the greater tuberosity fragment is at the articular margin, insertion of an intramedullary rod at the articular margin may displace the fragment. When there is a fracture of the lesser tuberosity, the entry point for the medullary canal is unaffected. Therefore, intramedullary fixation is probably better for three-part fractures with a fracture of the lesser tuberosity than it is for those with a fracture of the greater tuberosity.

Management of the Ender rods and sutures can be cumbersome, even in two-part fractures of the proximal part of the humerus. The application of this technique to three-part proximal humeral fractures requires, in addition, management of the tuberosity fragment.

The peril associated with Ender rod fixation of three-part fractures involving the greater tuberosity is the need for a bone bridge between the margin of the tuberosity fracture and the articular margin to place the rods into the medullary canal. It has been recommended that the Ender rods be modified by creation of an additional hole above the manufactured hole through which to place sutures and keep the rod distal to the level of the greater tuberosity ( Figs. 10-A, 10-B , 10-C, 10-D, and 10-E ) 15. The superior hole is used to form a tension-band construct that neutralizes the deforming forces across the surgical neck. Two additional sutures are placed through the lower hole, with one limb of each suture coming out of drill holes placed in the shaft fragment. These sutures counteract the tension-band suture that is trying to pull the Ender rod out of the medullary canal.

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Valgus Impacted Four-Part Fractures

The valgus impacted four-part fracture is characterized by impaction of the lateral aspect of the humeral articular surface through a fracture of the anatomic neck 3-5,26,27. This lateral impaction results in a valgus deformity of the humeral head such that the articular surface faces superiorly, toward the acromion, rather than medially, toward the glenoid. As the articular surface is imploded into the proximal humeral metaphysis, the greater and lesser tuberosities typically displace from each other as well as from the humeral shaft through intertubercular and surgical neck fractures lines.

Although this displacement pattern may fit Neer's criteria for four-part fractures 1, the fracture does not behave as such because of at least two important factors. First, true valgus impacted four-part fractures are characterized by little or no displacement (i.e., translation) of the medial aspect of the humeral articular surface with respect to the medial aspect of the shaft. Second, the shaft, periosteum, displaced tuberosities, glenohumeral joint capsule, and rotator cuff form a single continuous sleeve of tissue 3-5,26,27. The lack of displacement between the medial aspect of the humeral articular surface and the shaft preserves the inferomedial part of the periosteum and its associated vessels. Therefore, the prevalence of necrosis of the humeral head (5% to 10%) is much lower than that associated with standard four-part fractures 3-5,26,27. Moreover, the continuous sleeve of tissue connecting the shaft, tuberosities, glenohumeral joint capsule, and rotator cuff imparts substantial stability and encourages anatomical or nearly anatomical reduction of the tuberosities when the head is reduced 3-5,26,27.

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Radiographic Features

Initial radiographs should include an anteroposterior view in the scapular plane, a transscapular lateral view (the Y view), and an axillary view 1. At first glance, the severity of valgus impacted four-part fractures may be underestimated. Closer inspection reveals the humeral articular surface to be facing superiorly. The displacement of the greater and lesser tuberosities (especially the greater tuberosity) may seem severe, but the relative tuberosity displacement is primarily the result of the valgus impaction of the humeral head ( Fig. 11 ). The intertubercular fracture line is typically posterior to the bicipital groove. This is an important consideration when operative reduction is being contemplated.

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Treatment Options

Potential treatment options include early mobilization, percutaneous reduction and internal fixation, open reduction and internal fixation, and hemiarthroplasty. The vast majority of valgus impacted four-part fractures are amenable to percutaneous reduction and internal fixation. Nonoperative treatment often results in painful malunion and therefore is indicated only for elderly, sedentary patients with medical comorbidities that preclude operative treatment. Percutaneous reduction and internal fixation is an excellent option for patients who have an acute injury (seven to ten days old), good bone quality, and minimal comminution and can be relied on to cooperate with treatment. Open reduction and internal fixation is primarily indicated for acute fractures that are not reducible by closed means, for severe osteopenic bone, for extensive comminution, or for fractures that are between ten days and four months old. Hemiarthroplasty is reserved for fractures that are more than four months old or the rare acute fracture in an elderly, sedentary patient with severe osteopenia.

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Percutaneous Reduction and Internal Fixation

The patient is positioned so that radiographs can be made in two orthogonal planes. This should be verified prior to sterile preparation and draping. The optimal patient position is semirecumbent in a beach-chair configuration, with the back of the table elevated 30° to 45°. The affected extremity should be positioned off the edge of the table to allow adequate c-arm access. The anesthesia equipment is moved to the opposite side of the table to allow the c-arm to enter the operative field from superior with the plane of the c-arm parallel to the table's edge ( Figs. 4-A and 4-B ). The arm and shoulder are then prepared and draped.

Successful percutaneous reduction and internal fixation may be accomplished by following a series of individual steps: percutaneous reduction of the articular segment, fixation of the head, reduction and fixation of the greater tuberosity, and reduction and fixation of the lesser tuberosity 1. Reduction and fixation is not always required for both tuberosities. This decision is made after reduction and fixation of the head.

A small Cobb periosteal elevator is used to reduce the humeral head on the shaft through a small incision in the skin. With the arm held in 20° to 30° of abduction and neutral rotation, the level of the intertubercular fracture is identified with fluoroscopy. A 1.5 to 2.0-cm incision is made on the anterolateral surface of the arm over the fracture. The elevator is placed through this incision, through the deltoid, and into the fracture under fluoroscopic guidance. It is then placed under the lateral portion of the humeral head. This position is again verified radiographically. A superiorly directed force is applied to the undersurface of the head with use of the elevator. This maneuver should be done carefully to avoid overreduction or translation of the humeral head. In acute fractures, the head usually reduces very easily and stays in the reduced position after the elevator is removed.

Once the head fragment is reduced, it is fixed in that position with percutaneously placed 2.5-mm terminally threaded pins. Two retrograde anterolateral pins are usually sufficient. The first pin is placed on the skin, its relationship to the humerus is visualized radiographically, and the entry site is located. The pin enters the arm midway between the anterior and lateral surfaces. After the skin incision is made, a hemostat is used to spread the soft tissues bluntly until the bone is identified. This lessens the risk of injury to the axillary nerve. The pin is placed on the anterolateral surface of the humerus and advanced to within 1 cm of the subchondral surface of the head under fluoroscopic guidance. Accurate pin placement typically requires angling of the pin 45° medially and 30° posteriorly ( Figs. 12-A and 12-B ). A second pin is placed parallel and slightly superior or inferior to the first one. At least 1 cm should separate the pins at their site of entry into the bone. Accurate placement of the pins and the quality of the reduction are evaluated by rotating the humerus in a 90° arc of motion while continuously visualizing the humerus under fluoroscopy.

The greater tuberosity is often found to be anatomically reduced after the head has been reduced. If the tuberosity is anatomically reduced and is stable with motion (as assessed fluoroscopically), it should not need additional fixation. If reduction and fixation of the greater tuberosity is required, a 5-mm incision is made at the midpart of the acromion, approximately 2 to 3 cm distal to the lateral acromial border. A reduction hook or a small elevator is placed through this incision, through the deltoid, and down to the tuberosity surface. The tuberosity is reduced by pulling it forward and slightly distally. A guide-wire from a small cannulated-screw set is then placed percutaneously through the greater tuberosity approximately 1 cm inferior to its most superior edge. The guide-wire is then passed across the humerus and into the subchondral bone of the humeral head at an approximately 90° angle with the shaft. Accurate placement of the guide-wire is verified radiographically in two planes (by rotating the humerus). After measurement of the length of the screw, an appropriately sized cannulated screw is placed. Initial predrilling and tapping of the humerus usually is not necessary. A second, parallel screw is placed in a similar fashion approximately 1.5 cm distal to the first. Accurate screw placement is verified fluoroscopically.

The lesser tuberosity is visualized by rotating the c-arm, without moving the humerus. Residual displacement of the lesser tuberosity is better tolerated than is residual displacement of the greater tuberosity; therefore, it is important to visualize these relationships accurately 1,2 ( Figs. 13-A , 13-B, and 13-C ). A nonanatomic relationship between the lesser tuberosity and the articular surface may be misinterpreted as displacement of the tuberosity rather than residual displacement of the head. If the problem is residual displacement of the head, the relationship between the shaft and the lesser tuberosity will be normal, despite displacement between the head and the lesser tuberosity. Under these circumstances, it is probably better to accept a small (0.5 to 1.0-cm) amount of residual head displacement than to redo the previously placed fixation. If there is residual displacement of the lesser tuberosity, reduction is achieved with a reduction hook placed through the previously made anterolateral incision. Percutaneous screw fixation can be achieved through an anterior incision. Two parallel anteroposterior screws are placed with use of the same technique as used for the greater tuberosity.

The pins are cut under the skin, and the wounds are closed in a standard fashion. Pendulum exercises are instituted the next day. Passive flexion and external rotation with the patient supine are begun during the third postoperative week. The pins are removed at three to four weeks. More aggressive passive stretching and strengthening are instituted at six weeks after reduction.

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Open Reduction and Internal Fixation

Open reduction and internal fixation usually is not required for acute four-part fractures, except when an acceptable reduction could not be attained percutaneously. Under these circumstances, the patient and the c-arm are positioned as described above. The fracture is exposed through a standard deltopectoral incision. The head is then reduced by placing an elevator through the intertubercular fracture line under direct visualization. Percutaneously placed pins are then used as described above to fix the head and shaft fragments. Next, the tuberosities are sutured to themselves with interfragmentary nonabsorbable sutures.

Subacute fractures more than ten days but less than four months old are routinely treated with open reduction and internal fixation. Patient and c-arm positioning is identical to that described above. The fracture is exposed through a standard deltopectoral approach. The intertubercular fracture line is identified and may need to be recreated with an osteotome. The greater and lesser tuberosities are levered open to make them more mobile and to allow access to the undersurface of the valgus impacted head fragment. A small osteotome is used to score the medial junction of the head fragment and the shaft. Care is taken to avoid complete perforation of the medial cortex. The head is then elevated with a small elevator. In the subacute situation, there is a tendency for the head to redisplace into valgus. Therefore, allograft cancellous chips are packed under the elevated head. Fixation of the head can be performed with a number of devices. A humeral blade-plate is an excellent option in this setting because of its rigidity ( Figs. 14-A, 14-B , 14-C, and 14-D ).

Pendulum exercises are instituted on the first postoperative day. Passive flexion and external rotation exercises with the patient supine are added at seven to ten days. More aggressive stretching and strengthening exercises are started at six weeks after surgery.

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2004 in Instructional Course Lectures, Volume 53. The complete volume can be ordered online at, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

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