NONPROSTHETIC MANAGEMENT OF PROXIMAL HUMERAL FRACTURES


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Indications and DiagnosisMost 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.Isolated Fracture of the Greater TuberosityFractures 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.Results of SurgeryFlatow et al.

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