Greater tuberosity fractures

Isolated displaced GT fractures are relatively uncommon and account for a small percentage of PHFs. ^, As such, these fractures require a high index of suspicion as they may be subtle or missed by healthcare providers ( Fig. 15.10 ). As with most proximal humerus fractures, these fractures typically occur following a fall onto an outstretched hand but also are commonly associated with an anterior instability episode of the shoulder where the tuberosity is sheared off following impaction of the humerus on the glenoid rim during dislocation.

Anteroposterior Grashey view of a greater tuberosity fracture with superior displacement (arrows). These fractures can be subtle, especially when superimposed on the humeral head, and require orthogonal radiographs.

Evaluation of patients with GT fractures is similar to all PHFs, including a focused history and physical examination. However, as these injuries are commonly associated with instability of the shoulder it is paramount that a thorough neurovascular exam be performed. Peripheral nerve injury occurs in nearly 33% of patients following a shoulder fracture-dislocation, especially in patients older than 50 years. Isolated axillary nerve injuries are the most common nerve injury associated with two-part GT fracture-dislocations. ^,

Imaging is used to both identify the fracture as well as assess severity of displacement. A shoulder trauma series will often provide sufficient clarity of the fracture severity and displacement; however, a Grashey view with the humerus in external rotation has been found to help profile the GT and clarify severity of displacement. In many circumstances a CT scan with 3D reconstruction can be helpful as well. Evaluation of the CT should also look for glenoid injury, which can occur in cases of fracture dislocation. MRI can provide additional information in some scenarios as well, especially in older patients where there is the potential of preexisting rotator cuff pathology. This is especially true in GT fractures with isolated posterior displacement, as this would indicate that the fragment is only being displaced by the posterior cuff musculature, as opposed to a more typical posterosuperiorly displaced fragment, which is pulled by both the supraspinatous and posterior cuff. The presence of an associated acute versus chronic rotator cuff tear can impact decision-making in these injuries.

The amount of tuberosity displacement guides the decision-making regarding surgical intervention. In view of Neer’s criteria regarding displacement, most authors agree that the shoulder has little tolerance for GT displacement. McLaughlin suggested that displacement of 5 mm or more can cause impingement and rotator cuff dysfunction. Furthermore, Park and colleagues have suggested that fractures in manual laborers or athletes with as little as 3 mm of displacement should be surgically reduced. The direction of displacement of the tuberosity is just as important as the amount of displacement. Posterior displacement can affect external rotation, but it is generally better tolerated than superior displacement, which results in subacromial impingement and weakness with active elevation.

Nonoperative treatment is reserved for nondisplaced and minimally displaced GT fractures and for low-demand elderly patients. Nonoperative treatment follows the principles outlined previously with a period of sling immobilization of 2 to 3 weeks followed by early PROM. As radiographic healing occurs, typically at around 4 weeks, patients can discontinue the sling and start active assisted and active ROM with progression of therapy. Strengthening exercises are initiated around 8 to 10 weeks, depending on patient’s motion and radiographic healing.

In 2013, Rath and colleagues reported the short-term clinical outcomes of 69 patients following nonoperative treatment of minimally displaced GT fractures (<3 mm). The average Constant score improved from 40 to 95 points. Of interest, the mean duration of pain relief and improvement in ROM from the time of injury was 8.1 months. While nonoperative treatment is appropriate with select fractures, one series reported a 26% incidence of GT fracture migration in patients younger than 70 years of age following a fracture-dislocation. Displacement of the GT was 5.6 times more likely with dislocation than without. As such, it is critical to serially monitor these patients with radiographs to avoid late displacement, especially in cases of GT fracture dislocation.

Indications and surgical technique of greater tuberosity fractures.

Operative intervention is recommended for GT fractures with more than 5 mm of displacement (especially superior displacement) to avoid sequelae of symptomatic fracture malunion. Options for operative management include open repair with a variety of constructs including cerclage suture or wire fixation, screw fixation, and plating of the fragments. ^{, , ,} More recently, arthroscopic and arthroscopic-assisted techniques have been described. Regardless of the surgical technique used, the principles are the same for fracture mobilization and reduction, secure fixation, and repair of concomitant pathology such as rotator cuff tears to provide an environment that will permit early ROM.

Patients are placed in the beach chair position under general anesthesia. An interscalene nerve block may be considered for postoperative pain control. An arm-positioning device attached to the beach chair may be used to support the operative limb; alternatively, a padded Mayo stand may be used. A C-arm image intensifier is used to obtain orthogonal views and assess reduction and fixation. Open treatment can be performed either via a deltopectoral approach (our preference) or a deltoid splitting approach. While the deltopectoral approach is extensile, enables management of associated fractures (such as surgical neck) and allows for proximal and distal identification of the neurovascular structures, posterior exposure or a retracted GT fragment can be challenging with this approach. A deltoid splitting approach enables a more direct approach to the fracture planes and may be preferable in more severely displaced (especially posterior) fractures that does not require extensile exposure.

Fracture fragments and their rotator cuff attachments are tagged with heavy nonabsorbable suture in a cerclage fashion around the bony fragments. This allows for fragment control and aids in mobilization of fragments from scarring and displacement. Choice of fixation (sutures, wires, screws, plate and screws) is dependent on many factors including fracture comminution, fragment size, bone quality, rotator cuff integrity, and associated additional PHFs. Our preferred technique is cerclage sutures through the cuff insertion on the fragments through bone tunnels. Horizontal and vertical cerclage can be utilized ( Fig. 15.11 ). In cases of poor bone quality the biceps groove often yields the strongest bone for sutures tunnels and can be utilized. In these cases, and when the long head biceps (LHB) tendon is found to be pathologic, we will perform a biceps tenodesis to prevent biceps scarring or pain. In cases of large robust bony fragments, augmentation with screws (typically cancellous, with or without washers) can be utilized as well. If screws are used, we recommend screws be placed from posterosuperior in the fragment bicortically into the shaft beneath the humeral head anteromedially ( Fig. 15.12 ). Unicortical screws into the humeral head, especially in older patients with poor bone quality, may not provide sufficient fixation ( Fig. 15.13 ). Recent biomechanical evidence reveals that tension band constructs provide significantly higher load to failure when compared with two parallel cancellous screws used alone.

Intraoperative photographs of cerclage suture placement around a displaced greater tuberosity fracture. The fracture is approached via a deltopectoral approach. (A) Initial suture placed around fragment through rotator cuff insertion. (B) Three rows of cerclage sutures. (C) Final construct with sutures passed through bone tunnel in the bicipital groove, fracture reduced, and sutures tied to their matched pair.

Anteroposterior radiograph of final healed greater tuberosity fracture fixated with cannulated screws with screws placed in trajectory to allow bicortical fixation into the medial calcar for optimal fixation.

Scapular lateral radiograph of failed greater tuberosity fracture fixation with two cannulated screws that were placed into the humeral head without sufficient purchase, resulting in loss of fixation and failure.

Arthroscopic management of greater tuberosity fractures

Arthroscopic techniques have been described more recently. They have the additional advantage of addressing concomitant pathology, such as rotator cuff and labral tears that may be present in patients with an anterior fracture-dislocation. Techniques of fixation include arthroscopic assisted reduction with percutaneous pin or screw fixation, or double row suture bridge or anchor fixation. ^{, , ,} While arthroscopic techniques are attractive due to the minimally invasive approach and ability to easily manage concomitant pathology, it is technically demanding and not amenable to every GT fracture. Ideal patterns are smaller fragments of the GT in younger patients with good bone. When using double row suture bridge techniques, it is important to insure placement of medial anchors in stout bone. Placement of anchors within the fracture bed may not yield sufficient fixation strength as it lacks cortical fixation and the cancellous bone of the bed often is weakened from impaction or crush to the trabeculae that occurs at the time of fracture. To avoid this issue we often place medial anchors medial to the fracture bed in the lateral subchondral bone of the humeral head. Ji and colleagues evaluated 40 patients with displaced GT fractures managed with an arthroscopic suture bridge technique with a minimum of 2-year follow-up. Final ROM averaged 157 degrees of forward flexion, 37 degrees external rotation and T11 internal rotation, with average American Shoulder and Elbow Surgeons Shoulder (ASES) score of 92. Five cases were noted to demonstrate anchor prominence on final evaluation. Similar findings were noted in another review by Choi and colleagues, as well as in a comparison of open versus arthroscopic techniques by Liao et al. ^,

Lesser tuberosity fractures

Isolated LT fractures are even more uncommon than GT fractures. In 2009, Robinson and colleagues reported the surgical results of isolated displaced LT fractures in 17 patients. The estimated overall incidence reported in this study was low (0.46 per 100,000). Fractures can occur due to sudden eccentric loading of the subscapularis traumatically or more commonly with associated posterior dislocation of the GH joint. ^{, ,} Because of the subscapularis insertion, the LT fragment will displace medially in the event of a fracture. In addition to being rare, diagnosis of these injuries can be challenging, often leading to delayed treatment. Plain radiographs may not reveal the LT fracture. CT scans may be helpful in identifying and clarifying the extent of the fracture displacement. Small fragments that are minimally displaced and unlikely to block motion can be treated nonoperatively with a period of brace immobilization, often in neutral to slight external rotation, especially when associated with posterior GH dislocation, followed by progressive therapy. ^{, , ,} Displaced fractures, especially those that overhang the articular surface and can block internal rotation motion, are indicated for repair. ^{, , ,}

Open reduction may proceed using a deltopectoral approach with the LT fragment stabilized with screws, sutures, and/or suture anchor fixation, or a combination of constructs (i.e., hybrid fixation) ( Fig. 15.14 ). Commonly in these fractures the LHB tendon is unstable due to loss of the medial wall of the bicipital groove. Additionally, as with some GT fractures, repair may require sutures placed in the bicipital groove for optimal reduction and fixation. In these situations we routinely tenodese the LHB tendon to the top of the pectoralis tendon insertion.

(A–C) Trauma series demonstrating a two-part fracture-dislocation with a large displaced lesser tuberosity (LT) fracture in a 42-year-old man following a grand mal seizure. Note the displaced LT fracture fragment on the axillary lateral radiograph (arrow). (D–G) Two-dimensional (axial and sagittal cuts) and three-dimensional computed tomographic imaging after closed reduction reveals that the LT fracture fragment remained displaced in an inferior and medial position. (H–I) Postoperative anteroposterior and axillary radiographs at the 12-month follow-up visit following open reduction and internal fixation using a hybrid technique (partially threaded cancellous screw with a washer and transosseous sutures placed from medial to lateral to act as a secondary tension band).

(Courtesy Aaron J. Bois, MD.)

In 2015, Liu and colleagues reported their results in 22 of 29 patients available for follow-up who underwent ORIF of an LT fracture associated with a locked posterior dislocation. The mean patient age was 41.7 years, and the majority were male (21 of 22). The length of time until the initial surgery was the only prognostic factor to correlate with an inferior outcome; 9 of 22 patients (41%) in this study were misdiagnosed at the time of their initial presentation, leading to a delay in surgical treatment. Arthroscopic fixation of a displaced LT fragment has been described by Scheibel and colleagues utilizing a standard posterior viewing portal, anterior and anterosuperior portals, suture relay, and suture anchor fixation of the tuberosity fragment.

In cases of posterior fracture dislocation the stability of the shoulder should be assessed after LT repair. Rarely the shoulder will be persistently unstable posteriorly. In this situation we will repair the posterior capsulolabral injury. In open cases through a deltopectoral approach posterior repair can be completed with percutaneously placed anchors in the posterior glenoid via an anterior view. This can be simplified in scenarios where an all-arthroscopic repair of the LT is possible.

Two-part surgical neck fractures

Surgical neck fractures account for the majority (60% to 65%) of PHFs. Nearly 80% of these fractures are minimally displaced and warrant nonoperative management. However, some patients, when treated nonoperatively, do not have good outcomes. Chun and colleagues reported only 55% good or excellent results in 56 surgical neck fractures treated nonoperatively with a mean forward flexion arc of 104 degrees. It is critical to carefully assess the fracture pattern to understand the severity of displacement and angulation to avoid a symptomatic malunion or rarely a nonunion, as well as understand the patient’s physiologic age and activity level. Typically, surgical neck fractures occur in two distinct patient populations: young patients with high-energy trauma, and elderly patients with low-energy trauma. Physiologically young patients with significantly displaced or angulated (50% displacement, 45-degree angulation) fractures are often managed surgically with ORIF, either with percutaneous techniques, locked plating, or intramedullary nail fixation. In elderly patients bone quality and patient comorbidities may impact decision-making for optimal treatment, as well as choice of surgical intervention when indicated. ^, In the elderly patient, bony contact of fracture segments may be all that is necessary for a functional result.

Surgical neck fractures are evaluated using a standard trauma series of radiographs. In cases of comminution or deformity a CT scan with 3D reconstruction provides additional information and can help highlight comminution along the medial calcar of the humeral neck. Many surgical neck fractures have varus angulation, and varus deformity has been found to be a challenging fracture pattern, prone to redisplacement, hardware failure, and screw cutout, and inferior outcomes ( Fig. 15.15 ). These fracture patterns require restoration of medial calcar bony support, either with impaction or allograft strut support, especially in elderly patients with osteoporotic bone. ^{, ,}

(A) Varus angulated surgical neck fracture with medial calcar comminution. (B) Initial postoperative radiograph with locked plate fixation but absence of a “calcar screw” and a small number of screws/posts in the humeral head for fixation. (C) Redisplacement of the humeral head into varus with associated screw cutout superiorly, a challenge with varus fractures and calcar comminution resulting in poor bony support and fixation.

Two-part anatomic neck fractures

Unlike surgical neck fractures, which are very common, isolated anatomic neck fractures, involving only the articular surface of the humeral head, are very rare. An early series by Chun and colleagues reviewed 141 two-part proximal humerus and identified only 2 fractures isolated to the anatomic neck. Both were associated with GH fracture-dislocation and treated operatively, one with ORIF and one with hemiarthoplasty. More recently a review of 509 fractures including two-, three-, and four-part fractures by Tamai and colleagues identified no cases of isolated two-part anatomic neck fractures. All fractures involving displacement of the anatomic neck were observed in four-part fracture patterns, which is the far more common scenario. In the rare scenario of an isolated displaced anatomic neck fracture as identified by Chun and colleagues, treatment would be indicated based on severity of displacement and potential for osteonecrosis in determining nonoperative versus operative treatment and a fracture amenable to ORIF versus hemiarthroplasty or RSA.

Three-part fractures

In three-part fractures, cleavage lines occur through the surgical neck and between the GT and LT, usually just posterior to the bicipital groove ( Fig. 15.16 ). The GT is more commonly involved than the LT and is usually displaced in a posterior and superior position by the pull of the attached supraspinatus, infraspinatous, and teres minor. ^, The articular surface is retroverted due to the pull of the subscapularis on the intact LT. If the fracture involves the LT, the subscapularis pulls this segment medially and the articular surface is relatively anteverted by the posterior rotator cuff. Surgical treatment options include closed reduction and percutaneous fixation, ORIF, closed reduction and intramedullary nail fixation with or without suture supplementation, HA, and RTSA. The latter arthroplasty options are reserved for comminuted osteoporotic fractures that are unsuitable for osteosynthesis in elderly lower-demand, yet physiologically active patients.

(A–B) Anteroposterior and lateral radiographs of a three-part fracture with displacement of the surgical neck, retroversion of the articular fragment due to pull of the subscapularis on the lesser tuberosity, and posterosuperior displacement of the greater tuberosity due to pull of the supraspinatous and infraspinatous/teres minor.

In 1970, Neer reported his early experience in 39 patients with three-part PHFs treated by closed reduction. Only three patients demonstrated a satisfactory result by his criteria. Poor results were due to malreduction, nonunion, humeral head resorption, and osteonecrosis. He concluded that nonoperative intervention for these injuries was inadequate in active patients. A few series have recently compared operative fixation with conventional techniques (e.g., locked plate fixation) versus nonoperative treatment of these fractures. In 2011, Olerud and colleagues performed a randomized study in 60 patients (mean age, 74 years; range, 56 to 92 years) comparing ORIF using a locking plate to nonoperative management of displaced three-part PHFs. At the final 2-year follow-up, the results for ROM, function, and health-related quality of life scores were all in favor of the locking plate group; however, critical appraisal of the differences between the groups reveals only marginal improvements in the operative group. Specifically, the mean forward elevation in the locking plate group was 120 degrees (vs. 111 degrees in the nonoperative group) and the mean abduction was 114 degrees (vs. 106 degrees). Functional scores including the Constant score was 61 in the operative group (vs. 58), and the Disabilities of the Arm, Shoulder and Hand score was 26 (vs. 35). The small positive results in the operative group were also tempered by a 13% complication rate requiring a “major” revision surgery, and 17% of the patients underwent a “minor” reoperation (total reoperation rate of 30%).

Similarly, Fjalestad and colleagues performed an RCT comparing nonoperative treatment and ORIF in 50 elderly patients with displaced three- and four-part fractures. The authors did not find a difference in functional outcome at the 1-year follow-up between the treatment groups. In addition, Li and colleagues failed to demonstrate a significant difference in clinical outcomes when comparing operative and nonoperative management of three- and four-part fractures in elderly patients. As opposed to elderly patients, the majority of displaced three-part PHFs in young adults benefit from operative intervention to optimize functional outcomes.

More recently a few series have compared RTSA versus nonoperative treatment in elderly patients with three- and four-part PHFs. ^, Lopiz and colleagues found in a prospective randomized trial of 59 patients 80 years or older no difference in outcome measures at 1-year follow-up and concluded that acute RTSA offers minimal benefit over nonoperative treatment in elderly patients with three- and four-part PHFs. Conversely, Chivot and colleagues found that RTSA offered improved Constant scores (82.1% vs. 76.8%, P = .03), although not substantially so, and recommended that RTSA be reserved for high-demand elderly patients with these injuries.

A few series have recently compared ORIF versus RTSA in the management of these fractures as well. Fraser and colleagues prospectively randomized 124 elderly patients with three- and four-part PHFs undergoing operative treatment and found improved outcomes in the RTSA group (Constant score 68 vs. 54.6, P < .001) at 2-year follow up. Similarly, Yahuaca and colleagues retrospectively evaluated 425 PHFs undergoing surgical treatment (ORIF, HA, and RTSA) and found no difference in final ROM between groups at minimum 1-year follow-up. The authors did recognize that younger physiologically fit patients more commonly underwent ORIF. They also noted that ORIF and hemiarthoplasty had a higher reoperation rate compared to RTSA.

Four-part fractures

Four-part PHFs involve all segments of the proximal humerus ( Fig. 15.17 ). Displacement of the tuberosities relative to articular surface and each other often results in a symptomatic malunion and posttraumatic arthritis (PTA) following nonoperative treatment. As such, nonoperative management of four-part PHFs should only be employed in minimally displaced or angulated fractures (which are uncommon) or in medically unfit and/or low-demand elderly patients. Operative options include percutaneous K-wire fixation, ^, ORIF, ^, HA, and RTSA. ^{, , ,} Closed reduction and percutaneous wire fixation is a viable option for acute injuries (<7 to 10 days) with good bone stock and minimal comminution. Open reduction is generally performed for fractures not amenable to reduction by closed means, for comminuted fractures, and for injuries that are 10 days to 4 months old. Arthroplasty reconstruction, historically HA but now more commonly RTSA, is indicated in cases not amenable to operative reduction and fixation, especially in elderly patients with poor bone quality or fractures with a high likelihood of osteonecrosis (e.g., four-part fracture dislocation).

Anteroposterior Grashey radiograph of a four-part proximal humeral fracture. The lesser tuberosity is marked by the yellow arrow and the greater tuberosity marked by the red arrow .

The valgus-impacted four-part fracture is an uncommon but important subtype to identify. ^, This injury has a more favorable prognosis when compared with other multi-part PHFs secondary to the integrity of the medial capsular blood supply. ^, The fracture pattern is characterized by impaction of the lateral aspect of the humeral articular surface due to a fracture of the anatomic neck ( Fig. 15.18 ). The articular surface faces superiorly toward the acromion rather than the glenoid. The tuberosities typically displace into valgus secondary to impaction of the articular surface on the humeral metaphysis, but often do not displace superiorly. The prevalence of osteonecrosis approaches 5% to 10%, much less than that of the corresponding standard four-part PHFs (approximately 20% to 30%).

Anteroposterior radiograph of a valgus-impacted four-part proximal humerus fracture. The medial periosteal hinge remains intact, preserving partial vascular inflow to the humeral head.

(Courtesy Michael A. Wirth, MD.)

Jakob and colleagues achieved a satisfactory outcome in 74% of patients with valgus-impacted fractures who underwent closed reduction or limited ORIF. The major reason for failure was AVN, which occurred in five cases (26%). Resch and colleagues performed limited ORIF on 22 patients with four-part valgus-impacted fractures, demonstrating no evidence of osteonecrosis at a mean follow-up of 36 months (minimum, 18 months). The results were graded as excellent in 12 patients (54%), particularly in cases in which anatomic reduction was maintained.

Proximal humerus fracture-dislocations

Two-part fracture-dislocations are amenable to ORIF due to the integrity of the vascular supply that is maintained by the soft tissue attachments to one or both tuberosity segments. Three- and four-part fracture-dislocations with or without articular surface involvement similarly require operative intervention. Repeated attempts at closed reduction or delayed ORIF can result in an increased incidence of myositis ossificans. The results of ORIF for four-part fracture-dislocations are poor; however, this remains the standard of care in young physically demanding patients. Arthroplasty reconstruction serves as an appropriate treatment method for such injuries in older patients (i.e., over the age of 65 years). Again, historically this was an indication for HA, but most surgeons will now perform RTSA for these injury patterns, especially in elderly patients. Closed management should only be considered in the medically unfit patient.

Closed reduction and percutaneous pinning

Closed reduction and percutaneous pinning (CRPP) offers the least invasive method to operatively address proximal humerus fractures. CRPP begins by performing a reduction maneuver to reduce the fracture fragments and subsequently, wires with a threaded tip (Kirschner wires) are advanced. Typically, CRPP utilizes pins from the lateral and anterior humeral shaft extending into the humeral head. An attempt is made to create a pattern that can control for postoperative displacement. This arrangement may be augmented with additional pins or the placement of percutaneous screws ( Fig. 15.19 ).

(A–B) Anteroposterior and Grashey view of a four-part valgus impacted fracture. This fracture pattern is amenable to percutaneous fixation with a low rate of osteonecrosis if the medial hinge is intact (shown in B). (C–D) Intraoperative fluoroscopic imaging of reduction, retrograde wire fixation of the humeral head to the shaft, and K-wire provisional fixation of the greater tuberosity and final construct fixation. Note that greater tuberosity screw fixation places the screws into the medial calcar for bicortical fixation.

The goal of surgical fixation of PHFs is twofold: to restore the anatomic relationship between the articular surface and the tuberosities, and to preserve the vascularity of the articular fragment. Closed reduction with percutaneous fixation minimizes soft tissue dissection and can preserve vascular inflow for anatomic healing. Diminished adhesion formation and improved cosmesis are additional benefits of this approach. The caveat to this technique is that it involves an increased level of technical skill and ancillary support from operating room personnel. Percutaneous fixation of PHFs was initially used by Bohler to treat pediatric injuries, and was subsequently applied to adult surgical neck fractures. Because of the growing emphasis on biologic fixation, some authors have advocated percutaneous treatment of three- and four-part fractures. ^{, ,} The learning curve is substantial, but proponents of this method cite a decreased incidence of osteonecrosis because the region of the ascending branch of the anterior humeral circumflex artery is undisturbed ( Fig. 15.20 ). ^{, ,}

Vascular supply of the anterior humeral head (anterior view). 3, Anterior humeral circumflex artery; 4, anterolateral branch of the anterior humeral circumflex artery (arcuate artery); 5, greater tuberosity; 6, lesser tuberosity; 7, insertion of the subscapularis; 8, site of terminal entry of the arcuate artery into the bone; 9, bicipital groove.

(From Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head: an anatomical study. J Bone Joint Surg Am . 1990;72:1486–1494.)

The indications for CRPP ideally include two-part (e.g., surgical neck), three-part, and valgus-impacted four-part PHFs without comminution in compliant patients with good bone stock. Serial radiographic evaluation and shoulder immobilization for 4 to 6 weeks are required. Severe comminution and osteopenia are absolute contraindications to this technique. Additionally, numerous attempts to reduce fracture fragments should be avoided; in this situation, the surgeon should be prepared to convert to an open procedure. Fracture-dislocations can prove extremely difficult to manage with this method, and thus it is generally not recommended. ^{, ,}

Although this is technically challenging, percutaneous fixation has been demonstrated to have excellent overall results. Keener and colleagues reported on 35 patients from three institutions. The fracture patterns were two-, three- and four-part patterns with an average follow-up of 35 months. All fractures were noted to go on to healing with improvements in overage standardized outcome scores. Resch and colleagues reported on 27 patients with three- or four-part fractures treated with percutaneous fixation and noted good to very good results in three-part fractures and valgus-impacted four-part fractures. Jaberg and colleagues demonstrated good to excellent results but also noted several complications including pin track infections, pin loosening, deep infection, malunion, and AVN with humeral head collapse. In a later paper, Harrison and colleagues provided an intermediate follow-up of patients treated with percutaneous fixation and demonstrated an increased prevalence of osteonecrosis and PTA over time, even as late as 3 years postoperatively. Overall, the results of PHFs managed with percutaneous fixation demonstrate good initial results, but the potential for both early and late complication requires careful indications and expertise in this technique.

Two-part fracture

The patient is placed in the beach chair or semi-Fowler’s position that allows access to the entire shoulder. Commercially available beach chair positioner attachments and mechanical arm holders will help significantly. Reduction instruments include bone elevators and hooks to manipulate the fragments into position. Terminally threaded 2.5-mm pins and 4.0-mm cannulated screws are commonly used for this technique. The C-arm image intensifier is placed parallel to the table to allow AP and axillary views ( Fig. 15.21 ).

(A–B) Intraoperative beach chair positioning for concomitant use of C-arm during open reduction and internal fixation of a proximal humerus fracture. The C-arm can either be positioned parallel to the bed, for entry from the head of the bed, or perpendicular to the bed, for entry from the noninjured (contralateral) side.

(Courtesy Aaron J. Bois, MD.)

A provisional reduction maneuver should be performed to determine the feasibility of a closed reduction. With two-part surgical neck fractures, there is apex anterior angulation at the fracture site. The arm should first be placed in 20 to 30 degrees of abduction. Longitudinal traction is then applied to the arm, while the humeral shaft is directed lateral to the humeral head. Concomitant pressure against the anterior surface of the shoulder will help reduce the apex anterior angulation as shown in Fig. 15.22 . ^, A single pin is placed on the skin of the anterior shoulder in a distal-to-proximal direction from the lateral humeral cortex to the humeral head. An AP image confirms the inclination, and a skin marker is used to document pin positioning. A 1-cm incision is made on the lateral aspect of the shoulder at the level determined by the C-arm image. Blunt dissection is performed down to the bone with a hemostat. The hemostat is then used to palpate the anterior and posterior cortices of the humerus. The initial pin is then guided under power at the previously determined angle. Initial horizontal pin placement can prevent the pin from sliding across the cortex. While the assistant maintains the reduction, the pin is advanced under fluoroscopy to engage the humeral head. Because of the approximate 30 degrees of retroversion of the humeral head, fluoroscopy must be used to confirm appropriate pin placement. A second pin is then advanced parallel to the first with approximately 1.5 to 2 cm of separation. Several authors have demonstrated that parallel pin placement increases torsional stability and rigidity in biomechanical testing when compared with converging pins. ^, A third pin is then placed from the anterior humeral shaft into the humeral head. ^, An alternative surgical technique involves placement of two K-wires, one in the humeral head and another in the shaft. The K-wires are then utilized as joysticks to achieve fracture reduction, with subsequent placement of terminally threaded pins or cannulated screws. We routinely cut and shorten pins as much as possible to place them deep to the skin and allow for closure over the pin(s) to minimize potential for later pin protrusion as swelling decreases or for skin track infection.

The reduction maneuver involves slight shoulder abduction, longitudinal traction of the arm, and posterior pressure on the humeral shaft. Anteroposterior and axillary views using C-arm fluoroscopy confirm the reduction.

(Modified from Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am . 1992;74:508–515.)

Three- and four-part fractures

Three- and four-part PHFs add a level of complexity that proves difficult to manage with this technique, even in the most experienced hands. With a three-part valgus-impacted fracture, the humeral head is tilted into valgus while the GT remains at the correct height. After positioning the humeral shaft under the humeral head, a small incision is made laterally to allow placement of an elevator into the fracture site under the humeral head. Under fluoroscopy, the humeral head is then levered upward and into varus alignment. As the humeral head is reduced, the GT will be pulled below the articular surface due to the integrity of the rotator cuff insertion. A 2.5-mm threaded pin or 4.0-mm cannulated screw is then advanced through a separate superior incision to capture the GT and the humeral head. Cannulated screws are usually placed to hold the tuberosity and articular surface reduction, while additional pins or screws are inserted in an antegrade fashion to stabilize the tuberosity to the humeral shaft. ^{, ,} We have found that it is optimal to place tuberosity screws into the inferior medial calcar cortical bone to allow for bicortical fixation, as fixation in from the tuberosity into the head can at times be tenuous (see Figs. 15.12 and 15.13 ). To prevent over-reduction of the tuberosity as the inferiorly angled screw into the calcar is tightened, we often place a K-wire either in parallel to the screw trajectory or into the humeral head to maintain optimal reduction.

Four-part fractures, except for the valgus-impacted subtype, generally require ORIF. On the infrequent occasion that percutaneous fixation is attempted, the same steps to reduce the GT, articular surface, and humeral shaft are used. The LT may be reduced by internally rotating the arm and by placing a hook on the fragment through a laterally based incision. Once reduced, the fragment is held in place with a 4.0-mm cannulated screw. Once satisfied with fracture reduction and fixation, the threaded pins are trimmed below the skin, which is closed. Tenting of the skin from the pin can occur as shoulder swelling diminishes. Prominent pins, especially those that have penetrated the skin before planned removal, should be removed to minimize the risk of pin tract infection.

Intramedullary fixation

Intramedullary nail fixation of proximal humerus fractures has been utilized for all fracture patterns and has undergone multiple generational changes in the implant designs. First-generation nails (Rush rod fixation) did not provide sufficient stabilization to control for fragment displacement and rotation control. Proximal migration and acromial contact were noted to frequently require a secondary operation. Second-generation intramedullary nails were restructured to allow easier entry, improved fixation and now employed the assistance of guides for placement. Despite the advances, the second generation of nails had rates of screw backout and loss of fixation. Finally, the third generation of intramedullary nails now provides a more stable construct, with fixed angular stable constructs and added methods of achieving proximal bony purchase. These advancements were meant to decrease the rate of screw loosening and the rate of loss of fixation in the proximal fragments.

The advantages of intramedullary fixation include decreased exposure and minimal soft tissue dissection. The disadvantages include violation of the rotator cuff, nonunion, malunion, and hardware loosening. Rates of nonunion of 5% have been reported; whereas 3.2% rates of implant loosening have been recorded. Perhaps the most commonly thought reason for pain after nailing is violation of the rotator cuff typically felt to occur with placement of the nail, ^, and decreased ability to rigidly secure the tuberosity fragments.

Results from intramedullary nail fixation have demonstrated high union rates. A prospective trial of 29 patients including 21 proximal humerus fractures treated with intramedullary nail fixation demonstrated all fractures healed at an average of 2.7 months. A recent prospective RCT compared 36 patients with a two- or three-part proximal humerus fracture treated with either locking plate fixation or intramedullary nail fixation. At 12 months there were no statistical differences in clinical outcome scores, but the intramedullary nail group had more complications and a higher rate of reoperations. To help avoid complications, strategies such as a medial starting point have been utilized and have demonstrated high union rates and good postoperative ROM. Construct differences have also been compared. Lopiz and colleagues recently compared curvilinear and straight nails in a randomized clinical trial, and the overall rate of union was comparable, though straight nails had a lower rate of complications. A recent systematic review compared 958 patients pooled from 13 comparative studies. The end result demonstrates a similar performance between locked plate fixation and intramedullary nail fixation.

Surgical technique

The patient is placed in the beach chair position on a radiolucent table. A 3-cm longitudinal incision is made in line with the GT of the humerus. The deltoid is then split in line with its fibers. Under C-arm fluoroscopy, the entry hole of the nail is made with a curved awl or guide pin just medial to the GT and approximately 1.5 cm posterior to the bicipital groove (i.e., if using a curved nail). In three-part PHFs with involvement of the GT, the entry point for some commercially available nails is compromised. More modern nail designs are straight and have the advantages of fixed-angle locking capabilities for proximal screw fixation (i.e., third-generation nailing); nail entry is through a small split in the rotator cuff and subsequently through the superior articular surface of the humeral head. This helps to reduce damage to the rotator cuff footprint during nail insertion and avoids the GT fracture plane in these fractures. If the LT is involved, the insertion point is at the junction of the articular surface and GT to avoid the LT fracture plane. Adduction of the arm and extension of the shoulder provide adequate clearance from the acromion for the awl and subsequent nail insertion. If closed reduction can be performed (acute cases), it is generally accomplished with longitudinal traction on an adducted arm in neutral rotation. If closed reduction is not possible secondary to soft tissue interposition, adhesions, or early callus formation (subacute or chronic cases), open reduction may be performed before the nail is inserted. ^,

A 2-mm guidewire is passed across the fracture and down the intramedullary canal. The nail is inserted and locked proximally and distally. Care must be taken when placing the distal locking screws to avoid injury to the neurovascular structures, including the radial nerve, brachial artery, and median nerve (depending on lateral or anterior screw placement). Gentle blunt soft tissue dissection (nick-and-spread method) and screw placement under C-arm guidance are necessary to avoid iatrogenic injury to these structures. A small longitudinal incision (1 to 2 cm) may be necessary to safely expose the humeral cortex to avoid neurovascular injury during distal locking screw insertion. Proximal fixation of tuberosity fragments is possible with orthogonal locking screws in newer design implants when utilized in select three- and four-part fractures.

Open reduction and internal fixation of proximal humeral fractures with locked plate fixation

The current indication for ORIF of PHFs are displaced two-, three-, and four-part fractures and select fracture dislocations. Factors that impact decision-making include the patient’s age, activity level, hand dominance and arm involvement, and severity of fracture morphology. Locked plate fixation has enabled surgeons an opportunity for successful outcome managing fractures historically felt to be too severely comminuted, osteopenic or otherwise amenable to ORIF, even in elderly patients. ^, Critical aspects of displacement that may warrant surgical intervention include the relationship of the tuberosities to the humeral head, severity of articular angulation (varus or valgus), and articular dislocation ( Fig. 15.23 ).

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