Mark K. Bowen and Angelo DiFelice

1. Four-part proximal humerus fractures and fracture dislocations of the proximal humerus

2. Humeral head splitting fractures

3. Displaced anatomic humeral neck fractures that cannot be adequately reduced or fixed

4. Chronic shoulder dislocations with impaction fractures involving greater than 40% of the humeral head’s articular surface

5. Selected three-part proximal humerus fractures in older patients with osteoporotic bone

1. Soft tissue infection

2. Chronic osteomyelitis

3. Paralysis of the rotator cuff muscles

4. Deltoid muscle paralysis (relative)

1. Perform a complete history. Attempt to determine the cause of the fracture. Obtain pertinent medical history including history of seizures or syncope. Consider metastatic disease.

2. Document the preoperative neurovascular status of the limb, especially the axillary nerve.

3. Obtain radiographs (shoulder trauma series)

a. Anteroposterior (AP) in plane of scapula (“true AP”)

b. Transscapular lateral

c. Axillary view

d. AP and lateral of the unaffected shoulder to assist with templating

4. Templates of the prosthesis to be implanted

5. If needed, obtain computed tomography (CT) scan to assess degree of fracture displacement or to evaluate the humeral head’s articular surface in head splitting fractures or chronic dislocations.

1. Intravenous antibiotics should be given prior to the beginning of the operation.

2. The patient must be positioned with the arm able to hang free over the table’s side so that it can be easily hyperextended and internally and externally rotated.

3. Restoring the proper length of the humerus is critical to proper function: if the prosthesis is left proud stiffness will result; if the prosthesis is inserted too deep loss of soft tissue tension may cause instability.

4. Restoring proper humeral retroversion is critical to optimizing shoulder function and stability.

5. Achieving secure fixation of the greater and lesser tuberosities to each other, as well as the prosthesis and humeral shaft is the important final step in performing a successful shoulder reconstruction.

1. Avoid excessive operating room traffic.

2. Avoid excessive or aggressive reaming or broaching of the humeral canal to minimize the risk of intra-operative humeral fracture.

3. Avoid dissection beyond the medial border of the coracoid to minimize the risk of injuring the neu-rovascular structures.

4. Avoid implanting the humeral component in anteversion.

5. Avoid deep or proud placement of the humeral component that may significantly change gleno-humeral mechanics or lead to shoulder instability.

1. Passive motion is usually begun on the first postoperative day under the supervision of a therapist. The range of motion is limited by the stability of the intraoperative tuberosity fixation. The patient usually performs pendulum, saw, and tummy rub exercises for approximately 4 weeks.

2. After 4 weeks, the patient generally begins active assisted range-of-motion exercises to improve the shoulder’s range of motion.