Peter Biberthaler, Chlodwig Kirchhoff and James P. Waddell (eds.)Fractures of the Proximal HumerusStrategies in Fracture Treatments10.1007/978-3-319-20300-3_16

16. Two and Three Part Fractures

Volker Braunstein¹

(1)

OrthoPlus Muenchen / Munich, Lenbachplatz 2a, 80333 Muenchen / Munich, Germany

Volker Braunstein

Email: vbraunstein@mac.com

Introduction

According to Codman’s observation from 1934 [1] fractures of the proximal humerus produce a combination of 4 segments including greater tuberosity, lesser tuberosity, articular surface and the humeral shaft. Considering this observation all potential two-part and three part fractures can be identified. Numerous classifications base upon Codman’s conclusion result in heterogeneous recommendations regarding conservative and operative treatment. Beside fracture morphology the evaluation of factors like bone quality, blood supply of the humeral head and fracture fragments, lesions of the rotator cuff and patient demands are essential for adequate treatment [2]. The incidence of displaced proximal humeral fractures, particularly two-part and three-part patterns, requiring surgical intervention is relatively low [3].

In case of two-part surgical neck fractures impaction or dislocation of the metaphyseal zone and the degree of displacement an angulation are essential to find the adequate treatment option. Patient’s functional outcomes following non-operative management of two-part surgical neck fractures are generally good [4].

Isolated fractures of the greater tuberosity account for approximately 20 % of all proximal humeral fractures. They are often associated with anterior glenohumeral dislocation or can result a shear injury against the lower surface of the acromion or superior glenoid [5].

Operative treatment of greater tuberosity fracture is recommended by most authors in case of a dislocation of more than 5 mm, due to the risk of impingement and malunion resulting in impairment of glenohumeral joint motion [6].

Isolated lesser tuberosity fractures are exceedingly rare. They only account for approximately 2 % of all proximal humeral fractures [7]. The majority of authors recommend operative treatment in case of more than 5 mm displacement or 45° of angulation, mechanical block to internal rotation, continued pain, and weakness of terminal internal rotation [7]. However, due to the risk of late displacement and possible involvement of the bicipital groove Ogawa et al. [8] prefer to fix even minimally displaced lesser tuberosity fractures.

Three part fractures usually include a surgical neck and greater tuberosity fracture. The combination of surgical neck and lesser tuberosity fracture is uncommon. Operative treatment is required in case of tuberosity dislocation of more than 5 mm and in cases without metaphyseal impaction.

Open Management of Two Part and Three Part Fractures

Open management of two part and three part fractures will allow good exposure for reduction and fixation. However, soft tissue damage could influence the blood supply of the fractured bone fragments resulting in an impairment of bone healing.

The deltopectoral approach is the working horse for open fracture management of humeral head fractures. Respecting the integrity of the deltoid muscle is the major advantage of this approach. However, some authors are impaired by the potential small exposure, especially in case of superior and posterior dislocation of the grater tuberosity.

Therefore some authors prefer to split the deltoid muscle (e.g. using the Mackenzie or the transdeltoid lateral approach). The advantage of this kind of approach is the good exposure and visualization of displaced bone fragments. Though, beside the potential damage of the deltoid muscle the course of the axillary nerve must be kept in mind.

In case of isolated greater tuberosity fractures a large variation of approaches and fixation techniques are described in literature. Open management could be necessary in case of small fragments, comminution, and distinct dislocation [7]. Biomechanical studies proved superior primary mechanical stability for tension banding using heavy non-absorbable sutures and for two cancellous screws when compared to transosseous sutures [9].

The subscapularis tendon and the bone fragment unit will need to be mobilized and fibrous tissue removed frequently in case of isolated lesser tuberosity fractures. Therefore, open fractures management will be necessary in almost all cases. As the approach should consider the involvement of the medial wall of the intertubercular groove and the integrity of the tendon of the long head of the biceps the choice is limited to deltopectoral approaches for most cases. Cannulated screws with or without washers [10], heavy suture, and cerclage wire [11] are used for the fixation of the lesser tuberosity.

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