Proximal humeral fractures are extremely common injuries and are one of the true osteoporotic fractures. Most fractures can be effectively treated nonoperatively, as the rich vascularity and broad cancellous surfaces impart a high propensity for healing. Additionally, many fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. Open reduction and internal fixation of displaced fractures can improve outcomes, depending on the pre-injury functional status of the patient.
If operative treatment is selected, unique treatment challenges must be overcome, including obtaining and maintaining reduction of small bone fragments with strong muscle forces, often in osteoporotic bone.
Knowledge of local anatomy is paramount in the evaluation and treatment of these injuries. Information regarding humeral head vascularity, fracture patterns, bone quality, and overall geometry have direct implications for operative treatment with internal fixation.
The ascending branch of the anterior circumflex artery perfuses most of the humeral head. When fractured, the greater tuberosity tends to displace posterosuperiorly, the lesser tuberosity and the shaft displace medially, and the head may be pulled by the attached tuberosity, impacted into valgus, or in more severe cases dislocated, impacted in varus, or divided.
Internal fixation of two-part, three-part and selected four-part fractures may be compromised by local osteopenia; knowledge of the location of the strongest bone in the proximal humerus combined with the use of fixed-angle devices and occasionally bone graft or substitutes has improved the outcome of osteosynthesis.Locking plates are the most common device used, but technical detail is critical to minimize the risk of implant failure, loss of reduction, and reoperation.
The prime aim should always be :
1. The anatomical reduction with rigid multiplanarscrew fixation with locking plates with or without bone graft.
2. Early mobilization of the shoulder and early active rehabilitation program to ensure a good functional outcome and a good restoration of the activities of daily living.
Dr. Prateek Goyal
(Santokba Durlabhji Memorial Hospital, Jaipur)