2 part fracturesThe treatment approach to two-part fractures is multifactorial and must be individualized for each patient. Many patients sustaining these fractures are elderly, have low functional demands, and have poor bone quality. An assessment of the patient's medical comorbidities must be made.
There are four types of two-part fractures: Surgical Neck FracturesTwo distinct patient groups exist which should be treated with different approaches, even when the fracture is the same.
Court Brown et al 2001 showed in elderly patients (mean age 72) with displaced 2 part proximal humeral fractures, functional outcome is determined by the patients age and the degree of translation on the initial anteroposterior radiograph. Surgery did not improve the outcome, regardless of the degree of translation. They concluded: "The results of surgery may improve in future with the introduction of better techniques and the use of bone-strengthening agents, but currently we do not advocate the use of internal fixation to treat two-part fractures of the surgical neck of the proximal humerus regardless of the degree of initial displacement."
TreatmentIndications for stabilization of a surgical neck fracture include:
Closed reduction +- Pin fixation
Open reduction and internal fixation
Closed reduction +- Pin FixationInitially closed reduction may be attempted. In the two-part surgical neck fracture, the pectoralis major acts as a deforming force and displaces the shaft medially and anteriorly. If not reduced, this pattern of displacement will limit forward elevation. The arm should first be placed along the patient's side to relax the pectoralis major. If the fragments are impacted, axial traction is performed to disimpact the fracture. Next, a gentle posteriorly and laterally directed force is applied as the shaft is flexed and brought underneath the head. The fragments are then impacted and fracture stability is assessed. If the reduction can be obtained but not maintained, some form of fixation is needed.
Percutaneous fixation can be performed using terminally threaded pins placed from the anterolateral cortex of the shaft into the proximal fragment. The advantage of percutaneous fixation is the potential to avoid further compromise of the vascularity of the humeral head. Percutaneous pin fixation of proximal humerus (technique) Complications of percutaneous fixation
Open reduction and internal fixationWhen closed reduction cannot be obtained, open reduction and internal fixation should be performed. Reduction may be prevented secondary to interposed periosteum and biceps tendon or buttonholing through the deltoid or pectoralis major fascia. Many techniques of internal fixation have been reported:
The type of fixation used depends on the bone quality and the degree of comminution. Plate and screw fixation is less desirable in elderly osteoporotic bone because it is often difficult to achieve adequate cortical purchase in the proximal fragment. In the younger patient with good bone
quality, plate and screw fixation and blade plate fixation are more attractive
options. Wire or suture as tension bandsTension band fixation with suture or a wire loop is a good option in osteoporotic bone. This technique has the advantage of less soft tissue stripping and also uses the rotator cuff musculature in the repair. The cuff tendons are stronger than the osteoporotic bone. If a significant amount of metaphyseal comminution exists, the tension band can be supplemented with an intramedullary device Banco et al.
described a method of fixation termed the "parachute technique." With this
method, heavy sutures of 5-mm Dacron are placed through the rotator cuff tendons
and then through drill holes in the humeral shaft distal to the fracture so that
stability is achieved through impaction and compression of the fracture. Non locking Intramedullary nail combined with tension bandIntramedullary fixation with use of combinations of rods (Enders nail, rush pins), wires, and sutures to treat two-part fractures of the surgical neck has also been described. Although this method has been successful when it has been performed properly by some surgeons, there are concerns about torsional rigidity and the risk of displacement.
Plate and screwsSeveral plates have been designed for proximal humeral fixation. Locking plates are thought to provide a better hold on osteoporotic bone.
Locked Proximal humeral intramedullary nailLocking intramedullary nails designed specifically for proximal humeral fractures have been designed, improving hold and rididity. Recently nails have been developed where the screws lock into the nail.
Blade plateBlade plate fixation of the proximal humerus should probably be restricted to younger patients with good quality bone.
Rigid constructs tend to cut out of osteoporotic bone. Displaced Greater Tuberosity FracturesIsolated two-part fractures of the greater tuberosity are relatively common and comprise approximately 3% of all proximal humerus fractures.
The greater tuberosity has three facets:
The cuff muscles act to displace the greater tuberosity fragment superiorly and posteriorly. Superior displacement can be assessed on an AP view of the shoulder. The relationship of the greater tuberosity to the superior margin of the articular surface of the humeral head should be evaluated to determine the potential for impingement. The degree of posterior displacement is often underappreciated on the AP and lateral scapula (Y) views due to the tuberosity fragment overlying the humeral head. The axillary view and CT scan are
very useful in assessing posterior displacement of the greater tuberosity. In Neer's review of displaced proximal humeral fractures, 1 cm of displacement was considered an indication for surgical management. This general guideline may not apply to all cases of greater tuberosity fracture. Operative treatment is usually recommended for fractures that have:
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.
Techniques of tuberosity fixation include:
The method of fixation depends on several factors:
Suture fixation with a number 5 or larger nonabsorbable suture material using the rotator cuff for proximal fixation is preferable for smaller and comminuted fragments or for osteoporotic bone. Cancellous bone screws can be used for large noncomminuted fragments when the bone is of good quality. Bone screw fixation may be supplemented with a figure-of-eight suture. Surgical TechniquePosition - Beach chair Deltoid split - the axillary nerve limits the distal extent to approximately 5 cm from the lateral aspect of the acromion. A large fracture fragment with diaphyseal extension is difficult to mobilize, reduce, and fix through the deltoid split without undue risk to the axillary nerve and should be managed surgically through a deltopectoral approach. When a large fragment of the greater tuberosity
is displaced posteriorly and is behind the humeral head, a bone hook can be used
to pull the fragment into the surgical field. Then, placement of a traction
suture into the rotator cuff to control and manipulate the fragment allows the
fragment to be anatomically reduced to the proximal part of the humerus. If the fragment is larger, excision makes rotator cuff repair very difficult, if not impossible. The fragment is mobilized with traction sutures, and the cancellous
bed is exposed. Heavy nonabsorbable sutures are placed at the insertion of the
rotator cuff. These sutures are oriented along the lines of pull of the
supraspinatus, infraspinatus, or teres minor, depending on which tendons are
attached to the fragment. Any tear of the rotator interval between the
supraspinatus and subscapularis should be closed to decrease repair tension.
Drill holes are placed in the humeral shaft 1 to 2 cm distal to the fracture
site. The sutures are placed in a figure-of-eight fashion and tied. The
stability of the fracture is assessed to guide the postoperative rehabilitation
program. PROM from day1, protected with a sling. AROM is begun at 6 weeks. Once AROM has been regained, the patient can begin a strengthening program and more vigorous stretching exercises. MalunionsPersistent pain due to malunion of the greater tuberosity can occur with as little as 0.5 cm of superior displacement. The symptoms resulting from subacromial impingement can be treated with subacromial decompression if the displacement is <1 cm. If the displacement is minimal and the fragment is 1 cm in size, excision of the osseous prominence that is causing impingement followed by rotator cuff repair can yield a satisfactory result. When the greater tuberosity is displaced >1 cm, an osteotomy of the fragment is the preferred treatment. The fragment is then mobilized by dissection and release of scar tissue and the underlying capsule associated with the torn and scarred rotator cuff. Mobilization of the retracted rotator
cuff tissue is required to reduce the greater tuberosity fragment to an anatomic
position. Mobilization of the rotator cuff requires release of the rotator
interval and the underlying capsule at the site of the fracture. The results of the surgical management of malunions of the greater tuberosity have been reported to be less favourable than the results of reduction and fixation of acute fractures.
Displaced Lesser Tuberosity FracturesIsolated lesser tuberosity fractures are extremely rare. If there is no block to internal rotation, the patient can be treated by wearing a sling. ORIF is indicated if:
The fragment can be attached using nonabsorbable sutures passed from the fragment through drill holes in the proximal humerus; smaller fragments can be excised with direct repair of the subscapularis to the humerus.
Postoperatively: PROM from day 1, limiting external rotation based on the intraoperative assessment of fixation. At 6 weeks, AROM is begun and followed later by a strengthening and stretching program.
Displaced Anatomic Neck FracturesFractures of the anatomic neck are very rare. In young patients, these fractures should be treated with open reduction and internal fixation. In elderly patients, prosthetic replacement would be preferred because of the risk of osteonecrosis.
3 and 4 part fracturesFor 3 and 4 part fractures follow links on left or click on heading above. References
IANNOTTI, JOSEPH P. MD, PHD; RAMSEY, MATTHEW L. MD; WILLIAMS, GERALD R. MD; WARNER, JON J.P. MD NONPROSTHETIC MANAGEMENT OF PROXIMAL HUMERAL FRACTURES. Journal of Bone & Joint Surgery - American Volume. 85-A(8):1578-1593, August 2003.
Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am. 1992;74;509
ELKOWITZ, STUART J. M.D.; KOVAL, KENNETH J. M.D.; ZUCKERMAN, JOSEPH D. M.D. Decision Making for the Treatment of Proximal Humerus Fractures. Techniques in Shoulder & Elbow Surgery. 3(4):234-250, December 2002.
Green, Andrew; Izzi, Joseph Jr; Isolated fractures of the greater tuberosity of the proximal humerus. Journal of Shoulder & Elbow Surgery. 12(6):641-649, November/December 2003.
C. M. Court-Brown, A. Garg, and M. M. McQueen; The translated two-part fracture of the proximal humerus: EPIDEMIOLOGY AND OUTCOME IN THE OLDER PATIENT; J Bone Joint Surg Br, Aug 2001; 83-B: 799 - 804.
S. A. Hodgson, S. J. Mawson, and D.
Stanley; Rehabilitation after two-part fractures of the neck of the humerus Page created by: lee Van RensburgLast updated: 11/09/2015
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