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ADULT TRAUMA

Management of proximal humeral fractures

D.J.C. Burton!, A.T. Watters

Deptartment of Orthopaedics and Trauma, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK

KEYWORDSShoulder fractures;Rehabilitation;Internal fixation

SummaryAll aspects of proximal humeral fractures produce much debate. From classsificationsystems to modes of treatment and rehabilitation, the influence of patient age andmanagement of complications all may lead to confusion. Here we aim to give a balanced,contemporary overview of the subject and provide suggestions as to how to approach theseinjuries.& 2006 Published by Elsevier Ltd.

Introduction

Proximal humeral fractures are common (approximately4–5% of all fractures) and increasing in frequency, probablydue to their association with osteoporosis in our increasinglyaged population.1 They represent over 70% of humeralfractures occurring over the age 40. Overall this injury tendsto follow a bimodal age distribution, though they are lesscommon in younger people in whom they are usually theresult of higher-energy trauma. The exception to this is 2part fractures, which follow a unimodal distribution in theelderly. Fractures of the shaft and distal humerus on theother hand, are more common than proximal humeralfracture in the young population.

Management decisions for the majority of these injuriesare straightforward, though some cases lead to vigorousdebate regarding classification and treatment decisions canrange from the most conservative to the most aggressiveoperative intervention. The availability of new, specificimplants spurs some on toward operative intervention,whilst some texts still recommend treatment techniques

of questionable value, making diagnosis and treatmentconfusing.

In this article we will consider the common classificationsystems, investigations, relevant anatomy and the morecommonly proposed treatment regimes—together with thepreferred management options of the senior author (ATW).

Classification

Fracture classification systems are most useful when theyallow accurate anatomical description, guide treatment andallow an estimation of prognosis. The first classification thatseemed to meet these requirements was the Neer classifica-tion of 1970 2, although this was based on the anatomicalobservations of Codman as early as 1934.3 Despite markedintra-and inter-observer error,4 this remains the mostcommonly used classification system today.

Codman described the proximal humerus divided into4 fragments, along the lines of physeal union (Fig. 1). Thusthere are head, greater tuberosity, lesser tuberosity andshaft fragments, each with specific soft tissue attachments.Neer developed this scheme by describing the fragments asparts, when they are displaced from the other fragments by

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0268-0890/$ - see front matter & 2006 Published by Elsevier Ltd.doi:10.1016/j.cuor.2006.02.017

!Corresponding author. Tel.: +44 1937 574609.E-mail address: djcb1972@hotmail.com (D.J.C. Burton).

Current Orthopaedics (2006) 20, 222–233

10mm or 451 of rotation. Hence displaced fractures, orfracture dislocations, may be 2, 3 or 4 parts.

Additionally there are a group of humeral head fracturesthat are described as impression fractures, usually occurringwith a dislocation, in which the articular surface andsubchondral bone becomes indented by the glenoid rim.Impression fractures are divided according to the percen-tage of the articular surface affected, generally less than20%, 20–45% and greater than 45%. Head splitting fracturesare a further development of this mode of injury, as thehumeral head is cleaved into at least 2 separate fragments.

Jakob and the AO group developed a classification systemthat describes the degree of vascular isolation of thearticular fragment.5 Type A fractures are extracapsular, of2 anatomical (‘Codman’) fragments and lead to no vascularisolation of the humeral head. Type B fractures areintracapsular, of 3 fragments and lead to partial articularvascular isolation. Type C fractures are the most severe,leading to complete vascular isolation and are usually in 4fragments. Like all AO classifications, each type is sub-divided and, although this is useful for research, it leads to arather unwieldy system less suited for general clinicalapplications. Siebenrock et al. considered the AO system,like the Neer system, to be of insufficient reproducibility toallow comparison of studies using these classifications.6

Despite the reservations expressed, it is still important touse a classification system. Otherwise it becomes impossibleto compare different papers on the subject and reach anyconclusions regarding the validity, effectiveness and success

rates of the various treatment modalities described. Theauthors prefer to use the Neer system.

Vascular anatomy of the humeral head

Critical to the prognosis in proximal humeral fracture is theblood supply to the humeral head articular fragment. Thisreceives its main blood supply from the ascending branch(also known as the anterolateral branch) of the anteriorcircumflex humeral artery (itself a branch of the third partof the axillary artery). This artery enters the bone at theintertubercular groove and supplies the tuberosities and thehumeral head via the intraosseous arcuate artery, which lieswithin the head. To a lesser extent blood supply also arrivesvia the soft tissue attachments of the rotator cuff, mainlythrough the posterior circumflex humeral artery, whichsupplies a small part of the greater tuberosity and poster-oinferior head. Gerber et al. defined the territories of thesearteries in a series of cadaveric radiopaque injectionexperiments, proving that the vascularisation of the wholehumeral head was only possible via the anterolateral branchof the anterior circumflex humeral artery.7

Injuries that disrupt the blood supply to the articularfragment tend to be those that detach both the tuberositiesand damage the arcuate artery, i.e. Neer 4 part or AO C-typefractures and fracture dislocations. Head splitting fracturesalso tend to critically disrupt the blood supply to thearticular fragment. Impaired vascularity increases the

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Figure 1 Codman’s fracture fragments: green—articular fragment, red—greater tuberosity, blue—lesser tuberosity. (a) anteriorproximal humerus and (b) posterior proximal humerus.

Management of proximal humeral fractures 223

risk of Avascular Necrosis (AVN) and collapse of the humeralhead.

Diagnosis

Following standard history taking and examination of thepatient with a possible shoulder injury, including neurovas-cular assessment, full radiological examination is required.The complete shoulder trauma radiological series consists ofan anteroposterior view, scapula lateral view and an axillaryview (Fig. 2) (a Velpeau view may be required if the shouldercannot be abducted sufficiently for the axillary view).Without these 3 views the fractured proximal humeruscannot be completely assessed. The axillary view isparticularly important to assess head splitting fractures,visualise posterior displacement of the greater tuberosityand to assess the relationship between the articularsurfaces. Unfortunately this view is often considered

unnecessary by Accident and Emergency and Radiologydepartments, despite good evidence in the literature tothe contrary.8

Computed tomography (CT) is useful to further visualisecomplex fractures and to assess the humeral and glenoidarticular surfaces in impression, head splitting and glenoidrim fractures. It is also useful in assessing bone stock in casesof nonunion and anatomy in malunion (Fig. 3).

Treatment methods

Treatment methods will be described by fracture pattern.Debate becomes fierce as the complexity and number ofparts increase; there is also patient age, physiological stateand comorbidities to take into account along with expecteddemands to be put on the limb.

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Figure 2 Positioning for shoulder trauma series radiographs: (a) anteroposterior, (b) scapular lateral, (c) axillary, and (d) modifiedaxillary (Velpeau). (With thanks to J Henning, Senior Radiographer, Bradford Royal Infirmary.)

D.J.C. Burton, A.T. Watters224

Undisplaced and minimally displaced fractures

There is general agreement that fractures that are notsufficiently displaced or angulated to represent a part byNeer’s description may be treated conservatively. This isdone in a broad arm sling under clothes or with a bodyswathe. The ‘Polysling’ is an example of a rather morecomfortable form of support made of synthetic material andis ideal. The shoulder is immobilised for 10–14 days,although elbow and wrist exercises may commence im-mediately to prevent stiffness. An interim radiograph isobtained to ensure no deterioration in position. At 10–14days the patient may start gentle range of movement (ROM)passive exercise with the help of a physiotherapist.

The exception to this situation arises when there is over5mm of displacement of the greater tuberosity, whichshould be treated in the same way as 2 part greatertuberosity fractures. These fractures are best seen on theaxillary radiograph. The greater tuberosity fragment usuallymigrates proximally and posteriorly under the influence ofsupra- and infraspinatus. In cases of fracture dislocation the

closed reduction of the shoulder often leads to perfectreduction of the greater tuberosity, though this must bereimaged at 1 week to rule out late displacement. Any morethan 5mm of displacement may lead to impingement andthe fragment should be reduced and fixed when fresh, aslater osteotomy for malunion and impingement is fraughtwith difficulty (Fig. 4).

The approach for fixation of greater tuberosity fragmentsutilises a deltoid split. With the arm draped free thehumeral head may be rotated to visualise the fragment andits bed. If there is a single, large fragment then 3.5mmcancellous screws may be used, carefully countersunk toavoid impingement. If the fragment is not amenable toscrew fixation (due to comminution or poor quality bone), asuture technique is used, using a figure of eight patternthrough the rotator cuff tendon and then through a drill holein the shaft. The fragment is reattached and the surroundingcuff insertion repaired. A No. 2 Ethibond (Ethicon, USA) orFiberwire (Arthrex, USA) is appropriate in this situation.Neer regime rehabilitation may start 2–3 days post-operatively.9

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Figure 3 Computed tomography in proximal humeral fracture: (a) 2 part proximal humeral fracture dislocation unstable on closedreduction of the dislocation, (b) instability in (a) due to boney Bankart lesion of glenoid seen on CTand (c) 4 part fracture dislocationin a young patient, assessed prior to attempted open reduction and internal fixation.

Management of proximal humeral fractures 225

Two part fractures

This is the commonest fracture pattern seen. Two-partfractures of the proximal humerus may be impacted,angulated or displaced. Where there is impaction thefracture will usually unite promptly, but with associatedangulation into varus, valgus or posterior bow deformity.Significant functional impairment may result because ofimpingement or malposition of the articular surface.Displaced or ‘off-ended’ fractures, where the action ofopposing muscle groups pull the distal fragment mediallyand anteriorly, may be slow to unite and in some cases mayprogress to nonunion.

There are several schools of thought regarding themanagement of these injuries, ranging from ‘almost alwaysconservative’ to ‘almost always operate’.

Manipulative reduction under anaesthetic on its own hasbeen described in the past but due to the high incidence ofredisplacement has been largely discredited. Similarly‘traction reduction’ using a hanging plaster-of-Paris casthas also been discredited for failure to achieve reductionand for the discomfort that it causes. The authors believethat neither of these treatment options should be offered.Minimal fixation techniques following manipulative reduc-tion are well described.10,11 The technique most commonlyused is to pass three or four 2.5mm threaded Kirschnerwires across the fracture site after reduction. Pin tractinfection (particularly when the wires are not buried) and

wire migration are common complications. Where the wirespass through the shoulder girdle muscles they also causepain and interfere with movement and rehabilitation untilthey are removed. There are also many reported cases ofinadequate reduction, possibly due to tendon interposition,or loss of position despite wire fixation. Though thereremain some well-known proponents of the closed percuta-neous technique, for the reasons outlined above manysurgeons find it unsatisfactory.

Open reduction and internal fixation allows visualisationand accurate reduction of the fracture fragments. Manymethods of maintaining the reduction have been described,including the use of sutures, sutures with eyeletted nails,tension band wiring, intramedullary nails and various typesof plates and screws. More recently custom-designedproximal humeral systems have been introduced, of whichthe authors have experience of the Plant Tan (Medizentech-nic, Germany) and AO Philos (Synthes, Switzerland) systemswith fixed angle interlocking screws (Fig. 5).

Court-Brown et al. have reported the results of treatmentof a large series of patients, average age 72 years, andconcluded that the functional results of operative manage-ment in this older group are statistically no better thanthose treated conservatively.12 On this basis they advocateconservative management, with its lower complication rate.However, it should be noted that the internal fixation systemthat they used (Enders nails and sutures), is not ideal forachieving secure fixation in osteoporotic bone and they

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Figure 4 (a) Scapular lateral radiograph in anterior dislocation of the shoulder with greater tuberosity fracture and (b) afterreduction of the shoulder, significant posterior displacement of the fragment remains.

D.J.C. Burton, A.T. Watters226

concede that technical difficulties with achieving andmaintaining reduction may contribute to the overall poorresults of surgery.

Reports in the literature looking at the PlantTan proximalhumeral fixator plate in 2 and 3 part fractures have showngood functional results in the younger age group, thoughthe results in the older age group remain poor.13,14 Thetheoretical advantages of the interlocking, multidirectionalscrew system in the AO Philos plate (better hold inosteoporotic bone, low profile therefore less likely to causeimpingement) has yet to be confirmed in clinical trials, butoffers hope for better functional results in the elderlypopulation (Fig. 6).

It is the senior author’s current practice to advocate openreduction and internal fixation using the Philos system 15 inmost displaced-pattern 2 part surgical neck fracture, exceptin the very elderly and infirm and also in the more deformed(440 1) angulated pattern fractures occurring in youngerpatients. Initial results are promising, but review andanalysis are awaited.

Three part fractures

In this injury one tuberosity usually remains attached to thearticular fragment and the rotator cuff then acts as adisplacement force on this fragment. In all cases reductionand fixation are advocated, allowing early mobilisation andrehabilitation (Fig. 7).

Resch (Austria) is perhaps the best known exponent of thepercutaneous reduction of 3 and 4 part fractures, usingelevators introduced through appropriately placed stabholes and subsequent fixation with cannulated screws.16

This avoids further damage to the vascularity of the humeralhead during dissection. This technique is technically verydemanding, particularly in 4 part fractures and is notcommon practice in the UK. Gerber (Switzerland) hasemployed similar techniques for reduction and fixation ofsome 3 part fractures, though the initial approach for other3 part, and all 4 part fractures, was via a deltopectoralincision using a rasp introduced through the fracture linesfor reduction.11 The senior author’s preferred method issimilar to that for the internal fixation of the 2 part fracture,using the Philos plate and heavy sutures (Fibrewire forexample) to reattach the tuberosity fragment either directlyor by passing the suture through the rotator cuff tendon.The suture may then be passed through the holes in theplate or through drill holes in the humeral shaft. Care mustbe taken during dissection to not denude the proximalfragments of their soft tissue attachments as this increasesthe risk of AVN and nonunion with migration of the fracturefragments.

In very osteoporotic bone and in cases of fracturedislocation in the elderly, with complete loss of soft tissueattachments, a primary shoulder hemiarthroplasty allowsearly mobilisation and produces a confortable shoulder.17

When done immediately, this is far less technically demand-ing and yields more satisfactory results than at an interval

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Figure 5 (a) PlantTan proximal humeral fixator plate and (b) AO Philos plate and locking screw.

Management of proximal humeral fractures 227

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Figure 6 (a–c) Completely displaced 2 part fracture, treated by ORIF using the Philos system.

D.J.C. Burton, A.T. Watters228

following failed conservative or operative management(Fig. 8).

Four part fractures

This pattern of injury is not amenable to closed reduction.There is also a high failure rate with open reduction andinternal fixation due to avascular necrosis and nonunion.Four part fracture dislocation is associated with an evenhigher risk, the head fragment is usually found to becompletely free and devoid of soft tissue at operation(Fig. 9).

In the series from Austria alluded to above,16 there was an11% AVN rate using percutaneous reduction and cannulated

screw fixation with an average Constant score of 87% for4 part fractures. This was in a relatively young population(average age 54 years), using a technique not widelypracticed in the UK.

The treatment of choice in the elderly population isgenerally accepted to be primary hemiarthroplasty.Although hemiarthroplasty had been attempted before the1950s, it was Charles Neer who revolutionised the procedurefor the treatment of proximal humeral fractures.18 Arthro-plasty performed after an interval is made more difficult bysoftening of the bone, malunion of the tuberosities,contracture and intrarticular adhesions. The treatment ofmiddle-aged patients remains something of a grey area anddecisions must be made on an individual basis afterdiscussion with the patient.

The decision to perform hemiarthroplasty in young, activepatients is very difficult as it will almost inevitably lead,with the passage of time, to a requirement for revisionsurgery. The levels of discomfort and function from anonweight-bearing joint makes the sequelae of AVN of thehumeral head and femoral head noncomparable, making atrial of fixation of the 4 part fracture in young people aviable option in the first instance. Satisfactory levels offunction and comfort have recently been reported in youngpatients sustaining complex proximal humeral fracturescomplicated by AVN, having had restoration of anatomyusing a deltopectoral approach and a combination of plate,screw and transosseous suture.11

If humeral head replacement is performed the deltopec-toral approach is preferred. The key to the derangedanatomy is identification of the bicipital groove and the

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Figure 7 (a and b) Three part fracture proximal humerus.

Figure 8 Shoulder hemiarthroplasty for trauma.

Management of proximal humeral fractures 229

long head of biceps tendon, lying between the twotuberosities. It is usually unnecessary to divide thesubscapularis tendon as the split that commonly occursbetween the two tuberosities allows entry into the shoulderjoint and retrieval of the humeral head fragment. Care mustbe taken when retrieving the humeral head in cases offracture dislocation, particularly if there has been delaybetween injury and presentation, as it may lie very close tothe brachial plexus and axillary sheath.

A number of humeral head replacements are availableand are broadly grouped into modular or monobloc. Theoriginal Neer implant of the 1950s was modified in the 1970sand has remained in its monobloc form ever since. Thesenior author currently uses the Bigliani-Flatow (Zimmer,USA) modular implant, which comes with interchangeablehead sizes (both diameter and depth) and a range of lengthsand diameters. Other implants have increased modularity(separate neck for example) and all vary in the number anddistribution of holes in fins for reattachment of soft tissues.With increasing modularity comes increasing risk of dis-sociation 19 and theoretically increased risk of fret corrosionbetween the components.

The key to a successful hemiarthroplasty for trauma is theavoidance of injury to the deltoid muscle, correct retro-version of the prosthesis (usually about 301) and securereattachment of the tuberosities to each other, the humeralshaft and the prosthesis itself to ensure healing in thecorrect position.17 Correct soft tissue tension is vital and theheight of the prosthesis must therefore replicate the heightof the native humeral head closely, as there is a tendency

amongst inexperienced surgeons to shorten the humerus.Finally, the tuberosities should lie below the level of thehumeral head to ensure correct cuff tension and preventimpingement.

The long head of biceps tendon should be replaced in thebicipital groove at the end of the procedure or tenodesed tothe floor of the bicipital groove if it has become detachedfrom the glenoid.

The functional results of hemiarthroplasty are variableand the patient must be counselled that some stiffness andloss of range of movement are inevitable, although acomfortable shoulder is the primary goal. Functional resultis influenced by age of the patient, correct positioning of theimplant and the anatomical reduction of the tuberosities.20

Impression and head splitting fractures

Impression fractures are sustained following dislocation ofthe shoulder. In general terms articular defects ofo20% maybe treated conservatively in a shoulder immobiliser or slingafter joint reduction. Fractures involving 20–40% of thearticular surface may require a bone grafting procedure,either by transfer of a tuberosity into the defect (theMcLaughlin procedure for posterior dislocation21), or by iliaccrest grafting. Fractures of more than 40% of the headsurface require hemiarthroplasty as they tend to be grosslyunstable as the defect fails to engage the glenoid with anycongruency.

Head splitting fractures cleave the head into at least twoavascular fragments. Primary hemiarthroplasty is the pro-cedure of choice, however this is a difficult decision to makein the young patient. In this case an attempt at anatomicalreduction and fixation may be made after forewarning thepatient of the risks and benefits of each option.

Pathological fractures

Pathological fractures involving the proximal humerus maybe treated by intramedullary fixation if the prognosis for themalignant disease warrants stabilisation. The Polarus nail(Acumed, USA) range allows numerous possibilities forlocking in the proximal fragment and may be augmentedwith PMMA cement for greater stability. Where there isextensive replacement of the humeral head by tumour thena long stem humeral hemiarthroplasty with proximal anddistal locking options may be used. In many cases non-operative treatment is most appropriate (Fig. 10).

Rehabilitation

The rehabilitation of proximal humeral fractures is criticalto optimise outcome. The sooner that rehabilitation cancommence, the better. This is usually more successful underthe supervision of a physiotherapist. The classical Neerregime involves 3 phases.22

Phase 1: Passive-assisted exercises, including initialpendulums in both side-to-side and small circle movements,with the patient bending over slightly to allow the limb toswing. This progresses to assisted forward elevation andassisted external rotation in the supine position. Pulleysattached to the ceiling may be used, with the opposite hand

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Figure 9 Four part fracture dislocation in an elderly patient.

D.J.C. Burton, A.T. Watters230

as the motor to provide the assistance. The use of a ceilingpulley is not recommended in the presence of tuberosityfractures until they have healed, at approximately 6 weeks,as their use may lead to displacement.

Exercises are repeated 4 times per day after initial warm-up using a warm pack on the shoulder. These exercises areideally commenced immediately after stable fixation offractures, though they may be deferred 2–3 weeks if there isconcern regarding the strength of fixation or in the case ofpotentially unstable fractures that are to be treatedconservatively (greater tuberosity fractures for example).

Phase 2: Involves active, resisted and stretching exer-cises, usually between 6 and 12 weeks post injury. Activeexercises involve forward elevation against gravity and theuse of rubber ‘TheraBands’ to resist internal and externalrotation, one end held in the affected hand and the otherattached to a fixed point. Stretching may be done in adoorway, using the door jamb and top of door frame as fixedpoints against which to stretch. The unaffected limb is alsouseful to aid in stretching exercises, especially in internalrotation and by clasping the affected hand to move it aboveand behind the head, leading to abduction and externalrotation of the shoulder.

Phase 3: Increases resistance with the use of weights,starting at 1 lb and progressing up to a maximum of 5 lb. Ifthe patient develops pain then the weight should bereduced. Phase 3 starts at about 3 months post-injury andcontinues until functional gain reaches a plateau orpreinjury levels. Stretching is continued throughoutphase 3.

Complications

Neurovascular injury

The neurovascular injury rate has been reported to be ashigh as 4–6% in some series of displaced proximal humeralfractures.23 Damage to the axillary artery is a recognised,though uncommon, complication of proximal humeralfracture. It typically occurs in elderly, atheroscleroticvessels and after high-energy trauma. An expanding hae-matoma around the shoulder, with a pale, pulseless,paraesthetic forearm, raises suspicion of vascular injuryand indicates angiography. The consequences of vascularinjury are necrosis of the limb distally, distal embolisationand permanent damage to the brachial plexus secondary tocompression by the haematoma.

Any part of the brachial plexus may be injured. Morecommonly an axillary nerve palsy is seen following anteriorfracture dislocation, due to the position of the nerve on theanterior capsule. After careful documentation of the deficit,progress may be monitored with electromyography. Discus-sion with a centre managing brachial plexus injury is advisedat an early stage, as some surgeons prefer early explorationof the brachial plexus rather than an expectant policy.

Chest injury

Pneumothorax and haemothorax are both possible associa-tion with proximal humeral fracture, usually in high-energy

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Figure 10 (a and b) Pathological fracture secondary to breast carcinoma metastasis. Stabilised with the Polarus intramedullary nailwith PMMA cement augmentation.

Management of proximal humeral fractures 231

trauma. Intrathoracic dislocation of the humeral headfragment is an interesting though rare complication ! 24

Frozen shoulder

Post-traumatic frozen shoulder is largely preventable withadequate rehabilitation and physiotherapy starting as earlyas possible post injury. Failure to progress with range ofmovement (including passive range), with the cardinal lossof external rotation, suggests frozen shoulder. Impingementof fracture fragments and metalwork causing a mechanical

block to movement must be ruled out before embarkingupon arthroscopic or open capsular release, in the event offailed physiotherapy and stretches for this condition. Closedmanipulation is hazardous and may lead to refracture.

Avascular necrosis

Avascular necrosis may occur very occasionally in 2 partfractures of the proximal humerus, however it is followingclosed treatment (3–14%) of 3 part fractures and opentreatment of 3 and 4 part fractures (13–34%) that it is morecommon.25 A combination of primary traumatic insult to thevascularity of the humeral head followed by the secondaryinsult of manipulation and/or surgical dissection leads tonecrosis. If the fracture was reduced anatomically with acongruent joint and well positioned tuberosities then asatisfactory functional result may be achieved despite theavascular necrosis. However, a more common picture is thatof periarticular soft tissue contracture, degenerativechange, metalwork migration and a stiff, painful joint.Treatment is by hemiarthroplasty of the shoulder.A procedure that is more demanding in the chronic situationdue to contracture, abnormal anatomy and soft bone(Fig. 11).

Fracture nonunion

This is an uncommon complication caused by excessivemovement at the fracture site (over aggressive physiother-apy for example), extensive periosteal stripping in high-energy trauma, wide separation of fragments and soft tissueinterposition. The humeral shaft fragment may form apseudarthrosis with the undersurface of the head fragment,complete with synovial membrane formation, as a result ofexcessive movement of the fracture site that is bathed insynovial fluid from the shoulder joint above.

Where possible, treatment is with open debridement,reduction and fixation with bone grafting. This is onlypossible when the humeral head fragment has sufficientbone stock to allow fixation and the articular surface is ingood condition. A CT scan may be useful in planning.Humeral head replacement is the procedure of choice wherethe criteria above are not met, although painless pseudar-throsis may be very satisfactory in some elderly patientswith no functional demands.

Fracture malunion

Greater tuberosity migration into a superior positionproduces subacromial impingement, whilst posterior migra-tion produces impingement with the glenoid. Where there isgross malunion an osteotomy may be performed, through asuperior approach. This also allows correction of theposition of the rotator cuff, although this may have becomeshortened with time, making reduction difficult. Thisprocedure is often associated with unrewarding results andis best prevented by early recognition of greater tuberositymigration and managed in the acute situation. This can onlybe achieved with correct trauma series radiographs toidentify the lesion.

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Figure 11 (a and b) Avascular necrosis with metalworkmigration following ORIF proximal humeral fracture.

D.J.C. Burton, A.T. Watters232

Angular malunion of the surgical neck may be associatedwith a surprisingly good range of movement, providing thereis no frozen shoulder and tuberosity impingement. It may bebetter to perform capsular release and institute intensivephysiotherapy before embarking on an angular osteotomy ofthe proximal humerus. There are some deformities thatwarrant corrective osteotomy, these are usually gross andare more commonly due to anterior angulation at thefracture site leading to reduced forward flexion.

Acknowledgement

The authors’ thanks go to Jessica Henning, radiographer atBradford Royal Infirmary, for the line drawings.

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ARTICLE IN PRESS

Management of proximal humeral fractures 233