Malunion of Humeral Tuberosity Fractures

Abstract

Proximal humeral head fractures account for 5 % of all fractures, and 20 % require surgical management. A small proportion of fractures managed conservatively and some of those managed by surgery may heal with malunion. These patients typically present with pain, impaired mobility, loss of strength, and stiffness and usually require further treatment. The diagnostic work-up to confirm a suspected malunited fracture of the proximal humeral head includes physical examination to assess length discrepancy and ROM reduction compared with the contralateral limb, cuff integrity, and brachial plexus nerves; X-rays; 3D CT; and MRI. A conservative approach is preferred in the absence of severe functional impairment or pain and in patients expected to achieve significant clinical improvement but does not relieve pain or improve the ROM in symptomatic patients. The main indications for surgical management are pain and ROM limitation; older age is associated with a higher rate of comorbidities and poor bone stock. Malunion is frequently associated with two-, three-, and four-part fractures. Treatment type is based on fragment size, degree of displacement, and ability to be removed. Treatment options envisage head preservation or replacement. Management with head preservation is done where feasible by arthroscopy, because it enables treating associated conditions. Prosthetic replacement is indicated when malunion has severely damaged the head joint surface resulting in incongruent articular surfaces or head necrosis. The outcomes of surgical management are a function of the correction of the bone problems and of soft tissue release. The risk of postoperative complications is high due to the complex nature of malunited proximal humeral fractures.