Proximal humerus fractures are notoriously difficult to treat. The surrounding rotator cuff musculature makes intraoperative assessment of the reduction of fractures, especially those involving the articular surface, difficult to assess. Even fractures fixed with open reduction and internal fixation often require intraoperative fluoroscopic guidance to ensure appropriate anatomic reduction. The anatomic relationship between the articular surface and the surrounding rotator cuff has a critical influence on the final result. Furthermore, fixation is a challenge to maintain as the rotator cuff exerts strong deforming forces on the tuberosities, which are often of poor bone quality and do not hold hardware well. In spite of this, many unstable proximal humerus fractures are treated successfully with established methods of open reduction and internal fixation.
Four-part proximal humerus fractures, as classified by Neer,1,2 are particularly problematic. Historically, they have a very high rate of avascular necrosis following fixation. Because of this, Neer recommended hemiarthroplasty for the treatment of these fractures. However, a subgroup of four-part proximal humerus fractures, the four-part valgus-impacted fracture, is readily amenable to reduction and fixation. Neer did not specify this fracture in his initial classification system. In the more recent AO/ASIS classification, however, the valgus-impacted humeral head fracture is regarded as a separate type of fracture.3 The valgus-impacted four-part fracture is an ideal fracture for minimally invasive fixation, and it is the focus of this chapter.
Rotator Cuff Humeral Head Avascular Necrosis Great Tuberosity Proximal Humerus Fracture
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