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
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in to check access
Neer CS II. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am, 1970. 52(6):1090–1103.PubMedGoogle Scholar
Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am, 1970. 52(6):1077–1089.PubMedGoogle Scholar
Jakob RP, Kristiansen T, Mayo K, et al. Classification and aspects of treatment of fractures of the proximal humerus. In: Bateman J, Welsh R editors. Surgery of the Shoulder. Philadelphia, PA: B. C. Decker, 1984Google Scholar
Kanlic EM, Pesantez RF, Pachon CM. Minimally invasive plate osteosynthesis of the femur. Oper Tech Orthop, 2001. 11(3):156–167.CrossRefGoogle Scholar
Morgan S, Jeray K. Minimally invasive plate osteosynthesis in fractures of the tibia. Oper Tech Orthop, 2001. 11(3):195–204.CrossRefGoogle Scholar
Jaberg H, Warner JJP, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am, 1992. 74-A(4):508–515.Google Scholar
Resch H, Povacz P, Frohlich R, et al. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br, 1997. 79(2):295–300.CrossRefPubMedGoogle Scholar
Chen CY, Chao EK, Tu YK, et al. Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma, 1998. 45(6):1039–1045.CrossRefPubMedGoogle Scholar
Bohler J. Perkutane oisteosynthese mit dem Rontyenbildrier-Starker. Wiener Klin Wachenschr, 1962. 74:485–487.Google Scholar
Jakob RP, Miniaci A, Anson PS, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br, 1991. 73(2):295–298.PubMedGoogle Scholar
Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg, 1995. 4:73–80.CrossRefPubMedGoogle Scholar
deAnquin CE, deAnquin CA. Prosthetic replacement in the treatment of serious fractures of the proximal humerus. In: Bayley I, and Lessel L, editors. Shoulder Surgery, Berlin, Springer. 1982:207–217.Google Scholar
Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg Br. 1984. 66(1):104–108.PubMedGoogle Scholar
Laing PG. The arterial supply of the adult humerus. J Bone Joint Surg Am, 1956. 38A:1105–1116.Google Scholar
Gerber C, Schneeberger AG, Vinh TS, The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am, 1990. 72(10):1486–1494.PubMedGoogle Scholar
Wheeler DL, Colville MR, Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation. J Orthop Trauma, 1997. 11(5):363–367.CrossRefPubMedGoogle Scholar
Soete P, Clayson P, Costenoble V. Transitory percutaneous pinning in fractures of the proximal humerus. J Shoulder Elbow Surg, 1999. 8(6):569–573.CrossRefPubMedGoogle Scholar
Rowles DJ, McGrory JE, Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am, 2001. 83-A(11):1695–1699.PubMedGoogle Scholar