6 Sp e c ific fractu res

6.2 H um erus

6.2.1 Humerus, proximal

1 Assessment of fractures 573 5 Postoperative treatment 590

1.1 Imaging and classification 573
6 Pitfalls and complications 591
1.2 Indications for surgery 573
6.1 Stiffness 591
2 Surgical anatomy 575 6.2 Positioning of implants 591
6.3 Malunion and nonunion 591
3 Surgical treatment 576
6.4 Avascular necrosis 592
3.1 General strategy 576 6.5 Nerve lesions 592
3.2 Closed reduction 578 6.6 Infection 592
3.3 Approaches 578
3.3.1 Deltopectoral approach 7 Bibliography 593
3.3.2 Transdeltoid lateral approach
8 Acknowledgment 593
3.4 Instruments and implants for osteosynthesis 580
3.5 Prosthetic replacement 582

4 Surgical treatment of specific fractures 584

4.1 Type A fractures (extraarticular unifocal) 584
4.1.1 A1 fractures
4.1.2 A2 fractures
4.1.3 A3 fractures
4.2 Type B fractures (extraarticular bifocal) 587
4.2.1 B1 fractures
4.2.2 B2 fractures
4.2.3 B3 fractures
4.3 Type C fractures (articular) 588
4.3.1 C l fractures
4.3.2 C2 fractures
4.3.3 C3 fractures

572
 A uth or Pierre Guy
6.2.1 Humerus, proximal
1 A sse ssm e n t o f fractu res
1.1 Im a gin g and cla ssifica tio n
Evaluation and preoperative planning for proxim al hum erus
fractures requires a series of three x-rays taken at right angles
to each other (traum a series) (Fig 6.2.1-1):
■ true glenoid AP;
■ transcapular lateral;
■ axillary view.
An axillary view requires abduction of the shoulder
(Fig 6 .2 .1 -le -f), w hich is painful and difficult w ith an acute
fracture. A less painful alternative is the "bum ped up" trans­
Fig 6.2.1- la -h Trauma-series x-rays. With an acute fracture, all
x-rays are taken with the patient standing or sitting and the arm
supported to minimize pain.
a -b True glenoid AP view. The patient must stand facing the x-ray
source, with the posterior aspect of the affected side against
the x-ray plate. The opposite trunk is rotated at least 30°.
scapular view (Fig 6 .2 .1 -lc-d ) [1]. Additional views in external
and internal rotation of the hum erus can improve the under­
standing and m easurem ent of the displacement of the greater
tuberosity (Fig 6 .2 .1 -lg -h ) [2], CT scans can prove useful in
m ultifragm entary fractures or to quantify displacement of the
tuberosities (Fig 6.2.1-2). Only w ith adequate imaging of the
fracture can one proceed to accurate classification (Fig 6.2.1-3),
surgical treatm ent, and prognosis.
1.2 In d ic a tio n s for su rge ry
Indications for surgical intervention are governed by general
and associated local injuries, the type and stability of the frac­
ture, the quality of the bone (osteoporosis), and the patient's
age and general medical condition.
c -d Transscapular lateral view. The patient stands with the x-ray
source on the opposite side and the affected shoulder is placed
against the x-ray plate. The trunk is turned 30° away from the
x-ray beam, which is then directed posteriorly along the scap­
ular spine.
5 73
 6 Sp e c ific fractu res
6.2 H um erus
Fig 6.2.1 -1 a—h (cont) Trauma-series x-rays,
e - f Axillary view. The patient is supine with the x-ray
plate placed above the shoulder. Abduction of
about 30° is needed, which can be painful in an
acute setting.
Fig 6.2.1-2 Computed tomography (CT) scan demon­
strating an axial section of the humeral head that allows
one to evaluate the extent and localization of the in­
jury.
574
g -h Alternative axillary view. A less painful alternative for acute fractures. The
patient remains in a comfortable sling and is placed at the edge of the ta­
ble, a cassette is placed above the shoulder, and the beam is aimed upward
from below the table, cranial, through the axilla.
11-A3 11-B2
Fig 6.2.1-3 Müller AO Classification. Because of the unique anatomy of the
proximal humerus, the classification is modified for this special area.
Type A = Extraarticular, unifocal (surgical neck).
Type B = Extraarticular, bifocal.
Type C = Articular (anatomical neck).
 6.2.1 H u m eru s, proxim al
Stability and displacement are often interdependent. In m any
cases the fracture fragments are held together by muscles, ten­
dons (including the rotator cuff), and periosteum . Treatm ent
of these fractures— especially in elderly patients—has tradi­
tionally been nonoperative [3] w ith a predictable outcom e and
a good to excellent functional score in 88% of cases [4],
■ Nonoperative treatm ent is preferred for elderly patients,
patients w ith significant com orbities, and for m inim ally dis­
placed fractures.
However, nonoperative treatm ent of some fractures has re­
sulted in a poor outcom e [5]. Reduction and operative fixation
may be indicated in approxim ately 20% of cases. This group
comprises younger patients, or active older patients, w ith frac­
tures in w hich at least one of the following occurs:
Tuberosities are displaced m ore than 5 mm.
Shaft fragment(s) are displaced m ore th an 20 m m .
■ Head fragm ent angulation is greater than 45°.
The expectations of patients are im portant in decision making:
Young individuals w ant to regain preinjury levels of function;
active elderly patients may wish to resum e their sporting ac­
tivities, while others only hope to resume daily living activities.
2 S u rg ica l anatom y
It is crucial to differentiate betw een fractures of the anatom i­
cal and surgical neck (Fig 6.2.1-3) because the blood supply to
the m ain head fragm ent is usually disrupted after anatom ical
neck fractures, avascular necrosis (AVN) is likely to occur. In
contrast, surgical neck fractures are relatively unproblem atic
as the blood supply to the head is usually preserved. The lateral
ascending branch of the anterior circum flex hum eral artery
(Fig 6.2.1 -4) [6] runs a few m illim eters posterior, lateral, and
parallel to the biceps brachii tendon and bicipital groove.
■ The lateral ascending branch of the anterior circum flex hu­
meral artery carries the m ost im portant blood supply of the
humeral head and dam age may lead to avascular necrosis
m-
Its location is im portant for classification and prognosis, vas­
cularity-sparing dissection, and im plant placement. The m e­
dial aspect of the capsule has the second most im portant blood
supply. A large, intact, m edial spike on the head fragment
[6, 8] is an advantageous prognostic sign.
The tendon of the long head of the biceps brachii muscle plays
an im portant role in localizing the lateral hum eral ascending
artery and in orienting the greater and lesser tuberosities. In
fractures th at cannot be reduced via closed reduction, the te n ­
don may be trapped betw een bone fragments. The acromion,
coracoacromial ligament, and coracoid process form an arch
under w hich the hum eral head rotates. H um eral head move­
m ent is constrained by this arch, while the muscles of the rota­
tor cuff guide m ovem ent under the arch.
■ Anatom ical reduction of the tuberosities during internal
fixation and prosthetic replacem ent surgery w ill best restore
strength and range of m otion, and prevent com plications
such as im pingem ent.
575
 6 Sp e c ific fractu res
6.2 H um erus

Fig 6.2.1 -4 Vascular anatomy of the proximal

humerus.
1 Axillary artery.
2 Posterior humeral circumflex artery.
3 Anterior humeral circumflex artery.
4 Lateral ascending branch of the anterior
humeral circumflex artery.
5 Greater tuberosity.
6 Lesser tuberosity.
7 Tendon insertion of the infraspinatus
muscle.
8 Tendon insertion of the teres minor
Anterior Posterior muscle.

3 S u rg ica l treatm ent

3.1 G ene ral strate gy
The best results are obtained if the fragments are well reduced
and m aintained until healing has occurred [4,9,10] preferably
using the least invasive approach: nonoperative treatm ent,
closed or m inim ally invasive surgery, formal ORIF or a rth ro ­
plasty.
The selection of a suitable treatm ent depends upon the type of
fracture, quality of the bone, deform ing forces, the surgeon's
skills (experience, preference), the patient's compliance, and
the patient's expectations. Hoffmeyer [2] proposed an algo­
rithm w hich takes into account head fragment vascularity and
bone quality (Fig 6.2.1-5). This approach takes into account the
risk of avascular necrosis and lim itations of conventional plate
and screw fixation in poor bone.
The three types of fragments (tuberosity, shaft, and articular)
are exposed to different deform ing forces. The fixation must
counter these forces. The tuberosities undergo tension from
muscle pull, the shaft undergoes bending and torsional m o­
m ents, and the articular fragment undergoes compression.
M any reduction and fixation techniques have been proposed
that allow sufficient stability to initiate early rehabilitation.

576
 6.2.1 H u m eru s, proxim al

Fig 6.2.1-5 Proposed algorithm for the surgical treatment of displaced proximal humerus fractures (a modification of Hoffmeyer [2]).

5 77
 6 Sp e c ific fractu res
6.2 H um erus
Locking plates, providing angular stability, combined w ith su­
ture holes for soft-tissue fixation, have resulted in renewed
interest in plate and screw fixation. A rthroplasty is generally
kept as a salvage option w hen adequate ORIF is not possible.
3.2 C lo se d red uction
The patient is placed supine on a table or in a beach chair posi­
tion w ith the affected arm supported on an arm rest (Fig 6.2.1 -6).
The image intensifier is positioned at the top of the table (pa­
tient's head), and AP and axillary views are confirm ed. Before
draping, however, closed m anipulation is attem pted under the
image intensifier. If alignm ent is achieved and the reduction
is stable, the arm is imm obilized in a sling.
Fig 6.2.1-6 Beach chair position. The right shoulder is resting on a
radiolucent part of the operating table; the entire shoulder is checked
first with the image intensifier before draping.
578
Limited (percutaneous) technique: If closed reduction is not
achieved or is unstable, the arm is draped free on the operating
table, allowing for lim b m obility and access to the axillary
artery, if necessary. The surgeon may then attem pt the same
closed reduction and percutaneous fixation w ith K-wires if
reduction can be achieved.
If closed reduction fails, a lim ited-access reduction is attem pted
employing joysticks (small Schanz screws or K-wires), or hooks
placed through stab incisions. The fragm ents are then m anip­
ulated, and if adequate reduction can be achieved, the surgeon
m ay proceed w ith m inim ally invasive osteosynthesis. A vari­
ety of im plants have been proposed for definitive fixation
(term inally threaded K-wires (with hum erus block), small-
diam eter Schanz screws, cannulated screws). They will all
work if the deform ing forces on the fixed fragm ent can be ad­
equately countered. Attention should be given to adjacent
neurovascular structures th at m ust be avoided [11].
3.3 A p p ro ach e s
If percutaneous reduction cannot be achieved, open reduction
w ill be necessary in order to obtain good alignm ent and
fixation, allow ing early rehabilitation.
3.3.1 D e lto p ecto ral ap pro ach
The incision starts at the coracoid process and extends to the
hum erus at the level of the deltoid tuberosity (Fig 6.2.1-7).
The cephalic vein is identified proxim ally and usually re­
tracted laterally w hile exposing the deltopectoral plane. The
pectoralis fascia is incised lateral to the tendon of the short
head of the biceps brachii muscle, m aintaining the coraco-
acrom ial ligam ent proxim ally and incising the upper border of
the pectoralis major muscle insertion by 1-2 cm. The fracture
fragments are identified and the hem atom a is evacuated. The
long head of the biceps brachii muscle is identified under the
pectoralis m ajor muscle and serves as a reference for the lesser
 6.2.1 H u m eru s, proxim al

Fig 6.2.1 -7a-b Deltopectoral approach, b The deltopectoral groove is opened.

a Skin incision from the coracoid to the deltoid tuberosity. 7 Deltoid muscle.
1 Coracoid process. 8 Cephalic vein.
2 Axillary nerve. Muscle and vein are retracted to the lateral side exposing the
3 Acromion. humeral head.
4 Lateral end of clavicle. 9 Pectoralis major muscle.
5 Axillary artery. 10 Anterior circumflex humeral artery.
6 Brachial plexus. 11 Long head of biceps brachii tendon.

5 79
 6 Sp e c ific fractu res
6.2 H um erus
1
Fig 6.2.1-8 Transdeltoid lateral approach.
Incision from the anterolateral corner of the acromion extending
distally no further than 5 cm.
1 Acromioclavicular joint.
2 Axillary nerve.
(anterior and medial) and greater (lateral) tuberosities and
their associated rotator cuff muscles. By abducting the arm ,
the subdeltoid space is exposed to allow proxim al access. Distal
extension of the fracture and the use of longer plates may re ­
quire detachm ent of the anterior half of the distal deltoid m us­
cle insertion. A retractor is carefully placed behind the proximal
fragm ent w hich is delivered into the w ound, m indful of po­
580
tential traum a to the axillary nerve. Reduction is achieved
through the fracture, preserving vascularity. If a plate is used,
it should lie laterally to the lateral ridge of the bicipital groove
to preserve the lateral ascending branch of the anterior
circum flex hum eral artery (Fig 6.2.1-4).
3.3 .2 Tran sd elto id lateral ap pro ach
This approach is used for isolated fractures of the tuberosities
or injuries of the rotator cuff (Fig 6.2.1-8). The incision extends
distally from the anterolateral corner of the acrom ion to no
further th an 5 cm (m arked by a "safety-suture" to protect the
axillary nerve) along the raphe separating the anterior and
middle portion of the deltoid. Dissection is carried through
this raphe to the subdeltoid bursa. Proximal extension sharply
separates the anterior deltoid from the most anterior portion
of the trapezius muscle at th e lateral clavicle and acromion.
These thick soft-tissue flaps are reattached at closure. Internal
and external rotation allows inspection, reduction, and fixa­
tion of the tuberosities or rotator cuff.
3.4 In stru m en ts and im p lan ts fo r o ste o syn th e sis
The goals of osteosynthesis are anatom ical reattachm ent of the
tuberosities as well as attaching the hum eral shaft to the h u ­
m eral head/tuberosities to allow early m ovem ent and reh a­
bilitation. There are m any im plants or fixation options for the
proxim al hum erus. A careful preoperative study of individual
fragments and their deforming forces w ill allow the surgeon
to plan definitive fixation. Having the following devices avail­
able has proven useful: K-wires, cannulated screws, heavy
braided resorbable sutures, and 1 m m w ire. In osteoporotic
bone, the im paction of bone fragments w ill m inim ize devas­
cularization, lim it im plant prom inence, and avoid poor screw
purchase. An "osteosuture" w ith large-caliber resorbable su­
tures or nonresorbable surgical tape [2, 12], tension band w ir­
ing [13], or the m inim al use of screws provides relative
stability, w hich is sufficient to allow early rehabilitation.
 6.2.1 H u m eru s, proxim al
P late and screw fixa tio n
4.5 m m im plants such as the T-plate are not recom m ended
because of extensive dissection, intraarticular hardw are pen­
etration, and subacrom ial im pingem ent [14]. Good results
have been obtained w ith sm aller 3.5 and 2.7 m m im plants
[15], eg, the modified sm all-fragm ent clover leaf plate
(Fig 6.2.1 -9), w hen good purchase in the bone can be achieved.
There is renew ed interest in plate osteosynthesis for treating
proxim al hum eral fractures due to advances in locking plate
technology (chapter 3.3.4). This design aim s at improving
purchase and pull-out strength in osteoporotic bone by using
convergent and divergent locked screws (Video 6.2.1-1). It can
bridge m ultifragm entary fractures of the surgical neck, and
the rotator cuff can be attached to the plate through suture
holes. It is very effective (Fig 6.2.1-18).
A proxim al hum erus right-angle blade plate is available. The
blade is inserted over a K-wire and the plate allows placement
Fig 6.2.1 -9 The small-fragment clover leaf plate may be
modified by bending the top hole in hook fashion or cut­
ting it to prevent impingement.
of screws into the head or the m edial cortex. This plate is
especially useful in delayed union and nonunions w hen the
articulated tension device is used to provide compression. It is
sometimes used in acute fracture care for compression or
bridge plating. Because of the biom echanics, fractures of the
tuberosities and attached rotator cuff are often fixed w ith a
tension band wire.
In tram e d u llary n ailin g
The m ain indication for intram edullary nails is a m ultifrag­
m entary fracture of the surgical neck and metaphysis where
the tuberosities and hum eral head rem ain a single fragment
(11-A3.3). The second im portant indication is complete or im ­
pending pathological fractures.
■ Intram edullary nails cannot be used to stabilize tuberosity
fragm ents.
Video (£)
Video 6.2.1-1 The holding power of con­
vergent and divergent locking head screws
can be demonstrated using an apple.
581
 6 Sp e c ific fractu res
6.2 H um erus

Antegrade or retrograde nails (single and multiple) have been ■ The surgeon should be prepared to carry out a prosthetic
used successfully (Fig 6.2.1-10). The m ain complication of replacem ent in com plex articular fractures or patients with
antegrade nails is pain in the shoulder and rotator cuff severe osteoporosis w here poor im plant purchase is ex­
dysfunction. pected.

A d ju n cts to fixa tio n
Autogenous bone graft is used for atrophic nonunions or to
gain m ore stability by filling a void following reduction of an
im pacted fragment. If the anchorage of the screws is not reli­
able, m ethylm ethacrylate [16] or calcium phosphate bone ce­
m ent may be filled into the drill holes or the fracture gap to
improve fixation [15, 17].
3.5 P ro sth e tic rep lacem en t
Stable osteosynthesis allowing early rehabilitation rem ains
the preferred technique.
This is also advisable in elderly patients w ith little or no soft-
tissue attachm ent to the m ain articular fragm ent. Under these
conditions, results are better w ith prim ary hem iarthroplasty,
as com pared to secondary replacem ent [6], Success factors
which relate to tim ing, technique, and im plant position have
been identified [18],
Factors that negatively affect the outcome in hemiarthroplasty:
■ preoperative delay > 13 days;
■ tuberosity problems: loss of fixation, resorption, m al­
union;
malpositioned prosthesis [19],

11-A3.3

Fig 6.2.1-10a-c
a Surgical neck fracture with multiple fragments (11 -A3.3).
b Illustrative case: Active elderly patient, fall while skiing. Preoperative AP internal and external rotation views,
c Indirect reduction and stabilization using multiple retrograde flexible titanium elastic nails inserted through the lateral epi-
condyle (alternately posteriorly above the olecranon fossa). These achieve adequate minimal rigidity to allow rehabilitation
and maintain alignment. Protrusion of intramedullary nails is possible in osteopenic bone.

582
 6.2.1 H u m eru s, proxim al
A m alpositioned prosthesis is judged by
■ height: hum eral head to greater tuberosity distance:
■ lengthening (overstuffing): > 10-14 m m [19];
■ shortening: greater tuberosity < 10 m m below or 5 mm
above prosthesis;
■ offset: hum eral head to lateral cortex at greater tuberosity:
lateralization < 2 3 m m [19];
■ version: < 10° or > 40° of retroversion.
A rth ro p la sty te ch n iq u e
Following the decision not to carry out an ORIF, the tuber­
osities m ust be identified and secured w ith heavy sutures. The
articular fragm ent is retrieved and its cancellous bone is pre­
served for grafting. The proxim al subarticular m edial cortex of
the shaft (calcar equivalent) is preserved, reduced, and tem po­
rarily fixed to the adjacent shaft as a length reference. A trial
im plant is placed in the m edullary canal to establish proper
length and retroversion. Length determ ination can be assisted
by the following: intact m edial cortex; tension of the long head
of the biceps brachii, the rotator cuff, and the deltoid muscles;
anatom ical reduction of the tuberosities (top of greater tuber­
osity lying 5-10 m m distal to the im plant head's highest point).
Typically, 30-40° of retroversion should be established from
the epicondylar coronal plane, which is palpated.
In general, a cem ented im plant is recomm ended. The m edul­
lary canal should be ream ed and large-diam eter resorbable
sutures placed at the tendon-bone junction of each tuberosity
fragment, or through 2 m m drill holes. Sim ilar holes and su­
tures are placed in the shaft 1 cm distal to the surgical neck
fracture. The m edullary canal is prepared by placing a cement
restrictor. A n im plant should be cem ented w ith a 2 m m m an­
tle to ensure im m ediate rotational stability and to m aintain
desired height and version. Any cement w hich prevents bone
contact of fragm ents proxim ally should be removed, and the
tuberosity fragments m ust be accurately reduced and tenta­
tively fixed to the shaft and to each other using the previous
suture, drill holes, and holes in the im plant (Fig 6.2.1-11). The
Fig 6.2.1 -11 a—b Hemiarthroplasty,
a Tuberosity fixation technique during hemiarthro­
plasty. The sutures are secured not only to the im­
plant but also to the shaft and between the
tuberosities.
b Cemented prosthetic hemiarthroplasty where the
lesser tuberosity has been used to guide prosthetic
length. Tuberosities are fixed 5 -1 0 mm below the
level of the prosthetic head.
 6 Sp e c ific fractu res
6.2 H um erus
shoulder is rotated internally and externally and the arm el­
evated to confirm the absence of m ovem ent betw een the frag­
m ents and the shaft, and to confirm adequate range of motion;
m odular head im plants w ill allow fine tuning. Additionally,
bone-to-bone contact is ensured by placing the previously pre­
served hum eral head cancellous bone under the tuberosities
and definitively suturing them . The subscapularis-supraspina-
tus m uscular space is then closed.
4 S u rg ica l treatm ent o f s p e c ific fractu res
4.1 Type A fra ctu re s (e xtra a rticu la r u n ifo cal)
(Fig 6.2.1-12)
11-A1 11-A2 11-A3
Fig 6.2.1-12 Müller AO Classification.
4.1.1 A1 fractu res
Unifocal fractures of the greater or lesser tuberosity should be
treated by sling imm obilization in the following cases:
■ younger patients w ith displacement < 6 mm;
■ patients > 60 years w ith displacement < 10 mm.
584
Displacement of tuberosity fragments is best seen on AP x-rays
of the shoulder in internal and external hum eral rotation. The
axillary view m ay allow better visualization of lesser tuber­
osity fragments.
The pull of the rotator cuff may further displace tuberosity
fragments, causing im pingem ent and w eakness abduction of
greater and internal rotation.
Greater tuberosity fracture fragments m ay be am enable to per­
cutaneous reduction and fixation, or require a transdeltoid
lateral approach. Lesser tuberosity fractures are best treated
through a deltopectoral approach. Tuberosity reduction is held
tem porarily w ith K-wires, and then fixed w ith a cannulated
screw (Fig 6.2.1-13a-b) or a tension band (Fig 6.2.1-13c). Large-
diam eter resorbable sutures perforate the cuff at its bony in ­
sertion by m eans of a curved needle. A figure-of-eight loop
secures it around a screw head or through a 2.0 m m drill hole
in the cortex of the proxim al shaft. Large resorbable sutures
have successfully m aintained reduction, avoiding the fatigue
failure encountered w ith K-wires and the persistent foreign
body effect of nonresorbable sutures.
If there is an associated glenohum eral dislocation (11-A1.3),
careful closed reduction should be attem pted first. Fragment
reduction is then confirm ed and quantified and the fracture is
treated as described above.
4.1.2 A 2 fractu res
Surgical neck or subcapital fractures w ithout major displace­
m ent (11-A2.1: less th an 10 m m and angulation below 45°)
w ill norm ally be treated by sling imm obilization until the pain
is gone. This is followed by an early rehabilitation program.
Early rehabilitation (w ithin 14 days after surgery) results in a
better outcom e [3]. This consists of passive m otion and pendu­
lum exercises until the fracture heals clinically, w hen full ac­
tive m otion starts. Strengthening starts after clinical and x-ray
 6.2.1 H u m eru s, proxim al

Fig 6.2.1-13a-c
a Displaced greater tuberosity fracture 11 -(A l .2).
b Reduction and provisional K-wire fixation. A cannulated lag screw is used to compress the fracture,
c Tension band with wire or strong resorbable suture passed around the tendon-bone interface. Distal
fixation is through a drill hole (shown) or around a screw head.

evidence of union. If the fracture is impacted w ith an acceptable
am ount of varus or valgus alignm ent (11-A2.2 and 11-A2.3)
earlier active range of motion exercises are allowed in relation
to the patient's age. Varus alignm ent and subacromial impinge­
m ent will be tolerated less in a younger patient.
4.1.3 A 3 fractu res
Most com m inuted/displaced surgical neck fractures are treated
nonoperatively in the elderly, w ith operations reserved for
younger, or older active patients. A large nonrandom ized ob­
servational study [20] showed that 11-A3.2 tw o-part fractures
in the elderly w ho received nonoperative treatm ent resulted in
a predictable and "acceptable" outcome. Reduced function and
nonunion were associated w ith increasing age and shaft
fragm ent translation. There was no statistically significant
difference in outcom e (Neer score) betw een operative and
nonoperative cases w ith displacement > 66%, but a larger per­
centage of patients w ho were operated on returned to common
daily living activities.
Elderly active patients and younger patients do not tolerate
unstable fracture (11-A3.1: varus, 11-A3.3: com m inuted me-
taphysis) patterns well, and surgery is often indicated. In such
cases, closed reduction is attem pted in the operating room. If
this can be achieved, simple percutaneous K-wire fixation [10]
or cannulated screws are used. Extensive m etaphyseal com­
m inution can m ake these options impractical. In such cases, a
percutaneously applied locking plate [21], an antegrade intra­
m edullary nail, a single retrograde intram edullary nail, or
multiple retrograde flexible nails (Fig 6.2.1-10 ) can be inserted.

5 85
 6 Sp e c ific fractu res
6.2 H um erus

If a deltopectoral approach is required and screw purchase is

adequate, a conventional im plant or a locking plate can be
used (Fig 6.2.1-14).
Failed closed reduction is usually due to interposition of the
long head of the biceps brachii muscle, button-holing through
a split muscle, or interposed fragments. Under these condi­
tions a deltopectoral approach is perform ed, the situation is
corrected and fixation is applied.

Fig 6.2.1-14a-c
a Surgical neck fracture with anterior and medial translation and interposition of the biceps brachii tendon (11 -A3.2).
b Locking plate (PHILOS) fixation, AP view,
c Lateral view after anatomical reduction of the main fragments.

586
 6.2.1 H u m eru s, proxim al

4.2 Type B fra ctu re s (e xtra a rticu la r b ifo c a l) (Fig 6.2.1-15) 4.2.1 B1 fractu res
These bifocal fractures usually occur in fit elderly individuals
and show little or no displacement [22]. Displaced tuberosity
fractures m ust be reduced and fixed as described for A1 frac­
tures. The im pacted m etaphyseal fracture is usually stable, in
an acceptable position, and treated nonoperatively. W ith this
treatm ent, 80% of fractures are expected to have good or ex­
cellent functional results [22],
4.2 .2 B2 fractu res
These are unstable at the surgical neck and if they are
11-B1 11-B2 11-B3
combined w ith a rotary displacement of the head fragment
(B2.2), reduction w ill be required due to the muscle pull on
Fig 6.2.1-15 Müller AO Classification. the intact tuberosity (Fig 6.2.1-16a). These will often require a

Fig 6.2.1-16a-c Bifocal 11-B2.2 fracture.

a Rotation of the head fragment caused by the subscapularis muscle with complete avulsion of the greater tuberosity,
b Closed reduction by longitudinal traction, external rotation of the head fragment by means of a hook, and stabilization of
the greater tuberosity fragment with a K-wire.
c Percutaneous K-wire and cannulated screw fixation using 4 mm cannulated cancellous bone screws. The tension band wire
secures the rotator cuff.

587
 6 Sp e c ific fractu res
6.2 H um erus

percutaneous reduction as described in chapter 6.2.1:3.2
(Fig 6.2.1-16b) or an open procedure. If there is lim ited
fragm entation of the surgical neck, stabilization by m eans of
cannulated cancellous bone screws is possible (Fig 6.2.1-16c)
[23], Some surgeons use a closed/percutaneous reduction and
K-wire fixation technique described by Boehler [24], This
technique is dem anding; it requires an adequate closed reduc­
tion and good visualization in two orthogonal planes.
Open reduction requires a deltopectoral approach. The tuber­
osities/head fragments are reduced and fixed first. Definitive
fixation w ith lag screws allows easier reduction of this head/
tuberosity fragm ent to the shaft. Tem porary fixation of the
shaft w ith anteriorly placed K-wires facilitates plate place­
m ent. Depending on screw purchase a standard clover leaf
plate or a locking plate may be used. Tension band sutures
around the tuberosity fragments are anchored to screw heads
or in plate holes. W hen using plates, the surgeon m ust be
careful not to damage the residual blood supply to the
head, particuarly in m ultifragm entary fractures (11-B2.3).
H em iarthroplasty in these three-part fractures rem ains a sal­
vage procedure w hen stable fixation cannot be achieved.
4 .2 .3 B3 fractu res
Closed reduction is rarely possible in bifocal fracture disloca­
tions. A percutaneous approach may carefully be attem pted.
However, in m ost cases, open reduction of the dislocated head
fragm ent is necessary, employing the techniques described for
11-B2 fractures and reserving hem iarthroplasty as a salvage
procedure. Good results, even in posterior fracture dislocation
w ith avulsion of both tuberosities (11-B3.3), can be achieved
w ith ORIF. Hum eral head im paction fractures (Hill-Sachs le­
sion) caused by im paction upon the glenoid during dislocation
may be treated by elevation and bone grafting to restore ana­
tomy and to prevent recurrent displacement.
4.3 Type C fra ctu re s (a rticu lar) (Fig 6.2.1-17)
11-C1 1
Fig 6.2.1-17 Müller AO Classification.
4.3.1 C l fra ctu re s
This type of fracture of the anatom ical neck has less than 45°
angulation of the head fragm ent and less than 1 cm displace­
m ent of the tuberosity fragment. Any anatom ical neck frac­
ture is at risk of avascular necrosis. In a stable variant of this
fracture, the head is im pacted more th an 45° into the valgus
so that its articular surface points upw ards ("ice cream cone
type"). This specific fracture pattern may be treated nonop­
eratively in some elderly patients using an approach sim ilar to
11-B1.1 fractures (chapter 6.2.1:4.2.1).
W ith the com m on 11-C1 fracture, in younger or active older
patients, a vascularity-sparing approach is recomm ended.
Closed reduction and percutaneous fixation as described in
B fractures (Fig 6.2.1-16) is preferred, if possible. However,
slightly displaced four-part fractures treated by open reduction
and careful dissection and im plant choices w hich confer sta­
bility and preserve vascularity have show n surprisingly good
results [10], especially w ith the use of locking plates through
a lim ited transdeltoid approach [21], Prosthetic replacement
should be avoided in these fractures.

588
 6.2.1 H u m eru s, proxim al

Fig 6.2.1-18 a-f Case of a 69-year-old female, who fell on level ground.
a -b AP and lateral view. Displaced intraarticular fracture with valgus malalignment (11-C2).
c -d Postoperative x-rays, AP and lateral view.
e -f 15-month follow-up.

(With permission by Frankie Leung.)

589
 6 Sp e c ific fractu res
6.2 H um erus
4 .3 .2 C2 fractu res
These fractures are the "real" four-part fractures w ith more
th an 45° of angulation of the head fragm ent and m ore than
1 cm displacement of at least one tuberosity fragment.
Using percutaneous reduction and screw fixation, some au­
thors [10] achieved near-anatom ical reduction and very good
end results in a high percentage of patients w ith three-part
and less displaced four-part fractures.
W hen open reduction is chosen, the deltopectoral approach is
used. W ith the intention of reducing the risk of avascular n e­
crosis, m any authors prefer osteosynthesis w ith sm aller im ­
plants using lag screws and tension bands, or sutures, or two
plates 2.4. This approach is sound, reserving plate fixation for
cases w here sm aller im plants cannot achieve enough stability
and contact betw een the fragm ents (Fig 6.2.1-18) [10, 23].
However, other authors have reported poor results w ith the
m inim al-im plant technique [15], They advocate a vascularity-
sparing plate and screw fixation technique w ith additional
purchase achieved by using calcium phosphate bone cement,
w ith good results. This raises the issue of achieving stability
and repairing the damage to the bone caused by the reduction
of im pacted cancellous bone. These voids may be filled w ith
bone substitutes or autogenous cancellous bone chips.
H em iarthroplasty is reserved for cases w here stable ORIF
cannot be achieved.
4.3 .3 C3 fractu res
For anatom ical neck fracture dislocations and in split-head
fractures, m any surgeons recom m end prim ary hem iarthro­
plasty [6], if they cannot reconstruct the head fracture.
H em iarthroplasty is also recom m ended in the elderly if there
are no soft-tissue attachm ents to the hum eral head. There is
no clear comparative evidence to conclusively support either
recom m endation.
590
A deltopectoral approach is used for open reduction. The head
fragment(s) is (are) reduced first. In a split fracture these frag­
m ents are reduced and fixed w ith lag screws. Reduction is con­
firm ed by open view or x-ray. The reduction then proceeds as
in 11-C2 fractures.
The m ain problems are loss of fixation and avascular necrosis.
Loss of fixation is difficult to predict. The stability of fracture
fixation is tested during surgery by putting the shoulder
through a range of m otion. If the fixation is not stable enough
to allow this, rehabilitation will be lim ited and a poor result is
inevitable. W hen accurate reduction or stable fixation cannot
be achieved, im m ediate conversion to hem iarthroplasty is
probably the best option. H em iarthroplasty gives good pain
relief but function is poor. This, together w ith the longevity of
these im plants and the prospect of revision, favors m axim al
attem pts to repair (ORIF) rather th an replace the fractured
hum erus w hen feasible.
Avascular necrosis is frequent in three-part and four-part frac­
tures. Function is dim inished but is acceptable in the m ajority
of patients w ho develop avascular necrosis [4, 25].
5 P o sto p era tive treatm ent
Rehabilitation is essential to m axim ize function following a
proxim al hum erus fracture, regardless of w hether it is treated
operatively (by fixation or arthroplasty) or nonoperatively.
Im plant constructions should be sufficiently stable to allow
passive motion during surgery and rehabilitation im m ediately
after surgery. The same rehabilitation protocol (Tab 6.2.1-1) is
used for nonoperative and operative treatm ent and m ust start
10-14 days after surgery.
 6.2.1 H u m eru s, proxim al

Phase Duration Rehabilitation 6 P itfa lls and co m p lica tio n s

(weeks)

1 0 -3 Pendulum exercises 6.1 S tiffn e ss

2 3 -9
Gentle active-assisted motion
Avoid external rotation for 6 weeks
Orthopedic sling for 2 -3 weeks
If there is clinical evidence of healing
and fragments move as a unit, and no
displacement is visible on the x-ray,
then:
Active-assisted motion forward and
side arm elevation
Partial functional use week 3 -6
Week 6: Add active, nonassisted
motion
This is the most com m on complication following shoulder in ­
jury. A small num ber of patients w ill regain full range of m o­
tion, but in m ost abduction and external rotation is lim ited,
resem bling a "frozen shoulder". These problems can be m in i­
m ized by early physiotherapy as outlined in chapter 6.2.1:5.
Closed m obilization of a stiff shoulder under general anesthe­
sia may be indicated in a few cases but the danger of im plant
loosening or fracture should be kept in m ind. Arthroscopy
and even open release and m anipulation may be considered
under certain circum stances, especially in younger individu­
als [26],
6.2 P o sitio n in g o f im p lants

Week 6: Add isometric strength Im plant malpositioning and displacement of fragments or im ­

3 >9 If there is bone healing but joint plants can occur, especially in osteoporotic bone. M uscular
stiffness, then: activity and passive external forces, working on a long lever
arm , are often underestim ated. Screw length and position,
Add manual therapy passive motion
by physiotherapist
and stability of fixation should be checked by image intensifier
before the wound is closed [21, 27], If fixation is found to be
Add isotonic strength, concentric and inadequate, a larger sized screw or bone cem ent around the
eccentric screw should be used or consideration given to an a rth ro ­
plasty.
Tab 6.2.1-1 Shoulder rehabilitation protocol.
6.3 M alun ion and nonunion

If the above m entioned protocol is heeded, m alunions and

nonunions occur only rarely. If they are symptom atic w ith
significant pain and loss of function, open correction and in­
ternal fixation will benefit reliable patients whose bone and
soft tissues are of suitable quality (chapter 5.2). In the specific
case of proxim al hum eral nonunions, open reduction and in ­

591
 6 Sp e c ific fractu res
6.2 H um erus
ternal fixation of the tuberosities and/or the surgical neck to
the shaft w ith a tension band (wire or plate) provide best re­
sults [28],
6.4 A va scu la r n e cro sis
AVN of the hum eral head is relatively frequent w ith the over­
all rate approaching 35% (reported range: 6-75% ) [4, 25].
The m ost im portant predisposing factors are:
■ length of the dorsom edial m etaphyseal extension;
■ integrity of the m edial hinge;
■ fracture type [8].
Despite the high occurrence of AVN it is frequently asym p­
tom atic w ith 77% of patients still showing good to excellent
functional results [4]. This rate compares favorably w ith the
80% of cases w ith "acceptable" results in the prim ary a rth ro ­
plasty literature [29],
The functional outcom e of avascular necrosis is significantly
affected by m alunion: m alunited cases w ith avascular necrosis
display worse function [9] and cases w ith avascular necrosis
requiring an arthroplasty a worse result if there is associated
nonunion or m alunion. The most favorable choice w ould then
be open reduction and internal fixation if a stable, anatom ical
construction can be achieved. The best treatm ent for avascular
necrosis is prevention using vascularity-sparing techniques.
Should avascular necrosis become painful and require treat­
m ent, an arthroplasty will provide predictable pain relief if no
concurrent m alunion surgery is required [9], The selection of
cases for prim ary arthroplasty rem ains difficult as there is
little scientific evidence to guide the surgeon. Future develop­
m ents in im plants and technique need to be evaluated in pro­
spective random ized trials to provide a sound scientific basis
for treatm ent protocols.
592
6.5 N erve le sio n s
The axillary nerve is the m ost frequently injured peripheral
nerve at the tim e of injury and during open or percutaneous
surgery [11], During open reduction, soft-tissue retraction us­
ing retractors or hooks is a danger. The adjacent brachial plexus
is at risk in fracture dislocations.
■ Retractors m ust never be placed into the axilla and lim b
p o sitions that stretch the brachial plexus m ust be avoided.
6.6 In fe ctio n
Percutaneously inserted K-wires are usually buried under the
skin at the tim e of insertion. They may cause irritation w hen
swelling recedes and infection w ith or w ithout skin perfora­
tion. If K-wires are outside the skin after surgery, infection can
spread along their tracks.
If deep infection occurs w ith any form of operative treatm ent,
it should be treated aggressively. It will be necessary to wash
out and debride soft tissues and infected bone. The infecting
organism m ust be identified and treated w ith appropriate a n ­
tibiotics. If the fracture fixation rem ains stable, there is a good
chance for the fracture to heal and the infection to disappear.
In rare cases, the whole head fragm ent w ill be infected and
necrotic. It should be rem oved and a spacer m ade of antibiotic
cement can be inserted. This leaves the possibility that pros­
thetic replacem ent may be considered after the infection has
settled.
 6.2.1 H u m eru s, proxim al
7 B ib lio grap h y
[1] Wallace WA, H ellier M (1983) Improving radiographs of the injured
shoulder. Radiography; 49(586):229-233.
[2] H offm eyer P (2002) The operative managem ent of displaced fractures
of the proxim al hum erus. J Bone Joint Surg Br; 84(4):469-480.
[3] Gaebler C, M cQueen MM, C ourt-Brown CM (2003) M inimally
displaced proxim al hum eral fractures: epidemiology and outcome in
507 cases. Acta Orthop Scand; 74(5):580-585.
[4] Gerber C, Werner CM, V ienne P (2004) Internal fixation of complex
fractures of the proximal hum erus. J Bone Joint Surg Br; 86(6):848-855.
[5] L ili H, B ew er A , K orner J, et al (2001) [Conservative treatm ent of
dislocated proxim al hum eral fractures.] Zentralbl Chir; 126(3):205-210.
[6] Gerber C, Schneeberger AG, V inh TS (1990) The arterial
vascularisation of the hum eral head. An anatom ical study. J Bone Joint
Surg Am; 72(10):1486-1494.
[7] Plaschy S, Leutenegger A, R iiedi TP (1995) Humeruskopf C-Brüche
beim jungen Patienten: K ann die Kopfnekrose vermieden werden?
Unfallchirurg; 92:63-68.
[8] H ertel R, H em pfing A, Stiehler M, et al (2004) Predictors of
hum eral head ischemia after intracapsular fracture of the proximal
hum erus. J Shoulder Elbow Surg; 13(4):427-433.
[9] Gerber C, Hersche O, Berberat C (1998) The clinical relevance of
posttraum atic avascular necrosis of the hum eral head. J Shoulder Elbow
Surg; 7(6):586-590.
[10] R esch H, Povacz P, Frohlich R, et al (1997) Percutaneous fixation of
three- and four-part fractures of the proxim al hum erus. J Bone Joint
SurgBr; 79(2):295-300.
[11] K am ineni S, A nkem H, Sanghavi S (2004) Anatomical
considerations for percutaneous proxim al hum eral fracture fixation.
Injury; 35(11):1133—1136.
[12] Banco SP, A ndrisani D, Ram sey M, et al (2001) The parachute
technique: valgus impaction osteotomy for tw o-part fractures of the
surgical neck of the hum erus. J Bone Joint Surg Am; 83(Suppl 2, Pt
l):38-42.
[13] Darder A, Darder A , Jr, Sanchis V, et al (1993) Four-part displaced
proximal hum eral fractures: operative treatm ent using Kirschner w ires
and a tension band. J Orthop Trauma; 7(6):497-505.
[14] K ristiansen B, C hristensen SW (1986) Plate fixation of proximal
hum eral fractures. Acta Orthop Scand; 57(4):320-323.
[15] R obinson CM, Page RS (2004) Severely impacted valgus proximal
hum eral fractures. J Bone Joint Surg Am; 86(Supp\ 1, Pt 2): 143-155.
[16] H essm ann M, Baum gaertel F, G ehling H, et al (1999) Plate fixation
of proxim al hum eral fractures w ith indirect reduction: surgical
technique and results utilizing three shoulder scores. Injury;
30(7):453-462.
[17] Kwon BK, G oertzen DK, O'Brien PJ, et al (2002) Biomechanical
evaluation of proxim al hum eral fracture fixation supplemented with
calcium phosphate cement. J Bone Joint Surg Am; 84(6):951-961.
[18] Brem s JJ (2002) Shoulder arthroplasty in the face of acute fracture:
puzzle pieces. J Arthroplasty; 17(4 Suppl l):32-35.
[19] D em irhan M, K ilicoglu O, A ltinel L, et al (2003) Prognostic factors
in prosthetic replacem ent for acute proxim al hum erus fractures.
J Orthop Trauma; 17(3):181-189.
[20] C ourt-Brown CM, Garg A, M cQueen MM (2001) The translated
two-part fracture of the proximal hum erus. Epidemiology and outcome
in the older patient. J Bone Joint Surg Br; 83(6):799-804.
[21] L ili H, H epp P, Rose T, et al (2004) [The angle stable locking-
proxim al-hum erus-plate (LPHP) for proximal hum eral fractures using
a small anterior-lateral-deltoid-splitting-approach - technique and first
results.] Zentralbl Chir.; 129(l):43-48.
[22] C ourt-Brown CM, C atterm ole H, M cQ ueen MM (2002) Impacted
valgus fractures (B l.l) of the proxim al hum erus. The results of non­
operative treatm ent. J Bone Joint Surg Br; 84(4):504-508.
[23] Szyszkow itz R, Seggl W, Schleifer P, et al (1993) Proximal hum eral
fractures. M anagement techniques and expected results. Clin Orthop
Relat Res; (292):13-25.
[24] H erscovici D Jr, Saunders DT, Johnson MP, et al (2000)
Percutaneous fixation of proximal hum eral fractures. Clin Orthop Relat
Res; (375):97-104.
[25] W ijgman A J, Roolker W, Patt TW, et al (2002) Open reduction and
internal fixation of three and four-part fractures of the proxim al part
of the hum erus. J Bone Joint Surg Am; 84(11):1919-1925.
[26] B urkhart SS (1996) Arthroscopic subscapularis tenolysis: a technique
for treating refractory glenohum eral stiffness following open reduction
and internal fixation of a displaced three-part proximal hum erus
fracture. Arthroscopy; 12(1):87—91.
[27] M uckter H, Herzog L, Becker M, et al (2001) [Angle- and rotation-
stable internal fixation of proxim al hum erus fractures with the
hum erus fixation plate. Early clinical experience w ith a newly
developed implant.] Chirurg; 72( 11): 1327—1335.
[28] Healy WL, Jupiter JB, K ristiansen TK, et al (1990) Nonunion of
the proxim al hum erus. A review of 25 cases. J Orthop Trauma;
4(4):424-431.
[29] Bosch U, Skutek M, Fremerey RW, et al (1998) Outcome after
prim ary and secondary hem iarthroplasty in elderly patients with
fractures of the proxim al hum erus. J Shoulder Elbow Surg; 7(5):479-484.
8 A ckn o w led gm en t
We w ish to th a n k Rudolf Szyskowitz for his contribution to
this chapter in the first edition of the AO Principles of Fracture
M anagem ent.
5 93