- Discussion:
- 4 segment frx is most difficult to treat & is assoc w/ poorest results;
- added to problems of
three part frx, namely delayed union or non union, is avascular necrosis of the humeral head;
- the classic teaching is that the fragment is devoid of all soft tissue, making AVN certainty, irrespective of treatment;
- as noted by Darder et al 1993, only 9 of 35 patients w/ four part frxs developed AVN, and further, the results were satisfactory or better in 21/35 patients;
- pathognomic feature is the small, crescentic, proximal articular fragment severed from the antatomic neck of the humerus;
- Surgical Treatment:
- if small head fragment is impacted and not acting as a mechanical block to movement, surgery should be avoided, as attempts at open reduction may
destroy any remaining blood supply;
- avulsed abductor mechanism, often in one large fragment consisting of greater &
lesser tuberosity w/ intervening long head of
biceps tendon, may be
replaced w/o disturbing impacted head;
-
formal open reduction:
- relative contra-indications include 4 part frx dislocations, marked comminution, and patients older than 75 years of age;
- performed thru a
deltopectoral approach;
- exposure can be facilitated by detaching 2-3 cm of the anterior deloitd from the clavicle;
- long head of the biceps helps to serve as a landmark for reduction;
-
shoulder arthroplasty:
- relative indications include 4 part frx dislocations, marked comminution, and patients older than 75 years of age;
Open reduction and internal fixation of three- and four-part fractures of the proximal humerus.
Four-part valgus impacted fractures of the proximal humerus.
Four Part Displaced Proximal Humeral Fractures: Operative Treatment Using Kirschner Wires and a Tension Band. J Orthop. Trauma. Vol 7 No 6. p 497-505;
Open Reduction and Internal Fixation of Three and Four-Part Fractures of the Proximal Part of the Humerus.
Four-part proximal humerus fractures: evaluation and treatment
Injury to the axillary artery, a complication of fixation using a locking plate.
Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system
Evaluation and management of valgus impacted four-part proximal humerus fractures
Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures
