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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Four Part Humeral Fracture


- Discussion:
    - 4 segment frx is most difficult to treat & is assoc w/ poorest results;
    - vascular supply to the humeral head
    - 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;
    - Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band.
- 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;
            - ref: Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial.



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

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

Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus

Functional Outcomes for Surgically Treated 3- and 4-part Proximal Humerus Fractures

Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, June 20, 2012 1:38 pm