4-Part, slight displacement, valgus malalignment

These fractures should be properly reduced to achieve good results in terms of stability, function and pain relief. The anatomical neck fracture is fairly stable. The periosteum is typically not ruptured and the risk of avascular necrosis is reduced.

Operative fixation is the preferred treatment. However, the decision for surgery should also include the functional demands of the patients, the presence of comorbidities and the ability to undergo operative treatment.

Nonoperative treatment of minimally displaced fractures is largely satisfactory. Watch for significant prominence of the greater tuberosity which may produce painful limited motion through coraco-acromial impingement.

extraarticular 3 part surgical neck and tuberosity dislocation

Skill level

Equipment

Main indications

Less angulation/displacement and/or limited functional expectations

Supporting indications

Minimally displaced, stable fractures
Risks of surgery outweigh benefits

Advantages

No operative risks
No anesthetic risks

Disadvantages

Must accept fracture alignment
Possibility of additional displacement
Risk of poorer functional outcome

Less angulation/displacement and/or limited functional expectations

Supporting indications

Minimally displaced, stable fractures
Risks of surgery outweigh benefits

Advantages

No operative risks
No anesthetic risks

Disadvantages

Must accept fracture alignment
Possibility of additional displacement
Risk of poorer functional outcome

isolated anatomical neck slight displacement

Skill level

Equipment

Main indications

Acceptable closed reduction of fracture suitable for fixation with screws alone

Supporting indications

Good bone quality; large bone fragments
Young patients
Unacceptable deformity

Advantages

Minimal soft-tissue damage

Disadvantages

Closed reduction may not be achievable
Limited stability
Risk of damage to the axillary nerve

Acceptable closed reduction of fracture suitable for fixation with screws alone

Supporting indications

Good bone quality; large bone fragments
Young patients
Unacceptable deformity

Advantages

Minimal soft-tissue damage

Disadvantages

Closed reduction may not be achievable
Limited stability
Risk of damage to the axillary nerve

4 part slight displacement valgus malalignment

Skill level

Equipment

Main indications

Satisfactory reduction achieved closed

Supporting indications

Good bone quality
Unacceptable deformity
Need for more stability and/or earlier mobilization

Advantages

Less soft-tissue damage
Supplementary suture fixation possible (with increased proximal exposure)
Early mobilization may be possible

Disadvantages

Limited exposure may not permit satisfactory reduction
Limited exposure may compromise placement
Risk of damage to the axillary nerve
Technically demanding

Satisfactory reduction achieved closed

Supporting indications

Good bone quality
Unacceptable deformity
Need for more stability and/or earlier mobilization

Advantages

Less soft-tissue damage
Supplementary suture fixation possible (with increased proximal exposure)
Early mobilization may be possible

Disadvantages

Limited exposure may not permit satisfactory reduction
Limited exposure may compromise placement
Risk of damage to the axillary nerve
Technically demanding

Skill level

Equipment

Main indications

Significant displacement or angulation that can not be corrected closed

Supporting indications

Surgeon’s desire for improved stability and earlier use

Advantages

Usually allows early mobilization and light use
Possibility of supplementary suture fixation of tuberosities
More stable than fixation with screws alone
Open exposure makes correct reduction easier

Disadvantages

Risk of inadequate reduction or fixation
Risk of axillary nerve injury (if transdeltoid approach is used)
Technically demanding

Significant displacement or angulation that can not be corrected closed

Supporting indications

Surgeon’s desire for improved stability and earlier use

Advantages

Usually allows early mobilization and light use
Possibility of supplementary suture fixation of tuberosities
More stable than fixation with screws alone
Open exposure makes correct reduction easier

Disadvantages

Risk of inadequate reduction or fixation
Risk of axillary nerve injury (if transdeltoid approach is used)
Technically demanding

Skill level

Equipment

Main indications

Displaced fractures in elderly patients

Supporting indications

Comminuted fractures of the tuberosities and/or small fragments of the tuberosities such as avulsion or impression fractures
Proximal humeral fractures with a preexisting rotator cuff tear

Advantages

Shoulder function less dependent on healing of the tuberosities
Predictable satisfactory outcome in relation to pain relief and shoulder function
One-step procedure

Disadvantages

Special experience of the surgeon necessary
Minimal revision options if surgery fails

Displaced fractures in elderly patients

Supporting indications

Comminuted fractures of the tuberosities and/or small fragments of the tuberosities such as avulsion or impression fractures
Proximal humeral fractures with a preexisting rotator cuff tear

Advantages

Shoulder function less dependent on healing of the tuberosities
Predictable satisfactory outcome in relation to pain relief and shoulder function
One-step procedure

Disadvantages