4-Part, slight displacement, varus malalignment

These are varus impacted 4-part fractures with slight displacement. Both tuberosities are involved. The periosteum, especially the medial hinge, is typically not ruptured. They are less stable than valgus malaligned fractures. In the elderly, impaction of the osteoporotic humeral head onto the shaft medially is acceptable. If in doubt about the stability, it is recommended to check the stability under image intensification. The indication for surgery depends on the degree of displacement and patient’s demands.

Although these fractures do not pass through the articular surface, they are termed “articular fractures”; the articular surface is detached from both tuberosities. Quite often, the blood supply of the humeral head is impaired and the risk of subsequent avascular necrosis (AVN) is high. 4-part fractures according to Codman and Neer separate the proximal humeral epiphysis from both tuberosities and the metaphysis.