- See:
Three Part Fracture Dislocation and
Four Part Fracture:
- Discussion:
- tuberosity frag + displaced
surgical neck fragment;
- unstable shafts may be driven into mass of deltoid muscle & may be anterior to the proximal fragment;
- poor bone contact will lead to delayed or nonunion in most cases;
- subtypes:
-
greater tuberosity frx:
- if greater tuberosity is avulsed, lesser tuberosity remains attached to humeral head & the subscapularis insertion will internally rotate humeral
head so that articular surface faces posteriorly;
-
lesser tuberosity frx:
- if lesser tuberosity containing
subscapularis is avulsed, proximal frag is externally rotated by remaining rotator cuff, supraspinatus, infraspinatus, and teres minor;
-
greater tuberosity is attached to the head;
- humerus lies in internal rotation
- articular surface faces posteriorly
- the shaft is pulled medially by the pectoralis major
- long head of biceps may also be caught between the fragments, which obstructs reduction;
- Radiology:
- presence of round proximal frag w/ appearance of full moon on AP x-ray;
- Non Operative Treatment
- usually unstable and difficult to treat by closed reduction;
- rotation of prox frag is caused by avulsion of tuberosities;
- inactive pts sustaining three part frx from low energy forces may not be suitable candidates for open reduction;
- Operative Treatment:
- not to denude frx frag of blood supply (can lead to AVN);
-
prosthesis:
- accepted as rx of choice for this frx in an elderly patient.
- several technical considerations for achieving successful result have recently been stressed and include
(1) avoiding removal of the deltoid from its origin;
(2) restoring proper length to the humerus;
(3) inserting the prosthesis in the proper degree of retroversion;
(4) using cement when there is inadequate bony support.
The three-part fracture of the proximal part of the humerus. Operative treatment.
Percutaneous fixation of three- and four-part fractures of the proximal humerus.
Open reduction and internal fixation of three- and four-part fractures of the proximal humerus.
Arthroscopic subscapularis tenolysis: a technique for treating refractory glenohumeral stiffness following open reduction and internal fixation of a displaced three part proximal humerus fracture.
SS Burkhart MD. Arthroscopy. Vol 12. No 1. Feb 1996. p 87-91.
Open Reduction and Internal Fixation of Three and Four-Part Fractures of the Proximal Part of the Humerus.
Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system.
Treatment of two- and three-part fractures of the proximal humerus. Bigliani LU. Instructional Course Lectures. 38:231-44, 1989.
