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Three Part Proximal Humerus Fractures

- 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.

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.

Open reduction and fixation of proximal humeral fractures and fracture-dislocations.

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

The importance of inferomedial support in the hot air balloon technique for treatment of 3-part proximal humeral fractures