What is the management for a comminuted mildly angulated and displaced fracture of the humeral head?

Management of Comminuted Mildly Angulated and Displaced Fracture of Humeral Head

CT imaging followed by surgical fixation is the recommended management for comminuted mildly angulated and displaced fractures of the humeral head to optimize functional outcomes and reduce complications.

Initial Assessment and Imaging

1. Initial Radiographic Evaluation:

   • Standard shoulder radiographs (AP, lateral, axillary views)
   • Poor agreement between observers has been shown when grading humeral head fractures on radiography alone 1

2. Advanced Imaging:

   • CT scan is the preferred imaging modality for detailed fracture characterization
   • CT is superior for delineating fracture patterns and is the best examination for characterizing proximal humeral fractures 1
   • Three-dimensional volume-rendered CT images should be obtained to better characterize fracture patterns and humeral neck angulation, which directly affects functional outcomes 1
   • MRI is generally inferior to CT for evaluating fracture planes in complex humeral fracture patterns 1

Treatment Options

Surgical Management

For comminuted mildly angulated and displaced fractures of the humeral head, the following surgical options should be considered:

1. Open Reduction and Internal Fixation (ORIF) with Locking Plate:

   • Preferred for most displaced proximal humeral fractures with adequate bone quality
   • Locking plates provide excellent fixation in displaced unstable proximal humeral fractures, even with osteoporotic bone 2
   • Results in better functional outcomes compared to conservative treatment for displaced fractures 3
   • Timing: Surgery should be performed within 5 days of injury, as delay beyond this significantly increases complication rates 4

2. Hemiarthroplasty:

   • Consider for severely comminuted four-part fractures with high risk of avascular necrosis
   • Particularly indicated in elderly patients with poor bone quality 3

3. Reverse Total Shoulder Arthroplasty:

   • Consider in elderly patients with comminuted fractures and pre-existing rotator cuff deficiency 1
   • Used as a salvage procedure for failed total shoulder arthroplasties 1

Non-surgical Management

• Reserved for minimally displaced fractures or patients with significant medical comorbidities that preclude surgery
• Generally not recommended for displaced comminuted fractures as it leads to poorer functional outcomes compared to surgical fixation 3

Surgical Timing Considerations

• Optimal timing for ORIF is within 5 days of injury 4
• Surgery performed between 3-5 days after injury shows similar complication rates to early intervention (<48 hours) 4
• Delaying surgery beyond 5 days significantly increases complication risk (odds ratio 1.637) 4
• For head split and dislocated fracture types, reconstruction within 48 hours may reduce risk of avascular necrosis 4

Potential Complications and Prevention

1. Avascular Necrosis:

   • Risk increases with fracture severity and surgical delay
   • More common in four-part fractures (6.8% of cases) 4
   • Early surgical intervention may reduce risk

2. Loss of Fixation:

   • Occurs in approximately 12.8% of cases 4
   • Proper surgical technique is critical to prevent this complication
   • Many complications are related to incorrect surgical technique 5

3. Screw Perforation:

   • Most common complication (14% of patients) 5
   • Careful intraoperative assessment of screw placement is essential

4. Rotator Cuff Tears:

   • Complete tear of at least one rotator cuff tendon can be seen in up to 40% of humeral head fractures 1
   • Delay in repair of rotator cuff tears by up to 4 months has not been shown to have adverse outcomes 1

Follow-up Care

• Regular radiographic assessment to monitor fracture healing and implant position
• Physical therapy for range of motion and strengthening exercises once appropriate healing has occurred
• Monitor for complications including avascular necrosis, which may develop later in the healing process

Clinical Pearls

• CT is superior to MRI for fracture characterization but MRI may be useful for assessing rotator cuff integrity in patients with proximal humeral fractures that do not undergo surgical fixation 1
• The locking plate has expanded indications for ORIF in these fractures, allowing successful treatment even with osteoporotic bone 2
• Surgical technique is crucial - many complications are related to technical errors during surgery 5
• For three-part fractures, ORIF yields better outcomes (Constant scores 83-91) compared to four-part fractures (Constant score 52) 3