What is the management of an acute comminuted, displaced, and angulated fracture of the left proximal humerus (proximal humerus fracture) post-injury?

Management of Acute Comminuted, Displaced, and Angulated Fracture of the Left Proximal Humerus

For acute comminuted, displaced, and angulated fractures of the proximal humerus, angularly-stable plate fixation or interlocking intramedullary nailing is recommended as the primary surgical intervention, with CT imaging essential for preoperative planning. 1

Diagnostic Imaging

• Initial standard radiographs to confirm diagnosis and fracture pattern
• CT scan is the preferred imaging study for:
  • Characterizing complex fracture patterns
  • Assessing humeral neck angulation
  • Preoperative planning 2
• 3D volume-rendered CT images help better characterize fracture patterns 2
• MRI or ultrasound recommended if rotator cuff tear is suspected (present in up to 40% of humeral head fractures) 2

Treatment Algorithm

1. Surgical Management

For comminuted, displaced, and angulated fractures, surgical intervention is typically indicated:

• Angularly-stable plate fixation:

  • Provides excellent stability for complex fracture patterns
  • Facilitates early rehabilitation
  • May be suitable for fractures previously treated with hemiarthroplasty 3
  • LC-condylar plating yields better stability than conventional T-plate systems 4

• Interlocking intramedullary nailing:

  • Comparable outcomes to plate fixation
  • Less soft tissue disruption
  • Suitable for specific fracture patterns 1

• Percutaneous fixation with cannulated screws:

  • Minimally invasive option
  • Preserves blood supply to humeral head
  • Can be combined with tension-absorbing sutures 4
  • Less suitable for highly comminuted fractures

2. Arthroplasty Considerations

• Hemiarthroplasty or reverse shoulder arthroplasty should be considered in:
  • Elderly patients with advanced bone loss (osteoporosis)
  • Cases where anatomical reduction is impossible
  • Situations where stable fixation is questionable
  • Patients unable to comply with postoperative rehabilitation 1

3. Associated Injuries Management

• Address significant rotator cuff tears during open reduction and internal fixation 2
• Delay in repair of rotator cuff tears by up to 4 months has not shown adverse outcomes 2

Rehabilitation Protocol

• Early mobilization is crucial following surgical fixation
• Initiate rehabilitation based on fixation stability
• Avoid immobilization beyond 3 weeks to prevent joint stiffness 1
• Supervised physiotherapy is essential for optimal outcomes

Common Pitfalls and Considerations

• Poor bone quality may lead to loss of fixation and subsequent malunion
• Hemiarthroplasty carries risks of shoulder stiffness, tuberosity resorption, and glenohumeral instability 5
• Avascular necrosis of the humeral head is a potential complication in severe fractures, though reasonable function can still be achieved in some cases 4
• Decision-making should consider patient factors (age, bone quality, activity level) and fracture characteristics (pattern, displacement, comminution) 6

The choice between surgical techniques should be guided by fracture pattern complexity as determined by CT imaging, surgeon expertise, and patient-specific factors including bone quality and functional demands 6.