What is the treatment for significant joint space widening with humeral head and neck fracture?

Treatment for Significant Joint Space Widening with Humeral Head and Neck Fracture

For significant joint space widening with humeral head and neck fracture, perform closed or open reduction of the dislocation first without concomitant repositioning or internal fixation of the fracture fragments, as reduction of the dislocated humeral head typically results in acceptable repositioning of the fractured fragments through impaction. 1

Diagnostic Evaluation

• Obtain CT scan immediately to characterize the fracture pattern, as CT is superior to plain radiographs and MRI for delineating complex proximal humerus fractures 2, 3, 4
• Three-dimensional volume-rendered CT images should be obtained to assess humeral neck angulation and fracture displacement 3, 4
• Joint space widening indicates glenohumeral dislocation (typically posterior) associated with the humeral neck fracture 1, 5

Treatment Algorithm

Primary Treatment Approach

Reduce the dislocated humeral head (closed reduction preferred, open if necessary) without attempting to reposition or internally fix the fracture fragments 1

• The reduction maneuver applies longitudinal pressure that impacts the anatomic neck fracture, providing stabilization 1
• This approach achieves acceptable repositioning of fractured fragments in approximately 90% of cases 1
• Early physiotherapy should be initiated immediately after reduction without risk of redisplacement 1

Contraindications to Conservative Approach

This reduction-only method is contraindicated when: 1

• The humeral head is completely detached from all soft tissue attachments (high risk of avascular necrosis)
• Bone fragments remain displaced >10 mm after reduction of the dislocated humeral head
• Iatrogenic displacement occurs during attempted closed reduction 5

Surgical Intervention When Conservative Approach Fails

If closed reduction leads to iatrogenic displacement of an initially undisplaced neck fracture, proceed directly to primary humeral head replacement 5

• This scenario most commonly occurs with anterior dislocations associated with greater tubercle fractures 5
• Primary hemiarthroplasty should be performed within 2-30 days of injury to prevent avascular necrosis and severe humeral head collapse 5
• For geriatric patients with pre-existing rotator cuff dysfunction, reverse shoulder arthroplasty is preferred over hemiarthroplasty 4

Alternative Surgical Options for Displaced Fractures

If fragments remain significantly displaced after reduction: 4

• Open reduction and internal fixation with locking plates for younger, active patients
• Hemiarthroplasty for severely displaced fractures in frail patients
• Reverse shoulder arthroplasty for elderly patients with rotator cuff compromise

Critical Pitfalls to Avoid

• Do not attempt internal fixation of the fracture fragments during initial reduction - this increases surgical morbidity without improving outcomes when reduction alone achieves acceptable alignment 1
• Do not perform closed reduction on anterior dislocations with undisplaced neck fractures without extreme caution - this can iatrogenically displace the fracture, necessitating primary arthroplasty 5
• Recognize that completely detached humeral heads will develop avascular necrosis - these require primary arthroplasty rather than reduction alone 1, 5

Associated Injuries Assessment

• Evaluate for rotator cuff tears, which occur in up to 40% of humeral head fractures 3
• Significant rotator cuff tears are typically addressed during open reduction if surgical fixation becomes necessary 2
• For conservatively managed fractures, noncontrast MRI can assess rotator cuff integrity after initial healing 2

Rehabilitation Protocol

• Initiate early active motion immediately after reduction to prevent stiffness 4, 1
• Shoulder immobilization should be limited to 3 weeks maximum if surgical fixation is performed 6
• Complete functional recovery is achieved in approximately 78% of patients treated with reduction alone at 2-year follow-up 1