Treatment of Humeral Head Fractures
Treatment depends on fracture complexity and displacement: obtain CT imaging to characterize the fracture pattern, then pursue non-operative management for minimally displaced fractures, open reduction and internal fixation (ORIF) with locking plates for displaced 2-3 part fractures in younger patients with good bone quality, and consider hemiarthroplasty for complex 4-part fractures, especially in elderly patients. 1
Initial Diagnostic Approach
Imaging is critical for treatment planning:
Obtain standard shoulder radiographs first (AP views in internal and external rotation plus axillary or scapula-Y view) to assess fracture pattern and displacement 1
Order CT without contrast when radiographs show comminuted or complex fractures, as CT is superior for characterizing fracture patterns and changes clinical management in up to 41% of proximal humeral fractures 2, 1
Use three-dimensional volume-rendered CT images to better characterize fracture patterns and humeral neck angulation, which directly affects functional outcomes 2, 1
Do not rely solely on radiographs for surgical planning in comminuted fractures, as poor inter-observer agreement exists for grading humeral head fractures on plain films 2
Treatment Algorithm by Fracture Type
Two-Part and Three-Part Fractures
ORIF with locking plates is the primary treatment for displaced fractures in appropriate candidates:
Three-part fractures treated with ORIF achieve significantly better functional outcomes (average Constant score 68 points) compared to four-part fractures (55 points) 3
Displaced three-part fractures without dislocation show good results with careful ORIF, with average Constant scores of 67 points 3
Fracture dislocations (articular fragment outside the glenoid) do not have worse prognosis than displaced fractures if treated with timely ORIF, despite the increased risk of nerve injuries 3
Four-Part Fractures
Treatment selection is critical and age-dependent:
In younger patients (under 60 years), consider ORIF as fracture dislocations in middle-aged patients can achieve good functional results (average Constant score 62 points) with careful operative technique 3
In elderly patients with four-part fractures through the anatomical neck (type C3), strongly consider primary hemiarthroplasty due to poor outcomes with ORIF (high avascular necrosis rates of 63-67%) 3, 4
Primary hemiarthroplasty for four-part fractures achieves absolute Constant scores of 54.9 points at 5-year follow-up 5
Secure fixation of tuberosities is essential for functional outcomes, with dislocation rates of 13.5% in primary arthroplasty versus 75% in secondary arthroplasty 5
Associated Injuries
Assess and address concomitant soft tissue injuries:
Up to 40% of humeral head fractures have complete rotator cuff tendon tears 2, 1
Address rotator cuff tears during surgical fixation of the fracture 1
Delays in rotator cuff repair up to 4 months have not shown adverse outcomes, so immediate soft-tissue repair may not be required 2
Assess neurovascular status immediately, as fracture dislocations have a 19% incidence of traumatic nerve or plexus lesions compared to 2% in displaced fractures 3
Most axillary nerve injuries recover fully within 6-12 months, but brachial plexus injuries may have prolonged recovery 3
Postoperative Rehabilitation
Early active motion protocols are safe and effective:
No immobilization restrictions are necessary after stable locking plate fixation - early active motion without force or movement restrictions achieves equivalent outcomes to restrictive protocols 6
At 24 months, both early active motion and restrictive protocols achieve relative Constant Scores of 89.8% of the uninjured side 6
Avoid heavy lifting, exhausting physical activity, and blunt force on the arm for 3 months postoperatively regardless of rehabilitation protocol 6
Critical Pitfalls to Avoid
Do not perform MRI for acute fracture characterization - it is inferior to CT for evaluating complex fracture planes 2, 1
Do not perform CT arthrography acutely - glenohumeral hemarthrosis obscures soft-tissue structures and contrast obscures fracture planes 2, 1
Do not delay treatment in fracture dislocations with neurovascular compromise - early operative nerve decompression and fracture stabilization are essential 3
Do not attempt ORIF in elderly patients with four-part anatomical neck fractures - the high rate of avascular necrosis (63-67%) makes primary arthroplasty the better option 3, 4
Reserve MRI without contrast for assessing rotator cuff integrity only in patients managed non-operatively 2, 1