Management of Comminuted Proximal Humerus Fracture with Surgical Neck Extension
For a comminuted proximal humerus shaft fracture extending to the surgical neck with slight lateral displacement, operative fixation with locked plating is the recommended treatment approach, as this fracture pattern requires stabilization to prevent malunion and restore function. 1, 2
Initial Diagnostic Workup
Obtain CT imaging immediately after initial radiographs to fully characterize the fracture pattern and degree of comminution, as CT changes clinical management in up to 41% of proximal humeral fractures by revealing fracture complexity not apparent on plain films. 3, 1
- Three-dimensional volume-rendered CT images are essential for evaluating humeral neck angulation and planning the surgical approach. 1
- Assess for associated rotator cuff tears, which occur in up to 40% of these fractures and will affect surgical planning and prognosis. 1
Surgical Management Strategy
Proceed with open reduction and internal fixation using a locked plating system within 3-5 days of injury to minimize complications while allowing time for preoperative planning. 4
Critical Timing Considerations
- Surgery performed within 5 days has significantly lower complication rates compared to delayed intervention beyond 5 days (odds ratio 1.637 for complications when delayed >5 days). 4
- The 3-5 day window provides optimal balance between surgical planning and avoiding increased risk of fixation failure. 4
- Do not delay surgery beyond 5 days, as this substantially increases risk of loss of fixation, screw cutout, and avascular necrosis. 4
Fixation Technique for Comminuted Patterns
For comminuted fractures with medial column instability, consider dual-plate fixation combining a lateral locking plate with medial anatomical support, as this provides superior construct stability compared to single-plate fixation. 5
- The medial column requires direct support in comminuted patterns to prevent varus malunion and screw perforation. 5
- Dual-plate constructs demonstrate significantly greater stiffness and less stress concentration than single lateral plates. 5
Augment fixation with suture incorporation of rotator cuff tendons and tuberosities to enhance stability, particularly in osteoporotic bone or when significant surgical neck comminution is present. 6, 7
- Heavy nonabsorbable sutures incorporating the rotator cuff, tuberosities, and shaft create a tension-band construct that achieves 82% good-to-excellent results. 7
- This technique is particularly valuable when plate-and-screw fixation alone may be insufficient due to bone quality or fracture pattern. 6
Technical Execution
- Achieve anatomic reduction before inserting any fixation hardware, with restoration of medial cortical continuity and normal neck-shaft angle. 8
- Use short screws in the humeral head to minimize risk of screw cutout. 6
- Avoid over-compression during fixation, as this causes further comminution in osteoporotic bone. 8
Postoperative Protocol
Initiate immediate passive range-of-motion exercises without immobilization, as locked plate fixation provides sufficient stability for early rehabilitation. 2
- Eliminate prolonged immobilization to prevent joint stiffness and accelerate functional recovery. 2
- Progressive active-assisted exercises begin at 3-4 weeks postoperatively. 2
Common Pitfalls to Avoid
Failure to recognize medial column instability leads to varus collapse and screw perforation—always assess for medial comminution on CT and provide direct medial support when present. 5
Delaying surgery beyond 5 days significantly increases complication rates including loss of fixation (12.8%), screw cutout (4.9%), and avascular necrosis (6.8%). 4
Using long screws in the humeral head increases perforation risk—keep screws short and augment with suture fixation for additional stability. 6