HUMERUS FRACTURES

CONTENTS

Preface ix
Scott P. Steinmann

Two-Part Fractures and Fracture Dislocations 397

Charles M. Court-Brown and Margaret M. McQueen
Proximal humeral fractures are common and are usually osteopenic or osteoporotic and
about 85% occur in patients older than 50. Two-part fractures account for approximately
28% of proximal humeral fractures, with most being surgical neck fractures. This article
discusses the management of two-part fractures and analyzes the use of nonoperative
treatment, conventional plating, locked plating, antegrade intramedullary nailing,
retrograde pinning, and Kirschner wires in their treatment. The literature indicates
that nonoperative treatment is as effective as conventional plating, antegrade nailing,
and Kirschner wiring in treating two-part surgical neck fractures in older patients. The
early results of locked plating may be better, but more studies are required to prove this.
This article gives the results of nonoperative treatment of all types of two-part fractures
and fracture dislocations.

Four-Part Proximal Humerus Fractures: Evaluation and Treatment 415

John R. Reineck, Sumant G. Krishnan, and Wayne Z. Burkhead
Four-part proximal humerus fractures represent a difficult entity in the management of
upper extremity trauma. Most of these fractures are not amenable to operative fixation;
thus, surgical address is necessarily one of fracture arthroplasty. Timely reestablishment
of the Gothic arch using a fracture-specific prosthesis leads reliably to anatomic
tuberosity osteosynthesis. Hence, shoulder arthroplasty for fracture should be
considered an augmented osteosynthesis, with precise prosthetic implantation supple-
menting anatomic tuberosity reconstruction. Further investigations are ongoing
regarding the use of specific fracture implants and biologic substrates in an attempt to
improve further the rate of tuberosity healing in the older patient population after this
operation.

Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures 425
Bryan Wall and Gilles Walch
Proximal humeral fractures occurring in elderly patients often lead to significant
functional disability. The outcome of nonoperative management is disappointing.
Treatment with open reduction and internal fixation may result in osteonecrosis of the
humeral head, and pain. Hemiarthroplasty is often associated with tuberosity nonunion
and poor function. Reverse shoulder arthroplasty is an attractive alternative because of
the ability of the prosthesis to compensate for tuberosity complications. Early studies

VOLUME 23 Æ NUMBER 4 Æ NOVEMBER 2007 v

 have shown promise in using the prosthesis to treat these difficult patients. The next step
will require prospective, randomized studies to determine which patient groups derive
any benefit from reverse shoulder arthroscopy. The technology should be used
judiciously.

Proximal Humerus and Humeral Shaft Fractures in Children 431

M. Wade Shrader
Proximal humerus fractures and fractures of the humeral shaft are relatively rare in
children. The incidence of the former is about 1 to 3 cases/1000 population per year,
comprising fewer than 3% of all pediatric fractures. Fractures of the humeral shaft
represent fewer than 10% of all humerus fractures in children. Both types of fractures in
babies and young children can be treated nonsurgically, because of the joint’s ability to
remodel. Simple swaddling with a sling or swaddling cloth can be the solution. For older
children, splints and braces may be necessary for short periods of time. Fractures can
sometimes be a sign of parental child abuse, so suspicion should remain high when
evaluating children with these injuries.

The Operative Treatment of Diaphyseal Humeral Shaft Fractures 437

Peter A. Cole and Coen A. Wijdicks
Fractures of the humeral shaft comprise 1% to 3% of all fractures. Incidence rates reveal a
bimodal distribution in which there is one small peak during adolescence, followed by a
larger spike during the fifth and sixth decades of life. Most humeral diaphysis fractures
are simple patterns of the mid-diaphysis. This article emphasizes surgical approaches to
humeral fractures, providing a review of the surgical spectrum of treatment inclusive of
intramedullary nailing and plating, but also includes a brief discussion of the
conservative approach.

Humeral Nonunion 449

Anna R. King, Steven L. Moran, and Scott P. Steinmann
Humerus fractures comprise 5% to 8% of all fractures. Although uncommon, nonunions
can present a frustrating challenge to the orthopedic surgeon. Various risk factors that
may predispose patients to nonunion include obesity, osteoporosis, alcoholism, smoking,
poor bone quality, and scar tissue. Many methods of treatment have been described with
various degrees of success. The rates of healing of humeral nonunions by traditional
means of internal fixation with bone graft range from 70% to 92%, although in cases of
infection, poorly vascularized beds, and open, segmental, or severely comminuted
fractures, secondary bony healing may still be compromised.

Distal Humerus Fractures 457

Thomas W. Throckmorton, Peter C. Zarkadas, and Scott P. Steinmann
Fractures of the distal humerus in adults have traditionally presented a treatment
challenge for the orthopedic surgeon. The combination of anatomic complexity,
multifragmentary comminution, and a short distal segment, often in the setting of
osteoporotic bone, renders these fractures difficult to treat successfully and often make a
full restoration of function uncertain. Multiple methods of treatment for these fractures
have been described, including bracing, internal fixation, hemiarthroplasty, and total
elbow arthroplasty. This article reviews the epidemiology and classification of these
injuries and the numerous described fixation and arthroplasty techniques. The current
treatment algorithm and authors’ preferred method of internal fixation are also
illustrated. Additionally, the treatment of these injuries in the elderly population and
the complications of surgical treatment are reviewed.

vi CONTENTS
Apparent Capitellar Fractures 471
David Ring
Isolated capitellar fractures are rare but are identified as such, even when they are more
complex, because the displaced capitellar fracture is usually the most obvious and
identifiable radiographic finding and because teaching has traditionally underempha-
sized the involvement of the trochlea in such fractures. The author prefers the term
‘apparent capitellar fractures and draws on his experience to explain why he favors
three-dimensional CT for depicting fracture detail. This article discusses treatment
options, emphasizing open reduction and internal fixation to restore the native elbow.
Operative techniques, including extensile lateral exposure and olecranon osteotomy;
fixation techniques; and elbow arthroplasty, are described. Complications, such as ulnar
neuropathy and infection, are also covered.

Fractures of the Capitellum 481

Emilie V. Cheung
Fractures of the capitellum account for less than 1% of all elbow fractures. Because they
may be difficult to visualize on plain radiographs, the clinician must have a high index
of suspicion for their diagnosis. Anatomic alignment of these fractures is imperative;
slight residual displacement may result in significant loss of elbow motion. Surgical
management is described with open reduction internal fixation using variable pitch
headless screws, precontoured plates, or bioabsorbable pins. The optimal method of
fixation depends on the fracture pattern and degree of comminution. If the fracture
fragments are too small for stable fixation, excision of the fragments is recommended.
Osteonecrosis, as well as, end-stage arthrosis requiring total elbow arthroplasty, has been
reported as a rare, but potential, complication.

Index 487

CONTENTS vii