Fracture treatment of the shoulder girdle

Treatment of a head of humerus fracture

The most common fracture occurring at the shoulder girdle is the head of humerus fracture (accounting for 47% of all fractures of the shoulder girdle). The occurrence of this fracture increases with age and with the degree of osteoporosis, and thus, on an average, 2 to 3 times more women than men are affected.
Depending on the number of fragments generated during the breaking of the head of humerus, the extent of fragment dislocation and the height of the fracture course, the injury is divided into different types and different procedures are applied for treatment.
Type 0 fractures as non-dislocated "one-fragment fractures" differ from type A fractures as two-fragment fractures with rupture of the major tubercle or the minor tubercle. Further, there are type B fractures occurring in the surgical neck and showing 2 - 4 fracture fragments. Type C fractures occur in the anatomic neck. They may show 2 - 4 fracture fragments as well (Fig. 57)

Fig. 57: Classification of the proxmal humeral fracture.

Luxation fractures in front or in back (dislocation of the glenohumeral joint with associated bone fracture) are called type X fractures. After repositioning of the glenohumeral joint, this fracture is assigned to type A, B, or C in addition.
Further there are head splitting and impression fractures.

Treatment objective

The objective of the treatment is to maintain painless movability of the glenohumeral joint depending on the age and functional requirements of the patient. Thus, the treatment concept needs to be adjusted to the individual needs of the patients.

Treatment principles

60-85% of head of humerus fractures are type 0 fractures. The non-dislocated or only slightly dislocated head of humerus fracture (type 0 fracture) is not surgically treated. Since this type of fracture is stabilized by the periosteum, the joint capsule and the muscles, an immobilization in a tube bandage for 7 - 14 days until the pain is eased is sufficient. It is important to start early with functional exercises in order to prevent stiffening of the glenohumeral joint. After about 6 - 8 weeks, the bone fracture has solidly healed.
Due to the severe malalignment and the associated movability restrictions and pain, however, fracture types A - C, type X as well as the head splitting fractures require a restoration of the head of humerus to its original shape by means of surgery. Here, depending on the type of fracture, various types of material are used for stabilizing the bone fracture. A fracture may be stabilized using wire, screws or plates.

Fig. 58: TypeBI-fracture

Fig. 59: Targon nail

Fig. 60: Type-B-fracture

Fig. 61a: Type B fracture

Fig. 61b: X-ray of an open reduction and internal fixation.

 
Fig. 62: Type B fracture with a fracture of the greater tuberosity.

Fig. 63: X-ray after open reduction and internal fixation.

If, due to the severity of the injury, glenohumeral joint surgery to maintain its function is not possible using those materials, or if the blood vessels in the head of humerus were destroyed so that there is a high probability of necrosis of the head of humerus, there is the option of replacing the head of humerus with a prosthesis (artificial joint replacement). In the last few years, special fracture prostheses have been developed for this type of joint replacement which may be individually adjusted to the fracture. The prosthesis head may be positioned in various heights in order to compensate for potential fracture-related height loss. Further, the fracture prosthesis has specific fixtures for positioning the torn major and minor tubercles anatomically correct to the prosthesis. This is important since the tendons of the rotator cuff are attached to the tubercles.
The head of humerus splitting fracture is an exception. If more than 40% of the joint area is destroyed with this fracture, joint replacement using a head of humerus prosthesis (Fig. 66) is indicated here as well.

Fig. 64:

Fig. 65: Type C fracture with head split.

Fig. 66: X-ray after fracture arthroplasty.

Follow-up treatment

Follow-up treatment has to be performed according to the patient's individual requirements. The duration of incapability to work and the time of resumption of sports-specific training depend on the injury and the surgery procedure chosen.