Proximal Humerus Fracture in Patients Aged 65 or Younger with Displaced or Complex Fracture Patterns
Clinical Scenario
This protocol is for patients aged 65 years or younger presenting with a proximal humerus fracture. Younger patients have stronger bone and substantially greater functional demands on the shoulder, which shapes the threshold for intervention and the goals of care.
When This Protocol Applies
This approach is indicated when any of the following fracture characteristics are present:
- Dislocated humeral head
- Humeral head directed superiorly or posteriorly (not facing the glenoid)
- Splitting of the humeral head
- Greater tuberosity displaced above the humeral head or posteriorly
- Significant varus angulation of the humeral head
- Minor greater tuberosity displacement with minimal head shaft angulation in a young, high-demand individual
Treatment Approach
Management centres on surgical fixation — open reduction and internal fixation — with anatomical reconstruction of the fractured segments, including focused attention to the greater tuberosity. The complete technique, implant selection, and repair sequence are detailed in the full protocol.
Clinical Goals
Treatment aims for anatomical positioning of the greater tuberosity on postoperative imaging, satisfactory rotator cuff function, and restoration of the ability to lift the arm.
References
DOI: 10.1016/j.jcot.2019.04.016
- Younger individuals, however, have stronger bones & fixation provides a stable construct during fracture healing.
- They have significantly more demands from their shoulder function too.
- Dislocated head.
- Head facing superiorly/posteriorly (though in the socket, but not facing the glenoid).
- Splitting of head.
- GT is lying above the humeral head or displaced posteriorly.
- Significant varus angulation of the head (usually indicates severe medial pillar instability & progressive malposition).
- Minor displacement of GT, minimal head shaft angulation only in young and high demand individuals.
- Fractures of neck needing an ORIF are best fixed with locking plates and screws.
- It is also an implant of choice in displaced 3 & 4 part fractures.
- Every attempt must be made to reconstruct proximal humerus (even in split or dislocated head), particularly in younger patients.
- The crux of PHF surgery is to bring back the fractured GT in its anatomical position, to achieve satisfactory rotator cuff function.
- Sufficient time must be spent to identify, tag and repair the GT.
- Suture bites must be taken from the bone-tendon junction (not thru the bone).
- Nonunion of GT is the most frequent cause of inability to lift arm.
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