In younger patients (aged 65 or younger) with a complex proximal humeral fracture, open reduction and internal fixation is the initial surgical approach. When fixation does not achieve its intended goals, a defined next-line protocol governs the appropriate escalation.
This protocol applies to patients aged 65 or younger with proximal humeral fracture involving one or more of the following features: dislocated humeral head; humeral head facing superiorly or posteriorly; splitting of the humeral head; greater tuberosity displaced above the humeral head or posteriorly; significant varus angulation of the humeral head; or minor greater tuberosity displacement with minimal head-shaft angulation in a young, high-demand individual. Younger patients have stronger bones and significantly greater functional demands from the shoulder.
The initial surgical approach — open reduction and internal fixation of the proximal humerus with locking plates and screws, combined with greater tuberosity identification and anatomical repair with sutures at the bone-tendon junction — aims to restore anatomy and preserve shoulder function. Escalation to the next treatment line is indicated when this intervention fails to achieve:
When the above targets are not achieved, the next evidence-based step involves an arthroplasty procedure directed at the proximal humerus — with the priority remaining reconstruction of the joint, even in the presence of complex fracture patterns. The complete structured regimen and operative considerations are available in the full protocol.
DOI: 10.1016/j.jcot.2019.04.016