Hemiarthroplasty for Complex Four-Part Fracture of the Proximal Humerus: Technical Considerations and Surgical Technique

The four-part fracture complex described by Neer is a rare but severely disabling injury to the proximal humerus [18]. It is an injury which, while historically rare, has become increasingly more common as the population ages and remains physiologically active. This injury is specifically disabling when it involves the dominant arm. The severity of this injury is due to the associated vascular compromise, which occurs secondary to interruption of the ascending branch of anterior humeral circumflex artery as it courses around the proximal humerus and enters at the tuberosities around the bicipital groove [16]. These endostial vessels are at risk in fractures which involve one or both tuberosities. Disruption of this major blood supply leaves the proximal humerus susceptible to avascular necrosis. Four-part fractures are particularly susceptible since they include disruption of both tuberosities and are associated with a high incidence of avascular necrosis, ranging from 34% to 85% [15,24,26,27]. In addition to vascular compromise, these fractures are often associated with significant comminution, which makes stable open reduction/internal fixation extremely difficult. Because of these factors many surgeons have opted for a “wait and see” approach to treatment in some patients. The other treatment options have included closed reduction, open reduction with or without fixation, and hemiarthroplasty [2,15,17–20,23,24,26]. Schai, in comparing the results of these treatments in a group of patients who had sustained four-part proximal humeral fractures, noted that hemiarthroplasty gave statistically significant better results than both open reduction/ internal fixation or conservative care [23]. In other series conservative treatment had only a 5% successful outcome [26]. Some authors have noted that four-part fractures treated acutely by hemiarthroplasty had significantly better results than those chronic four-part malunions treated later by arthroplasty [5,10,21]. With all these factors considered, hemiarthroplasty is, in the acute setting, the procedure of choice for most four-part fractures of the proximal humerus [3,4,9,13,25,27].