[Fractures of the proximal humerus]

Proximal humeral fractures are common particularly in the elderly. The decision of the optimal treatment is dependent on many factors. On the one hand the biological age of the patient and the bone structure plays a key-role, on the other hand the living conditions and individual needs are of importance. Most fractures with minimal displacement respond satisfactorily to simple conservative treatment including short sling immobilisation and functional aftertreatment under supervision of the physiotherapist. Most recently there is a trend towards more aggressive surgical intervention with percutaneous insertion of cannulated screws also in the slightly displaced fracture situation. This protocol allows for earlier functional and less painful aftertreatment, less risk of displacement of the fracture fragments and better outcome. In severely unstable fractures with marked displacement of the fragments an operative stabilisation is advocated by most surgeons. Again there is a trend from plating towards cannulated screw fixation combined with tension absorbing (resorbable) sutures. In special cases which are described in detail a minimal invasive percutaneous screw technique with less stripping of bone and therefore preservation of the crucial blood supply of the humeral head is recommended. Instead of percutaneous pinning using K-wires only, cannulated screws are inserted today. Plating of proximal humerus joint fractures is the exception in our days, only the subcapital unstable fracture of the elderly would be an indication. LC-condylar plating seems to yield better stability than the conventional T-plate-system. In the most severe fractures of the proximal humerus (4-segment-fractures and dislocation fractures according to Neer, respectively C-2- and C-3-fractures according to the AO-classification) there is still controversy on the best management. Most authors prefer hemiarthroplasty in this situation whereas the other group of orthopaedic surgeons try open reduction and internal fixation particularly in the younger individuals. This stabilisation provides the orthopaedic surgeons with a formidable challenge and requires a lot of experience in this field. Also the understanding of the fracture morphology is needed for optimal results. In spite of good stabilisation techniques often partial or total humeral head necrosis occurs in the most severe fractures. Surprisingly enough results with reasonable function can be obtained even with partial avascular necrosis of the humeral head. A crucial part of the management is team work with the physiotherapist and an individual program for each fracture situation, depending on the stability of the fixation. Close contact between these two professions is of utmost importance. Finally it can be stated that the management of proximal humeral fractures is fairly standardised but it is always dependent on the experience and resources of the attending surgeon and must be tailored to the individual needs of the patient.