Shoulder arthroplasty in the face of acute fracture: puzzle pieces

Surgical management of acute 4-part humeral fracture-dislocations presents many challenges to the orthopaedic surgeon. Intraoperative surgical reconstruction requires a detailed understanding of the osseous and the muscular anatomy and physiology. The proximal humerus must be reconstructed in a way that establishes proper humeral head version and proper myofascial sleeve tension within the rotator cuff and deltoid musculature. This article reviews and discusses the salient surgical principles and techniques that allow anatomic reconstruction of the proximal humerus. Tuberosity placement and fixation techniques are emphasized, recognizing that anatomic restoration of the cuff is crucial if the patient is to achieve a pain-free and functional limb after joint arthroplasty for fracture.