Evaluation and management of valgus impacted four-part proximal humerus fractures

A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation.

Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.