Fractures involving splitting of the humeral head

Abstract

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.

Head-split fractures of the proximal humerus

“…Patients presenting with head-split fractures generally can be divided into two groups. One group includes younger and predominantly male patients involved in high-energy trauma (i. e., bicycle, motorcycle-, or car accident; epileptic seizure) with typically good bone quality and good potential for revascularization [4]. The other group includes older mainly female patients involved in low-energy trauma (i. e., a simple fall) and typically poor bone quality with limited regenerative potential [9].…”

“…The number of fragments in the setting of severe comminution is underestimated by standard radiography in more than 60% of cases [10]. Chesser et al reported that head-split fractures in particular can be difficult to recognize, and, when left untreated, poor outcomes can be expected [4]. Greiwe et al reported that only 37.5% of the head-split fractures were identified on preoperative radiographs and 50% on CT [9].…”

“…Functional outcome scores showed significantly better results in simple fractures [7]. Chesser et al describe good results with internal fixation (one or two cancellous screws) in simple head-splitting fractures in three of the eight patients who were young (19-41 years), and opted for hemiarthroplasty in patients older than 55 years [4].…”

“…A missed diagnosis of head-split fractures can lead to severe complications. Chesser et al described three cases of missed diagnoses where the patients developed bony ankylosis and stiffness [4]. However, just one of them was unsatisfied because of the pain, requiring a secondary surgical treatment.…”

Hemiarthroplasty for Head-split Fractures of the Proximal Humerus

“…Head-split fractures are rare (less than 5% of all proximal humerus fractures) and difficult to identify on injury radiographs. 13,14 The outcome of head-split fractures, regardless of management, is thought to be worse than nonhead-split fractures because of a perceived higher energy of injury and disruption of the terminal blood supply to the articular fragments. 14 Treatment for head-split fractures in older patients has typically been humeral head replacement due to the disruption of articular surface congruity and vascularity.…”