Proximal humeral fractures are the second most common upper-extremity
fracture and the third most common fracture, after hip fractures and distal
radial fractures, in patients who are older than sixty-five years of
age1. Although the
overwhelming majority of proximal humeral fractures are either nondisplaced or
minimally displaced and can be treated with sling immobilization and physical
therapy, approximately 20% of displaced proximal humeral fractures may benefit
from operative treatment. Many surgical techniques have been described, but no
single approach is considered to be the standard of care. Surgeons who treat
proximal humeral fractures should be able to identify the fracture pattern and
select an appropriate treatment on the basis of this pattern and the
underlying quality of the bone. Orthopaedic surgeons should have experience
with a broad range of techniques, including transosseous suture fixation,
closed reduction and percutaneous fixation, open reduction and internal
fixation with conventional and locked-plate fixation, and hemiarthroplasty. In
the future, locked-plate technology and the use of osteobiologics may play an
increasingly important role in the treatment of displaced proximal humeral
fractures, facilitating preservation of the humeral head in appropriately
selected patients.
The goals of this article are to enable the reader to: (1) become familiar
with the recent literature on the classification of and treatment options for
proximal humeral fractures, and (2) better identify fracture characteristics
and devise an appropriate treatment plan.
Transosseous Suture Fixation
Surgical Technique
Park et al.2
described different operative approaches for each fracture pattern described
by Neer 3. For
two-part greater tuberosity fractures, an anterosuperior approach along the
Langer lines extending from the lateral aspect of the acromion toward the
lateral tip of the coracoid is used. The split occurs in the anterolateral
raphe and allows exposure of the displaced greater tuberosity fracture. When a
surgical neck fracture exists, Park et
al.2 prefer a
standard deltopectoral approach. Nonabsorbable suture is used to capture
rotator cuff tissue anteriorly, laterally, and posteriorly to the fragment.
The displaced humeral head is reduced and fixed to the shaft through drill
holes or suture anchors. Three-part fractures involving the greater tuberosity
and the surgical neck can be repaired by initially bringing the head to the
shaft, followed by reduction and fixation of the greater tuberosity. Flatow et
al.4 described an
anterosuperior approach and the use of heavy nonabsorbable sutures for greater
tuberosity fractures (Fig.
1).
Indications
Transosseous suture fixation has been described as a treatment option for
proximal humeral fractures that have at least 1 cm of displacement between the
head and the shaft fragments or 5 mm of displacement of the tuberosity
fragment. The proponents of this technique emphasize the advantage of avoiding
the risks associated with hardware, which include pain, neurovascular
compromise, migration, failure, and the need for removal. The underlying
rotator cuff musculature can be used as a means to realign the fractures and
enhance stability. Furthermore, the long-term functional recovery of the
rotator cuff is a key component of overall patient outcome.
Contraindications
Contraindications to this approach include previous attempt(s) at internal
fixation or fractures older than six weeks. Also, the use of this technique
for highly comminuted four-part fractures is not recommended.
Results
Flatow et al.4
reported that all twelve patients who had transosseous suture fixation of an
isolated greater tuberosity fracture had good or excellent results with
osseous union. Park et
al.2, in a review of
twenty-eight shoulders with two-part greater tuberosity, two-part surgical
neck, and three-part greater tuberosity and surgical neck fractures that were
treated with transosseous suture fixation, reported that 78% of the patients
had an excellent result according to the criteria of Neer et
al.5 and that there
was no difference between the results obtained with two-part greater
tuberosity fractures and those obtained with two-part surgical neck or
three-part fractures. Panagopoulos et
al.6 used
transosseous suture fixation for four-part valgus-impacted proximal humeral
fractures, and the mean Constant-Murley
score7 for the
operative shoulder was 87 compared with 94 for the contralateral shoulder.
Partial osteonecrosis of the humeral head developed in one patient.
Closed Reduction and Percutaneous Fixation
Surgical Technique
With the aid of an image intensifier, the fracture is reduced by closed
means into anatomic alignment. For surgical neck fractures, two to three
threaded Kirschner wires (0.045 to 0.0625 mm) are inserted into the lateral
cortex distal to the deltoid insertion and advanced into the subchondral bone
of the humeral head without penetrating the articular surface. For greater
tuberosity fractures in isolation or in conjunction with a surgical neck
fracture, the two wires should purchase the medial cortex >20 mm from the
inferior border of the head.
Resch et al.8
described a technique for closed reduction and percutaneous fixation of three
and four-part proximal humeral fractures. For three-part fractures, the
subcapital fracture is reduced with adduction, internal rotation, and axial
traction on the arm. A pointed hook retractor is inserted into the subacromial
space to manipulate the greater tuberosity fragment anteriorly and inferiorly
into anatomic position. Under image intensification, the shoulder is brought
through internal and external rotation to confirm reduction of the greater
tuberosity and two cannulated self-tapping 2.7-mm screws are used to fix the
fragments.
For four-part valgus impacted fractures or true four-part fractures, a
periosteal elevator is used to elevate and laterally translate the articular
fragment9. When the
head is elevated, the periosteum on the medial side acts as a hinge and the
greater tuberosity is reduced into anatomic position. A blunt trocar and a
2.7-mm cannulated screw is advanced toward the superior aspect of the greater
tuberosity, and a screw is directed toward the humeral head. Another screw is
positioned at the inferior portion of the greater tuberosity and directed into
the shaft to provide fixation between the head and shaft. The lesser
tuberosity is provisionally fixed with a Kirschner wire, and a screw is placed
from anterior to posterior.
Patients are generally immobilized for three to four weeks in most
protocols. After this initial period, passive motion is started, consisting of
pendulum exercises, forward elevation, and external rotation with the arm at
the side10. Active
motion starts at six weeks, provided that radiographs demonstrate evidence of
healing.
Indications
Percutaneous fixation of proximal humeral fractures requires less
dissection and therefore less disruption of the vascular supply than
traditional open approaches do. Advocates cite the high risk of osteonecrosis
in these fractures as an important reason to avoid extensive exposure of the
individual fragments. Percutaneous fixation also has the advantage of
decreased scarring in the scapulohumeral interface and subsequent easier
rehabilitation10.
Contraindications
Contraindications include the presence of severe osteopenia or
osteoporosis. Comminution of the medial portion of the calcar or proximal part
of the humeral shaft is also a relative contraindication. Patients who are
noncompliant or noncooperative should not be treated with this technique.
Tuberosity comminution that prevents screw or pin fixation precludes use of
this technique. Finally, if a stable closed reduction cannot be obtained, an
open reduction with internal fixation should be performed.
Pearls and Pitfalls
This procedure is technically demanding and has a substantial learning
curve. Many anatomical studies have evaluated the relationship of the
neurovascular structures to the pins. Rowles and
McGrory11 evaluated
ten cadaver shoulders in which percutaneous pin fixation (two lateral, one
anterior, and two greater tuberosity pins) was performed. They found that the
proximal lateral pins were a mean distance of 3 mm from the anterior branch of
the axillary nerve. The anterior pins were a mean distance of 2 mm from the
long head of the biceps tendon and 11 mm from the cephalic
vein11. The
proximal tuberosity pins were a mean distance of 6 mm from the axillary nerve
and 7 mm from the posterior humeral circumflex artery. The pins were found to
tent these structures when the shoulder was placed in internal rotation
(Figs. 2-A and
2-B)11.
Kamineni et
al.12 also
performed a cadaver study in which the results were evaluated after inserting
one anteroposterior and two lateral Kirschner wires, as described by Jaberg et
al.13, into forty
shoulders. The axillary nerve was injured by the lateral wire in three
specimens, and the damage included two direct penetrations. The anterior wire
caused a perineural injury of a terminal branch of the axial nerve. They
concluded that fixation should be performed through a limited open approach to
prevent these
injuries12.
Results
Resch et al.8
reviewed the cases of twenty-seven patients with three-part or four-part
fractures treated with closed reduction and percutaneous screw fixation. For
the three-part fractures, the mean Constant score was 85.4 without evidence of
postoperative osteonecrosis. Thirteen of the eighteen patients with four-part
fractures had valgus impacted fractures, and partial osteonecrosis developed
in only one patient. Of the five laterally displaced four-part fractures, two
required revision to a hemiarthroplasty.
Keener et al.10,
with use of closed reduction and percutaneous fixation, treated thirty-five
patients with two-part, three-part, and four-part fractures. The mean
follow-up was thirty-five months. All fractures healed, and the mean pain
score on a visual analog scale was 1.4. The mean American Shoulder and Elbow
Surgeons score14
was 83.4, and the mean Constant score was 73.9. Osteoarthritis developed in
four patients, and four fractures healed in malunion. There were no infections
and no neurovascular injuries.
Fenichel et
al.15
retrospectively reviewed (mean follow-up, 2.5 years postoperatively) the cases
of fifty patients who had unstable two or three-part fractures that were
treated with percutaneous pin fixation with use of threaded pins. Excellent or
good results were obtained in thirty-five patients; fair results, in eight;
and poor results, in seven. The average Constant score was 81. Fractures of
the surgical or anatomic neck were associated with better scores (average
score, 86) than those with tuberosity fragments (average score, 78). There
were no occurrences of osteonecrosis, neurovascular complications, or deep
infections. Seven patients had a severe loss of reduction, however, and three
of the seven needed revision surgery.
Open Reduction and Internal Fixation—Conventional Plate
Surgical Technique—Double-Plate Fixation
Wanner et al.16
used two one-third tubular plates to treat patients with two, three, or
four-part proximal humeral fractures. A standard deltopectoral approach was
used to gain access to the fracture. An emphasis was placed on anatomical
reduction, with particular attention given to reducing the greater and lesser
tuberosities and achieving correct length of the humeral shaft and
retroversion of the head. Lateral plate fixation to reduce the greater
tuberosity was achieved first, typically with a five or six-hole one-third
tubular plate. This was followed by fixation of a ventral plate at a 90°
angle to the lateral plate. A four-hole one-third tubular plate with one
proximal and one distal screw was usually used. Bone cement was injected into
the screw holes when bone quality was deemed to be poor.
Indications
Prior to the use of locking-plate technology, conventional plate fixation
was used for the majority of patients who had open reduction and internal
fixation of proximal humeral fractures. Many different plates have been used
in a variety of supplementation
techniques16-21.
The poor bone quality in this region of the proximal part of the humerus
results in a decreased ability to secure these conventional plates with
screws22. The
loosening and pull-out of screws are common reasons for
failure23.
Traditional plate techniques can still provide satisfactory outcome when
anatomic reduction can be
achieved18.
Furthermore, double-plating techniques as described by Wanner et al. can
provide satisfactory
outcome16.
Contraindications
Traditional plate constructs are usually reserved for young patients with
an intact medial hinge, an adequate diaphyseal cortex (>4 mm), and no
metaphyseal comminution. Patients who have osteoporosis or whose fracture
lacks any of the above characteristics would likely benefit from locking-plate
technology. The disadvantage of traditional plating systems is the high rate
of osteonecrosis due to extensive soft-tissue dissection. The rate of
osteonecrosis has been reported to be as high as 35% in some case
series18,21.
Results
Wanner et al. 16
treated sixty shoulders with one-third tubular plates fixed orthogonally on
the anterior and lateral cortices. Sixty-three percent of the patients had
good or very good results. Seven patients (12%) had complications that
included fracture displacement, osteonecrosis, adhesive capsulitis,
subacromial impingement, and hardware loosening. Conventional plate fixation
may produce satisfactory clinical results even in the setting of
osteonecrosis18,21;
however, anatomic reduction with conventional plate fixation in the absence of
osteonecrosis produces superior clinical
results18.
Open Reduction and Internal Fixation—Locked Plate
Surgical Technique
We prefer to place the patient in the beach-chair position with the c-arm
placed over the shoulder and draped into the sterile field. The c-arm
fluoroscopic image intensifier provides an anteroposterior view of the
glenohumeral joint, and the humerus can be rotated to obtain radiographs of
the shoulder in internal and external rotation
(Figs. 3-A and 3-B). We use a
standard deltopectoral approach to the shoulder. The anterior third of the
deltoid may be reflected to allow greater exposure of the proximal part of the
humerus. The rotator cuff tendons are tagged with multiple number-2 braided
nonabsorbable sutures, whether as a part of a tuberosity fragment or in
continuity with the head fragment. The tagging sutures are used to bring the
tuberosity fragments in continuity with the lateral cortex of the shaft
fragment, which may indirectly reduce the head fragment to the shaft. If the
head fragment is impacted onto the shaft, a periosteal elevator can be
inserted into the fracture site to disimpact the head and thus restore the
medial portion of the calcar. When the fracture is anatomically reduced, the
tagging sutures are passed through the suture holes of the proximal humeral
locking plate. The plate should be positioned directly on the middle of the
lateral cortex and approximately 8 mm distal to the superior aspect of the
greater tuberosity. Some plates have an oblong hole at the level of the
humeral shaft into which a cortical screw can be partially advanced to allow
the height of the plate to be adjusted; once the plate is in the correct
position, the cortical screw can be completely advanced to secure the plate.
With use of the insertion guide and sleeve assembly, the locked screws can be
placed in the humeral head. After achieving fixation in the humeral head, at
least three diaphyseal screws are inserted. The final fluoroscopic images
should demonstrate anatomic reduction of the proximal humeral fracture
(Figs. 4-A through 4-F).
Indications
For AO/ASIF type-B (bifocal) and type-C (anatomic neck) proximal humeral
fractures24,
humeral head preservation may be possible with locked-plate fixation
supplemented with local bone graft or bone-graft substitute. Because of the
fixed-angle relationship between the plate and screws, locked-plate fixation
provides a mechanical advantage in fractures with metaphyseal comminution,
particularly when there is insufficient osseous contact opposite the
plate25. The
indications for locked-plate fixation continue to evolve as long-term outcomes
after locked-plate fixation for proximal humeral fractures become
available.
Contraindications
Open reduction and internal fixation with locked-plate fixation is
contraindicated in some fracture-dislocations, head-splitting fractures, and
impression fractures that involve >40% of the articular
surface26-28.
Pearls and Pitfalls
As in other applications of locked-plate fixation, the proximal humeral
fracture must be reduced prior to placement of the hardware. The precontoured
proximal humeral locking plate must be placed at the appropriate height, as an
excessively superior position may cause impingement of the plate on the
acromion. Restoration of the medial hinge is critical to successful anatomic
healing of the proximal humeral fracture. If the medial hinge is disrupted, it
must be reduced. Some advocate the use of a 2.0-mm intramedullary plate to
maintain the reduction (Figs. 5-A and
5-B)29.
In cases of comminution or malreduction of the medial hinge, the placement of
calcar-specific screws is critical to support the medial column and therefore
maintain fracture
reduction30. If
calcar screws are necessary, the plate must be positioned to ensure that the
screw will purchase the inferior part of the
calcar30.
Results
From 2002 to 2004, the senior authors (C.N.C. and J.D.MacG.) managed
patients with AO/ASIF type-B proximal humeral fractures with open reduction
and locked-plate fixation. Eight patients (six women and two men) with an
average age of sixty-nine years and a mean follow-up of fifteen months were
evaluated with subjective questionnaires, physical examination, and plain
radiographs. The injured shoulders demonstrated a mean forward flexion of
110° and a mean abduction of 99°. The contralateral shoulders
exhibited a mean forward flexion of 168° and a mean abduction of 159°.
Shoulder strength was slightly lower in the injured shoulders (mean, 13.2 lb
[5.9 kg]) than in the contralateral shoulders (mean, 15.9 lb [7.2 kg]). The
mean Constant score for the injured shoulders was 70.4 compared with 88.8 for
the contralateral shoulders. The mean Neer score was 76.3 for the injured and
95.4 for the contralateral shoulders. All radiographs demonstrated evidence of
excellent healing and well-positioned implants. There was no evidence of
hardware loosening, failure, or nonunion.
Hemiarthroplasty
Surgical Technique
The technique for shoulder hemiarthroplasty is well described in the
literature and follows the principles originally outlined by
Neer31-35.
Typically, a standard deltopectoral approach is used. Deep soft-tissue
dissection may be minimal, depending on the fracture pattern and soft-tissue
injury. It is essential to identify and tag the tuberosities with use of
sutures at the bone-tendon junction to gain control of the rotator cuff and
its insertion. The humeral head and shaft fragments are then exposed, and
sutures are passed through drill holes in the shaft. The glenoid should be
carefully inspected to determine if a glenoid component is warranted.
Once the joint has been adequately exposed and cleaned, preparation of the
humeral shaft begins. It is critical to place the humeral component so that it
has the correct amount of height and retroversion (typically 30° to
40°); to accomplish this, the bicipital groove can be used as a
landmark36.
Different trial modular heads can be used to identify the optimal
configuration. For most joints, the stem should be cemented to ensure
rotational control of the prosthesis. Once the humeral component is secure,
bone graft may be placed to promote healing between the tuberosities and the
shaft.
Finally, the proximal anatomy is restored, with particular emphasis on
correct and secure positioning of the tuberosities through a variety of
suturing techniques. Our preferred technique
(Figs. 6-A through 6-D) is to
pass the greater tuberosity cerclage sutures medial to the humeral neck and
tie them around the greater tuberosity fragment. In biomechanical studies, the
incorporation of medial circumferential cerclage around the tuberosities
decreased interfragmentary motion and strain, maximized fracture stability,
and facilitated postoperative
rehabilitation37,38.
A second set of sutures can then be passed into the lesser tuberosity and
tied. Ideally, a vertical tension band can be used to fix the tuberosities to
the shaft. The shoulder should be taken through a range of motion before the
wound is closed to ensure that stable fixation has been achieved.
Indications
Hemiarthroplasty is indicated as the treatment for proximal humeral
fractures (four-part fractures, three-part fractures in older patients with
osteoporotic bone, fracture-dislocations, head-splitting fractures, and
impression fractures) that involve >40% of the articular
surface26,27,39.
The tenuous fixation of fracture fragments in osteoporotic
bone39 and the high
rate of osteonecrosis that is seen in the humeral head after healing of three
or four-part fractures suggest that hemiarthroplasty provides a better
treatment alternative for these fracture patterns.
Contraindications
Active infection of the shoulder joint and/or the surrounding soft tissue
is an absolute contraindication to hemiarthroplasty. Open reduction and
internal fixation should be considered in younger patients, particularly those
with good bone stock, even when the fracture pattern is complicated. Patients
need to undergo intensive rehabilitation to achieve an optimal outcome after
hemiarthroplasty, and individuals who cannot do so for medical or
psychological reasons are not good candidates for hemiarthroplasty.
Pearls and Pitfalls
Hemiarthroplasty for the treatment of proximal humeral fracture is a
demanding operation, and many variables, including patient factors, surgical
technique, and rehabilitation, can influence outcome after this procedure. To
maximize the probability of an optimal outcome, surgeons should pay particular
attention to two important goals: restoring the tuberosities to an anatomical
position, and placing the humeral component in the correct amount of
version.
The importance of anatomical restoration of the tuberosities, including
secure fixation and restoration of humeral length and retroversion, cannot be
overemphasized (Figs. 7-A and
7-B). Malunion or nonunion of tuberosity osteosynthesis is the
most common and perhaps most serious complication that can occur after
hemiarthroplasty for displaced proximal humeral fractures. Ideally, the
humeral implant should have a low-profile lateral fin to facilitate proper
positioning and suture fixation of the tuberosity. The mean head-to-tuberosity
distance (and standard deviation) should be 8 ± 3 mm as shown by
Frankle et al.37
and Mighell et
al.26. Factors that
have been shown to be associated with tuberosity malunion include poor
intraoperative positioning of the prosthesis (excessive height and/or
retroversion), the initial tuberosity position, patient age in excess of
seventy-five years, and female
gender40.
Loss of anatomic landmarks makes restoration of humeral height difficult.
Shortening the humerus decreases the lever arm of the deltoid muscle and
therefore decreases the motion and power of that muscle in forward elevation.
Lengthening may contribute to superior humeral migration and impingement
and/or nonunion of the tuberosity.
Most authors recommend 30° to 40° of retroversion, typically with
use of the bicipital groove as the landmark for orientation of the
prosthesis36,
although an individualized approach has been proposed in which the
contralateral humerus is used for comparison to estimate the proper amount of
retroversion for each
patient41. The
tendency is to position the humeral head in excessive retroversion because of
imprecise landmarks and the desire to prevent anterior dislocation. Placement
of the head in too much retroversion may lead to excessive posterior rotator
cuff tension, suture pull-out, and malunion or nonunion of the greater
tuberosity.
Another point to remember is that restoration of the epiphyseal width is
critical to reproducing the soft-tissue tension of the deltoid and
supraspinatus muscles. The opposite shoulder can be used as a template to
gauge the epiphyseal width.
The optimal timing of hemiarthroplasty is important. Most recent
reports26,42
have shown that acute treatment is generally preferable to later
hemiarthroplasty because acute hemiarthroplasty is technically easier to
perform; however, one study found no difference between early or late
treatment when a breakpoint of thirty days after injury was
used43.
Results
While hemiarthroplasty has been shown to provide good pain relief, the
achievement of excellent range of motion with this method has been less
predictable. Rehabilitation, particularly passive range of motion in the early
stage41,44
and long-term active range of motion and strengthening, is considered
essential to the achievement of an optimal outcome after shoulder
hemiarthroplasty41,43.
The results obtained in recent studies of hemiarthroplasty for proximal
humeral fractures have been reasonably good, although not quite as good as the
results reported in earlier
studies26,39-45.
In a retrospective multicenter review, Kralinger et
al.44 found that
patients with healed, undisplaced tuberosity fractures had significantly
higher Constant scores and subjective patient satisfaction (p = 0.0001) than
patients whose tuberosities did not heal or healed with >0.5 cm of
displacement. Pain did not correlate with displacement of the tuberosity,
however.
Robinson et
al.45
retrospectively reviewed the results of shoulder hemiarthroplasty for proximal
humeral fractures at a single center and found consistent improvement in the
Constant score from six weeks to six months postoperatively but little change
thereafter. At one year, patients reported reasonable pain relief but poorer
scores for function, range of motion, and strength. Factors assessed six weeks
postoperatively that predicted the one-year Constant score included patient
age, a persistent neurological deficit, the need for early reoperation, and
the degree of displacement of both the prosthetic head (<5 mm displacement
of the prosthetic head from the central axis of the glenoid) and the
tuberosities.
The treatment of displaced proximal humeral fractures is complex and
requires careful assessment of patient factors (such as age and activity
level) and fracture-related factors (such as bone quality, fracture pattern,
degree of comminution, and vascular status). The goal of treatment is a
pain-free shoulder with restoration of pre-injury function.
The first step is to assess the vascular status of the humeral head with
use of the Hertel radiographic criteria for perfusion of the humeral
head46 and the
AO/ASIF classification of fractures of the proximal part of the
humerus24. In the
Hertel criteria, metaphyseal extension of the humeral head of <8 mm and
medial hinge disruption of >2 mm were determined to be good predictors of
ischemia (Figs. 8-A through
8-D)46.
The combination of metaphyseal extension of the humeral head, medial hinge
disruption of >2 mm, and an anatomic neck fracture pattern had a 97%
positive predictive value for humeral head
ischemia46. The
AO/ASIF classification for proximal humeral fractures provides information
about the energy and severity of the fracture and the likelihood of vascular
injury. Type A is a unifocal, extra-articular fracture with an intact vascular
supply. Type B is a bifocal, extra-articular fracture with possible injury to
the vascular supply. Type C is an articular fracture of the anatomic neck with
a high probability of
osteonecrosis24.
Once a proximal humeral fracture has been determined to have adequate blood
supply, the operative management is guided by the fracture pattern and the
cortical thickness. The AO/ASIF classification provides a guide in the degree
of surgical intervention required for successful treatment. The cortical
thickness of the humeral diaphysis is a more reliable and reproducible
predictor of bone mineral density and the potential of success of internal
fixation than is patient
age47. The combined
cortical thickness is the average of the medial and lateral cortical thickness
at two levels (Fig. 9). A
cortical thickness of <4 mm is appropriate for sling immobilization,
osteosuture, and hemiarthroplasty. Adequate screw purchase with standard
internal fixation requires a cortical thickness of >4 mm.
AO/ASIF type-A fractures are generally treated with sling immobilization
(Fig. 10). Proximal humeral
fractures with surgical neck translation of >66% or tuberosity displacement
of >5 mm may benefit from transosseous suture fixation (cortex <4 mm) or
closed reduction and percutaneous fixation (cortex >4 mm). For
multifragment fractures, open reduction with locked-plate fixation allows
preservation of the periosteal blood supply and is appropriate for cortices
less than or greater than 4 mm, regardless of the thickness of the cortex.
Recent studies have emphasized the importance of stabilizing the medial column
to prevent varus malunion, plate failure, screw cutout, and impingement. In
cases with an adequate medial cortex, the medial hinge should be reduced; in
cases with medial comminution, calcar-specific screws should be used to
stabilize the medial column. Local adjuvants, such as calcium phosphate
cement, demineralized bone matrix, or allografts, may improve the rate of
union and minimize malunion. Hemiarthroplasty is the treatment of choice for
fractures with vascular compromise, certain fracture-dislocations,
head-splitting fractures, and impression fractures with >40% of articular
surface involvement, although locking-plate technology is allowing surgeons to
attempt fixation in some of these fractures, particularly in younger patients.
?