Management of proximal humeral fractures based on current literature.

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 …