Type C: 4/5 patients treated successfully by functional bracing

Campbell et al

Type C: 2/3 healed successfully with nonoperative management

Kumar

One fracture distal to the prosthesis tip treated successfully by nonoperative

Worland et al

Distal to the prosthesis tip = closed humerus fractures nonoperative treatment

fractures located at the prosthesis tip (type A and type B) ??

did NOT heal with nonoperative management. › 5 cases in a series of 7 Boyd et al

› one case Bonutti et al

› 4 of 5 type B fractures failed to heal, Kumar et al

fractures with loose prosthesis longer-stemmed implant

4 options:› press-fitting proximally and distally› cementing proximally and distally› press-fitting proximally with cement

distally› cementing proximally with press-fitting

distally

Press-fitting proximally and distally› good quality of the humeral bone› tight fit can be achieved › obliquity fracture site

cement proximally and distally: › bone proximally is good to fair › bone distally is good › Transverse fracture

press-fitting proximally and cement distally:› bone proximally is fair to poor › bone distally is good› fracture is rotationally stable

shape / can be made

small amount of osteolysis proximally: › cement or bone graft

extensive osteolysis proximally:› bone graft is packed around the implant

within the cortical shell so extensive osteolysis:

› allograft prosthetic composite

implant is secure and the joint is reasonably mobile:› approach the fracture site alone for

fracture fixation (plate with screws, pins and cerclage cables)

Allograft / Posterior iliac crest autograft bone: nonunion -/+

Fracture: transverse or nearly transverse as rotational stability can be attained through the use of the screws, pins and cerclage plate

Fracture: oblique / implant stability, acute reduction of the fracture and cerclage

Fracture: oblique / implant stability, chronic allograft + autograft

› 3/6 healed with nonoperative › 1 failed nonoperative management› 2 treated with immediate OP

Type A fractures + loose humeral component OP: long-stem

bone graft(allograft in acute cases and posterior iliac crest autograft in cases with delayed healing or nonunion)

fixation with a cortical strut allograft or a plate and screws/cables

Type B fractures + good alignment / well-fixed humeral component: nonoperative

However nonoperatively high fail not progressed toward union by 3

months OP

Type B fracture + well-fixed humeral component: › plate / strut graft with screw fixation in the

distal portion and cerclage fixation in the proximal portion + Bone graft

Type B + loose humeral component cemented long-stem + posterior iliac crest bone graft

Type C fracture + well-fixed humeral component: trial of nonoperative› postoperative care:

Within days after surgery: gently exercised with active movement

passive external rotation outward to neutral and in elevation to 100°

avoid stress at the fracture site continue with a passive program until healing

long-stemmed implant + cemented: active-assisted motion program at 4 to 6 weeks

Radial nerve injury› careful dissection and exposure at the time

of fracture fixation swelling of the arm, forearm, and hand

› elevation, elastic support, and the gentle active-motion program

acute infection failure of humeral shaft healing

› 6 months, autograft/vascular bone graft

well-aligned Type B fractures + well-fixed humeral component: nonoperative› High fail rate in Type B fractures› 3 months

humeral component fixed: open reduction and internal fixation

humeral component is loose: long stem Well-reduced Type C fractures: trial of

nonoperative treatment