[Reconstructive surgery following malunion of fractures of the proximal humerus in adults]

Abstract

Malunion, avascular necrosis of the head segment and nonunion of the neck are the most frequent complications of displaced fractures of the proximal humerus. Malunion of the tuberosities may be well tolerated or it can require surgical treatment. Cranial displacement of the greater tuberosity appears to be much better tolerated than dorsal displacement. If power and active mobility are maintained but pain persists, the malunion may have led to impingement, which can be relieved by coraco-acromioplasty. If active mobility is reduced, tubercular osteotomy and relocation using tension band wiring techniques may be warranted. Malunion at the neck level may be treated with subcapital, usually flexion-abduction, osteotomies and yield excellent results. A collapsed head segment after avascular necrosis of the head requires either hemiarthroplasty or total joint replacement. As the nonunions are usually fairly distal and almost always extra-articular, they are treated with open reduction and internal fixation using tension band-wiring techniques and autogenous bone grafting. Arthrodesis has essentially lost its role in reconstructive surgery after fracture complications and is only used if severe additional problems are present such as infection, neurological problems, or severe soft tissue defects.