Prospective study of 100 operatively treated intracapsular proximal humerus fractures. Asks which fracture morphology features predict humeral head ischemia, verified intraoperatively by borehole backflow and laser Doppler flowmetry. Goal: identify objective preoperative thresholds to guide the fixation vs. arthroplasty decision.
The Neer classification taught generations of surgeons to count fragments and grade displacement — but this paper shows those variables are the wrong ones to measure when predicting which heads will die.
On every proximal humerus CT or X-ray, measure the posteromedial calcar and assess medial hinge displacement. When the calcar is under 8 mm, sensitivity for ischemia is 1.0. No ischemic head in this series had a longer calcar. Add a disrupted hinge and an anatomic neck pattern, and the positive predictive value for ischemia reaches 97%.
In practice: a valgus-impacted 4-part fracture with a long calcar may still be perfused and worth fixing. An anatomic neck fracture with a 3 mm calcar and a displaced hinge is almost certainly ischemic. Primary arthroplasty is the defensible choice.
One important nuance: proven ischemia is not an absolute contraindication to fixation. The authors document full revascularization after stable osteosynthesis in initially ischemic heads. So in young patients with good bone quality, fixation remains reasonable even with a short calcar, with staged arthroplasty as a fallback.
Prospective study of 100 operatively treated intracapsular proximal humerus fractures. Asks which fracture morphology features predict humeral head ischemia, verified intraoperatively by borehole backflow and laser Doppler flowmetry. Goal: identify objective preoperative thresholds to guide the fixation vs. arthroplasty decision.
The Neer classification taught generations of surgeons to count fragments and grade displacement — but this paper shows those variables are the wrong ones to measure when predicting which heads will die.
On every proximal humerus CT or X-ray, measure the posteromedial calcar and assess medial hinge displacement. When the calcar is under 8 mm, sensitivity for ischemia is 1.0. No ischemic head in this series had a longer calcar. Add a disrupted hinge and an anatomic neck pattern, and the positive predictive value for ischemia reaches 97%.
In practice: a valgus-impacted 4-part fracture with a long calcar may still be perfused and worth fixing. An anatomic neck fracture with a 3 mm calcar and a displaced hinge is almost certainly ischemic. Primary arthroplasty is the defensible choice.
One important nuance: proven ischemia is not an absolute contraindication to fixation. The authors document full revascularization after stable osteosynthesis in initially ischemic heads. So in young patients with good bone quality, fixation remains reasonable even with a short calcar, with staged arthroplasty as a fallback.