Three Part Fractures
Three part fractures involves a fracture of surgical neck of humerus along with fracture of either greater tuberosity or lesser tuberosity. While surgical neck is quite displaced to miss out, small degree of tuberosity displacement may be easily missed and may require additional radiographic views.
Open reduction and internal fixation is the preferred treatment. Failure of the treatment may lead to hemiarthroplasy i.e. replacement of head component with prosthesis.
Four-Part Fractures
In this injury, there is fracture of the head which results in its separation from rest of the structures and there are fractures of lesser and greater tuberosities. Very often, the head is dislocated anteriorly, laterally, or posteriorly. The greater and lesser tuberosities are not always separated, and they may be held together by muscle attachments.
This injury is best shown by anteroposterior views. A computed tomogram clearly delineates the fracture.
Four-part fractures have not done well with nonoperative treatment and repaired fractures do better than nonoperative cases.
Historically, results of surgery of four part fractures have not been found good but improved techniques of fixation and better patient selection have brought better results.
Avascular necrosisof the head is a significant problem in these fractures. A subtype of the fracture, namely the valgus-impacted fracture is less likely to develop avascular necrosis. Recent works of various surgeons have concluded that
Hemiarthroplasty should not be avoided at all costs in young patients.
However hemiarthroplasty has a role to play in classic four-part fracture with an enucleated head.
In active, young patients with a valgus-impacted fracture, internal fixation with minimal soft tissue dissection should be done. This should be followed byonly pendulum and hand and elbow exercises dependong on the quality of the fixation followed by gradual strengthening exercises.
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