![]() ![]() Management of PHF, as for all fractures, combines an assessment of the mechanical and biological factors affecting fracture healing with a judgement about the likely prognosis for healing and function based on a multiplicity of intrinsic (shoulder) and extrinsic (comorbid) factors. The functional outcome of a proximal humeral fracture (PHF) is never that of a completely normal shoulder, however treated. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability.Ĭite this article: EFORT Open Rev 2018 3 DOI: 10.1302/2058-5205 The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical ‘neck’ fracture a fracture line at the lower surface of the torus is the surgical ‘neck’ fracture. The metaphysis can be considered as a ‘torus’ or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation. Periosteum has a poorly defined role in fracture healing in the proximal humerus. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred. ![]() Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone. ![]()
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