Hemiarthroplasty for Head-split Fractures of the Proximal Humerus

Hemiarthroplasty has been recommended for 3- and 4-part fractures of the proximal humerus. Outcomes are most affected by final implant and tuberosity position. Reports of outcome and management of head-split fractures with humeral head replacement are lacking. The purpose of this study was to report the outcomes after humeral head replacement and the radiographic characteristics identified in head-split fractures. Thirty-five hemiarthroplasties performed for the acute treatment of 3- and 4-part or head-split fractures were retrospectively reviewed in a blinded database. Thirty patients (8 head-split fractures) with a mean age of 67±12 years were followed for a mean of 52±32 months. Clinical, radiographic, and objective outcomes of the head-split fractures were collected at a minimum of 12 months’ follow-up and compared with a control group of 22 three- and 4-part fractures. Radiographs were reviewed to identify characteristic features of the head-split fractures. Head-split fractures demonstrated superior forward elevation (138°±50° vs 106°±54°) but similar American Shoulder and Elbow Surgeons (68±33 vs 63±29) and Simple Shoulder Test (7.4±4.8 vs 7.0±4.0) scores compared with the control group. The pelican sign, a radiographic representation of the tuberosity and attached articular surface, was identified on preoperative radiographs. Head-split fractures are rare and commonly missed on preoperative radiographs. The recognition of the pelican sign improves the detection of head-split fractures. After hemiarthroplasty, forward elevation is improved in patients with head-split fractures compared with other fracture types.