GENERAL CONSIDERATIONS

The practicalities of surgical management of proximal humeral fractures are common to the various injuries treated. A generic description of the investigations required and practical set-up of the operating room will therefore be presented before discussing specific injuries.

Radiological assessment

• It is essential that all shoulder fractures be assessed with a minimum of two shoulder views – the anteroposterior (AP) and axial views.

• A scapular lateral completes the trauma series but is not always essential.

• The axial view can be obtained successfully in most cases – in the rare instances where the patient will not permit sufficient movement of the injured limb away from the side, angled views (modified axial) should be obtained. Never miss a dislocation (too many are missed, and most of these have not had an axial view taken).

• In complex cases a CT scan might assist, particularly in assessing whether the humeral head is intact and has anytuberosityattachmentsremaining.Ahumeralhead fragmentwithanattached tuberosity ismuchless likely to suffer avascular necrosis thanonewithnoremaining tuberosity attachments. Three-dimensional CT is particularly useful for assessing glenoid fossa fractures.

Anaesthesia

• General anaesthesia or scalene blocks can be used. Even if general anaesthesia is selected, a scalene block can add useful analgesia.

• The risk of phrenic nerve palsy and pneumothorax should be considered if a scalene block is to be used, particularly if there is already chest trauma (which not infrequently accompanies shoulder trauma).

• Great care has to be taken to avoid interference with anaesthetic tubes and pipes by the surgeon or assistant in general anaesthetic cases.