PMC9203719_01
(a) preoperative x-ray of our first patient (62-years-old) showing a simple (type I) split head fracture with anterior dislocation and impaction of the humeral head underneath the glenoid; there is also severe metaphyseal comminution and associated fracture of both tuberosities. (b) coronal, axial and 3-D-CT scans showing the impaction of the humeral head under the glenoid and the split-head component, (c) intraoperative picture with the final implant in the appropriate height after metaphyseal fixation with cables - note the Ethibond sutures that were used for later tuberosities fixation, (d) postoperative x-ray showing good height of the prosthesis, tuberosities re-attachment and fixation of the metaphyseal area and (e) follow-up x-ray at 24 months showing good tuberosity healing without evidence of prosthesis migration.
10.1177_24715492221108285-fig1.jpg
PMC9203719_01_10.1177_24715492221108285-fig1.jpg
fig1-24715492221108285
Radiological examination revealed a locked anterior fracture-dislocation, type I splitting of the humeral head without adequate metaphyseal extension, severe metadiaphyseal comminution and fracture of the greater and lesser tuberosities (Figure 1a). The patient was unable to undergo further radiological imaging due to his discomfort and locked arm position; subsequent coronal and axial CT scans and 3D-CT reconstruction revealed the split head component and the severe metaphyseal comminution (Figure 1b). A long-stemmed cemented hemiarthroplasty (GLOBAL  FX Shoulder Fracture System, DePuy Synthes) was applied thereafter with appropriate height and version (Figure 1b). Regarding the height we aimed to apply the top border of the humeral stem at the level of the anatomic neck fracture flash with the medial calcar and also a ruler was used to measure the 5.6 + /- 0.5 cm pectoralis major tendon reference point (Figure 1c). Just prior to cementation drill holes were placed on either side of the bicipital groove and four Number 5 non-absorbable Ethibond sutures were inserted through each for vertical tension-band fixation of the tuberosities (Figure 1c). Postoperative x-ray showed appropriate height of the prosthesis and adequate tuberosities reattachment (Figure 1d); the shoulder was immobilized in a sling for 4 weeks and passive assisted exercises were initiated from the second postoperative day. The patient was followed up regularly in an outpatient basis and at his last follow up 24 months postoperatively, he demonstrated acceptable range of motion, with 170  of forward elevation, a Constant score of 86 points and good tuberosity healing (Figure 1e).
PMC9203719_02
(a) preoperative anteroposterior and semi-axial x-rays of the second patient (57 years-old) showing a complex (type IV) split head fracture of the humeral head with severe metaphyseal comminution and associated tuberosity fractures, (b) coronal, axial and 3-D-CT scans showing the complex meta-diaphyseal extension and the split-head fracture, (c) intraoperative picture with the avascular head fragment and the prosthesis in place just prior to tuberosities fixation; note the reconstruction of the metaphyseal area with cerclage wires, (d) postoperative x-ray showing tuberosities reattachment, correct height of the prosthesis and fixation of the metaphyseal area and (e) follow-up x-ray at 32 months showing tuberosities healing and no signs of prosthesis migration.
10.1177_24715492221108285-fig2.jpg
PMC9203719_02_10.1177_24715492221108285-fig2.jpg
fig2-24715492221108285
Radiological examination revealed a type IV splitting-head fracture of the proximal humerus with severe metaphyseal comminution and displaced tuberosities (Figure 2a). Axial, coronal and 3D-CT reconstruction scans better revealed the split-head component (Figure 2b). After preparation at the fracture site the humeral head was found splitted and multifragmented without any evidence of vascularity and was removed as a source of bone grafting later (Figure 2c). A long-stemmed cemented hemiarthroplasty (GLOBAL  FX Shoulder Fracture System, DePuy Synthes) was applied thereafter with the appropriate height and version as has been described before (Figure 2c). Postoperative x-ray control showed good position of the prosthesis and tuberosities (Figure 2d); the shoulder was immobilized in a sling for 4 weeks and passive assisted exercises were initiated from the second postoperative day. The patient was followed up regularly in an outpatient basis and at his last follow up visit, 32 months postoperatively, he demonstrated excellent range of motion, with 175  forward elevation, a Constant score of 90 points and good tuberosity healing (Figure 2e).