Abstract
Management of humeral head fractures presents numerous challenges, particularly in cases of separation fractures, which are relatively rare and often caused by high-energy trauma. Due to the complexity of these fractures and the absence of a standardized treatment algorithm, surgical intervention can be technically intricate and fraught with postoperative complications. In young patients, the decision to pursue open reduction and internal fixation must be meticulously made to achieve optimal outcomes while minimizing long-term sequelae. We present a rare case of a man, age 25 years, sustaining a complex proximal humerus fracture. The patient presented with a proximal humerus fracture involving a head-splitting pattern comprising five fragmented pieces, necessitating careful anatomical reduction and fixation. Despite the technical challenges encountered during surgery, including the meticulous reconstruction of the humeral head “puzzle” using headless screws, the postoperative recovery was relatively uneventful. While some restrictions in range of motion were noted postoperatively, the absence of early complications like osteonecrosis bodes well for the patient’s long-term functional prognosis. This is a thought-provoking case accentuating that by apposite surgical techniques and tailored treatment strategy to individual young patients, successful management of humeral head fractures can be achieved while minimizing potential complications and optimizing functional recovery in this challenging patient population.
Separation fractures of the humeral head are a rare subgroup of proximal humerus fractures.1,2 They typically result from high-energy injuries and pose a surgical challenge due to technical operative complexities and postoperative complications.3 Additionally, their rarity contributes to the absence of a universally accepted treatment algorithm.1-3 The challenges in managing complex humeral head fractures, particularly those involving separation fractures in young patients, can be multifaceted and demanding.4 Four-part with head-splitting fractures of the proximal humerus are associated with high risk of avascular necrosis (21%–75%). Also, in young patients with this kind of injury, treatment options only include open reduction and internal fixation (ORIF) and hemiarthroplasty. Overall, hemiarthroplasty can be a viable alternative when dealing with non-reconstructable articular surface, severe head split, and extruded anatomic neck fractures. On the other hand, reverse total shoulder arthroplasty can be the treatment of choice in elderly patients sustaining these type of fractures, whilst this cannot be the case when treating young patients.1-4 The management of humeral head fractures in young individuals requires a multidisciplinary approach that considers the intricate nature of these fractures, the compromised vascular supply to the head, and the elevated risk of postoperative complications.1,3,4 At the outset of treatment, the decision-making process poses a significant challenge due to the lack of a standardized treatment algorithm, necessitating careful consideration of various factors. Surgical intervention, such as ORIF, presents technical hurdles in achieving anatomical reduction, especially in complex fracture patterns requiring meticulous osteosynthesis and fixation.5,6 The intricate nature of these fractures often calls for innovative surgical techniques and a multidisciplinary approach to navigate through the complexities of treatment effectively.4-6 Furthermore, the postoperative phase following surgical management of humeral head fractures presents a formidable landscape fraught with potential complications. Compromised vascularity of the humeral head places patients at risk of aseptic necrosis, a common complication observed in many cases, impacting long-term outcomes.5-7 The high rate of postoperative complications necessitates careful monitoring and may require revision surgeries and alternative procedures to address complications effectively.7,8 In this context, we present the uncommon case of a man, age 25 years, sustaining a proximal humeral fracture with a head-splitting fracture involving five pieces, illustrating the complexity of treating humeral head fractures in younger individuals with high demands.
Case Presentation
A man, age 25 years, presented to our Emergency Department due to a reported fall from a height of approximately 1.8 m (approximately 6 ft.) The initial clinical assessment demonstrated acute right shoulder pain and mediocre subcutaneous edema with no skin lacerations or ecchymosis of the chest, arm, or forearm; no neurovascular impairment was revealed. Lateral shoulder sensation and deltoid muscle functionality were satisfactory, indicating the axillary nerve was not injured. A routine radiological workup took place and plain right shoulder radiography demonstrated the patient sustained a complex proximal humerus fracture (Figure 1). From the other radiographs, no chest wall injury was described. A computed tomography (CT) of his right shoulder was then carried out, revealing a head-splitting fracture comprising five pieces (Figure 2). Sling immobilization was immediately applied, and the patient was admitted to the hospital.
Initial radiograph depicting the complex proximal humerus fracture (yellow arrow).
Computed tomography scan: humeral head fracture segments (yellow arrows) in transverse sections and 3D imaging (blue arrow points to the scapula).
The next day, the patient was scheduled for surgical treatment of the complex proximal humerus fracture. Taking into consideration the patient’s young age, ORIF was deemed the appropriate treatment option. Surgery was carried out with the patient in a beach chair position under general anesthesia. After typical aseptic skin preparation, a deltopectoral approach was utilized. During surgery, the fractured humeral head was meticulously osteosynthesized separately on the operating table, followed by ORIF using an anatomical proximal humerus plate for stabilization, including fixation of the tubercles. The exacting task of pertinent surgical treatment involved securing the fragmented head parts with headless screws before assembling the entire construct, resembling a “puzzle,” onto the plate within the humeral metaphysis (Figure 3). Sling immobilization was continued after surgery.
Immediate postoperative imaging, where humeral head’s ‘puzzle’ is distinguished (blue arrow).
The early postoperative course was uneventful, and the patient was discharged after 3 days of hospitalization. The patient’s postoperative recovery proceeded without complications. Both clinical and radiological criteria were employed to evaluate bone union. Scheduled follow-up appointments were conducted at 2 weeks, and 1-, 3-, 6- and 12-months post-surgery (Figure 4). Physiotherapy was initiated roughly 2-months, postoperatively. While some restriction in range of motion was noted, particularly in external rotation and abduction, limb movement remained painless (Figure 5). The patient reported a DASH (Disabilities of the Arm, Shoulder, and Hand) score of 29.2 at the 3-month mark, indicating moderate impairment. However, there were no radiographic indications of osteonecrosis during the short-term at one-year follow-up (Figure 6). DASH score improved gradually during the follow-ups, ranging from 22 at 6 months postoperatively to 9 at one-year post-surgery. Approximately 5 months after the operation, the patient returned gingerly to his pre-injury activities. On the last scheduled follow-up, one year after the surgery, the patient was generally satisfied with his upper limb functionality and was capable of performing his daily routine with no considerable complaints.
Follow-up radiograph 15 days postoperatively
Clinical evaluation on the 6th postoperative month: decrease in range of motion but without pain.
Radiograph 6 months postoperatively - Satisfactory radiological imaging with the humeral head maintaining its sphericity.
Discussion
Treating separation fractures of the humeral head in young patients poses significant challenges from the outset, primarily due to the critical decision-making regarding the choice of treatment.13 In cases where ORIF stands as the primary solution, surgeons encounter formidable technical hurdles, particularly in achieving an anatomical reduction of the humeral head and associated fractures.8,9 This often necessitates intricate procedures involving the use of headless screws to secure proper alignment of the fractured components and to anchor the head securely to the metaphysis.3,10,11 However, even with meticulous anatomical restoration, the compromised vasculature of the humeral head poses a significant risk, leading to a frequent complication known as aseptic necrosis, observed in over 40% of cases.1,2,12,13 Furthermore, the postoperative phase presents a daunting landscape, with a staggering rate of complications exceeding 80%.1,13 These complications range from osteonecrosis to defective perforation of the fractures and even prolapse of the shoulder joint, further complicating the recovery process.2,3,14 Consequently, the high incidence of postoperative complications often necessitates revisiting the chosen approach, prompting the need for revision surgeries.5,8,14
Subsequent therapeutic interventions come with their own set of challenges, exacerbating the complexity of managing such cases, particularly in young patients.15 Hemiarthroplasty, while sometimes considered, may not yield satisfactory functional outcomes in this demographic.15,16 Alternatively, opting for a second revision surgery becomes an immensely demanding task, especially in the presence of poor bone stock.3,13,17 Techniques such as reverse total shoulder arthroplasty, although available, pose significant technical challenges and carry the risk of devastating consequences for the affected limb in the event of further complications or hardware failure.4,18,19
In essence, the treatment journey for separation fractures of the humeral head in young patients is fraught with complexities at every stage, from the initial decision-making process to navigating through postoperative complications and subsequent revisions.14,16,19 Such challenges underscore the critical need for meticulous planning, innovative surgical techniques, and multidisciplinary collaboration to optimize outcomes and mitigate risks in this patient population. The elevated incidence of postoperative complications, including osteonecrosis and hardware failure, emphasizes the critical need for meticulous treatment planning.11,15,18 While ORIF may serve as the initial treatment choice, the potential requirement for subsequent revisions or alternative procedures like hemiarthroplasty or reverse total shoulder arthroplasty underscores the intricacy of managing these fractures in younger individuals.20
When navigating the intricate landscape of decision-making in treating humeral head fractures, especially in young patients, the complexities extend beyond surgical intervention.18,19 An evaluation of available data sheds light on the challenges faced by surgeons in determining the optimal approach for these fractures.16,20 Available literature emphasizes the significance of comprehensive preoperative assessments, considering factors such as bone density and associated injuries, to guide treatment decisions effectively.19,21 Additionally, the utilization of allograft augmentation in specific cases underscores the nuanced considerations required in addressing severe osteopenia, highlighting the importance of individualized approaches.16,18 Furthermore, the need for precise decision-making becomes paramount during the surgical management of separation fractures of the humeral head in younger individuals.20,22
Given the intricate nature of humeral head fractures in young patients, the consideration of hemiarthroplasty as a treatment modality requires careful evaluation.18,22,23 While hemiarthroplasty may be contemplated in cases where ORIF proves challenging, its implementation in a young population needs to balance the potential benefits against the risks.1,2,3,16 Studies have highlighted the technical demands and potential complications associated with hemiarthroplasty in younger patients.1-4 Such considerations emphasize the importance of tailored treatment strategies that weigh the long-term functional outcomes against the risk of complications, particularly in cases of challenging separation fractures of the humeral head.2,19,22
The uniqueness of this case lies in several key aspects. First, the complex fracture pattern. The patient presented with a rare and complex fracture pattern involving a head-splitting fracture of the proximal humerus with five pieces of the humeral head. Such fractures are uncommon and pose significant challenges in treatment due to their intricate nature. It was necessary to remove the comminuted humeral head from the patient and fix it separately on a table, and then fix the humeral head construct with the rest of the humerus with pertinent plate and screws. Second, the young age of the patient, 25 years, added complexity to the treatment approach. Young patients typically have higher functional demands and expectations, requiring meticulous surgical techniques to achieve optimal outcomes and minimize long-term complications. Because of this fact, it is evident that hemiarthroplasty or reverse total shoulder arthroplasty were not selected as viable options in our case. Third, the successful outcome despite the copious challenges. Despite the complexity of the fracture and the technical difficulties associated with achieving anatomical reduction, the patient experienced an uneventful postoperative course. The successful outcome, including painless limb movement and a relatively low DASH score at 3 months, postoperatively, highlights the effectiveness of the chosen treatment approach and the skill of the surgical team. And finally, the absence of osteonecrosis. Despite concerns regarding compromised vasculature and the potential for aseptic necrosis in such fractures, no radiographic signs of osteonecrosis were observed at the one-year follow-up. This is noteworthy as it suggests that the chosen treatment approach may have mitigated the risk of this complication. Overall, the patient’s progress suggests successful fracture management and promising long-term outcomes, with careful monitoring recommended to assess continued healing and functional improvement. Nonetheless, at this point it is essential to underline that one-year follow-up cannot be considered adequate duration to rule out osteonecrosis, and therefore there is still chance for the requirement of revision surgery in the future.
Very few similar cases could be retrieved from existing literature. Gokkus et al.24 presented the case of a proximal humerus head-splitting fracture where the split part was anteriorly dislocated and trapped between the anterior glenoid and the subscapularis muscle. In their case, open anatomic reduction and internal fixation proved a successful treatment option.24 In another interesting case reported by Younghein et al.,25 a healthy woman, age 40 years, sustained a 3-part head-splitting fracture of the proximal humerus that involved a large unicameral bone cyst. ORIF was determined as treatment option over hemiarthroplasty, with the aim of preserving a hemiarthroplasty procedure in case of future revision. However, ORIF proved felicitous and the patient underwent another operation 1 year, postoperatively, where arthroscopic debridement was performed to alleviate joint stiffness and increase range of motion.25 On the other hand, a 2015 study by Gavaskar et al.3 involving a small group of 16 patients aged under 55 years with simple and complex head-splitting fractures, indicated that locked plate osteosynthesis yielded satisfactory outcomes in simple head-splitting fractures, while complex fractures were correlated to higher rates of non-union, avascular necrosis and inferior shoulder functionality.3 A present-day review by Meshram et al.14 exploring the treatment options of 3- or 4-part proximal humeral fractures in middle-aged and active elderly patients suggested that the treatment of choice in these patient groups depends on copious factors such as bone quality, anatomical reduction possibility, fracture pattern, rotator cuff status and patient expectations, whilst there is no universal treatment algorithm.14 Out of the limited cases reported and our own experience, it can be deduced that opting for ORIF when treating such complex fractures in young patients can be a viable initial alternative versus hemiarthroplasty, whilst the later can be the treatment choice in case of ORIF failure and need for revision surgery. What’s more, not any review, systematic review or meta-analysis could be found analyzing the treatment of complex head-splitting proximal humeral fractures in young active patients.
Notwithstanding, the high rate of postoperative complications in such cases underlines the importance of careful treatment planning and the potential need for revisions or alternative procedures to optimize patient outcomes. Moving forward, further research and exploration of optimal treatment strategies for humeral head separation fractures in young patients are crucial. Enhancing our understanding of the pathophysiology of such injuries and identifying innovative surgical techniques could pave the way for improved outcomes and reduced complications in this challenging patient population. Moreover, continued collaboration among multidisciplinary teams and integration of advanced technologies will be essential in addressing the complexities associated with these fractures and ensuring the best possible results for patients in similar situations.
Conclusion
Separation fractures of the humeral head present considerable treatment challenges, especially in young patients. Despite advancements in surgical techniques like ORIF, achieving precise anatomical reduction remains technically demanding due to the fractures’ complex nature. Moreover, the compromised blood supply to the humeral head increases the risk of complications such as aseptic necrosis, significantly impacting patient outcomes. This case underscores the nuanced nature of managing separation fractures of the humeral head and stresses the significance of tailored treatment strategies in young patients to optimize outcomes and minimize complications. Overall, the combination of the rare fracture pattern, the patient’s young age, and the successful outcome despite challenges make this case unique and noteworthy in the context of proximal humerus fractures.
Footnotes
Declarations: All authors declare that they have no conflict of interest. No funding was received to conduct this study. All raw data are available upon request.
- Received November 28, 2024.
- Revision received June 13, 2025.
- Accepted June 26, 2025.
References
- 1.↵Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;(11):CD000434. doi:10.1002/14651858.CD000434.pub4
- 2.↵Peters PM, Plachel F, Danzinger V, Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component. J Bone Joint Surg Am. 2020;102(1):68-75. doi:10.2106/JBJS.19.00320
- 3.↵Gavaskar AS, Tummala NC. Locked plate osteosynthesis of humeral head-splitting fractures in young adults. J Shoulder Elbow Surg. 2015;24(6):908-914. doi:10.1016/j.jse.2014.10.003
- 4.↵Chesser TJ, Langdon IJ, Ogilvie C, Sarangi PP, Clarke AM. Fractures involving splitting of the humeral head. J Bone Joint Surg Br. 2001;83(3):423-426. doi:10.1302/0301-620x.83b3.11218
- 5.↵Kee HT, Yeak RDK, Ahmad Hanif KA, Seri Masran SM, Che-Hamzah F. A Reshaping Recovery: The Reverse Shoulder Arthroplasty Triumphs in Salvaging Chronic Four-Part Proximal Humerus Fractures. Cureus. 2023;15(12):e50363. doi:10.7759/cureus.50363
- 6.↵Dey Hazra RO, Blach RM, Ellwein A, Katthagen JC, Lill H, Jensen G. Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery. Aktuelle Entwicklungen der Versorgungsrealität proximaler Humerusfrakturen – eine Auswertung von 1162 Fällen an einem Level-1-Traumazentrum mit schulterchirurgischem Schwerpunkt. Z Orthop Unfall. 2022;160(3):287-298. doi:10.1055/a-1333-3951
- 7.↵Halvachizadeh S, Berk T, Rauer T, Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?. PLoS One. 2020;15(4):e0230789. Published 2020 Apr 9. doi:10.1371/journal.pone.0230789
- 8.↵Hamed R, Zoubli A, Ghazali H, Mekki I, Maaref A, Jerbi S. Post-traumatic fracture-dislocation of the humeral head with intrathoracic migration: A case report. Tunis Med. 2023;101(11):852-854.
- 9.↵Annamalai Regupathy. CLINICAL OUTCOMES OF AO PHILOS PLATING FOR PROXIMAL HUMERUS FRACTURES. International Journal of Current Research and Review. 2012;4(20):94-98. doi: 10.31782/2231-2196
- 10.↵Shermetaro J, Valk J, Sosnoski D, Brossy K. An Irreducible Posterior Fracture-Dislocation of the Shoulder: A Case Report. Cureus. 2022;14(4):e24535. doi:10.7759/cureus.24535
- 11.↵Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev. 2023;15:129-137. doi:10.2147/ORR.S340536
- 12.↵Panagopoulos A, Pantazis K, Iliopoulos I, Seferlis I, Kokkalis Z. Sword-Like Trauma to the Shoulder with Open Head-Splitting Fracture of the Head. Case Rep Orthop. 2016;2016:3539503. doi:10.1155/2016/3539503
- 13.↵Kriechling P, Whitefield R, Makaram NS, Brown IDM, Mackenzie SP, Robinson CM. Proximal humeral fractures with vascular compromise. Bone Joint J. 2024;106-B(8):842-848. doi:10.1302/0301-620X.106B8.BJJ-2023-1114.R1.
- 14.↵Meshram P, Mohammed M, Althani S. Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options. Ann Jt. 2024;9:38. doi:10.21037/aoj-24-11
- 15.↵Wang L, Lyu F, Rong J, Sun H, Li B, Liu J. Factors influencing shoulder stiffness after open reduction and internal fixation of proximal humeral fractures. Jt Dis Relat Surg. 2024;35(2):285-292. doi:10.52312/jdrs.2024.1529
- 16.↵Klute L, Henssler L, Schliemann B, Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process. Arch Orthop Trauma Surg. 2023;143(12):7053-7061. doi:10.1007/s00402-023-05028-0
- 17.↵Hasan AP, Phadnis J, Jaarsma RL, Bain GI. Fracture line morphology of complex proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(10):e300-e308. doi:10.1016/j.jse.2017.05.014
- 18.↵Jawa A, Burnikel D. Treatment of Proximal Humeral Fractures: A Critical Analysis Review. JBJS Rev. 2016;4(1):e2. doi:10.2106/JBJS.RVW.O.00003
- 19.↵Calori GM, Colombo M, Bucci MS, Complications in proximal humeral fractures. Injury. 2016;47 Suppl 4:S54-S58. doi:10.1016/j.injury.2016.07.039
- 20.↵Soliman OA, Koptan WM. Four-part fracture dislocations of the proximal humerus in young adults: results of fixation. Injury. 2013;44(4):442-447. doi:10.1016/j.injury.2012.09.005
- 21.↵JJayarajah U, Amarasooriya M, Sooriyarachchi R. Multifragmentary proximal humerus fracture successfully treated with k-wire fixation: A case report. Int J Surg Case Rep. 2021;87:106415. doi:10.1016/j.ijscr.2021.106415
- 22.↵Iglesias-Rodríguez S, Domínguez-Prado DM, García-Reza A, Epidemiology of proximal humerus fractures. J Orthop Surg Res. 2021;16(1):402. doi:10.1186/s13018-021-02551-x
- 23.↵Cancio-Bello AM, Barlow JD. Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management. Curr Rev Musculoskelet Med. 2023;16(2):66-74. doi:10.1007/s12178-022-09818-8
- 24.↵Gokkus K, Agar E, Sagtas E, Aydin AT. Proximal humerus head-splitting fracture associated with single-part anterior dislocation. BMJ Case Rep. 2014;2014:bcr2013202188. doi:10.1136/bcr-2013-202188
- 25.↵Younghein JA, Eskander MS, DeAngelis NA, Wixted JJ. Three-part head-splitting proximal humerus fracture through a unicameral bone cyst. Orthopedics. 2012;35(6):e988-e990. doi:10.3928/01477447-20120525-50.
