Obere ExtremitätSchulter · Ellenbogen

Original Contribution

Obere Extremität 2019 · 14:118–126https://doi.org/10.1007/s11678-019-0508-2Received: 16 October 2018Accepted: 23 January 2019Published online: 21 February 2019© The Author(s) 2019

M. Königshausen · E. Mempel · V. Rausch · J. Gessmann · T. A. Schildhauer ·D. SeyboldGeneral and Trauma Surgery, BG University Bergmannsheil, Ruhr University Bochum, Bochum, Germany

Combined fractures of thehumeral head and the glenoid

Combined glenohumeral fractures ofthe humeral head and the glenoidare rare fracture combinationsand their treatment depends ondifferent criteria. When treatingthese fractures, one has to considerthe fracture morphology of bothfracture localizations at the proximalhumerus, on the one hand, andat the glenoid, on the other hand.In terms of fracture localization,greater tuberosity fractures canbe distinguished from proximalhumerus fractures (with subcapitalfracture component), both of whichmay occur with glenoid fractures. Onthe glenoid side, the more frequentlarge glenoid rim fractures and therarer glenoid fossa fractures can befound together with a fracture of theproximal humerus.

In recent decades, proximal humerusfractures have been intensively re-searched, which is reflected by numerouspublications in the literature [1, 6, 7, 11,18–20, 23–25, 27, 31, 32, 38, 41, 42,48–50, 53]. Glenoid fractures have alsobeen considered in a more differentiatedmanner in recent years and relevantstudies have been published [2, 4, 9, 15,21, 22, 26, 28, 33, 34, 45, 46, 51]. How-ever, only few data are available aboutsimultaneously occurring (combined)glenohumeral fractures, and their spe-cific therapy in the literature is mostlydescribed as isolated cases in studiesfocusing on glenoid fractures or in casereports [12, 28, 33, 37, 39, 51]. Thesecombination fractures potentially in-volve the anterior glenoid rim (Ideberget al.: 1B [15], Euler–Rüedi: D1 [10],Scheibel et al.: 1b/c [47]) and the glenoid

fossa fractures (Ideberg et al.: II–V, Eu-ler–Rüedi: D2/3) combined with greatertuberosity or proximal humerus frac-tures (Neer I–VI), and all combinedglenohumeral fractures are potentiallysummarized in one type of combinationfracture as type E Euler–Rüedi [10].

The aim of the present baseline studywas to analyze all the different fracturetypesof theglenoidand thehumeralheadin combined glenohumeral fractures us-ing a specific classification for these frac-tures. Furthermore, the morphology ofthe fracture is evaluated, the choice oftreatment is demonstrated, and any com-plications encountered during follow-upare described. In addition, a summaryof the existing literature about gleno-humeral fractures is given.

Patients andmethods

Data collection

All combined fractures of the prox-imal humerus and the glenoid werereviewed retrospectively using an in-stitutional database (BergmannsheilBochum, RuhrUniversity, Level I traumacenter) covering the period 1998–2016.All glenohumeral fractures identifiedon the humeral side were differenti-ated into proximal humerus fractures(and the respective number of fractureparts derived by Codeman [8] and Neer[35]) or only isolated greater tuberosityfractures (one or two fragments or com-minuted) and into large fractures of theglenoid rim (one or two fragments orcomminuted) or glenoid fossa fractures(Ideberg et al. classification [15]). Theauthors define a glenoid rim fractureas an isolated fracture of the glenoid

(without the scapula) with the exclusiveinvolvement of the cancellous part of theglenoid (including the glenoid corticalwall). The “large” glenoid rim fracturemust be differentiated from small chipfractures, which usually consist of onlya small cortical fragment [34, 54]. Bycontrast, the fossa fracture is definedas a glenoid fracture with its extensioninto (the cortex of) the scapula (e. g.,including the lateral, medial, or supe-rior border [margo medialis/lateralis/superior] or coracoid process).

Fracture classification

We divided “glenohumeral combinationfractures” into four types in a classifi-cation shown in . Table 1. This classifi-cation takes into account the increasingsize/severity of the glenohumeral frac-ture parts involved. The very rare addi-tional coracoid process fracture, whichcan occur simultaneously with an ante-rior glenoid rim fracture and a greatertuberosity fracture, was not seen at ourhospital but is described in case reportsor case series [40, 52] and is subsumedas type 1b.

Fracture characteristics andmorphol-ogy were distinguished and the degree ofdisplacement of the glenoid fracture andthe isolated greater tuberosity fracturewas measured (in millimeters). Glenoidfractures were defined as having no ormild displacement (0–3mm) or as dis-placed (≥4mm; [22]). There is no con-sistent and clear definition of displace-ment of the greater tuberosity fracturein the literature. The authors generallyuse three categories of greater tuberosityfracturedisplacement inwhicha“moder-ate” displacement is considered because

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Table 1 Classification of glenohumeral combination fractures

Type 1a: Large glenoid rim fracture (GRF) AND greater tuberosity fracture (GTF)

Type 1b: Typ 1a with additional coracoid process fracture (CPF)

Type 2: Large glenoid rim fracture (GRF) AND proximal humerus fracture (PHF)

Type 3: Glenoid fossa fracture (GFF) AND greater tuberosity fracture (GTF)

Type 4: Glenoid fossa fracture (GFF) AND proximal humerus fracture (PHF)

of its controversial indication for ther-apy. Thus, tuberosity fractures between0 and 2mmwere defined as mild or non-displaced, those between 3 and 4mmwere defined as moderately displaced,and those of ≥5mm were defined as dis-placed.

Indications for surgery

The indications for surgery of largeglenoid rim fractures are under debate.We usually indicate surgery in casesof ≥20% anterior glenoid surface in-volvement in combination with medialdisplacement of ≥3mm or a fracturegap of ≥5mm (enface view) in middle-aged patients. In younger individuals(≤35 years), the indication for (usuallyarthroscopic) refixation ismore stringentwith the aim of restoring the glenoidsurface to avoid re-instability. In glenoidfossa fractures we consider the limit foroperative treatment to be ≥4mm medialdisplacement and ≥4mm fracture gap(enface view) because of the inferior re-sults achieved for glenoid fossa fracturesin a nonoperatively treated case seriesof patients with ≥5mm displacement or≥5mm fracture gap [22]. The indica-tion for surgery for greater tuberosityfractures is ≥4mm cranial displacementand ≥5mm posterior displacement andfor proximal humerus fractures the Neercriteria [36] are applied (in addition tothe 4-mm limit for cranial tuberositydisplacement) with, additionally, a tiltof the humeral head of more than 20°.The concentricity of the humeral head isa prerequisite for nonoperative treatmentin order to avoid chronic decentricity,which can occur in glenoid fractures.The criterion of concentricity can onlybe reliably used in combined fractureswith only tuberosity fractures (type 1and type 3), because in most cases ofproximal humerus fractures (type 2 andtype 4) the humeral head is displaced

and, therefore, cannot be used for theassessment of the centricity. However,specific patient conditions (e. g., age,comorbidities) were considered in allthese indications, and in some cases,surgery was indicated individually bythe treating surgeon.

Follow-up

All of the patients had initial con-ventional radiographs (anteroposterior[a.p.] view and axial view/Y view) andin most cases (n= 42, 81%) a computedtomography scan (CT) in the initialimaging, which were all analyzed. Intotal, 44 patients (85%) returned forfollow-up after 25 months on average(2–168 months). Eight patients (15%)did not return andwere lost to follow-up.Within the different groups, the respec-tive treatment (operative/nonoperative)and potential secondary interventionswere analyzed regarding reason and typeof surgery. In addition, detectable ordocumented complications during thefollow-up were evaluated. Age, gender,and trauma mechanism were noted. Inthe case of nonoperative treatment ofboth fractures or one of the combinedfractures, pendulum exercises were rec-ommended for 10 days followed bypassive range of motion (ROM) with upto 90° abduction/flexion for 4–6 weeks.In the case of operative treatment, thestandard postoperative protocol usu-ally includes passive ROM with 60°abduction/flexion for 3 weeks and sub-sequently 90° passive ROM for a further3 weeks; in exceptional cases, however,the treating surgeon may make individ-ual decisions regarding the postoperativerehabilitation protocol depending on theintraoperative findings.

Results

In total, 52 patients with a combinedglenohumeral fracture were identifiedretrospectively; type 1 glenohumeralcombination fractures were the mostfrequent (n= 26) fracture type followedby type 2 (n= 20). Glenohumeral combi-nation fractures with involvement of theglenoid fossa were rarely encountered:There were four type 3 and two type 4glenohumeral combination fractures.

Type 1

Thepatientswith a large glenoid rim frac-ture combined with a greater tuberosityfracture (n= 26) had an average age of64 years (25–92 years, female: n= 14,n=male: n= 12). The most frequenttrauma mechanisms were shoulder dis-locations in 24 cases (92%) and a directimpact on the shoulder in two cases (8%).

The overall displacement (coronaryplane) of the large anterior glenoidrim fracture was 8.4mm on average(0–21mm) and the displacement in theen-face view (sagittal plane, “fracturegap”) was 5mm on average (1–14mm).In the majority of cases (n= 21, 81%),the large glenoid rim fracture consistedof one fragment (two fragments: n= 3[11%], comminuted: n= 2 [8%]).

The greater tuberosity fracture of allshoulders with type 1 fracture was dis-placed by 4.5mm on average (0–20mm).The greater tuberosity displacement wasclassifiedasnoormilddisplacement in13patients,moderate insix, andasdisplacedin seven patients. Regarding the dif-ferentiation into the respective directionof the dislocation, the greater tuberositywas displaced cranially in ten (on average3mm) of the shoulders and posteriorlyin 11 (Ø 7mm; nondisplaced: n= 5, Ø0mm). In the patient cohort, the greatertuberosity consisted of one fragment ineight patients, two fragments in four pa-tients, and it was comminuted in mostof the cases (n= 14).

The therapeutic management of thepatients differed in the cohort. In 11(42%) patients, both lesions were treatednonoperatively and in nine patients(35%) the combined fractures weretreated surgically (including two older

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Abstract · Zusammenfassung

Obere Extremität 2019 · 14:118–126 https://doi.org/10.1007/s11678-019-0508-2© The Author(s) 2019

M. Königshausen · E. Mempel · V. Rausch · J. Gessmann · T. A. Schildhauer · D. Seybold

Combined fractures of the humeral head and the glenoid

AbstractBackground. Glenohumeral combinationfractures are severe shoulder injuries forwhich, however, few data are available in theliterature. The aim of the study was to analyzethe incidence and numeric distributionof glenohumeral combination fracturesusing a classification system. Furthermore,treatment methods and complications arediscussed.Methods. This retrospective study is basedon the data evaluation of a level I traumacenter between1998 and 2016. Glenohumeralcombination fractures are classified into fourtypes, and the incidence, treatmentmethod,and complications are evaluated. Additionally,the fracture morphology and displacement ofthe different fracture types are analyzed.

Results. In total, 52 patients with a glenohu-meral combination fracture were identified.There were 26 (50%) type 1 fractures (anteriorglenoid rim fracture/greater tuberosityfracture), 20 (38%) type 2 fractures (anteriorglenoid rim fractures and proximal humerusfractures), four (8%) type 3 fractures (glenoidfossa fractures and greater tuberosityfractures), and two (4%) type 4 fractures(glenoid fossa fractures and proximal humerusfractures). In the majority of patients (n= 25),both lesions of the combined fractures weretreated operatively, in 15 both fractures weretreated nonoperatively, and in 12 patients onlyone of the two lesions was treated surgically.Complications were encountered in 21% ofcases, particularly on the humeral side.

Conclusion. Glenohumeral combinationfractures are rare. Type 1 and type 2 fracturesare the most frequent combination fractures.The indications for treatment are basedon the displacement of the respectivefragments, which can be addressed duringthe same operation if surgery is indicated.Complications are more frequently found onthe humeral side.

KeywordsGlenoid cavity · Proximal humerus · Combi-nation fractures · Fossa glenoidalis · Glenoidrim

Kombinationsfrakturen von Humeruskopf und Glenoid

ZusammenfassungHintergrund. Glenohumerale Kombinations-frakturen sind schwere Schulterverletzungen,über die jedoch kaum Daten innerhalb der Li-teratur vorliegen. Ziel der Studie war es daher,die Inzidenz und die numerische Verteilungglenohumeraler Kombinationsfrakturen zuanalysieren und anhand einer Klassifikationdarzustellen. Darüber hinaus werden dieBehandlungsmethoden und die einzelnenKomplikationen dargestellt.Methoden. Die vorliegende retrospektiveStudie basiert auf der Datenauswertung einesLevel-I-Traumazentrums zwischen 1998 und2016. Die verschiedenen glenohumeralenKombinationsfrakturen werden in 4 Typeneingeteilt und die Inzidenz, Behandlungs-weise und Komplikationen im weiterenVerlauf ausgewertet. Zusätzlich werden die

Frakturmorphologie und die Dislokation beiden verschiedenen Frakturtypen analysiert.Ergebnisse. Insgesamt wurden 52 Patientenmit einer glenohumeralen Kombinati-onsfraktur identifiziert. Es fanden sich 26(50%) Typ-1-Frakturen (anteriore Glenoid-randfraktur/Tuberculum-majus-Fraktur), 20(38%) Typ-2-Frakturen (anteriore Glenoid-randfraktur/proximale Humerusfraktur), 4(8%) Typ-3-Frakturen (Fossa-glenoidalis-Fraktur/Tuberculum-majus-Fraktur) und 2(4%) Typ-4-Frakturen (Fossa-glenoidalis-Fraktur/proximale Humerusfraktur). In derMehrzahl der Fälle (n= 25) wurden beideVerletzungen dieser kombinierten Frakturenoperativ behandelt, in 15 Fällen wurden beideFrakturen konservativ behandelt, und bei 12Patientenwurde nur eine der beiden Frakturen

operiert. Komplikationenwurden in 21% derFälle insbesondere auf der humeralen Seitefestgestellt.Schlussfolgerung. Glenohumerale Kombi-nationsfrakturen sind seltene Frakturmuster,wobei Typ 1 und Typ 2 am häufigstenvertreten sind. Die Indikationen orientierensich an der Dislokation der jeweiligenFragmente und können im Fall einer Op.-Indikation in derselbenOp. behandelt werden.Komplikationen werden dabei häufiger amHumerus festgestellt.

SchlüsselwörterFossa glenoidalis · Proximaler Humerus ·Kombinationsfrakturen · Fossa glenoidalis ·Glenoidrand

patients aged 77 and 92 years who weretreated with a reversed prosthesis). Infour of the patients (15%), only theanterior glenoid rim fracture was fixed(using an open approach in three casesand arthroscopically in one case) whilethe greater tuberosity was managed con-servatively because of no or moderatedisplacement (Ø 1mm, 0–3mm; n= 2cranial displacement, n= 1 posterior dis-placement). By contrast, in two patients(8%) only the greater tuberosity wasrefixed while the glenoid rim fracture

was treated nonoperatively because theglenoid rim lesion was overlooked in onecase and because of mild displacement inthe second case (3mm, coronary plane;. Fig. 1). An overview of the differenttypes of fractures and their respectivetreatment is given in . Fig. 2.

The large glenoid rim fractures thatwere treated by surgery had a largeraverage medial displacement of 14mm(4–21mm) in contrast to the glenoidrim fractures that were treated nonoper-atively with 6mm on average (0–14mm)

in the coronary plane. Also, the greatertuberosity fractures that were treated op-erativelyweremore displaced (Ø7.6mm;1–20mm), than those treated conser-vatively (Ø 2mm; 0–7mm). Two olderpatients (86 and 76 years of age) weretreated nonoperatively despite havinglarge displaced glenoid rim fractures (8and 14mm [coronary plane]; posteriorlydisplaced greater tuberosity fracture inone case [7mm]) because of rejectionof the recommended surgery and co-morbidities. In one patient, only the

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Fig. 18 a Three-dimensional CT of a 58-year-old female patientwith type 1a glenohumeral combi-nation fracture anddisplaced greater tuberosity (whitearrow) withmild displacement of the anteriorlarge glenoid rim fracture (black arrow). bGreater tuberosity treated viamini-open approach (screwswith suturewiring); glenoid rim fracture treated nonoperatively (a.p.view)

greater tuberosity was fixed, leaving themedially displaced glenoid rim fracture(13mm) to be managed nonoperatively,because the fracture was overlookedbefore (and during) the surgery (asmentioned earlier).

During the follow-up, complicationswere observed in four patients (15%).There were two cases with a secondarydisplacement of a nonoperatively treatedcomminuted greater tuberosity (one af-ter operative refixationof the glenoid andanother after nonoperative treatment ofthe glenoid). The first showed a com-minuted greater tuberosity with a slightcranial displacement of 1mm on the ini-tial radiographs and a secondary increaseof the cranial displacement of 6mm ofthe greater tuberosity was observed af-ter 3 weeks (with continued nonopera-tive treatment and no further displace-ment on subsequent radiographs). In thesecond case, the (comminuted) greatertuberosity (3mm cranial displacement)was observed with a secondary cranialdisplacement of 9mm after 6 weeks butthepatient declined further therapy. Fur-thermore, one patient suffered from a re-dislocation after refixation of only theglenoid rim fracture and presented witha chronic locked shoulder dislocation af-ter 6 weeks but did not want to undergofurther treatment because of advancedage (82) and comorbidities. One patientneeded arthroscopy several months afternonoperative treatment of the combinedglenohumeral fracture because of resid-

ualpain; pathologyof the longheadof thebiceps was found, which was addressedvia tenodesis.

Type 2

In total, 20 patients (38%) had a combi-nation fracture of a glenoid rim fractureand a proximal humerus fracture. Theaverage age of the patients was 63 years(47–82 years) including 11 female andnine male patients. In all cases, thetrauma mechanism was a direct im-pact on the shoulder. The glenoidrim fracture displacement was Ø 7mm(0–18mm) on average in the coronaryplane and 4mm (1–10mm) on aver-age in the sagittal plane. The majorityof the patients had complex proximalhumerus fractures in combination witha large anterior glenoid rim fracture.The most frequently observed fractureswere three-part fractures (including thegreater tuberosity) in 13 (65%) patients,followed by four-part fractures in four(25%) cases, while there were only two(10%) patients with a two-part fracturein the surgical neck.

In the majority of the patients, bothinjuries of the combined fractures weretreated surgically (n= 12, 60%; . Fig. 3).In these cases, the average medial dis-placement of the anterior glenoid rimfracture was 9mm (2–18mm). In six pa-tients (30%), only the proximal humeruswas treated operatively, while the ante-rior glenoid rim fracture was managed

nonoperatively with an average glenoidrim fracture displacement of 5.5mm(coronary plane, 0–13mm). In two ofthese patients, the glenoid rim lesion(4- and 6-mm medial displacement)was overlooked on the initial radio-graphs and treated nonoperatively. Inone patient with a wide medially dis-placed (13mm) glenoid rim fragment,the proximal humerus was treated sur-gically and the remaining glenoid rimfracture was managed nonoperatively,because of the individual decision of thetreating surgeon.

In only two of all patients was non-operative treatment of both lesions de-cided because of mildly displaced prox-imal humerus two-part and three-partfractures and a non- or mildly and me-dially displaced glenoid rim fracture (2and 1mm). There was no case in whichonly the glenoid rim fracture was fixedleaving the proximal humerus fractureto be treated nonoperatively (. Fig. 2).

Complications were found in six cases(30%), particularly on the humeral side.Inonepatient inwhomonly theproximalhumerus was fixed with plate osteosyn-thesis, the humeral head showed a de-centricity on the postoperative follow-up radiographs togetherwitha secondarydisplacement of the greater tuberosity. Ina patient who was treated with a hemi-arthroplasty on the humeral side (andscrew fixation of the glenoid rim frac-ture), a secondary displacement of therefixed greater tuberosity with a partialresorption was observed. Periarticularcalcifications at the humerus were foundduring follow-up in one patient. Partialavascular necrosis (AVN) was found intwo patients on the humerus after plateosteosynthesis. One patient showed par-tial AVN of the humeral head and inanother patient partial AVN of only thegreater tuberosity was observed. On theglenoid side, screw loosening was foundin one case but without further surgeryor displacement of the fragment.

Type 3 and 4

Combined glenohumeral fractures witha glenoid fossa fracture are much lesscommon than type 1 or type 2 fractures(. Fig. 2). Type 3 and type 4 combination

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Original Contribution

Both non-operatively: n=11 (42%) (Ø 64 y., f: n=6, m: n=5)

Both non-operatively: n=2 (10%) (54 y./72 y., male)

Both operatively: n= 12 (60%)

PHF operatively (plate osteosynthesis), GRF non-operatively:

Combined Glenohumeral Fractures n= 52

Large Anterior Glenoid Rim Fracture AND Humeral Head Fracture

Type 1: (GRF / GTF): n= 26

GRF operatively, GTF non-operatively (screws and/ or anchor): n=4 (15%) (Ø 70 y., f: n=3, m: n=1)

GRF non-operatively, GTF operatively (screws): n=2 (8%) (Ø 60 y., f: n=2)

Type 2: (GRF / PHF): n= 20

ORIF (PHF: plate osteosynthesis, GRF: screws/anchors: n=11; PHF: n=1 Hemiarthroplasty, GRF: screws)

(Ø 63 y., f: n=8; m: n=4)

n= 6 (30%) (Ø 64 y., f: n=3, m: n=3)

Both operatively: n = 9 (35%) ORIF (screws and/or anchors: n= 7, n=2 reversed prosthesis) (Ø 60 y., f: n=3, m: n=6)

GFF non-operatively, GTF non-operatively: n=1 (81 y., female)

GFF non-operatively, PHF non-operatively: n=1 (65 y., male)

GFF operatively, PHF operatively: n=1 (60 y., male)

Glenoid Fossa Fracture AND Humeral Head Fracture

Type 3: (GFF / GTF): n= 4

GFF operatively, GTF operatively: n=3 (23 y., female; 43 y., male; 63 y., female)

Type 4: (GFF / PHF): n= 2

Fig. 28 Numeric distribution of combined glenohumeral fractures and their respective therapy.GRFglenoid rim fracture,GTFgreater tuberosity fracture, PHFproximal humerus fracture,GFFglenoid fossa fracture, f female,mmale, y years of age,ORIF open reductionwith internal fixation

fractures were found in only six cases(female n= 3, male n= 3; Ø 56 years,23–81 years). In all cases, the traumamechanisms were a direct fall on theshoulder but usually from some height(e. g., ladder, riding accident).

In the type 3 group (n= 4), greatertuberosity fractures comprised one frag-ment in one case, two fragments in onecase, and they were comminuted in twopatients. The greater tuberosity displace-ment was on average Ø 3mm (0–5mm;non-/mildly displaced [lateral]: n= 2,moderately displaced [lateral]: n= 1,displaced [cranial/dorsal]: n= 1). Bothproximal humerus fractures in the type 4group (n= 2) were two-part fractures.

According to the Ideberg et al. classifi-cation of glenoid fractures, mostly type 2glenoid fossa fractures (n= 5) were notedand in only one case (n= 1) was a type 5glenoid fossa fracture found. The averagemedial displacement of the glenoid fossafracture was Ø 4mm (0–7mm) in thecoronary plane (intra-articular step-off)and the displacement in the sagittal plane(“fracture gap”) was Ø 4mm (1–8mm).

In two cases, the combined fractureswere treated nonoperatively and in fourpatients the combined fractures wereboth treated operatively (. Figs. 2 and 4).All surgically treated glenoid fossa frac-tures (n= 4) were treated with plateosteosynthesis (open reduction and in-ternal fixation [ORIF]) using a posteriorapproach. Theoperatively treated greatertuberosity fractures (n= 4) were fixedvia a mini-open approach using screws(n= 3) or tension wiring (n= 1) andthe surgically treated proximal humerusfracture (n= 1) was treated by plate os-teosynthesis. As a complication, in thepatient with a type 4 glenohumeral com-bination fracture, the proximal humerusplate showedabendingof theplate – aftera likely secondary stress fracture duringthe posttreatment course on a follow-up radiograph 3 years after ORIF (ofboth lesions; . Fig. 5). The plate at theproximal humerus and the glenoid wassubsequently removed. Further com-plications were not found in the type 3and 4 groups.

The operatively treated glenoid frac-tures (n= 4) had a medial displacement

of 5mm (3–7mm) on average and a dis-placement in the sagittal plane of Ø5mm (1–8mm). The operatively treatedgreater tuberosity fractures had a (cra-nial or lateral) displacement of 3mm(1–5mm) on average. Within the groupof nonoperatively treated glenoid fossafractures (n= 2), the medial displace-ment was 0 and 5mm with a displace-ment in the sagittal plane of 2 and6mm. Despite the significant displace-ment of the glenoid (5mm coronaryplane/6mm sagittal plane) in one ofthese two patients, a nonoperative treat-ment was chosen because of advancedage (81 years; greater tuberosity fracture:1mm displaced laterally).

Discussion

Large anterior glenoid rim fractureswith a concomitant fracture of thegreater tuberosity (type 1) were most fre-quently seen at our hospital followed bycombination fractures of the proximalhumerus (type 2). The rarest gleno-humeral fracture combinations wereglenoid fossa fractures together with

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Fig. 38 Type2glenohumeral combination fracture ina59-year-old femalepatientwitha three-part proximal humerus frac-ture (a, CT, axial view) 6weeks afterORIFof both lesions; slight inferior decentricity after passivemotion (b, a.p.view)but reg-ular concentricity in the axial view (c)

Fig. 48 A23-year-old femalepatientwithatype3combination fractureof the left shoulderafterORIFfor a displaced glenoid fossa fracture (type 2, Ideberg et al.classification) andpercutaneous fixationof the greater tuberosity (a, .p.view)with free range ofmotion in flexion/abduction (b) and internalrotation and only a slight residual deficit in external rotation 16months after surgery (c)

a greater tuberosity fracture or a prox-imal humerus fracture. There are onlyfew data available about the rare com-bined glenohumeral fractures in theliterature. Especially in studies dealingwith glenoid fractures, scapula bodyfractures, or first-time shoulder dislo-cations, occasional descriptions can befound about additional fractures of thehumeral head mostly under “associatedinjuries.”

In a study about the nonoperativetreatment of large anterior glenoid rimfractures (n= 14), five cases with an ad-ditional nondisplaced greater tuberosityfracture were found and were all treatednonoperatively, but two of these patientswith a fracture of the greater tuberosityhad a loss of external rotation of 10˚and 20˚, respectively [34]. Robinsonet al. described 11 cases with a com-bined glenoid rim and greater tuberosityfracture (type 1a) in a large cohort of 538

patients with first-time traumatic ante-rior shoulder dislocations, which corre-sponds to 2% of all traumatic shoulderdislocations [43]. The re-instability rateof thewholecollectivewasanalyzed inthefirst6weeksandsevenof the11combinedfractures showed re-instability with sub-sequent ORIF. During the surgery, theauthors estimated “restoration of shoul-der stability” by testing of the full passiveROM. The authors describe restorationof stability during surgery after fixationof only the glenoid rim without fixationof the greater tuberosity in four of thecases. In theother threepatients inwhomstability could not be restored by fixingthe glenoid only, fixation of the greatertuberosity was carried out. At 1 year af-ter the surgery, “satisfactory functionalscores” and no instability were reported[43]. In contrast to these data, no re-instability was found in our group of pa-tients with type 1 fractures, in whomthe combined fractures were both treatednonoperatively.

A few combination fractures havebeen reported in retrospective studieswith the focus on either large operativelytreated glenoid rim fractures [33, 39,51] or refixed greater tuberosity frac-tures [17]. In two studies dealing withoperative treatment of large anteriorglenoid rim fractures, one fracture ofthe greater tuberosity was fixed percuta-neously during the same operation andan additional greater tuberosity fractureand a proximal humerus fracture weretreated by ORIF [33, 51]. In their studyof 20 surgically treated (ORIF) ante-rior glenoid rim fractures, Osti et al.

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Fig. 58 Type 4 combination fracture in a60-year-oldmalepatient afterORIF (a, a.p.view, intraopera-tive radiographs). After 3 years, a healed secondary fracturewas observedmore distally at the level ofthe sliding hole and a twisted proximal humerus platewith amore varus position (b, a.p.view)

found five patients with an associatedfracture of the greater tuberosity andtwo patients with a concomitant proxi-mal humerus fracture (both three-partfractures). Both proximal humerusfractures were (additionally) treated sur-gically (ORIF) and one of the greatertuberosity fractures was refixed becauseof “significant displacement.” Three ofthe patients with concomitant injuriesshowed a restricted ROM presumablybecause of a less aggressive rehabilitationprotocol [39].

In a study of arthroscopic refixation ofgreater tuberosity fractures, three type 1combination fractures were found andthe additional glenoid rim fractures wereall treated with suture anchors. The au-thors describe early degenerative changeof theglenoid rimand intermittent shoul-der pain after 2 years [17].

Garofalo et al. published the onlystudy (n= 26) of glenohumeral combina-tion fractures (of type 1 and type 2) thatwereall treatedbyreversedprosthesisandadditional bone grafting. The patientshad overall excellent and good results atthe final follow-up [13]. However, thenumber of proximal humerus fracturesand only greater tuberosity fractures intheir cohort of combination fractures isnot listed explicitly and remains unclear.In terms of complications, only one case

of superficial infection and two cases ofheterotopic ossificationswere found [13].

Concomitant fractures of the humeralhead are more rarely described in the lit-erature incombinationwithglenoid fossafractures (type 3 and 4). Nork et al. de-scribed in their surgically treated patientcohort of 17 patients one casewith a con-comitant proximal humerus fracture, butno further information isgivenabout thatcase [37]. Two further studies includea mixed cohort of intra- and extra-ar-ticular scapula fractures (n= 62 [3] andn= 22 [14]) and concomitant “humerusfractures” (n= 7 [3], n= 3 [14]), but theyare amixedcollectivewithextra-articularscapula fractures and it remains unclearwhether humerus shaft fractures or prox-imal humerus fractures are involved [3,14].

Type 1 glenohumeral combinationfractures were most frequently seen atour hospital over the observation period(50% of all combination fractures), fol-lowed by type 2 (38%). Type 3 fractureswere present in 8% of cases and type 4 inonly 4%. The incidence of the differentglenoid fractures corresponds to the nu-merical distribution of the glenoid frac-tures in the literature, in which glenoidrim fractures are more frequently seenthan glenoid fossa fractures [15, 45]. In-terestingly, five (83%) of the six glenoid

fossa fractures were type 2 Ideberg et al.classification, which suggests a uniformtraumatic pathomechanismof such com-bined glenohumeral fractures, becausein isolated glenoid fossa fractures thereis not such a clear distribution in favorof one fracture type [15, 22, 45].

The highest complication rate in ourstudy was found after ORIF in type 2combination fractures, followed by com-plications in type 1 fractures. The reasonthat only one complication was found inthe type 3 and 4 fractures is probablydue to the low number of cases in theseboth groups. It is noteworthy that mostof the complications were found on thehumeral side in type 1 (and type 4) butparticularly in type 2 fractures. This cor-responds to the results of studies of (iso-lated)proximalhumerusfractures,whichusuallyhavehighercomplicationrates af-ter surgery (ORIF and hemiarthroplasty)thanstudiesofoperatively treatedglenoidrim or glenoid fossa fractures [5, 18, 24,25, 27, 29, 30, 38, 39, 44–46, 50, 53].

In one case of a type 1 combinationfracture and in two cases of type 2 frac-tures, the anterior glenoid rim fracturewasoverlookedon the initial radiographsand only the greater tuberosity or theproximal humerus were treated surgi-cally. Thus, the surgeon should be awareof the occurrence of glenohumeral com-bination fractures and should bear inmind to check the anterior sclerotic lineof the glenoid [16] in order to excludeconcomitant glenoid rim lesions.

Limitations

There are some limitations in the presentstudy. The analysis included patientrecords but not clinical scores witha specific follow-up. Although most pa-tients return for regular follow-up, somecomplications can presumably go unno-ticed in the posttreatment course if theyare lost to follow-up or treated at anotherhospital. The indications for surgery andthe term “displaced” are not definedclearly in the literature. Therefore, theindications were not standardized andwere partially based on the evaluationof the treating surgeon or, occasionally,on the individual wishes of the patient.

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Practical conclusion

4 In glenohumeral combination frac-tures, both lesions should be con-sidered individually regarding theindication for treatment based onthe degree of displacement of therespective injury.

4 Another decisive criterion is theconcentricity of the humeral headin type 1 and type 3 fractures inwhich only the greater tuberosity isfractured.

4 If necessary, both lesions can beaddressed in one operation with thepatient in the same position (e.g.,beach-chair position; type 4 com-bination fractures are an exceptionto this and needed to be transferedfrom the lateral decubitus position[ORIF of the fossa glenoidalis] intobeach-chair position [for ORIF of theproximal humerus]).

4 Complications can occur mainly atthe proximal humerus in contrast tothe glenoid, which warrants regularradiographic follow-up.

4 Clinical follow-up studies are neededto further differentiate the indica-tions for treatment and the clinicalprognosis of the different types ofglenohumeral combination fractures.

Corresponding address

Dr. M. KönigshausenGeneral and Trauma Surgery,BG University Bergmannsheil,Ruhr University BochumBürkle-de-la-Camp Platz 1,44789 Bochum, Germanymatthias.koenigshausen@bergmannsheil.de

Compliance with ethicalguidelines

Conflict of interest M. Königshausen, E.Mempel,V. Rausch, J. Gessmann, T.A. Schildhauer, andD. Sey-bolddeclare that theyhave no competing interests.

This article does not contain any studieswith humanparticipants or animals performedby anyof the au-thors.

OpenAccessThis article is distributedunder the termsof the Creative CommonsAttribution 4.0 InternationalLicense (http://creativecommons.org/licenses/by/

4.0/), which permits unrestricteduse, distribution,and reproduction in anymedium, provided yougiveappropriate credit to the original author(s) and thesource, providea link totheCreativeCommons license,and indicate if changesweremade.

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