 Type C: 4/5 patients treated successfully by functional bracing  Campbell et al  Type C: 2/3 healed successfully with nonoperative management  Kumar  One fracture distal to the prosthesis tip  treated successfully by nonoperative  Worland et al

 Distal to the prosthesis tip = closed humerus fractures  nonoperative treatment

 fractures located at the prosthesis tip (type A and type B) ??  did NOT heal with nonoperative management. › 5 cases in a series of 7 Boyd et al › one case Bonutti et al › 4 of 5 type B fractures  failed to heal, Kumar et al

 fractures with loose prosthesis  longer- stemmed implant  4 options: › press-fitting proximally and distally › cementing proximally and distally › press-fitting proximally with cement distally › cementing proximally with press-fitting distally

 Press-fitting proximally and distally › good quality of the humeral bone › tight fit can be achieved › obliquity fracture site

 cement proximally and distally: › bone proximally is good to fair › bone distally is good › Transverse fracture  press-fitting proximally and cement distally: › bone proximally is fair to poor › bone distally is good › fracture is rotationally stable  shape / can be made

 small amount of osteolysis proximally: › cement or bone graft  extensive osteolysis proximally: › bone graft is packed around the implant within the cortical shell  so extensive osteolysis: › allograft prosthetic composite

 implant is secure and the joint is reasonably mobile: › approach the fracture site alone for fracture fixation (plate with screws, pins and cerclage cables)  Allograft / Posterior iliac crest autograft bone: nonunion -/+

 Fracture: transverse or nearly transverse as rotational stability can be attained through the use of the screws, pins and cerclage  plate  Fracture: oblique / implant stability, acute  reduction of the fracture and cerclage  Fracture: oblique / implant stability, chronic  allograft + autograft

› 3/6 healed with nonoperative › 1 failed nonoperative management › 2 treated with immediate OP  Type A fractures + loose humeral component  OP: long-stem  bone graft(allograft in acute cases and posterior iliac crest autograft in cases with delayed healing or nonunion)  fixation with a cortical strut allograft or a plate and screws/cables

 Type B fractures + good alignment / well- fixed humeral component: nonoperative  However  nonoperatively  high fail  not progressed toward union by 3 months  OP

 Type B fracture + well-fixed humeral component: › plate / strut graft with screw fixation in the distal portion and cerclage fixation in the proximal portion + Bone graft  Type B + loose humeral component  cemented long-stem + posterior iliac crest bone graft

 Type C fracture + well-fixed humeral component: trial of nonoperative › postoperative care:  Within days after surgery: gently exercised with active movement  passive external rotation outward to neutral and in elevation to 100°  avoid stress at the fracture site  continue with a passive program until healing  long-stemmed implant + cemented: active-assisted motion program at 4 to 6 weeks

 Radial nerve injury › careful dissection and exposure at the time of fracture fixation  swelling of the arm, forearm, and hand › elevation, elastic support, and the gentle active-motion program  acute infection  failure of humeral shaft healing › 6 months, autograft/vascular bone graft

 well-aligned Type B fractures + well-fixed humeral component: nonoperative › High fail rate in Type B fractures › 3 months  humeral component fixed: open reduction and internal fixation  humeral component is loose: long stem  Well-reduced Type C fractures: trial of nonoperative treatment