Proximal humerus fracture dislocation with malunion of the humeral head in the subscapularis recess

This patient presented with a chronic anterior dislocation of the humeral head after a proximal humerus fracture, the humeral head was malunited in the subscapularis recess. Osteotomy of the humeral head was required to remove the bone from the anterior glenoid. The fracture was addressed with hemiarthroplasty and repair of the tuberosities. The use of a stem that provides a "window" for proximal bone grafting, the removal of the cement circumferentially from the proximal stem during implantation, and the stable suture repair of the tuberosities with Fiberwire provided a good outcome with union of the tuberosities. The anterior inferior subluxation of the humeral head persisted for 6 months but eventually it was resolved. Contrary to the belief that this is the result of a "fracture hematoma" it seems that this finding is associated with muscle atony or contusion of the rotator cuff or axillary nerve neuropraxia. X-rays are shown below. 

Locked proximal humerus fracture dislocation

Fracture locked dislocations of the proximal humerus are challenging injuries due to the energy of the trauma and the instability that is encountered during surgery. Small bony bankart lesions as in this case do not need to be fixed. The progressive development of stiffness usually balances the instability. If the fracture fixation is combined with labrum or bankart repair then there is a concern for development of significant stiffness. The following x-rays demonstrate a patient who was treated with ORIF of the humerus fracture and no repair of the small bony bankart lesion. She regained active elevation of her shoulder to 160 degrees without instability.