A proximal humerus fracture is classified using Neer's classification. Which surgical option is most appropriate for a 4-part fracture in a young patient?

1. A

   A. Humerus nailing

2. B

   B. Humerus plating

3. C

   C. Hanging cast/K-wires

4. D

   D. Shoulder hemiarthroplasty

Appeared in: INI-CET EXAM -2026

Explanation

• In a young patient, the primary goal is always to preserve the natural joint (osteosynthesis) rather than replace it (arthroplasty).
• Humerus plating allows for Open Reduction and Internal Fixation (ORIF), providing the most stable construct to anatomically align all four displaced fragments of the humerus.
• This stable fixation is crucial for healing, reducing the risk of malunion, and allowing for early, controlled rehabilitation to maximize functional recovery of the shoulder.
• While the risk of avascular necrosis is high in 4-part fractures, attempting to save the head with plating is the standard of care for younger individuals.

Why Other Options Were Wrong

• Option A: Intramedullary nailing provides less control over the reduction and fixation of the greater and lesser tuberosity fragments, which is critical in a 4-part fracture.
• Option C: A hanging cast or percutaneous K-wires cannot provide adequate stability for a highly unstable and displaced 4-part fracture. This would likely lead to malunion or nonunion.
• Option D: Shoulder hemiarthroplasty involves replacing the humeral head with a prosthesis. This is considered a salvage procedure and is avoided in young patients due to the limited lifespan of the implant and the desire to preserve native bone.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Surgical management of complex proximal humerus fractures based on Neer's classification and patient age to guide bedside assessment, documentation, and the next nursing action.
• A nurse's role includes meticulous post-operative neurovascular assessment of the affected arm (checking pulse, color, sensation, and movement) to detect complications like nerve injury or compartment syndrome.
• Patient education is vital, covering sling use, activity restrictions, and the importance of adhering to the prescribed physical therapy regimen to prevent stiffness and regain function.
• What if? If the patient was an 85-year-old with osteoporosis and low functional demands, shoulder hemiarthroplasty would become the most appropriate option, as the goal would shift from joint preservation to reliable pain relief and faster mobilization.

How to Approach the Question

• First, identify the key clinical details in the question: the patient's age ('young') and the injury's severity ('4-part fracture').
• Analyze the treatment goal based on these details. For a 'young' patient, the goal is joint preservation. For a '4-part fracture', the goal is stable fixation.
• Evaluate each option against these goals.
• Eliminate conservative options (hanging cast) as they are inadequate for a severe, unstable fracture.
• Compare the surgical options. Recognize that joint replacement (hemiarthroplasty) is a last resort in young patients.
• Differentiate between the internal fixation methods (nailing vs. plating), understanding that plating offers better control for complex, multi-fragmentary fractures like this one.

Concept Tested & Keywords

• Concept Tested: Surgical management of complex proximal humerus fractures based on Neer's classification and patient age.
• Stem keywords: proximal humerus fracture, Neer's classification, 4-part fracture, young patient
• Lead-in keywords: most appropriate
• Clinical cues: Patient age ('young patient') is a critical factor guiding treatment towards joint preservation.
• Clinical cues: Fracture complexity ('4-part fracture') indicates a severe, unstable injury requiring robust fixation.

Question ID

QWMHrrejTR9T7YBpz68zt1

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 129-131

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 2090-2092