Author: Deborah Allen Topic updated on 04/07/15 10:01am 17

Proximal Humerus Fractures

Introduction

Epidemiologyincidence

4-6% of all fracturesthird most common fracture pattern seen in elderly

demographics2:1 female to male ratioincreasing age correlates with increasing fracture risk in women

Pathophysiologymechanism

low-energy fallselderly with osteoporotic bone

high-energy traumayoung individualsconcomitant soft tissue and neurovascular injuries

pathoanatomyvascularity of articular segment is more likely to be preserved if 8mm of calcar isattached to articular segment

Associated conditionsnerve injury

axillary nerve palsy most commonfracture-dislocations

more commonly associated with nerve injuries

Anatomy

Osteology anatomic neck

represents the old epiphyseal platesurgical neck

represents the weakened area below Vascular anatomy

anterior humeral circumflex artery one of primary blood supplies to the humeral headbranches

anterolateral ascending branchis a branch of the anterior humeral circumflex artery

arcuate arteryis the terminal branch

courseruns parallel to lateral aspect of tendon of long head of biceps in the bicipitalgroovehas an interosseous anastomosis

posterior humeral circumflex artery recent studies suggest it is the main blood supply to humeral head

Classification

Valgus impactednot true 4-part fractureshave preserved posterior medial capsular vascularity to the articular segment

AO/OTA organizes fractures into 3 main groups and additional subgroups based on

fracture locationstatus of the surgical neckpresence/absence of dislocation

Neer classification based on anatomic relationship of 4 segments

based on anatomic relationship of 4 segments greater tuberositylesser tuberosityarticular surfaceshaft

considered a separate part ifdisplacement of > 1 cm45 angulation

Evaluation

Symptomspain and swellingdecreased motion

Physical examinspection

extensive ecchymosis of chest, arm, and forearmneurovascular exam

45% incidence of nerve injury (axillary most common)distinguish from early deltoid atony and inferior subluxation of humeral head

arterial injury may be masked by extensive collateral circulation preserving distalpulses

Imaging

Radiographsrecommended views

complete trauma seriestrue APscapular Yaxillary

additional viewsapical oblique Velpeau West Point axillary

CT scanindications

preoperative planninghumeral head or greater tuberosity position uncertainintra-articular comminution

MRIindications

rarely indicateduseful to identify associated rotator cuff injury

Treatment

Nonoperativesling immobilization followed by progressive rehab

indications 85% of proximal humerus fractures are minimally displaced and can be treatednonoperatively including

minimally displaced surgical neck fracture (1-, 2-, and 3-part)greater tuberosity fracture displaced < 5mmfractures in patients who are not surgical candidates

additional variables to consideragefracture typefracture displacementbone qualitydominancegeneral medical conditionconcurrent injuries

techniquestart early range of motion within 14 days

OperativeCRPP (closed reduction percutaneous pinning)

indications2-part surgical neck fractures3-part and valgus-impacted 4-part fractures in patients with good bone quality,

3-part and valgus-impacted 4-part fractures in patients with good bone quality,minimal metaphyseal comminution, and intact medial calcar

ORIFindications

greater tuberosity displaced > 5mm 2-,3-, and 4-part fractures in younger patients head-splitting fractures in younger patients

intramedullary roddingindications

surgical neck fractures or 3-part greater tuberosity fractures in younger patientscombined proximal humerus and humeral shaft fractures

outcomes85% success rate in younger patients

hemiarthroplastyindications

anatomic neck fractures in elderly or those that are severely comminuted4-part fractures and fracture-dislocations (3-part if stable internal fixationunachievable)rotator cuff compromiseglenoid surface is intact and healthychronic nonunions or malunions in the elderlyhead-splitting fractures with incongruity of humeral headhumeral head impression defect of > 40% of articular surfacedetachment of articular blood supply (most 3- and 4-part fractures)

outcomesimproved results if

performed within 14 daysaccurate tuberosity reductioncerclage wire passed through hole in prosthesis and tuberosities

poor results withtuberosity malunion proud prosthesisretroversion of humeral component > 40

total shoulder arthroplastyindications

rotator cuff intactglenoid surface is compromised (arthritis, trauma)

reverse shoulder arthroplasty indications

elderly individuals with nonreconstructible tuberosities

Treatment by Fracture Type

One-Part Fracture (most common)

Surgical Neck fx Most common type if stable then early ROM

if unstable then period of immobilization followed byROM once moves as a unit

Anatomic Neck fx ORIF in young patient

ORIF vs. hemiarthroplasty in elderly patient hemiarthroplasty if severely comminuted

Two-Part Fracture

Surgical Neck Most common fx pattern (85%) Deforming forces: 1) pectoralis pulls shaft anterior andmedial 2) head and attachedtuberosities stay neutral Posterior angulation tolerated betterthan anterior and varus angulation

Nonoperative Closed reduction often possible SlingOperative indicated for >45 angulation technique- CRPP- Plate fixation- Enders rods with tension band- IM device

Greater tuberosity Often missed Deforming forces: GTpulled superior and posterior by SS,IS, and TM Can only accept minimaldisplacement or else it will block ER

Nonoperative indicated for GT displaced < 5 mmOperative indicated for GT displacement > 5 mmAP radiograph of a left shoulder demonstrates a 2-partproximal humerus fracture at the surgical neck.

displacement or else it will block ERand ABD

proximal humerus fracture at the surgical neck.- isolated screw fixation only in young with good bonestock- nonabsorbable suture technique for osteoporotic bone(avoid hardware due to impingement)- tension band wiring

Lesser tuberosity Assume posterior dislocation untilproven otherwise

Operative ORIF if large fragment excision with RCR if small

Anatomic neck RareOperative ORIF in young ORIF vs. hemiarthroplasty in elderly patient

Three-Part FractureSurgicalneck and GT

Subscap will internally rotatearticular segment Often associated with longitudinalRCT

Surgicalneck and LT Unopposed pull of external rotatorslead to articular surface to point

anterior Often associated with longitudinalRCT

Trend towards nonoperative management with highcomplications with ORIF Young patient- percutaneous pinning (good results, protect axillarynerve)- blade plate / fixed angle device- IM fixation (violates cuff)- T plate (poor results with high rate of AVN, impingement,infection, and malunion) Elderly patient- hemiarthroplasty with RCR or tuberosity repair

Four-Part FractureValgus impacted3- and 4-partfracture

Radiographically will see alignmentbetween medial shaft and headsegments

74% good results with ORIF Low rate of AVN if posteromedial component intact thuspreserving intraosseous blood supply Surgical technique1. raise articular surface and fill defects2. repair tuberosities

4-part with articularsurface and head-splitting fracture

Characterized by removal of softtissue from fracture fragment leadingto high risk of AVN (21-75%) Deforming forces: 1) shaft pulledmedially by pectoralis

Young patient- ORIF vs. hemiarthroplasty (nonreconstructible articularsurface, severe head split, extruded anatomic neckfracture)

Elderly patient- hemiarthroplasty

Techniques

CRPP (closed reduction percutaneous pinning) approach

percutaneoustechnique

use threaded pins but do not cross cartilageexternally rotate shoulder during pin placementengage cortex 2 cm inferior to inferior border of humeral head

complicationswith lateral pins

risk of injury to axillary nerve with anterior pins

risk of injury to biceps tendon, musculocutaneous n., cephalic vein ORIF

approachshoulder anterior approach (deltopectoral) superior deltoid-splitting approach

indicated for GT and valgus-impacted 4-part fracturesincreased risk of axillary nerve injury

techniqueheavy nonabsorbable sutures

heavy nonabsorbable sutures(figure-of-8 technique) should be used for greater tuberosity fx reduction andfixation (avoid hardware due to impingement)

isolated screwmay be used for greater tuberosity fx reduction and fixation in young patientswith good bone stock

locking platehas improved our ability to fix these fracturesscrew cut-out is the most common complication following fixation of 3- and 4-part proximal humeral fractures and fractures treated with locking plates more elastic than blade plate making it a better option in osteoporotic boneplace plate lateral to the bicipital groove and pectoralis major tendon to avoidinjury to the ascending branch of anterior humeral circumflex artery placement of an inferomedial calcar screw can prevent post-operative varuscollapse, especially in osteoporotic bone

Intramedullary rodding approach

superior deltoid-splitting approachtechnique

lock nail with trauma or pathologic fracturescomplications

rod migration in older patients with osteoporotic bone is a concernshoulder pain from violating rotator cuffnerve injury with interlocking screw placement

Hemiarthroplasty approach

shoulder anterior approach (deltopectoral) technique for fractures

cerclage wire or suture passed through hole in prosthesis and tuberosities improvesfracture stabilityplace greater tuberosity 10 mm below articular surface of humeral head (HTD = headto tuberosity distance)

impairment in ER kinematics and 8-fold increase in torque with nonanatomicplacement of tuberosities

height of the prosthesis best determined off the superior edge of the pectoralis majortendon post-operative passive external rotation places the most stress on the lesser tuberosityfragment

Total shoulder arthroplasty Reverse shoulder arthroplasty

Rehabilitation

Important part of managementBest results with guided protocols (3-phase programs)

early passive ROM for first 6 weeksactive ROM and progressive resistanceadvanced stretching and strengthening program

Prolonged immobilization leads to stiffness

Complications

Screw penetration most common complication after locked plating fixation

Avascular necrosis risk factors

4 part fractureshead splitshort calcar segmentsdisrupted medial hinge

no relationship to type of fixation (plate or cerclage wires)Nerve injury

axillary nerve injury (up to 58%)increased risk with anterolateral acromial approach axillary nerve is found 7cm distal to the tip of the acromion

suprascapular nerve (up to 48%)Malunion

usually varus apex-anterior or malunion of GTtreated with corrective osteotomy/fixation if patient is young or active

Nonunion

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See More Cases

usually with surgical neck and tuberosity fxtreatment of chronic nonunion/malunion in the elderly should include arthroplasty lesser tuberosity nonunion leads to weakness with lift-off testing greater tuberosity nonunion leads to lack of active shoulder elevationgreatest risk factors for non-union are age and smoking

Rotator cuff injuries and dysfunctionMissed posterior dislocationAdhesive capsulitisPosttraumatic arthritisInfection

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(SBQ07.16) A cadaveric study in 1990 established much of the orthopaedic literature on humeral head vascularity fortwo decades until recent experiments have provided new data. This original study in 1990 concluded that theanterolateral branch of the anterior circumflex artery supplies blood to what aspect of the proximal humerus? Review Topic

1. Anterior portion of humeral head2. Lesser tuberosity3. Entire humeral head except posteroinferior portion of lesser tuberosity and head4. Entire humeral head except posteroinferior portion of greater tuberosity and head5. Entire humeral head except entire greater tuberosity

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Clin. Orthop. Relat. Res.. 2013 Jan;471(1):39-43. PMID: 22752734 (Link to Pubmed)Trauma - Journal Club - Proximal Humerus Fractures

Functional outcomes after nonoperative management of fractures ofthe proximal humerus. Hanson B, Neidenbach P, de Boer P, Stengel DJ Shoulder Elbow Surg. 2009 Jul-Aug;18(4):612-21. PMID: 19559373 (Link to Pubmed)Trauma - Journal Club - Proximal Humerus Fractures

12/10/2014

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The impacted varus (A2.2) proximal humeral fracture: prediction ofoutcome and results of nonoperative treatment in 99 patients. Court-Brown CM, McQueen MMActa Orthop Scand. 2004 Dec;75(6):736-40. PMID: 15762264 (Link to Pubmed)Trauma - Journal Club - Proximal Humerus Fractures

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