2. PROXIMAL HUMERUS FRACTURES
• Defined as fractures occurring at or proximal to surgical neck of
humerus
• m/c humerus fracture-45%
• Age > 65- 2nd M/C Fs of upper extremity
• Incidence increases with age
• F:M- 3:1
• Most of Pts are osteoporotic post menopausal woman
• Most fractures are nondisplaced(85%), good prognosis
• < 5% of paediatric fractures
3. ANATOMY
• 4 parts
• Head of humerus
• Greater tuberosity
• Lesser tuberosity
• Shaft
• 3 ossification centre's
- humeral head, GT, LT
4. ANATOMY
• GT-Supraspinatus, Infraspinatus & teres minor
• LT- Subscapularis
• intertubercular sulcus/ bicipital groove-tendon of the long head of the
biceps brachii
• “a lady between two majors”
• Surgical neck-axillary nerve and circumflex humeral vessels
5. ANATOMY
• Axillary nerve- Deltoid, teres mionor,
• Abduction
• Regimental badge area
• just antero inferior to glenohumoral joint. It is at risk of traction injury
and injury while anterior fracture-dislocation
6. ANATOMY
• Arcuate artery of Liang- supplies head
• Ascending branch of ACHA(anterior circumflex humeral artery) supplies
most of blood to articular segment
• Posterior circumflex humeral artery- blood supply to humeral head
7. MECHANISM OF INJURY
• Fall on outstretched arm
• Direct trauma
• Older Pt- low energy trauma(FOOSH)
• Young Pt-high energy trauma
• Indirect cause- seizures & electric shock
• Pathological- malignant/ benign lesions
8. DEFORMING FORCES
• GT is pulled posteromedially by supraspinatus and infraspinatus
tendons
• LT is pulled anteriorly and medially by Subscapularis tendons
• The shaft segment is pulled anteromedially by Pect. Major tendon
• Deltoid abducts the proximal fragment
9. CLINICAL FEATURES
• Pain may not be severe, as the fracture may be deeply impacted
• Signs of axillary nv/brachial plexus injury
•
29. LEGO SYSTEM BY HERTEL ET AL (BINARY
SYSTEM)
• Lego blocks
• 5 yes-or-no questions had to be answered concerning the 5
basic fracture planes:
• (1) Is there a fracture plane between the head and greater
tuberosity?
• (2) Is there a fracture plane between the greater tuberosity
and shaft?
• (3) Is there a fracture plane between the head and lesser
tuberosity?
• (4) Is there a fracture plane between the lesser tuberosity and
shaft?
• (5) Is there a fracture plane between the greater tuberosity
and lesser tuberosity?
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral
head ischemia after intracapsular fracture of the proximal humerus.
J Shoulder Elbow Surg 2004;13:427-33. http://dx.doi.org/10.1016/j.
jse.2004.01.034
30. LEGO SYSTEM
• assessed the humeral head vascularity in the context of different
fracture plane locations
• Hertel et al emphasized the importance of the location of fracture
planes, rather than the specific number of fracture fragments
31. HGLS CLASSIFICATION SYSTEM:-(
CODMAN'S MODIFICATION OF HERTEL' S
SYSTEM)
• A fracture plane is represented by a
hyphen (-)
Codman E. Fractures in relation to the subacromial bursa. In: Codman E,
32. TREATMENT
Minimally displaced fractures- One part fractures
• Non-operative
• Sling immobilization/swathe for comfort
• Early range of motion when pain permits(usually after 1-2weeks)
• Pendulum exercises and gentle isometric strengthening of biceps and triceps to compress
fracture fragments
• After 3-4 weeks-supine passive flexion and external rotation exercises may be added
• 4-5 weeks-overhead pulley exercises
• 6-8 weeks- strengthening
• Resistive exercises started b/w 6-12 weeks
• Full ROM and function is expected outcome by 1 year
33. TWO PART FRACTURES :-
• Anatomic neck fractures
• Rare
• Difficult to treat by closed reduction
• For younger Pt- ORIF
• For older Pt- Hemiarthroplasty due to risk of avascular necrosis of humeral head
34. TWO PART FRACTURES
(SURGICAL NECK FRACTURES)
• Non operative-
• Angulated/displaced surgical neck fractures which are stable( move as a
unit)
• In lower demand Pt
• Severely debilitated pt
• Those who can not tolerate surgery
• Closed reduction and percutaneous pin
35. TWO PART FRACTURES
(SURGICAL NECK FRACTURES)
• Closed reduction and percutaneous pin
• Indications-
• Pt with good bone quality
• Noncomminuted/ minimally comminuted fractures that can be reduced by
closed means
• Contraindications-
• Severe comminution
• Osteopenia
36. TWO PART FRACTURES
(SURGICAL NECK FRACTURES)
• Advantages
• Avoidance of devascularisation of fracture fragments
• Minimization of injury to blood supply of humeral head
• Reduced operative morbidity
• Disadvantage-
• Risk of nerve injury- axillary
• Pin loosening
• Pin migration
• Inability to move the arm
• Risk of pin migration
• Loss of reduction
37. TWO PART FRACTURES
(SURGICAL NECK FRACTURES)
• ORIF
• IM device
• Plate and screws
• Prosthetic replacement
• For PT with extreme osteopenia
• May be hemiarthroplasty, total shoulder, or reverse shoulder prosthesis
38. TWO PART FRACTURES
(GT FRACTURES)
• often associated with anterior dislocation
• Reduces to good position once the shoulder is relocated
• If it does not reduce, the fragment can be reattached through a
small incision interosseous sutures, or in young hard bone-
cancellous screws
• ORIF with /without rotator cuff repair is indicated for GT fractures
which are displaced >5-10 mm
• Otherwise, they may develop non union/ subacromial impingement
39. TWO PART FRACTURES
(LT FRACTURES)
• Must rule out associated Posterior dislocation
• May be treated closely unless displaced fragment blocks internal
rotation
40. THREE PART FRACTURES
• Usually involve displacement of surgical neck and GT
• Unstable due to opposing muscle forces- so closed reduction and its
maintenance is often difficult.
• In active Pts it is best managed by ORIF
• Younger Pt- attempt ORIF using plate and srews
• replacement- indicated in elderly
41. FOUR PART FRACTURES
• Very severe injuries with a high risk of complications like
• Vascular injury
• Brachial plexus damage
• Injuries of chest wall
• (later) Avascular necrosis of humeral head
• In younger Pts, an attempt should be made at reconstruction by ORIF if head is
within glenoid fossa and there appears to be soft tissue continuity
• Fixation can be done with locking plate and screws, sutures and /or wire fixation
• Primary prosthetic replacement- indicated in elderly
42. FRACTURE-DISLOCATIONS
• Fracture-dislocations:-
• 2 part FD:-
• May be treated closed after shoulder reduction
• 3 and 4 part-
• ORIF in younger
• Prosthetic replacement in older
• Brachial plexus and axillary artery are in proximity to humeral head fragment with anterior fracture
dislocation
• Recurrent dislocation is rare following fracture union
• Prosthetic replacement of anatomic neck fracture dislocation is recommended because of high
incidence of osteonecrosis
• May be associated with increased incidence of Myositis ossificans with repeated attempts at closed
reduction
43. ARTICULAR SURFACE FRACTURES
• Hill-sach's and reverse Hill sach's
• Pt with > 40% of humeral head involvement - may require replacement
• <40 years - ORIF should be considered initially, if possible
44. • Studied 231 pt
• >16 years
• Follow up- 2 years
• Results-
• No significant difference b/w surgical treatment compared with nonsurgical
treatment
Rangan, Amar, et al. "Surgical vs nonsurgical treatment of adults with displaced
fractures of the proximal humerus: the PROFHER randomized clinical
trial." Jama 313.10 (2015): 1037-1047.
46. • Constant and Murley score
• excellent (score 86-100), good (score 71-85), fair (score 56-70) and
poor (0-55).
• conservatively treated patients- 75.69
• close reduction and percutaneous K wire fixation -82.79
• open reduction and internal fixation with anatomical locking plate -73.6.
47. SURGICAL CONSIDERATIONS
• Pt position-
• Supine
• beach chair position
• Allows weight of arm to facilitate fracture reduction
• Prosthetic replacement is usually performed
48. SURGICAL CONSIDERATIONS
• Surgical approach-
• Deltopectoral
• Allows for extensile approach to proximal humerus
• ORIF/ arthroplasty is well performed through this approach
• Deltoid split:-
• Allows for easier plate placement on GT and requires fewer assistants to
retract deltoid muscle
49. COMPLICATIONS
• Vascular injury
• Infrequent(5-6%)
• m/c sit- axillary artery(proximal to ACHA)
• Incidence high in older individuals due to atherosclerosis and loss of vessel
elasticity
• Neural injury
• Brachial plexus injury- 6%
• Axillary nv injury-
• Vulnerable with anterior fracture dislocation, because the nerve nv courses
on the inferior capsule and is prone to traction injury or laceration
50. COMPLICATIONS
• Chest injury
• Intrathoracic dislocation may occur with surgical neck fracture-
dislocations
• Pneumothorax
• Haemothorax
• Myositis ossificans:-
• Uncommon
• Ass with chronic unreduced fracture dislocations, repeated
attempts at closed reductions
• May also be related to timing of surgery and deltoid split
approaches
51. COMPLICATIONS
• Shoulder stiffness
• May be minimized with an aggressive, supervised physical therapy regimen
and may require open lysis of adhesions for recalcitrant cases
• Avascular necrosis-
• 10-30% in 3 part fractures
• 10-50% in 4 part fractures
• High in anatomic neck fractures
• Hertel criteria
• Metaphyseal extension of humeral head < 8mm 97% predictive
value
• Medial hinge disruption of > 2mm, and
