proximal humerus fracture presentation introduction epidemiology classification treament complications

1. Proximal Humerus Fracture
Frcs orthopaedic trauma fisrt aid

2. Definition
Fracture proximal to surgical neck
Parts of proximal humerus.
1-Articular surface/head
2-Greater tuberosity
3-Lesser tuberosity
4-Surgical neck

3. INCIDENCE
• 4-6% of all fractures
• 3rd most common non-vertebral
fracture pattern seen in the elderly (>65
years old)
• Two-part surgical neck fractures most
common
• 2:1 female to male ratio

5. Risk Factors
• Osteoporosis
• Diabetes
• Epilepsy
• Female

7. Mechanism
• low-energy falls in
elderly with
osteoporotic bone.
• High-energy trauma in
young.

8. Relevant Anatomy
Osteology
• Anatomic neck old epiphyseal
plate
• surgical neck weakened area
below head
• more often involved in
fractures
• average neck-shaft angle is
135 degrees

10. Ligaments
1-Coracohumeral ligament
• attaches to coracoid and greater
tuberosity and strengthens the
rotator interval
2-SGHL
• restraint to inferior translation at 0°
degrees of abduction (neutral
rotation)
3-MGHL
• resists AP translation in the midrange
(~45°) of abduction
4-IGHL
• restraint to AP translation at 90°
degrees of abduction

11. Muscle attachment proximal humerus
Greater tuberosity
From superior to inferior
• Supraspinatus.
• Infraspinatus.
• Teres minor.
Lesser tuberosity
• Subscapularis.
Lateral lip bicipital groove
• Pectoralis major
Medial lip bicipital groove
• Teres major
Teres major

12. Blood supply of proximal humerus
1-Anterior humeral circumflex artery
• large number of anastomosis with
other vessels in the proximal humerus
Branches
• anterolateral ascending branch
• arcuate artery is the terminal branch
and main supply to greater tuberosity.
2-posterior humeral circumflex artery
• recent studies suggest it is the main
blood supply to humeral head

13. Risk of avascular necrosis
• vascularity of articular segment is more
likely to be preserved if ≥ 8mm of calcar is
attached to articular segment
• Hertel criteria (predictors of humeral
head ischemia)
1. <8 mm of calcar length attached to
articular segment
2. Disrupted medial hinge
3. Increasing fracture complexity
4. Displacement >10mm
5. Angulation >45°

14. Deforming force
• Pectoralis major displaces shaft
anteriorly and medially
• Supraspinatus, Infraspinatus,
and Teres minor externally
rotate greater tuberosity
• Subscapularis internally rotates
articular segment or lesser
tuberosity

15. Associated conditions
Nerve injury
• Axillary nerve injury most common
Arterial injury
• uncommon (incidence 5-6%), higher likelihood in older patients
• most often occur at level of surgical neck or with subcoracoid
dislocation of the head

16. Neer classification
• Based on anatomic relationship
of 4 segments
1. Greater tuberosity
2. Lesser tuberosity
3. Articular surface
4. Shaft
a segment separate part if
• Displacement of > 1 cm
• 45° angulation

17. • One-part: nondisplaced or minimally displaced fracture (often of the humeral
neck)
• Two-part: displacement of tuberosity of more than 1 cm; or surgical neck
with head/shaft angled or displaced.
• Three-part: displacement of the greater or lesser tuberosities and articular
surface
• Four-part: displacement of shaft, articular surface, and both tuberosities.
“Head splitting” is a variant, with split through the articular surface (usually
requires replacement for treatment).

18. Surgical neck two part fracture

19. Greater tuberosity 2 part fracture

20. Lesser tuberosity 2 part fracture

21. Greater tuberosity 3 part fracture

22. Lesser tuberosity 3 part fracture

23. Greater tuberosity 4 part fracture

24. Lesser tuberosity 4 part fracture

25. Clinical presentation
Symptoms
• pain and swelling
• decreased motion
Physical exam
• inspection
• extensive ecchymosis of chest, arm,
and forearm
• neurovascular exam
• axillary nerve injury most common
• determine function of deltoid muscle
and lateral shoulder sensation
• arterial injury may be masked by
extensive collateral circulation
preserving distal pulses
• examine for concomitant chest wall
injuries

26. Investigations:-
• Radiographs
• True AP (Grashey)
• Scapular Y
• Axillary
Additional views
• Apical oblique
• Velpeau
• West Point axillary
findings
• combined cortical thickness
(medial + lateral thickness >4 mm)
• studies suggest correlation with
increased lateral plate pullout
strength

27. Investigations:-
CT scan
indications
• preoperative planning
• Humeral head or greater
tuberosity position uncertain
• Intra-articular comminution
• concern for head-split fracture

28. Ap grashey view

29. Scapular Y view

30. Axillary view

31. Nonoperative
sling immobilization followed by progressive rehabilitation.
Indications
• minimally displaced
surgical and anatomic
neck fractures.
• Greater
tuberosity fracture
displaced < 5mm.
• Surgically unfit.
>5mm displacement will result in
impingement with loss of
abduction and external rotation.

32. CRPP (closed reduction percutaneous pinning)
indications
1. 2-part surgical neck fractures
2. 3-part and valgus-impacted 4-part fractures in patients with good
bone quality, minimal metaphyseal comminution, and intact medial
calcar
outcomes
• higher complication rate compared to ORIF, HA, and RSA
• Axillary nerve at risk with lateral pins
• musculocutaneous nerve, cephalic vein, and bicep tendon at risk with
anterior pins

33. ORIF
• indications
1. Greater tuberosity displaced > 5mm.
2. Displaced 2-part fractures
3. 3-, and 4-part fractures in younger patients.
4. head-splitting fractures in younger patients.
outcomes
• medial support necessary for fractures with posteromedial comminution
• consider use of a fibula strut if concerned about medial support or bone
quality
• calcar screw placement critical to decrease varus collapse of head

34. Intramedullary nailing
indications
1. surgical neck fractures or 3-part greater tuberosity fractures in
younger patients.
2. combined proximal humerus and humeral shaft fractures.
outcomes
• biomechanically inferior with torsional stress compared to plates
• favorable rates of fracture healing and ROM compared to ORIF

35. Arthroplasty
• indications
1. Hemiarthroplasty
• younger patients (40-65 years old) with complex fracture-dislocations or
head-splitting components that may fail fixation
• recommended use of convertible stems to permit easier conversion to RSA
if necessary in future
2. Reverse total shoulder
• low-demand elderly individuals with non-reconstructible tuberosities and
poor bone stock
• older patients with fracture-dislocation

36. Arthroplasty outcome
outcomes
• improved results if
• Anatomic tuberosity reduction and healing.
• Restoration of humeral height and version
• Humeral height is best judged from the superior border of the pectoralis
major insertion
• poor results with
• tuberosity nonunion or malunion.
• retroversion of humeral component > 40.

37. Surgical neck fracture
• Most common fx pattern Deforming forces:
1) pectoralis pulls shaft anterior and medial
2) head and attached tuberosities stay neutral
• Nonoperative
• Closed reduction often possible
• Sling
• Operative
• -indications controversial
• -technique
• --- CRPP
• --- Plate fixation
• --- IM nail

38. Greater tuberosity fracture
• Deforming forces: GT pulled superior and posterior by
SS, IS, and TM
• Can only accept minimal displacement (<5mm) or
else it will block ER and ABD
• Nonoperative
• indicated for GT displaced < 5 mm
• Operative
• indicated for GT displacement > 5 mm
• - isolated screw fixation only in young with good bone
stock
• - non-absorbable suture technique for osteoporotic
bone (avoid hardware due to impingement)
• -tension band wiring

39. Lesser tuberosity fracture
• Assume posterior dislocation until
proven otherwise
• Nonoperative
• Minimally or non-displaced
• Operative
• ORIF if large fragment
• excision with RCR if small

40. Anatomic neck fracture
• Nonoperative
• Minimally or non-displaced
• Operative
• ORIF in young
• ORIF v. hemiarthroplasty v.
reverse total shoulder
arthroplasty in elderly

41. Surgical neck & greater tuberosity fracture
• Unopposed pull of posterior cuff
musculature leads articular surface to
point anterior
• Often associated with longitudinal RCT
• Trend towards nonoperative
management given high complications
with ORIF
• Young patient
• - percutaneous pinning (good results,
protect axillary nerve)
• - IM fixation (violates cuff)
• - locking plate (poor results with high
rate of AVN, impingement, infection, and
malunion)
• Elderly patient
• - Hemiarthroplasty with RCR or
tuberosity repair vs. reverse total
shoulder arthroplasty

42. Four part valgus impacted fracture
• Specific type of displaced four-part
fracture.
• valgus impaction of the head fragment.
• low rate of rate of avascular necrosis.
• axial trauma to the abducted upper limb,
• direct impaction between the humeral
head and the glenoid cavity.
• posteromedial displacement (dorsal
tilting of the head) because of its
physiological anatomical conformation in
retroversion.
• low rate of rate of avascular necrosis

43. Four part valgus impacted fracture
• Radiographically will see alignment
between medial shaft and head
segments
• Low rate of AVN if posteromedial
component intact thus preserving
intraosseous blood supply
• Surgical technique
• 1. raise articular surface and fill
defects
• 2. repair tuberosities

44. Four part head splitting fracture
• High risk of AVN (21-75%)
• Deforming forces:
• 1) shaft pulled medially by pectoralis
• Young patient
• ORIF vs. hemiarthroplasty
• hemiarthroplasty favored for non-
reconstructible articular surface, severe
head split, extruded anatomic neck fracture.
• Elderly patient
• -Hemiarthroplasty v. reverse total shoulder
arthroplasty

45. complications
Screw cut-out
• incidence
• most common complication following
periarticular locking plating fixation (up to
14%)

47. complications
Avascular necrosis
• risk factors for humeral head ischemia
are not the same for developing
subsequent avascular necrosis
• better tolerated than in lower
extremity
• no relationship to type of fixation
(plate or cerclage wires)

48. Complications
Nerve injury
Axillary nerve (up to 58% )
• increased risk with lateral (deltoid-splitting) approach
• axillary nerve is usually found ~5-7cm distal to the tip of the
acromion
• at risk with lateral pins in CRPP
Suprascapular nerve (up to 48%)
Musculocutaneous nerve
• at risk with anterior pins in CRP

49. complications
Malunion
• usually varus apex-anterior or malunion of GT
• results inferior if converting from varus malunited fracture to TSA
• use reverse shoulder arthroplasty instead
Nonunion
• most common after two-part surgical neck fracture
• treatment of chronic nonunion/malunion in the elderly should include arthroplasty
• lesser tuberosity nonunion leads to weakness with lift-off testing
• greater tuberosity nonunion after arthroplasty leads to lack of active shoulder elevation
• greatest risk factors for nonunion are age and smoking

50. complications
Rotator cuff injuries and dysfunction
Long head of biceps tendon injuries
• also at risk with anterior pin in CRPP
Missed posterior dislocation
• consider in all patients with lesser tuberosity fracture
Adhesive capsulitis and scar tissue
Posttraumatic arthritis
Infection