2-4 % of upper extremity # 5% of all #. second most common fracture of the upperextremity. Pt > 65 yrs – third most common # 65% of # occur in Pt’s > 60 yrs F:M – 3:1 Incidence increases with age.
Old Pts low energy trauma. [FOOSH] Most # are nondisplaced, good prognosis –nonsurgical Risk factors: Poor quality bone impaired vision &balance, medical comorbidities, decreased muscletone. Young Pts – High energy trauma. Severe soft tissue disruption always requiresurgical intervention Seizures & electric shock – indirect causes.
Articular head, G.T, L.T, for insertion for rotatorcuff & shaft. Metaphyseal flare – surgical neck mostcommon site of # Anatomic neck. Articular segment is almost spherical, with adiameter of curvature averaging 46 mm (rangingfrom 37 to 57 mm) Inclination of the humeral head relative to theshaft averages 130 degrees
Humeral retroversion – 18*-40* Bone density of subchondral bone is strongest. Greater tuberosity has three regions into whichthe supraspinatus, infraspinatus, and teres minorinsert Subscapularis tendon lesser tuberosity, whichis separated from the greater tuberosity by thebicipital groove.
PH is formed by 3 ossification centres Fusion of these ossification centers at the physiscreates a weakened area that is susceptible tofracture . Primary deforming forces – pectoralis major &rotator cuff. Blood supply: distal branches of axillary artery. Arcuate artery of Liang – supplies H. head. Tethered trifucation – at the level of surgical neck– vascular injury.
Ecchymosis appears 24-48 hrs. Look for rib, scapular, cervical # in high energytrauma. Concurrent brachial plexus injury 5% Axillary nerve is susceptible in anterior #dislocation. Gentle rotation of arm & palpation of # - guide for# stability .
Edwin smith papyrus: closed / open. Kocher : location of #, supratubercular,periT, infraT, subT. Codman: 11 different types, described # along thelines of epiphyseal scars. Watson & Jones: based on mechanism of injury AO – 27 possible subgroups, emphasizes onvascular supply of articular portion of PH.
DePalma and Cautilli emphasized the differencebetween fractures with and without dislocation ofthe joint surfaces Neer classification: # classified by evaluating thedisplacement of parts from each other. Criteria to consider as a part, fragment must berotated 45* or 1 cm from the another fragment.
Articular surface # are two types Impression # mostly occurs in association withchronic dislocations. Head splitting # are associated with other # inwhich splitting of AS is significant component. Neer -Commonly used because it based on theregional anatomy & emphasis on degree ofdiplacement.
almost exclusively in older people tend to develop periarthritis about the shoulder,these fractures should be treated by methods thatallow early motion and early restoration of function
Most # [>80%] can be treated conservatively. Two part nondisplaced is the most commonvariant. 3 & 4 part # represent 13-16% of PH%. Good outcome doesn’t require anatomicreduction. Considerations: assessment of #, bone quality,status of rotator cuff. Pt age, activity level,preinjury health.
Non-displaced # - < 5mm of superior or 10 mm ofposterior GT displacement in active Pts & < 10mm of superior displacement in nondominant armin sedentary pt. Surgical neck # - any bone contact in elderly pt, inyoung pt <50% shaft diameter displacement &<45* angulation in dominant arm.
Reduced demand: Pt willing to accept stiffness Poor health: pt unable to tolerate surgery &anaesthesia. Poor rehabilitation candidate.
Principle: early protection & combined withgradual mobilization. Early sling immobilisation for 7-10 days. Active finger, wrist, elbow movts By 2 wks, gentle active assisted ROM ex By 6 wks, light resistive ex By 3 months, shoulder strengthening ex.
most commonly occur as a result of seizures orsecondary to glenohumeral dislocations. These often reduce anatomically with reduction ofthe humeral head and can be managednonoperatively. displaced more than 1 cm, open reduction andinternal fixation are required fixation with screws, wire, or suture as dictated bythe size of the fragment, the comminution, or thequality of the bone
If tuberosity has been displaced and retracted, asignificant tear in the rotator cuff mechanismexists also, Careful identification and repair of the rotator cuffdefect are required
Two-part # involving the anatomical neck renderthe articular fragment avascular and may requireprosthetic replacement. Involving the surgical neck usually can be treatedby a sling, hanging arm cast, or other conservativemeasures. Indications for operative treatment of two-partfractures include open fractures, the inability toobtain or maintain an acceptable closed reduction,injury to the axillary artery, and selected multipletrauma patients
Indications for CRPF # without significant communition in pt with goodquality bone. Pt should be willing to comply with postop careplan. Contraindications: Severe communition &osteopenia. Inability to reduce the #.
The safe starting point for the proximal lateralpins and the end point for the greater tuberositypins. X = distance from the superiormost aspect of thehumeral head to the inferiormost aspect of thehumeral head. 2X = the starting point for the proximal lateral pin. The end point for the greater tuberosity pinshould be >2 cm from the inferior most margin ofthe humeral head.
Shoulder immobilised for 4 wks Pt were reviewed every wk for checking the pinsposition, Pins can be removed by 4-6 wks time, beginassisted motion.
If open reduction is necessary, internal fixationwith a combination of intramedullary rod fixationand tension band technique or intramedullary rodfixation with a proximal locking screw. A hand-bent semitubular plate used as a blade-plate device also is satisfactory in osteopenicbone. In younger patients, an AO buttress plate withscrews also is useful.
ORIF one of the tuberosities remains with the articularhead fragment, thereby retaining its vascularity
Rationale: injury caused avascularity of articularsegment which even with a satisfactoryreduction & fixation would eventually collapse –posttraumatic arthritis. Indications:1. four part# & # dislocations,2. three part # & # dislocations in elderly pts withosteopenic bone, anatomic neck3. Head splitting #4. Anatomic neck # that can not be R & F.5. Chronic dislocation with impression # involving>40% articular surface.
More likely after surgical than nonoperative #care. Careful postop followup is necessary.1) INSTABILITY Glenoid # , rotator cuff tear, muscle atony. ORIF glenoid, repair of cuff, isometric ex.2) MALUNION Incorrect diagnosis, poor reduction, inadequatefixation. Release of adhesions, with or with outosteotomy Vs trim of prominence.
3) NONUNION Motion too early, poor bone. Preserved head – ORIF & BG Cavitated head – HHR4) AVASCULAR NECROSIS: Four part # & dislocation HHR5) NEUROVASCULAR INJURY Four part with head in axilla If nerve injury + at the time of closed injury,prognosis is good.
6) INFECTION: Immune compromise & extensive soft tissueloss Hard ware removal & debridement.7) ARTHRITIS Hardware penetrating the jt8) Refractory shoulder stiffness9) CHARCOT SHOULDER: unusual fragmentation occurs after #10) Heterotopic bone formation. Soft tissue injury, repeated manipulation,delayed reduction beyond 7 days.
NEER CLASSIFICATION: Classified according to the amount ofdisplacement. Grade I fracture is displaced less than 5 mm. Grade IV fracture involves total displacement.
Open reduction indicated for1) the rare displaced Salter-Harris types III and IVfractures,2) interposition of the biceps tendon in the fracturesite,3) fracture-dislocations4) open fractures