Proximal humerus fractures

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Proximal humerus fractures

  1. 1.  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.
  2. 2.  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.
  3. 3.  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
  4. 4.  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.
  5. 5.  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.
  6. 6.  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 .
  7. 7.  Scapular AP, Y- lateral, abducted & Velpeauaxillary view. CT – to assess glenoid #, dislocation,communition, & posteriorly displaced GT ormedially displaced LT fragments. MRI: Pt had preinjury shoulder problem [cuff tear],pathological #, nonunion.
  8. 8.  Edwin smith papyrus: closed / open. Kocher [1896]: 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.
  9. 9.  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.
  10. 10.  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.
  11. 11.  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
  12. 12.  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.
  13. 13.  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.
  14. 14.  Reduced demand: Pt willing to accept stiffness Poor health: pt unable to tolerate surgery &anaesthesia. Poor rehabilitation candidate.
  15. 15.  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.
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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 #.
  20. 20.  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.
  21. 21.  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.
  22. 22.  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.
  23. 23.  ORIF one of the tuberosities remains with the articularhead fragment, thereby retaining its vascularity
  24. 24.  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.
  25. 25.  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.
  26. 26. 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.
  27. 27. 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.
  28. 28.  NEER CLASSIFICATION: Classified according to the amount ofdisplacement. Grade I fracture is displaced less than 5 mm. Grade IV fracture involves total displacement.
  29. 29.  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

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