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Proximal humerus fractures by krr

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PROXIMAL HUMERUS FRACTURES

Published in: Education

Proximal humerus fractures by krr

  1. 1. MODERATOR: DR.SUBRAMANIAN PRESENTER: DR.RAMACHANDRA
  2. 2. It is the commonest # affecting shoulder girdle in adults. Proximal humeral # account for almost 7% of all # and 80% of all humeral #. In pts above the age of 65 years proximal humeral # are the 2nd most frequent upper extremity #.
  3. 3. Shoulder has greatest range of motion of any articulation in body. It is due to shallow glenoid fossa that is only 25% of humeral head. Major contribution to stability is by soft tissue composed of muscle, capsule, & ligaments. Proximal humerus is retroverted 35 to 40 degrees relative to epicondylar axis.
  4. 4. Four osseous segments in proximal humerus are: Humeral head Lesser tuberosity Greater tuberosity Humeral shaft
  5. 5.  Greater tuberosity is displaced by supraspinatus & external rotators.  Lesser tuberosity is displaced by subscapularis.  Humeral shaft displaced by pectoralis major.  Deltoid insertion causes abduction of proximal fragment.
  6. 6. Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman. Younger pts present following high energy trauma. Less common with excessive shoulder abduction, direct trauma, electric shock or seizures.
  7. 7. The proximal humerus can # as a consequence of 3 main loading modes: Compressive loading of the glenoid onto the humeral head. Bending forces at the surgical neck. Tension forces of the rotator cuff at the greater & lesser tuberosities.
  8. 8. The majority of proximal humeral # occur as isolated injuries. In polytrauma pts, proximal humeral # frequently exhibit comminution extending into the humeral shaft.  In the presence of # dislocations, glenoid rim and neck # and avulsion # of the coracoid may occur.
  9. 9.  The association of arterial injuries is rare and is reported in the literature as isolated case reports.  Electromyographic evidence of neurologic injury can be present in as many as 67% of proximal humeral #.  The most frequently affected nerves are the axillary nerve (58%) & suprascapular nerve (48%), with combined neurologic lesions being frequent.
  10. 10. The association of rotator cuff tears has been found to increase with age. Full-thickness tears have been found in only 6% of proximal humerus pts under 60 years of age compared to 30% in those pts above 60 years of age.
  11. 11. Pts typically present with upper extremity held closely to chest by contralateral hand, pain, swelling & tenderness. Ecchymosis may or may not be present. Careful neurovascular exmn. is essential. mainly for Axillary nerve function. It is assessed by presence of sensation on lateral aspect of proximal arm overlying deltoid.
  12. 12. CODMAN’S CLASSIFICATION  NEER CLASSIFICATION AO/OTA CLASSIFICATION
  13. 13.  A- Greater tuberosity  B- Lesser tuberosity  C- Head  D- Shaft
  14. 14. Most commonly used classification is Neer’s classification. Useful in guiding treatment. Based on four part anatomy of proximal humerus : Humeral head, lesser & greater tuberosities, proximal shaft.
  15. 15. Criteria for displacement Greater than 1cm of seperation of a part or Angulation of 45 degrees. Osteonecrosis is most likely after displaced four part fractures.
  16. 16.  X ray AP view of shoulder in plane of scapula.
  17. 17.  Neer Lateral Y view of shoulder.
  18. 18.  Axillary view of shoulder.
  19. 19. CT of proximal humeral # is helpful in providing further understanding of fracture configuration. Axial images can confirm displacement of the lesser and greater tuberosity fragments in the transverse plane.
  20. 20. Coronal images give more detail about the alignment of the humeral head & assessment of comminution at the level of the humeral calcar, the integrity of the inferomedial hinge, and extent of metaphyseal # extension. Sagittal images help in determining a flexion or extension deformity of the proximal humerus with regard to the shaft.
  21. 21. NON OPERATIVE TREATMENT OPERATIVE TREATMENT
  22. 22. Immobilization of the arm to the chest using a simple collar and cuff sling Gilchrist or Velpeau type shoulder immobilizer used. At 2 weeks passive ROM exercises of the shoulder.
  23. 23.  At 3 or 4 weeks radiographs are taken & gentle assistive exercises (pulley elevation, external rotation with a stick, extension with a stick) are begun.  At 6 weeks, rapid progression to terminal stretches and light resistive exercises is started
  24. 24. Predictors for outcomes have been found to be age factor. Court-Brown et al. studied 131 two-part surgical neck #. At 1yr follow up pts able to return to housework Non operative treatment yielded results similar to those of surgical treatment even in # with translation of 66% or more.
  25. 25. Court-Brown et al. further assessed non operative treatment of four-part valgus- impacted # in elderly patients. Good or excellent results were achieved in 81% of patients according to Neer’s criteria.
  26. 26.  The treatment of displaced proximal humeral # is complex & requires careful assessment  Pt factors (age & activity level)  Fracture-related factors (bone quality, fracture pattern, degree of comminution, & vascular status).  The goal of treatment is a pain-free shoulder with restoration of pre-injury function.
  27. 27. Good predictors of ischemia are:  Metaphyseal extension of the humeral head of <8 mm  Medial hinge disruption of >2 mm Ischemia of head:  The combination of metaphyseal extension of the humeral head.  Medial hinge disruption of >2 mm  Anatomic neck # pattern Radiographic criteria for perfusion of humeral head
  28. 28. Operative management is guided by fracture pattern & cortical thickness. Combined cortical thickness is the average of medial & lateral cortical thickness. A cortical thickness <4mm- sling, osteosuture & hemiarthroplasty. A cortical thickness >4mm- internal fixation.
  29. 29. INDICATIONS CONTRAINDICATIONS  proximal humeral fractures that have at least 1 cm of displacement between the head and the shaft fragments  or 5 mm of displacement of the tuberosity fragment.  previous attempt(s) at internal fixation  More than 6wks old #.  Four part comminuted #
  30. 30.  Flatow et al. reported isolated greater tuberosity # had good or excellent results with osseous union.  78% of the pt had an excellent result according to the criteria of Neer et al. in 2 or 3 part #.
  31. 31. INDICATIONS  greater tuberosity # isolation or in conjunction with a surgical neck #.  three and four-part proximal humeral #.  four-part valgus impacted # or true four part #.  severe osteopenia or osteoporosis.  Comminution of the medial portion of the calcar or proximal part of the humeral shaft. CONTRAINDICATIONS
  32. 32. Two surgical approaches are commonly used to perform open reduction and internal fixation (ORIF). These are the Delto pectoral approach Deltoid-splitting approach.
  33. 33. INDICATIONS CONTRAINDICATIONS  AO type-B (bifocal)  AO type-C (anatomic neck)  Fracture-dislocations  Head splitting fractures  Impression fractures that involve >40% of the articular surface
  34. 34.  The plate should be positioned directly on the middle of the lateral cortex and approximately 8 mm distal to the superior aspect of the greater tuberosity. Humeral head preservation may be possible with locked-plate fixation supplemented with local bone graft or bone-graft substitute.
  35. 35. The main indications for proximal humerus interlocking IMIL nailing are displaced two- part surgical neck # especially those with extension into the humeral diaphysis, and pathologic #. Three-part greater tuberosity fractures may also be amenable to fixation with IM nailing
  36. 36. INDICATIONS CONTRAINDICATIONS  Four-part #, three-part # in older pts with osteoporotic bone.  Fracture-dislocations  Head-splitting fractures  That involve >40% of the articular surface  Active infection of the shoulder joint and/or  Surrounding soft tissue
  37. 37.  Delto pectoral approach  proximal anatomy is restored by  greater tuberosity cerclage sutures medial to the humeral neck and tie them around the greater tuberosity fragment.
  38. 38.  A second set of sutures can then be passed into the lesser tuberosity and tied.
  39. 39. Osteonecrosis: 3% to 14% of 3 part # , 4 to 14% of 4 part # & high rate in anatomical neck #. Infections Nonunion Malunion Shoulder stiffness Implant failure Pin tract infection
  40. 40. Neurovascular injury Impingement syndrome Rotator cuff injury
  41. 41. DHANYAVAAD

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