Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Proximal humerus fractures by krr


Published on


Published in: Education

Proximal humerus fractures by krr

  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.
  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.
  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