anatomy , classification,treatment

1. PROXIMAL HUMERUS
FRACTURES
Dr P. ROHIT RAJ
MBBS MS ORTHO
ASSISTANT PROFESSOR
ORTHOPAEDIC DEPARTMENT
VISHWABHARATHI MEDICAL COLLEGE

3. INDEX
 1) INTRODUCTION
 2) MECHANISM OF INJURY
 3) CLINICAL ANATOMY
 4) IMAGING STUDIES
 5) CLINICAL FEATURES
 6) CLASSIFICATION
 7) MANAGEMENT
 8) OPERATIVE APPROACHES
 9) COMPLICATIONS

4. INTRODUCTION
 Proximal humerus fractures comprise 4% to 5%
of all fractures and represent the most common
humerus fracture (45%).
 The increased incidence in the older population
is due to osteoporosis.
 The 2:1 female-to-male ratio is likely related to
bone density

6. MECHANISM OF INJURY
 Indirect trauma : By fall on outstreatched
hand is the most common cause. This is
common in elderly osteoporotic women.
 Direct trauma : Usually a result of high
energy violence, commonly seen in young
patients and associated with severe fractures
and significant soft tissue disruptions

7. MECHANISM OF INJURY
 Less common mechanisms include:
 Excessive shoulder abduction in an individual
with osteoporosis, in which the greater
tuberosity prevents further rotation.
 Direct trauma, usually associated with greater
tuberosity fractures.
 Electrical shock or seizure.
 Pathologic processes: malignant or benign
processes in the proximal humerus

8. CLINICAL ANATOMY
 The inclination of the humeral head relative to the
shaft averages 130 degrees.
 Humeral retroversion, as measured with respect to the
epicondyles of the distal humerus, averages about 20
degrees.

10. CLINICAL ANATOMY
 The four osseous segments (Neer) are:
 The humeral head.
 The lesser tuberosity.
 The greater tuberosity.
 The humeral shaft

11. CLINICAL ANATOMY
 Deforming muscular forces on the osseous
segments :
 The greater tuberosity is displaced superiorly and
posteriorly by the supraspinatus and external
rotators.
 The lesser tuberosity is displaced medially by the
subscapularis.
 The humeral shaft is displaced medially by the
pectoralis major.
 The deltoid insertion causes abduction of the
proximal fragment.

13. CLINICAL ANATOMY
 Neurovascular supply:
 The major blood supply is from the anterior and posterior
humeral circumflex arteries.
 The arcuate artery is a continuation of the ascending
branch of the anterior humeral circumflex. It enters the
bicipital groove and supplies most of the humeral head.
 Small contributions to the humeral head blood supply
arise from the posterior humeral circumflex.
 Fractures of the anatomic neck have a poor prognosis
because of the precarious vascular supply to the humeral
head.

14. CLINICAL ANATOMY
 The axillary nerve courses just
anteroinferior to the glenohumeral
joint, traversing the quadrangular
space. It is at particular risk for traction
injury owing to its relative rigid
fixation at the posterior cord and
deltoid.

15. IMAGING STUDIES
 Trauma series, consisting of AP and lateral views in the
scapular plane as well as an axillary view.
 Axillary is the best view for evaluation of glenoid
articular fractures and dislocations, but it may be
difficult to obtain because of pain.
 Velpeau axillary: If a standard axillary cannot be
obtained because of pain or fear of fracture
displacement, the patient may be left in the sling and
leaned obliquely backward 45 degrees over the cassette.
The beam is directed caudally, orthogonal to the cassette,
resulting in an axillary view with magnification

17. IMAGING STUDIES
 Computed tomography is helpful in evaluating
articular involvement, degree of fracture
displacement, impression fractures, and glenoid
rim fractures.
 Magnetic resonance imaging is generally not
indicated for fracture management, but it may be
used to assess rotator cuff integrity.

19. CLINICAL FEATURES
 Patients typically present with the upper
extremity held closely to the chest by the
contralateral hand, with pain, swelling,
tenderness, painful range of motion, and
variable crepitus.
 Chest wall and flank ecchymosis may be
present and should be differentiated from
thoracic injury.

20. CLINICAL FEATURES
 A careful neurovascular examination is essential,
with particular attention to axillary nerve function.
 This may be assessed by the presence of
sensation on the lateral aspect of the proximal arm
overlying the deltoid.

 Motor testing is usually not possible at this stage
because of pain.

21. CLASSIFICATION
 NEERS CLASSIFICATION
 Four parts: These are the greater and lesser
tuberosities, humeral shaft, and humeral head.
 A part is defined as displaced if >1 cm of
fracture displacement or >45 degrees of
angulation

22.  Fracture types include:
 One-part fractures: Undisplaced or minimally displaced
 Two-part fractures:
 #Anatomic neck.
 #Surgical neck.
 #Greater tuberosity.
 #Lesser tuberosity.
 Three-part fractures: Usually the fragments are
 Surgical neck with greater tuberosity.
 Surgical neck with lesser tuberosity.
 Four-part fractures.
 Fracture dislocation: May be ass with 2 part #, 3 part #, or 4 part#

23. MANAGEMENT

25. CLASSIFICATION OF
INDIVIDUAL SUBTYPES

26. UNDISPLACED OR MINIMALLY
DISPLACED ONE-PART FRACTURE
 50% of proximal humerus # are undisplaced.
 Such # occur in younger age group of patients
because of better bone stock and stronger and
thicker periosteal sleeve of tissue preventing #
displacement.
 May be associated with rotator cuff injuries.
Arthroscopic debridement and repair may be
successful in these patients.

27. TREATMENT
 Managed Nonoperativley.
 Oral analgesia, supplemented by topical ice/heat therapy is prescribed,
and a sling or shoulder immobiliser is given to rest the arm.
 Radiographs are taken at 1 to 2 weeks to ensure any secondary
displacement has not occurred.
 Elbow, wrist and hand mobilisation begins immediatley.
 Pendular exercises are started at around 1week. Active shoulder
isometric exercises are begun at 3weeks progressing to isotonic exercises
at 6 to 12 weeks.
 Pt advised to continue exercise during the first year.

28. Fractures of the proximal humerus
Treatment:
Slightly displaced humeral
neck fractures may be
treated satisfactorily by
external support alone.
Firstly, the arm should be
supported in a sling or a
collar.

29. Fractures of the proximal humerus
After 2 weeks the body
bandage may be discarded
unless pain is commanding.
The sling should be worn under
the outer clothes.
The patient is advised to
commence rocking movements
of the shoulder abduction,
flexion (1) and to remove the
arm from the sling three or four
times per day to flex and
extend the elbow (2).

30. Fractures of the proximal humerus
At 4 weeks the sling can be
placed outside the clothes.
Gentle active movements
should be practised
throughout the day. Over
the next 2 weeks the
patient should be
encouraged to discard the
use of the sling in gradual
stages.

31. Fractures of the proximal humerus
At 6 weeks the patient
should be referred for
physiotherapy if, there is
considerable restriction of
movement.

32. TWO-PART GREATER TUBEROSITY
FRACTURES
 10% of proximal humerus #.
 Recovery is late because of associated disfunctioning or
impingment of rotator cuff.
 50% are isolated fractures. Remaining 50% fractures associated
with nerve injury or dislocation or soft tissue injury.
 TERRIBLE TRIAD : Combination of GT avulsion, ant
dislocation of shoulder and nerve or plexus injury.
 10% of GT# fracture have associated anatomical neck fracture
which is not visible on AP view of x-ray.

34. TREATMENT
 Undisplaced # are treated non-operatively.
 Secondary displacements are common due to pull by
supraspinatus and infraspinatus tendons.
 older surgically unfit pts are treated non operatively.
 Operative treatment is given for younger and older pts who are
surgically fit with # displacement of >5mm.
 ORIF with 3.5mm cancellous screws or with k-wires can be
performed.
 Open reduction done by limited deltoid splitting approach.

35. TWO-PART LESSER TUBEROSITY
FRACTURE
 Very rare.
 Mostly displaced medially due to pull by
subscapularis tendon.
 Associated with high velocity injuries, more
common in middle aged males.
 Associated with avulsion of subscapularis tendon
due to forced externl rotation.

36. TREATMENT
 OPERATIVE TREATMENT
 ORIF through deltopectoral approach.
 For single large fragment internal fixation
performed with 3.5mm cancellous screws.
 For multiple small fragments reduction is
maintained by interosseous sutures.

37. TWO-PART SURGICAL NECK
FRACTURES
 25% Of proximal humerus fractures.
 More common in older age group of pts.
 Extra-articular # hence lesser risk of osteonecrosis of humeral head.
 Fracture may be angulated or separated or comminuted.
 Angulated # may be in varus or in valgus or in neutral alignment.
 Shaft is impacted with humeral head and is directed anteromedially by
the pull of pectoralis major.

39. TREATMENT
 Surgical neck fractures with <45 degree
angulation may be treated by sling
immobilisation with early range of motion.
 Displaced, unstable or fractures with >45 degree
angulation may require closed or open reduction
and internal fixation with k-wires.
 Locking compression plates or percutaneous k-
wires can be done.

43. TWO PART ANATOMICAL
NECK FRACTURES
 Extremely uncommon injuries.
 Associated with high rate of osteonecrosis
 Frequently occurs in association with posterior
dislocation of head of humerus.

45. TREATMENT
 Open reduction and internal fixation in
younger patients.
 Shoulder hemiarthroplasty for older patients.

47. THREE PART FRACTURE
 Usually the fragments are
1)Surgical neck with greater tuberosity or
2)Surgical neck with lesser tuberosity
 As with 2-part fractures 3-part fractures may
be in neutral, valgus or in varus alignment.

48. TREATMENT
 These are unstable due to opposing muscle forces; hence
closed reduction and maintenance of reduction are often
difficult.
 Displaced fractures require operative fixation, except in
severely debilitated patients or those who cannot tolerate
surgery.
 Younger individuals should have an attempt at ORIF;
preservation of the vascular supply is very imp .
 Older patients may benefit from primary prosthetic
replacement (hemiarthroplasty).

49. Pinning technique

50. FOUR PART FRACTURES
 It includes involvement of all four osseous
components as described by neer.
 It may or may not be associated with
dislocation.
 Risk of osteonecrosis is more in four part
fractures

51. TREATMENT
 Incidence of osteonecrosis ranges from 13% to
35%.
 ORIF may be attempted in young patients if the
humeral head is located within the glenoid
fossa and there appears to be soft tissue
continuity. Fixation may be achieved with
multiple Kirschner wire, screw fixation, suture
or wire fixation, or plate and screws.

52. Four-part proximal humerus fracture treated with closed
reduction and percutaneous pinning. The postoperative x-ray
shows satisfactory fracture union. The patient had excellent
function 1 year after surgery.

53. TREATMENT
 Primary prosthetic replacement of the humeral
head (hemiarthroplasty) is the procedure of
choice in the elderly.
 Hemiarthroplasty is associated with
unpredictable results.
 Four-part valgus impacted proximal humerus
fractures represent variants that are associated
with lower rate of osteonecrosis and have had
better reported results with ORIF

54. THREE PART AND FOUR PART
FRACTURES WITH DISLOCATIONS
 Very rare.
 Anterior dislocations are much more common
than posterior dislocations.
 2types
1)Anterior fracture dislocation
2)Posterior fracture dislocation

55. ANTERIOR FRACTURE
DISLOCATIONS
 Have better prognosis following ORIF.
 2 subtypes
 1) Type 1 injuries (Viable humeral head with
retained capsular attachments). Seen in younger
patients with high energy injuries.
 2) Type 2 injuries ( Nonviable humeral head
devoid of significant capsular attachments).
Seen in older patients with low energy trauma.

56. TREATMENT
 Type 1 anterior fracture dislocations : ORIF is
attempted for all fractures, as the risk of
osteonecrosis is very less.
 Closed manipulation should never be attempted.
 Through extended deltoid approach fractured
tuberosities are tagged with stay sutures.
 Following relocation of head fracture may be
reconstructed with locking plate or k-wires.

57. TREATMENT
 Type 2 anterior fracture dislocations : humeral
head is devoid of soft tissue attachments and
no evidence of arterial bleeding.
 Head salvaging reconstruction with plate
fixation is tied for younger patients.
 For older patients its between closed reduction
and arthroplasty.
 Attempt of gentle closed manipulation is given
under GA.

58. POSTERIOR FRACTURE
DISLOCATIONS
 Rare and occur in middle aged males.
 Usually bilateral produced by seizures due to
alcohol withdrawal, hypoglycemia.
 Unilateral injuries typically occur from fall
from height or road traffic accidents.
 It is analogous to type 1 anterior fracture
dislocation.

59. TREATMENT
 As with type 1 anterior fracture
dislocation ORIF is attempted in all cases
of fracture dislocation due to low risk of
osteonecrosis.

60. OPERATIVE APPROACHES
 1) DELTOPECTORAL APPROACH
 2) DELTOID SPLITTING APPROACHES
a) Limited deltoid splitting approach
b) extended deltoid splitting approach
 3) OTHER APPROACHES

61. COMPLICATIONS
 1) NEUROVASCULAR INJURY
 2) CHEST INJURY
 3) OSTEONECROSIS
 4) NON UNION
 5) MALUNION
 6) MYOSITIS OSSIFICANS
 7) INFECTION
 8) POST TRAUMATIC SHOULDER
STIFFNESS

62. COMPLICATIONS
 Vascular injury:
This is infrequent (5% to 6%); the axillary artery is the most
common site (proximal to anterior circumflex artery). The
incidence is increased in older individuals with atherosclerosis
because of the loss of vessel wall elasticity.
 Neural injury
 Brachial plexus injury: This is infrequent (6%).
 Axillary nerve injury: This is particularly vulnerable with
anterior fracture-dislocation.

63. COMPLICATIONS
 Chest injury: Pneumothorax and hemothorax must be
ruled out in the appropriate clinical setting.
 Myositis ossificans: This is uncommon and is associated
with chronic unreduced fracture-dislocations and repeated
attempts at closed reduction.
 Shoulder stiffness: It may be minimized with an
aggressive, supervised physical therapy regimen and may
require open lysis of adhesions .
 Osteonecrosis: This may complicate 3% to 14% of three-
part proximal humeral fractures, 13% to 34% of four-part
fractures, and a high rate of anatomic neck fractures.

64. OSTEONECROSIS AFTER 6YEARS
OF SURGERY

65. COMPLICATIONS
 Nonunion: This occurs particularly in displaced two-
part surgical neck fractures with soft tissue
interposition. Other causes include excessive traction,
severe fracture displacement, systemic disease, poor
bone quality, inadequate fixation, and infection.
 Malunion: This occurs after inadequate closed
reduction or failed ORIF and may result in
impingement of the greater tuberosity on the acromion,
with subsequent restriction of shoulder motion.

66. NON-UNION

67. MALUNITED PROXIMAL
HUMERUS FRACTURE