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 anatomy and classification

10,198 views

Published on

proximal humerus #s anatomy

Published in: Health & Medicine

Proximal humerus fractures anatomy and classification

  1. 1. BY G T SAI PRASANTH MODERATOR : DR ARUN KAMAL SIR 01-10-2014
  2. 2.  ANATOMY OF SHOULDER GIRDLE  PATHOPHYSIOLOGY OF PROXIMAL HUMERUS FRACTURES  CLASSIFICATION OF PROXIMAL HUMERUS FRACTURES  RECENT ADVANCES
  3. 3. BONES  The bones that are involved in the formation of shoulder girdle include :  Humerus  Scapula with clavicle  Glenohumeral joint  Glenohumeral joint is a ball and socket type of synovial joint formed between the head of humerus and glenoid cavity of scapula.
  4. 4. SCAPULA • Flat bone on the postero lateral aspect of thorax between 2-7 ribs. • Spine of scapula divides the posterior surface into Supraspinous and infra - spinous fossa . • The scapula has three borders and three angles • The ant & post surfaces act as attachments for muscles acting on shoulder joint.
  5. 5. HUMERUS  The proximal end of humerus has a head, surgical and anatomical neck, greater and lesser tubercles.  The anatomical neck separates the head from the tubercles and is the attachment of shoulder capsule.  The surgical neck – Importance ?
  6. 6. FACTS ABOUT PROXIMAL HUMERUS  The humeral articular segment occupies approximately one third of a sphere, with a diameter of curvature averaging 46 mm.  The inclination of the humeral head relative to the shaft averages 130 degrees (with a range of 123 to 136 degrees).  The geometric center of the humeral head is offset an average of 2.6 mm posteriorly (range of -0.8 to 6.1 mm) and 7 mm (range of 3 to 11 mm) medially from the axis of the humeral shaft.  The humeral head is normally retroverted by an average of 20 degrees, with respect to the distal humeral interepicondylar axis.
  7. 7. MUSCLES  The muscles around the proximal humerus include :  Rotator cuff muscles : Supraspinatus, Infraspinatus, Teres minor and Subscapularis.  Deltoid  Pectoralis major  Teres major and Latissimus dorsi
  8. 8. Supraspinatus, infraspinatus and teres minor insert on the greater tubercle and cause lateral rotation . Subscapularis causes medial rotation along with pectoralis and T. major
  9. 9. GLENOHUMERAL JOINT AND THE LIGAMENTS  The shallow glenoid cavity is deepened by the glenoid labrum (fibrocartilagenous).  Only a third of the head articulates in the glenoid cavity at a given point.  Stabilized by the overlying muscles.  The ligaments include :  The joint capsule  Glenohumeral ligaments  Coracohumeral ligament  Coracoacromial arch  Transverse humeral ligament
  10. 10. NERVES & VESSELS  The nerves supplying the proximal humerus region include :  The axillary nerve  Suprascapular nerve  Lateral pectoral nerves  The vessels supplying the proximal humerus and the glenohumeral joint include :  Circumflex humeral arteries  Anterior circumflex  Posterior circumflex  Anastomosis around the shoulder joint.
  11. 11.  The main blood supply to the humeral head comes from the anterior circumflex humeral vessels through its anterolateral ascending artery.  The posterior circumflex vasculature becomes important after a fracture dislocation/ 3 or 4 part fracture.  The chances of osteonecrosis developing in a complex proximal humeral fracture is somewhat less as the soft tissue attachments of the fracture fragments maintain blood supply.  Only fractures with complete comminution with complete capsular disruption will go for osteonecrosis.  The axillary nerve lying at the surgical neck is prone for injury after a fracture.
  12. 12. BURSAE  Bursae are synovial fluid filled cavities present around the joint to reduce friction.  They directly communicate with the shoulder joint.  Subscapular bursa : protects the tendon of subscapularis  Subacromial bursa: between supraspinatus tendon and shoulder capsule inferiorly and acromion, coracoacromial arch and deltoid superiorly.
  13. 13. PATHOPHYSIOLOGY OF PROXIMAL HUMERUS FRACTURES  Proximal humerus fractures are mainly osteoporotic fractures  Can either be due to high energy trauma or low energy trauma.  The latter are mainly seen in elderly due to osteopenia & osteoporosis.  Occur either due to direct impact on the shoulder where the head gets fractured against the glenoid or indirect impact i.e fall on outstretched hand.
  14. 14.  Patients with direct injuries to shoulder tend to be more dilapidated as compared to the other group.  The maximum bone density is found in the subchondral bone right beneath the articular surface.  The posterosuperior quadrant of the humeral head is the most minerally dense area.
  15. 15. CLASSIFICATION OF PROXIMAL HUMERUS FRACTURES  Codman described that the proximal humerus tends to fracture along the lines of physeal fusion into four fragments: lesser tuberosity, greater tuberosity, head and the shaft.  Neers classification is the most commonly used classification presently.  Each of the four fragments are considered as unique parts only if they are separated by more than 1 cm or angulated by more than 45 degrees to one another
  16. 16.  Undisplaced or minimally displaced fractures are termed one-part fractures.  Displaced fractures are classified according to the number of displaced fragments, regardless of the number of secondary fracture lines, into two-, three-, or four-part configuration.  Fracture-dislocations are also classified according to the direction of displacement of the humeral head (anterior or posterior).
  17. 17. Normal anatomy
  18. 18. Undisplaced or Minimally Displaced One-Part Fractures (OTA Types A, B, or C)  Most common type of proximal humerus fracture (>50%)  Occurs in younger and fitter individuals with good bone stock.  Minimally displaced fracture lines can be present on the radiograph on any of the four parts.  Associated subluxation of shoulder joint may occur due to hemarthrosis, capsular atony.  Mostly treated by conservative management.
  19. 19. Undisplaced and stable one part fracture configurations
  20. 20. Two-Part Greater Tuberosity Fractures and Fracture-Dislocations (OTA Types A1.1, A1.2, and A1.3)  The spectrum includes : Isolated fractures & fractures with glenohumeral dislocation and nerve injury.  Terrible triad of shoulder ?  Mechanism:  Axial loading causing anatomical neck # with greater tuberosity #( 10 % prevalence).  Traction injury during a glenohumeral dislocation which causes greater tuberosity fracture due to avulsion injury.  Multifragmentary vs single fragment greater tuberosity fractures  Due to the risk of redislocation due to the muscle pull even 5mm displacement must be operated upon.
  21. 21. Seemingly isolated GT # may also have Anatomical neck # Properly oriented AP view needed
  22. 22. Rotator cuff deficient High riding humerus Retraction Causing pull Large frgmnt Small frgmnt
  23. 23. Two-Part Lesser Tuberosity Fractures and Fracture- Dislocations (OTA Type A1.3, Subgroup 4)  Very rare fractures, middle aged males, due to a very high force.  Forced external rotation causing isolated fractures or associated with posterior dislocation of shoulder.  The attached subscapularis tendon pulls the fragment medially.
  24. 24. Two-Part Extra-Articular (Surgical Neck) Fractures (OTA Types A2 and A3)  25 %, older individuals, low risk of osteonecrosis.  Three types of surgical neck fractures:  angulated, translated/separated, and comminuted  Angulated fractures:  Neutral alignment or head tilted in varus or valgus.  The shaft is usually impacted into the head hence good healing potential.  Translation/separation & comminution:  Can be mild or complete translation. Severe comminution – cortical discontinuity.  The head usually adopts a varus position due to pull of the rotator cuff and shaft dispalces anteromedially due to the pull of P. major
  25. 25. IMPACTED TRANSLATED COMMINUTED
  26. 26. Two-Part Anatomic Neck Fractures (OTA Type C1.3)  Extremely uncommon injury  Associated with a high risk of osteonecrosis  When present occurs with posterior dislocation of shoulder joint
  27. 27. Three- and Four-Part Fractures Without Dislocation (OTA Types B1, B2, C1, and C2)  10 %, multifragementary, the variation in these fractures depend on the nature of deforming forces.  Anatomical neck fracture is a constant feature - movement of shaft in relation to head – 2* tuberosity fracture.  The various factors that play a part in the outcome of these #’s:  Humeral head angulation and displacement :  Neutral angulation :  Head in neutral/internal rotated if three part greater tuberosity #  Impacted valgus fracture :  The head faces superiorly (increased neck shaft angle) with splaying of tuberosities.  Impacted varus fracture :  The fractured humeral head is tilted into varus.
  28. 28. Valgus angulation fractures The 1 & 2nd pictures show undisplaced and mild valgus displacement The 3 & 4th pictures show severe valgus angulation with lateral translation of head with increased chances of osteonecrosis
  29. 29. Varus angulation with Inferior subluxation of humeral head
  30. 30.  Tuberosity fracture configuration & Displacement :  The tuberosities # secondary to head displacement.  The deformity tends to progress due to the muscle pull.  The three part G T # >>>>>>>>> L T #  The avulsed G T fragement moves posterosuperiomedially whereas the avulsed L T fragment anteromedially.  Humeral head viability and risk of osteonecrosis:  The risk of osteonecrosis increases with loss of capsular attachment to the head fragment.  Long posteromedial metaphyseal spike of bone attached to the humeral head--- better perfusion.  Preservation of a medial hinge in a valgus fracture  No reliable method is present to predict the occurrence of osteonecrosis.  Articular surface involvement :  Humeral head impacted into the glenoid causing head split.  The tuberosity fragments carry parts of humeral articular surface.
  31. 31. Pic 1: “Double shadow “of humeral Head pathognomic of head split fractures
  32. 32. Complex Fractures with Glenohumeral Dislocation (OTA Types B3 and C3)  Complete dislocation of fractured humeral head from glenoid cavity  Anterior fracture dislocations are more common than posterior fracture dislocations.  Most severe and have higher chances of developing ON.  Three part and four part anterior fracture dislocation are divided into :  Type I injuries  Type II injuries
  33. 33.  Type I injuries:  Viable Humeral Head With Retained Capsular Attachments  Young adults, high velocity injury.  The dislocated humeral head retains the capsule attachments through periosteal sleeve around lesser tuberosity.  Type II injuries :  more common, occurs in older females.  low-energy trauma, non viable humeral head.  the fracture resembles a three or four part valgus fracture, but with the humeral head dislocated anteroinferiorly, and not engaged on the glenoid.  The humeral head fractures in a valgus position and the exposed sharp medial calcar tears the capsule.  The capsule is torn which leads to increased risk of developing ON.
  34. 34. TYPE I INJURY WITH ANTERO- INFERIOR DISLOCATION OF HEAD
  35. 35. TYPE II INJURIES
  36. 36.  Current classification systems for these fractures are based on anatomical and pathological principles, and not on systematic image reading.  These fractures can appear in many different forms, with many characteristics that must be identified.  However, many current classification systems lack good reliability, both inter-observer and intra-observer for different image types.  21 fracture characteristics are identified & they are applied along with classical Codman approaches to classify fractures.
  37. 37.  The new classification system, based on fracture characterization and using Codman classification graphs, presents a new image reading protocol with 21 fracture characteristics divided into five groups.
  38. 38. Bibliography  Rockwood and Greens fractures in adults 7th edition  Keith L Moore Clinically applied anatomy 6th edition  Frank H Netter atlas of Human anatomy, 4th edition.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27052 77/
  39. 39. THANK YOU

×