proximal humerus fracture

1. SHOULDER

2. FUNCTIONAL RESULTS AFTER FRACTURE
SURGERY: UNPREDICTABLE
• Complex anatomy
• Interaction of anatomic
structures
• Numerous muscle
attachments
• Subacromial Bursa

4. BLOOD SUPPLY
• Vascularisation of the humeral head is possible ONLY
via the ascending branch of the anterior humeral
circumflex artery
Gerber et al. JBJS 72A:1486,1990

5. INITIAL WORKUP
• History: Mechanism of injury – High/Low energy
• Clinical Assessment:
Look: ?? Dislocation,
Feel: Axillary nerve, Clavicle # ??,
Surgical emphysema (rib #s)
• Neurological Exam: Brachial plexus injury
• Vascular Injury

6. FACTORS GUIDING CHOICE OF T/T
PATIENT FACTORS*
• Physiological age
• Patient’s choice
• Hand dominance
• Multiple medical co-morbidities
• Poor mental status (non compliant)
• Associated injuries
• Timing of presentation
*Krishnan SG et al. Hemiarthoplasty for proximal humeral fracture. Orthop Clin North
Am.2008;39:441

7. 34 female
COPD
Smoker
Obese

8. At 3 momths

9. At 6 months

10. AW 46 Female
Slim
Healthy
Non-smoker
Dominant hand

11. AW 46 O - AT SURGERY

12. TECHNIQUE OF REDUCTION

13. SURGERY
• Reduction held with 3 K wires
• Retain/ Reconstruct medial buttress

14. MEDIAL BUTTRESS – ALLOGRAFT
• Robinson CM. JBJS(Br) 2010;92-B:672
• Gardener MJ. J Orthop Trauma 2008;22:195

15. MEDIAL BUTTRESS – SYNTHETIC BONE
SUBSTITUTE (CALLOS)

16. MEDIAL BUTTRESS – CALLOS 14/12

17. MEDIAL COMMUNITION -
MEDIALISATION
• Lee CW. Prognostic factors for unstable fractures treated with locking-plate fixation. J
Shoulder Elbow Surg 2009;18:83

18. COMPLICATIONS
• Screw penetration
• Varus malreduction – implant failure*
• AVN – 5 – 17%**
• *Agudelo J et al Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J
Orthop Trauma 2007;21(10):676
• **Greiner S et al. Humeral head necrosis rate at midterm FU for PH#. Injury 2009;40:186-91

20. 83 FEMALE
COPD, DIABETIC, OSTEOPOROSIS

21. 4 PART FRACTURE DISLOCATION:
VASCULAR COMPROMISE WITH ROTATOR CUFF INJURY

22. 89 Female
IHD
HT

24. NON-UNION WITH ROTATOR CUFF
COMPROMISE

27. 1. Failure of fixation of
tuberosities
2. Lack of maintenance of
offset - Stem height
3. Version of the humeral stem

28. STANDARD TECHNIQUE FOR
FIXATION OF TUBEROSITIES
• 4 Horizontal Tension
Bands – across both
tuberosities and around
neck of prosthesis
• 2 Vertical Tension Bands
• Ticron 5

29. HEMI – STEM HEIGHT
• Provides adequate lever arm for the rotator cuff.
• Shortening >1cm prevents optimum function*
• How do we calculate??
medial calcar**
prosthesis : glenoid relationship
distance from pec major tendon to top of humeral
head is constant (51 – 54mm)***
*Boileau P et al. Shoulder arthroplasty for fractures: problems and solutions. Shoulder
arthroplasty.Heidelberg:Springer-Verlag;1999:297
**Mighell MA et al. Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg.
2006;72:387
***Murachovsky J et al. Pectoralis major tendon reference: a new method. J Shoulder Elbow Surg 2006;15:675

30. HEMI - RETROVERSION
• Range 20° - 40°*
• Reliance on the bicipital groove**
• Use of the fracture jig
*Kontakis et al.The bicipital groove as a landmark for orientation of the humeral
prosthesis. J Shoulder Elbow Surg 2001;10:136
**Baig et al. Bicipital groove orientation: considerations for the retroversion of a
prosthesis. J Shoulder Elbow Surg 2006;15:195

31. DISPLACED FRACTURES????
Is functional outcome of displaced fractures similar
in both conservative & surgical t/t ??

32. DISPLACED FRACTURES????
Is functional outcome of displaced fractures similar
in both conservative & surgical t/t ??
Handoll et al Cochrane Review 2007
McLaurin TM. PHF Are we operating on too many? Bull Hosp J Dis 2004;62:24
Zyto K et al Non-operative t/t of comminuted fractures of the PH in elderly patients.
Injury 1998;29(5):349
Rasmussen S et al. Displaced PHF:results of conservative t/t.Injury 1992;23(1):441
Rangan A et al. JAMA. ProFHer Trial 2010

33. PROXIMAL HUMERAL FRACTURES
• Buckle #
• SH Classification.
• Displacement % Varus/Valgus

34. WHAT IS ACCEPTABLE REDUCTION?
• The proximal physis contributes 80% of the length of the
humerus.
• Enormous remodelling potential
• The older child with greater deformity may be treated with
closed reduction -controversial
• Approximate indications are:
– 5-12 years - accept 60 degree angulation and 50%
displacement
– >12 years - accept 30 degrees angulation and 30%
displacement

35. INDICATIONS FOR MUA/ PINNING
• >50% displacement of the humeral head relative to the shaft
• Angulation AP or lateral x-ray of
>60 degrees in a child <12 years
>30 degrees in a child >12 years
• Pathological fracture of the proximal humerus
• Associated injuries, i.e. brachial plexus injury, vascular injury
• In association with other unilateral upper limb fractures and
multiple trauma

36. FRACTURE DISLOCATIONS

37. ROTATOR CUFF - COMPONENTS
• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis

38. ROTATOR CUFF - COMPONENTS
• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis
Which is the 5th component?

39. ROTATOR CUFF: PRIME FUNCTIONS
• Prime INITIATOR of Abduction
• ROTATION of the Humerus (90% of external rotation
strength)
• STABILISER of the joint (Muscular balance)
• COMPRESSOR of the Humeral head into the glenoid fossa
DELTOID ---- FORCE of Abduction (55%)

40. BIOMECHANICS:
ARM ELEVATION
STABILITY: Rotator Cuff & Long head of Biceps
Shoulder Girdle Complex muscles
FORCE & ENDURANCE: Deltoid
Rotator Cuff
BALANCE BETWEEN DELTOID FORCE & ARM WEIGHT

41. DELTOID MOMENT > ARM WEIGHT MOMENT
= ELEVATION

42. PROF GRAMMONT’S CONCEPT
• CR – medialised & stabilised
• 10mm more lateralisation of humerus L2>L1
• Deltoid length/force increased (164%) F2>F1

43. PROF GRAMMONT’S CONCEPT
• CR – medialised & stabilised
• 10mm more lateralisation of humerus L2>L1
• Deltoid length/force increased (164%) F2>F1

44. ROTATOR CUFF TEAR - MINOR
• Elevation normal – ENDURANCE shorter
• Elevation by external rotation of the shoulder –
biceps becomes the head depressor for the
deltoid to act

45. ROTATOR CUFF TEAR – WHO?
• Age 45 yrs
• 40% “never done strenuous physical work”
• Cuff defects frequently bilateral
• Many heavy manual labourers never develop
cuff defects
• 50% no recollection of shoulder trauma
Neer CS II Impingement Lesions,Clin Orth173:70-77;1983

46. INJURY - ACUTE TEARS
• Uncommon
• High Impact injury
Fall from a height
Mountain biking
RTAs (Motor bikers)
Often associated with shoulder dislocation
& other injuries: Brachial plexus
• Overhead athletics

47. OVERHEAD ATHLETICS / SPORTS
• Pathology*
Tensile overload
Outlet impingement
Internal impingement
• Asymptomatic throwers have rotator cuff abnormalities
*Rotator cuff tears in overhead athletes. Economopoulos KJ1, Brockmeier SF.
Clin Sports Med. 2012 Oct;31(4):675-92.

48. HIGH IMPACT INJURY
COMPLETE TEARS
• Investigation – MRI
• Surgical repair
• Open
• Arthroscopic

49. OVERHEAD ATHLETICS
• Acute Partial Tears
• Acute on chronic tears

50. ACUTE PARTIAL TEARS
• <50% partial thickness tears*
• Conservative management
• Surgical
Debridement*
Decompression surgery**
• Good results
*Débridement of small partial-thickness rotator cuff tears in elite overhead throwers. Reynolds SB et al
Clin Orthop Relat Res. 2008 Mar;466(3):614-21
**Partial thickness rotator cuff tears: Results of arthroscopic treatment. Snyder SJ et al Arthroscopy: The Journal of Arthroscopic & Related
Surgery Vol 7, Issue 1, March 91, 1-7
**Rotator cuff tears in overhead athletes. Economopoulos KJ1, Brockmeier SF.
Clin Sports Med. 2012 Oct;31(4):675-92.

51. ACUTE COMPLETE TEARS
• Investigation: Ultrasound / MRI
• Treatment: Surgical
• Time: within 3 weeks*
*Acute Tears of the Rotator Cuff: The Timing of Surgical Repair. Bassett RW, Cofield RH
Clinical Orthopaedics & Related Research: May 1983 Vol 175