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Proximal humerus fracture
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- 2. Case ผู้ป่วยหญิง อายุ 30ปี ปวดแขนขวา 2 ชั่วโมงก่อนมาโรงพยาบาล สาเหตุ ขับ MC ล้มเอง Event 9.00 25/06/2560 Arrived at MNRH 11.00 25/06/2560
- 3. Primary survey A :can speak, not tender along C-spine, active neck flexion B : trachea in midline, equal breath sound, chest compression test negative C : pulse 78 bpm full regular, no external bleeding, abdomen soft, not tender, no guarding, no rebound tenderness D : E4M6V5, pupil 2 mm RTLBE
- 4. Primary survey E :marked tender at right arm, no external wound, avulsion wound at right zygoma 2x2 cm laceration wound at right orbital rim 2 cm avulsion wound at chin 3 cm no active bleeding
- 5. Secondary survey A :no drug/food allergy M : no current medication, denied herb used P : no underlying disease, denied major trauma, denied history of surgery L : NPO 00.00 E : ขับ MC เสียหลัก ล้มเอง ไม่สลบ จําเหตุการณ์ได้ แขนขวาและ ใบหน้ากระแทกพื้น ไม่ปวดศีรษะ ไม่คลื่นไส้อาเจียน ปวดแขนขวา มาก ขยับได้น้อยเนื่องจากเจ็บ ขยับปลายนิ้วได้ปกติ ไม่อ่อนแรง ไม่ชา
- 6. Physical examination Vital sign: T36.9c, BP 119/64 mmHg, PR 78 bpm, RR 18/min General appearance : Thai adult woman, good consciousness, well cooperated HEENT : no pale conjunctiva, anicteric sclera avulsion wound at right zygoma 2x2 cm laceration wound at right orbital rim 2 cm avulsion wound at chin 3 cm no active bleeding
- 7. Physical examination Heart :normal S1S2, no murmur Lung : equal breath sound, no adventitious sound Abdomen : soft, not tender, no guarding, no rebound tenderness Extremities : marked tender at proximal right arm, mild swelling, no external wound, normal movement of right hand and finger, radial pulse 2+, ulnar pulse 2+, capillary refill <2 sec Neurological exam : motor grade V all except right arm cannot evaluate due to pain
- 9. Management at ER •Check neurovascular + Immobilization (on arm sling) • Imaging CXR Film right arm AP, transcapular Y view Film skull AP, lateral, towne, water • Medication Pain control tramol 50 mg IV stat then q 6 hr plasil 10 mg IV prn q 6 hr ATB cefazolin 1 g IC stat then q 6 hr Vaccine Tetanus vaccine 0.5 ml IM
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- 13. • Epidemiology – incidence •4-6% of all fractures • third most common fracture pattern seen in elderly – demographics • 2:1 female to male ratio • increasing age correlates with increasing fracture risk in women • Pathophysiology – mechanism • low-energy falls – elderly with osteoporotic bone • high-energy trauma – young individuals – concomitant soft tissue and neurovascular injuries
- 14. • Associated conditions –nerve injury • axillary nerve palsy most common – fracture-dislocations • more commonly associated with nerve injuries
- 15. Anatomy • Osteology – anatomicneck (epiphyseal plate) – surgical neck (weakened area)
- 16. Anatomy • Vascular anatomy –anterior humeral circumflex artery – posterior humeral circumflex artery
- 17. Classification • Neer classification(4 segments) – greater tuberosity – lesser tuberosity – articular surface – shaft • considered a separate part if – displacement of > 1 cm – 45° angulation
- 19. Evaluation • Symptoms – painand swelling – decreased motion • Physical exam – inspection • extensive ecchymosis of chest, arm, and forearm – neurovascular exam • 45% incidence of nerve injury (axillary most common) • arterial injury may be masked by extensive collateral circulation preserving distal pulses
- 20. Imaging • Radiographs • completetrauma series – true AP – scapular Y – axillary • CT scan – indications • preoperative planning • humeral head or greater tuberosity position uncertain • intra-articular comminution • MRI – indications • rarely indicated • useful to identify associated rotator cuff injury
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- 22. Diagnosis • Closed fractureright proximal humerus (4 parts)
- 23. Treatment • Nonoperative – slingimmobilization followed by progressive rehab • indications » minimally displaced surgical neck fracture (1-, 2- , and 3-part) » greater tuberosity fracture displaced < 5mm » fractures in patients who are not surgical candidates – start early range of motion within 14 days
- 24. Treatment • Operative – CRPP(closed reduction percutaneous pinning) • indications – 2-part surgical neck fractures – 3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar – ORIF • indications – greater tuberosity displaced > 5mm – 2-,3-, and 4-part fractures in younger patients – head-splitting fractures in younger patients
- 25. Treatment • Operative – intramedullaryrodding • indications – surgical neck fractures or 3-part greater tuberosity fractures in younger patients – combined proximal humerus and humeral shaft fractures
- 26. Treatment • Operative – hemiarthroplasty •indications – anatomic neck fractures in elderly (initial varus malalignment >20 degrees) or those that are severely comminuted – 4-part fractures and fracture-dislocations (3-part if stable internal fixation unachievable) – rotator cuff compromise – glenoid surface is intact and healthy – chronic nonunions or malunions in the elderly – head-splitting fractures with incongruity of humeral head – humeral head impression defect of > 40% of articular surface – detachment of articular blood supply (most 3- and 4-part fractures)
- 27. Treatment Operative – totalshoulder arthroplasty • indications – rotator cuff intact – glenoid surface is compromised (arthritis, trauma) – reverse shoulder arthroplasty • indications – elderly individuals with nonreconstructible tuberosities
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- 33. Rehabilitation • 3-phase programs –early passive ROM for first 6 weeks – active ROM and progressive resistance – advanced stretching and strengthening program
- 34. Complications • Screw penetration –most common complication after locked plating fixation (up to 14%) • Avascular necrosis • Nerve injury – axillary nerve injury (up to 58%) – suprascapular nerve (up to 48%) • Malunion • Nonunion
- 35. Complications • Rotator cuffinjuries and dysfunction • Missed posterior dislocation • Adhesive capsulitis • Posttraumatic arthritis • Infection