The document discusses proximal humerus fractures, detailing their definition, incidence, risk factors, and relevant anatomy. It covers classification systems like the Neer classification, associated conditions, and surgical management approaches, including nonoperative and operative treatments. Complications and risks, including avascular necrosis and nerve injuries, are outlined, along with the implications for various patient demographics.

1. Proximal Humerus Fracture
Frcs orthopaedic trauma fisrt aid

2. Definition
Fracture proximal to surgical neck
Parts of proximal humerus.
1-Articular surface/head
2-Greater tuberosity
3-Lesser tuberosity
4-Surgical neck

3. INCIDENCE
• 4-6% of all fractures
• 3rd most common non-vertebral
fracture pattern seen in the elderly (>65
years old)
• Two-part surgical neck fractures most
common
• 2:1 female to male ratio

5. Risk Factors
• Osteoporosis
• Diabetes
• Epilepsy
• Female

7. Mechanism
• low-energy falls in
elderly with
osteoporotic bone.
• High-energy trauma in
young.

8. Relevant Anatomy
Osteology
• Anatomic neck old epiphyseal
plate
• surgical neck weakened area
below head
• more often involved in
fractures
• average neck-shaft angle is
135 degrees

10. Ligaments
1-Coracohumeral ligament
• attaches to coracoid and greater
tuberosity and strengthens the
rotator interval
2-SGHL
• restraint to inferior translation at 0°
degrees of abduction (neutral
rotation)
3-MGHL
• resists AP translation in the midrange
(~45°) of abduction
4-IGHL
• restraint to AP translation at 90°
degrees of abduction

11. Muscle attachment proximal humerus
Greater tuberosity
From superior to inferior
• Supraspinatus.
• Infraspinatus.
• Teres minor.
Lesser tuberosity
• Subscapularis.
Lateral lip bicipital groove
• Pectoralis major
Medial lip bicipital groove
• Teres major
Teres major

12. Blood supply of proximal humerus
1-Anterior humeral circumflex artery
• large number of anastomosis with
other vessels in the proximal humerus
Branches
• anterolateral ascending branch
• arcuate artery is the terminal branch
and main supply to greater tuberosity.
2-posterior humeral circumflex artery
• recent studies suggest it is the main
blood supply to humeral head

13. Risk of avascular necrosis
• vascularity of articular segment is more
likely to be preserved if ≥ 8mm of calcar is
attached to articular segment
• Hertel criteria (predictors of humeral
head ischemia)
1. <8 mm of calcar length attached to
articular segment
2. Disrupted medial hinge
3. Increasing fracture complexity
4. Displacement >10mm
5. Angulation >45°

14. Deforming force
• Pectoralis major displaces shaft
anteriorly and medially
• Supraspinatus, Infraspinatus,
and Teres minor externally
rotate greater tuberosity
• Subscapularis internally rotates
articular segment or lesser
tuberosity

15. Associated conditions
Nerve injury
• Axillary nerve injury most common
Arterial injury
• uncommon (incidence 5-6%), higher likelihood in older patients
• most often occur at level of surgical neck or with subcoracoid
dislocation of the head

16. Neer classification
• Based on anatomic relationship
of 4 segments
1. Greater tuberosity
2. Lesser tuberosity
3. Articular surface
4. Shaft
a segment separate part if
• Displacement of > 1 cm
• 45° angulation

17. • One-part: nondisplaced or minimally displaced fracture (often of the humeral
neck)
• Two-part: displacement of tuberosity of more than 1 cm; or surgical neck
with head/shaft angled or displaced.
• Three-part: displacement of the greater or lesser tuberosities and articular
surface
• Four-part: displacement of shaft, articular surface, and both tuberosities.
“Head splitting” is a variant, with split through the articular surface (usually
requires replacement for treatment).

18. Surgical neck two part fracture

19. Greater tuberosity 2 part fracture

20. Lesser tuberosity 2 part fracture

21. Greater tuberosity 3 part fracture

22. Lesser tuberosity 3 part fracture

23. Greater tuberosity 4 part fracture

24. Lesser tuberosity 4 part fracture

25. Clinical presentation
Symptoms
• pain and swelling
• decreased motion
Physical exam
• inspection
• extensive ecchymosis of chest, arm,
and forearm
• neurovascular exam
• axillary nerve injury most common
• determine function of deltoid muscle
and lateral shoulder sensation
• arterial injury may be masked by
extensive collateral circulation
preserving distal pulses
• examine for concomitant chest wall
injuries

26. Investigations:-
• Radiographs
• True AP (Grashey)
• Scapular Y
• Axillary
Additional views
• Apical oblique
• Velpeau
• West Point axillary
findings
• combined cortical thickness
(medial + lateral thickness >4 mm)
• studies suggest correlation with
increased lateral plate pullout
strength

27. Investigations:-
CT scan
indications
• preoperative planning
• Humeral head or greater
tuberosity position uncertain
• Intra-articular comminution
• concern for head-split fracture

28. Ap grashey view

29. Scapular Y view

30. Axillary view

31. Nonoperative
sling immobilization followed by progressive rehabilitation.
Indications
• minimally displaced
surgical and anatomic
neck fractures.
• Greater
tuberosity fracture
displaced < 5mm.
• Surgically unfit.
>5mm displacement will result in
impingement with loss of
abduction and external rotation.

32. CRPP (closed reduction percutaneous pinning)
indications
1. 2-part surgical neck fractures
2. 3-part and valgus-impacted 4-part fractures in patients with good
bone quality, minimal metaphyseal comminution, and intact medial
calcar
outcomes
• higher complication rate compared to ORIF, HA, and RSA
• Axillary nerve at risk with lateral pins
• musculocutaneous nerve, cephalic vein, and bicep tendon at risk with
anterior pins

33. ORIF
• indications
1. Greater tuberosity displaced > 5mm.
2. Displaced 2-part fractures
3. 3-, and 4-part fractures in younger patients.
4. head-splitting fractures in younger patients.
outcomes
• medial support necessary for fractures with posteromedial comminution
• consider use of a fibula strut if concerned about medial support or bone
quality
• calcar screw placement critical to decrease varus collapse of head

34. Intramedullary nailing
indications
1. surgical neck fractures or 3-part greater tuberosity fractures in
younger patients.
2. combined proximal humerus and humeral shaft fractures.
outcomes
• biomechanically inferior with torsional stress compared to plates
• favorable rates of fracture healing and ROM compared to ORIF

35. Arthroplasty
• indications
1. Hemiarthroplasty
• younger patients (40-65 years old) with complex fracture-dislocations or
head-splitting components that may fail fixation
• recommended use of convertible stems to permit easier conversion to RSA
if necessary in future
2. Reverse total shoulder
• low-demand elderly individuals with non-reconstructible tuberosities and
poor bone stock
• older patients with fracture-dislocation

36. Arthroplasty outcome
outcomes
• improved results if
• Anatomic tuberosity reduction and healing.
• Restoration of humeral height and version
• Humeral height is best judged from the superior border of the pectoralis
major insertion
• poor results with
• tuberosity nonunion or malunion.
• retroversion of humeral component > 40.

37. Surgical neck fracture
• Most common fx pattern Deforming forces:
1) pectoralis pulls shaft anterior and medial
2) head and attached tuberosities stay neutral
• Nonoperative
• Closed reduction often possible
• Sling
• Operative
• -indications controversial
• -technique
• --- CRPP
• --- Plate fixation
• --- IM nail

38. Greater tuberosity fracture
• Deforming forces: GT pulled superior and posterior by
SS, IS, and TM
• Can only accept minimal displacement (<5mm) or
else it will block ER and ABD
• Nonoperative
• indicated for GT displaced < 5 mm
• Operative
• indicated for GT displacement > 5 mm
• - isolated screw fixation only in young with good bone
stock
• - non-absorbable suture technique for osteoporotic
bone (avoid hardware due to impingement)
• -tension band wiring

39. Lesser tuberosity fracture
• Assume posterior dislocation until
proven otherwise
• Nonoperative
• Minimally or non-displaced
• Operative
• ORIF if large fragment
• excision with RCR if small

40. Anatomic neck fracture
• Nonoperative
• Minimally or non-displaced
• Operative
• ORIF in young
• ORIF v. hemiarthroplasty v.
reverse total shoulder
arthroplasty in elderly

41. Surgical neck & greater tuberosity fracture
• Unopposed pull of posterior cuff
musculature leads articular surface to
point anterior
• Often associated with longitudinal RCT
• Trend towards nonoperative
management given high complications
with ORIF
• Young patient
• - percutaneous pinning (good results,
protect axillary nerve)
• - IM fixation (violates cuff)
• - locking plate (poor results with high
rate of AVN, impingement, infection, and
malunion)
• Elderly patient
• - Hemiarthroplasty with RCR or
tuberosity repair vs. reverse total
shoulder arthroplasty

42. Four part valgus impacted fracture
• Specific type of displaced four-part
fracture.
• valgus impaction of the head fragment.
• low rate of rate of avascular necrosis.
• axial trauma to the abducted upper limb,
• direct impaction between the humeral
head and the glenoid cavity.
• posteromedial displacement (dorsal
tilting of the head) because of its
physiological anatomical conformation in
retroversion.
• low rate of rate of avascular necrosis

43. Four part valgus impacted fracture
• Radiographically will see alignment
between medial shaft and head
segments
• Low rate of AVN if posteromedial
component intact thus preserving
intraosseous blood supply
• Surgical technique
• 1. raise articular surface and fill
defects
• 2. repair tuberosities

44. Four part head splitting fracture
• High risk of AVN (21-75%)
• Deforming forces:
• 1) shaft pulled medially by pectoralis
• Young patient
• ORIF vs. hemiarthroplasty
• hemiarthroplasty favored for non-
reconstructible articular surface, severe
head split, extruded anatomic neck fracture.
• Elderly patient
• -Hemiarthroplasty v. reverse total shoulder
arthroplasty

45. complications
Screw cut-out
• incidence
• most common complication following
periarticular locking plating fixation (up to
14%)

47. complications
Avascular necrosis
• risk factors for humeral head ischemia
are not the same for developing
subsequent avascular necrosis
• better tolerated than in lower
extremity
• no relationship to type of fixation
(plate or cerclage wires)

48. Complications
Nerve injury
Axillary nerve (up to 58% )
• increased risk with lateral (deltoid-splitting) approach
• axillary nerve is usually found ~5-7cm distal to the tip of the
acromion
• at risk with lateral pins in CRPP
Suprascapular nerve (up to 48%)
Musculocutaneous nerve
• at risk with anterior pins in CRP

49. complications
Malunion
• usually varus apex-anterior or malunion of GT
• results inferior if converting from varus malunited fracture to TSA
• use reverse shoulder arthroplasty instead
Nonunion
• most common after two-part surgical neck fracture
• treatment of chronic nonunion/malunion in the elderly should include arthroplasty
• lesser tuberosity nonunion leads to weakness with lift-off testing
• greater tuberosity nonunion after arthroplasty leads to lack of active shoulder elevation
• greatest risk factors for nonunion are age and smoking

50. complications
Rotator cuff injuries and dysfunction
Long head of biceps tendon injuries
• also at risk with anterior pin in CRPP
Missed posterior dislocation
• consider in all patients with lesser tuberosity fracture
Adhesive capsulitis and scar tissue
Posttraumatic arthritis
Infection