Proximal Humerus Fractures- Brief introduction , Mechanism of injury , classification and Detailed non-operative and surgical management.

1. PROXIMAL HUMERUS
FRACTURES
Dr.Prasanth

2. BRIEF INTRODUCTION
• Defined as Fracture occurring at or proximal to
surgical neck
• 80 % of all humeral #
• 7% of all #..
• Pt > 65 yrs – Second most common fracture of
the upper extremity
• 65% of # occur in Pt’s > 60 yrs
• F:M – 3:1
• Incidence increases with age.

3. MECHANISM
• High energy injuries in normal bone resulted in
marked communition of the surgical neck area with
extension into proximal humerus shaft.
• FOOSH with shoulder in flexion , abduction &
internal rotation, the humerus head is forced into
valgus, hinging around the inferomedial aspect of
the stronger calcar bone.
• Patient falls directly on the shoulder, the deforming
forces on the humeral head will create a varus
deformity.

4. • Most # are non displaced, good prognosis –
nonsurgical
• Risk factors: Poor quality bone ,impaired vision &
balance, medical co morbidities, decreased muscle
tone.
• Young Pts – High energy trauma
• Severe soft tissue disruption always require surgical
intervention
• Seizures & electric shock – indirect causes

6. ANATOMY
• Muscle insertions on these
segments and the magnitude
and directionof the forces
causing injury, determine the
pattern of fracture lines
,displacement and angulation.
• Greater tuberosity has three
regions into which the
supraspinatus, infraspinatus,
and teres minor insert
• Subscapularis tendon
 lesser tuberosity, which is
separated from the greater
tuberosity by the bicipital
groove.

7. VASCULARITY
• The axillary artery is known as “tethered
trifurcation” at the level of the surgical
neck.
• Tethered Trifurcation - In the third part of
axillary artery where the vessel is
tethered to the humerus by the anterior
and posterior humeral circumflex
branches
• ACHA is the main arterial supply , in
complex fractures PCHA was preserved
in 85% of cases and only 20% of ACHA.
• If the medial calcar of the humerus is
spared by the fracture, the vessel is
spared.

8. CLASSIFICATIONS
• NEER’S CLASSIFICATION
Refinement of
Codman’s four-
segment
classification
4 segments
1.Humeral head
2.Greater tuberosity
3.Lesser tuberosity
4.Humeral shaft

9. AO/OTA CLASSIFICATION

10. HERTEL’S LEGO CLASSIFICATION

11. MAYO/FUNDACION JIMENEZ DIAZ

12. DEFORMING FORCES OF PHF
• The greater tuberosity is
pulled posteromedially by
the effect of the supra-
and infraspinatus
tendons.
• The lesser tuberosity is
pulled antero medially by
the subscapularis
tendon.
• The shaft segment is
pulled anteromedially by
the pectoralis major
tendon.

13. IMAGING AND OTHER DIAGNOSTIC
STUDIES
• Radiographs :- consist of three views
• AP- Perpendicular to the plane of scapula(Grashey view)
• Neer View (Scapula Y view)
• Axillary view
• CT scan
• MRI
• Angiography
• USG
• Dual energy X–ray absorptiometry (DEXA).

14. AP Grashey view of the shoulder

15. Neer view (lateral Y) of shoulder

16. Axillary view

17. Treatment options for
proximal humerus
fractures

18. NON-OPERATIVE TREATMENT OF
PROXIMAL HUMERAL FRACTURES
• The majority of proximal humeral fractures are
nondisplaced or minimally displaced and nonoperative
treatment is indicated.
• Fracture stability can be assessed both
radiographically and clinically.
• Radiographically, stable fractures exhibit impaction or
interdigitation between bone fragments
• Clinically, fracture stability may be assessed by
palpating the proximal humerus just distal to the
acromion with one hand, while rotating the arm at the
elbow with the other. If the proximal humerus is felt to
move as a unit with the distal segment, the fracture is

19. INDICATIONS FOR NON OPERATIVE
TREATMENT
• Surgical neck fractures with contact and no gross
instability.
• Greater and lesser tuberosity fractures.
-Displacement < 1cm
-Overlap with the head < 20%
• Varus posteromedial fractures.
-Varus < 45 degrees.
-Minor tuberosity displacement.
• Valgus fractures.
-Head not pointing superior or lateral.
-Minor tuberosity displacement.
• Elderly patients with contraindications for anaesthesia.

20. RELATIVE CONTRAINDICATIONS
• Open fracture
• Associated vascular injury
• Polytrauma
• Associated disruption of suspensory complex
shoulder
• Pathologic fractures , Head dislocation ,
Excessive tuberosity displacement , excessive
varus or valgus displacement in frail , elderly
patients.

21. • In GT fractures displacement must be less than 1 cm for
non operative, if GT heals with displacement of > 1 cm lead
to impingement in ext. rotation, elevation or both.
• If LT heals with displacement of > 1 cm lead to
impingement in internal rotation.
• Varus posteromedial fractures have a better outcome than
valgus impacted fractures with non operative
management.
• Valgus fractures having worst prognosis when treated non
operatively , marked valgus displacements leads to higher
chances of disruption of the vascularity of the humeral
head and more displacement of tuberosities.

22. NON OPERATIVE TREATMENT
PROTOCOL
• Immobilization of the arm to the chest using a simple
collar and cuff sling.
• Gilchrist or Velpeau type shoulder immobilizer used.
• For fractures involving GT fragment, it is better to
immobilise in some external rotation because the
posterosuperior rotator cuff is under more tension in
int. rotation.
• For fractures of surgical neck, to counteract the pull of
pectoralis major on the proximal aspect of diaphysis ,
considerate to put a pillow or small bump in the axilla.

24. • Surgical neck fractures with potential for instability
should be evaluated with radiographs on a weekly
basis for 1st
4 weeks.
• Rest of the fractures obtain radiographs at week 3,6
& 12 after the injury.
• Early sling immobilization for 7 – 10 days.
• Active finger , wrist , elbow movements.
• First 2-3 weeks , passive ROM exercises are best
tolerated in supine position.
• At 6 weeks, active assisted ROM exercises are
added.
• Strengthening exercises are started after 3 months.

25. OUTCOMES
• 60 % of the shoulders can be expected to be
completely pain free.
• 10% complain of moderate to severe pain.
• Complete recovery only seen in 46%.
• Motion is usually limited, between 90 – 120 degrees
of elevation.
• Unsatisfactory results-
Valgus impacted fractures > Varus
posteromedial fractures > Isolated fractures of GT.

26. OPERATIVE TREATMENT
Indications :
• Fracture dislocations.
• Head depression fractures involving more than
20% - 25% of the articular surface.
• Unstable surgical neck fractures with tuberosity
displacement over 1cm.
• Severe valgus/varus displacement of humeral head.
• Open fractures , fractures associated with
disruption of suspensory complex of shoulder.
• Fractures associated with vascular injuries and
pathologic fractures.

27. Surgical options :
• Open Reduction and Internal Fixation
• Intramedullary Nailing
• Closed Reduction and Internal fixation with
Percutaneous pins and screws
• Tension Band Fixation
• Hemiarthroplasty
• Reverse Total Shoulder Arthroplasty

28. Open reduction and internal fixation
DELTOPECTORAL APPROACH
• Most common surgical exposure used for both internal
fixation and arthroplasty worldwide.
1. Skin incision is placed lateral to the tip of coracoid i.e,
junction between the medial 3rd
and lateral 2/3rd
of distance
between tip of coracoid and acromion.
2. Identify deltopectoral interval and cephalic vein proximally
and mobilizing the cephalic vein medially or laterally allows
for improved exposure .

29. 3. Arm is then placed in abduction to relax the deltoid.
4. Anterior distal deltoid insertion is gently elevated off the
lateral side of the humerus , just enough to allow the
correct lateral plate placement.
5. Next , clavipectoral fascia is opened , careful soft tissue
management is required to avoid devascularization of the
fractured fragments.
6. Identification of the long head of the biceps on the
anterior aspect of the proximal shaft will facilitate
understanding of fracture pattern and aid with fracture
reduction and plate placement.
7. Proximity to the ascending branch of ACHA, dissection
around and behind long head of biceps tendon avoided
whenever possible.

30. NOTE:
-Biceps tendon may be injured with the fracture
then biceps tenodesis commonly performed.
- Biceps tendon intact may make fracture reduction
more difficult , especially in subacute injuries with
substantial humerus shortening , then also tenodesis done.

32. SUPERIOR DELTOID SPLITTING APPROACH
• This approach to the fracture by longitudinal incision
starting from anterolateral corner of acromion and
splitting the deltoid (Ant. and Middle raphe).
• This approach benefits better access to the greater
tuberosity and lateral humeral shaft plate fixation and
lesser disruption of the fracture vascularity.
• This approach caries a higher risk of iatrogenic axillary
nerve injury ( If deltoid split more than 5 cm ).
• This approach not useful for antero inferior fracture
dislocations.

35. Internal fixation using Locking plates
• Orif using periarticular precontoured locking plates.
• High rates of post operative displacement and varus
collapse mainly in elderly with 3 & 4 part fractures.
• Most frequent complication :
Intra-articular screw penetration.
1. Primary screw penetration ( Intra operative insertion of
excessively long screws )
2. Secondary screw penetration ( fracture collapse with
loss of reduction leading to late screw penetration )

36. SCREW PENETRATION

37. • Structural bone grafting and cementing techniques have
demonstrated in increase in the strength of fixation and
decrease the rates of loss of reduction ,collapse and screw
penetration.
• The use of fibular strut grafting has been described to
improve stability of varus-impacted fractures in which the
medial calcar may not be reliably reconstructed.
• Goal being to create a buttress at the inferior aspect of
the anatomic neck to prevent delayed varus collapse
• Split of the head in only two segments and fracture dislocations
in the very young patients considered for plate fixation.
• In fracture dislocations, head is reduced first and provisional
fixation is done.

38. Fibular strut grafting for varus impacted fractures

39. Placement of plate and fixation
• The plate should be placed low enough, so that its superior
border is at least 5mm below the superior edge of the
greater tuberosity.
• But high enough so that lower locking screws will support
the calcar region.
• In osteoporotic patients- typically augment with cement at
least 4 screws, especially at superior aspect of the head
and at calcar region. About 5CC of cement is introduced
through each screw.
• Once the plate and screws have been placed
transtendinous sutures are tied onto the plate to provide
additional fixation

40. Elective Cement Augmentation

43. Internal fixation : Intramedullary Nailing
• Biomechanical advantages in osteoporotic bone
• It allows stabilization with minimum surgical invasion
• Indications-
• Displaced two part surgical neck fractures
• Pathological fractures
• Contraindications-
• Varus four-part fractures with lateral displacement
of the humeral head
• Head-splitting fractures

44. • Most modern implants , using now a days are “Third
Generation Proximal Humeral IM nails”.
• The most usual entry point is just lateral to the articular
surface of the humeral head and just medial to greater
tuberosity.
• In lateral view entry point should be approximately
1 to 1.5 cm posterior to anterior margin of GT.
• IM nailing violates the rotator cuff , and thus may lead to
post operative shoulder pain.

46. Closed Reduction and internal fixation
with Percutaneous pins and screws
• It has theoretical advantage of minimizing soft tissue
trauma, thereby promoting healing and reducing the
risk of AVN of the humeral head.
• It also has the advantage of decreased scarring in the
• scapulohumeral interface and subsequent easier
rehabilitation.
• Indications-
• Fracture without significant communition in pt with
good quality bone.
• Pt should be willing to comply with postop care
plan.

47. • Contra indications
• Comminution of calcar ,greater tuberosity and
osteopenia are absolute contraindications.
• Inability to reduce Fracture Fragments
• Fracture Dislocation
• Non Compliant patients

48. To avoid injury to the axillary nerve, lateral
pins should enter the humeral cortex at a
point at least twice the distance from the
upper aspect of the head to the inferior
head margin with the wire angulated
approximately 45 degrees to the cortical
surface. The end point for the greater
tuberosity pin should be >2 cm from the
inferior most margin of the humeral head.

49. Tension Band Fixation (Osteosuture)
• It is most frequently used as an adjunct to plates and
screw fixation, IM nailing, and arthroplasty.
• The main goal of tension band fixation is the
neutralization of tension forces generated by the
rotator cuff at the level of the tuberosities, and
bending at the level of the surgical neck.
• The main advantage of tension band fixation is the
minimal amount of hardware that is required. Thus
avoiding the risks associated with hardware, which
include pain, neurovascular compromise, migration,
failure, and the need for removal.

50. Contraindications
• Previous attempt(s) at internal fixation or
• Fractures older than six weeks.
• Highly comminuted four part fractures

51. Tension-band construct with transosseous
suture fixation

53. Hemiarthroplasty
• Also known as humeral head replacement
Indications-
• Four-part fractures,
• Three-part fractures in older patients with
osteoporotic bone,
• Fracture-dislocations
• Comminuted head-splitting fractures
• Head depression fractures involving more than 40%
of the articular surface

54. Favours hemiarthroplasty –
-Intact tuberosity / large tuberosity fragments
-Younger , Male
Contraindications-
• Active infection of the shoulder joint and/or the
surrounding soft tissue

55. Postoperative Care
• Passive range-of-motion exercises are started on the
first postoperative day. They are limited to neutral
rotation and 90 degrees of forward elevation.
• Patients are followed up clinically and radiographically
at 2 weeks, 6 weeks, and 3 months.
• Active-assisted range-of-motion exercises are started
at 6 weeks and strengthening exercises at 3 months

57. Reverse Total Shoulder Arthroplasty
• By placing a hemisphere onto the glenoid surface and a
concave tray onto the humeral stem, reverse shoulder
arthroplasty allows for rotation to occur at the glenohumeral
joint through activation of the deltoid, without the need for a
functional rotator cuff/tuberosity unit.
Indications
• Complex acute proximal humeral fractures
• Proximal humerus malunion or nonunion where the normal
anatomy of the tuberosities cannot be reliably restored
• Glenohumeral joint arthritis with advanced rotator cuff
• pathology
• Massive irreparable rotator cuff tears with painful
pseudoparesis

58. Favours reverse hemiarthroplasty –
-smaller tuberosity fragments
-osteopenia
- older , female

59. The ideal candidate for reverse total shoulder arthroplasty in a patient with a
complex proximal humerus fracture is a low demand elderly patient with pre-
existing rotator cuff pathology and glenoid pathology.

60. COMPLICATIONS
• Avascular necrosis of humeral head and/or tuberosity
• Non-union- The normal time for clinical union of a
proximal humeral fracture is typically 4 to 8 weeks.
Nonunion is said to be present if a fracture site is still
mobile 16 weeks post injury.
• Malunion
• Post-traumatic Shoulder stiffness
• Post traumatic arthritis
• Infection
• Iatrogenic-such as inadequate reduction, incorrectly
positioned implants, screw penetration into the joint, loss
of fixation, tuberosity disruption, and nerve injury.
• Heterotopic bone formation

61. Risk of Avascular Necrosis
Four-part fractures and fracture dislocations are
considered to have the highest risk for humeral head
necrosis.
Hertel’s Criteria
• Metaphyseal extension of the humeral head < 8
mm
• Medial hinge disruption of >2 mm, and
• Fracture through anatomical neck
• The combination above above factors had 97%
positive predictive value for humeral head ischemia

62. Metaphyseal extension of the humeral
head of >9 mm
Metaphyseal extension of the humeral
head of <8 mm.

63. Undisplaced medial hinge Medial hinge with >2 mm of displacement

64. Humeral Head Osteonecrosis
• Due to primary and secondary causes.
Primary- Due to fracture pattern.
Secondary- Due to consequence of operative
management ( Ecxessive fracture manipulation and
stripping of soft tissues).
• Predisposing factors : Medical comorbidities , Drug
treatment , smoking , Alcohol abuse and malnutrition.

65. • Radiological changes : Patchy humeral head sclerosis, to
complete humeral head resorption and collapse.
• In some individuals, osteonecrosis is not associated with
severe symptoms and no treatment is required other than
periodic follow up evaluations.
TREATMENT :
Patients who have early radiological changes , Core
Decompression may done occasionally.
but most patients have advanced collapse and enough
symptoms then conversion to shoulder arthroplasty.
patients with isolated humeral head AVN and no
other fracture related issues , Hemiarthroplasty is the
procedure of choice.