Upper extremity fracture

1. Upper Extremity
Fracture Principle
(SHOULDER)
Marsa - Orthopaedi & Traumatologi Bandung

2. Proximal Humerus
Fracture
Classification
A0
• Organizes fractures into 3 main
groups and additional subgroups
based on
• Fracture location
• Status of the surgical neck
• Presence/absence of
dislocation

3. AO
classification
Type A: extra-articular unifocal (either tuberosity +/- surgical
neck of the humerus)
•A1: extra-articular unifocal fracture
•A2: extra-articular unifocal fracture with impacted metaphyseal fracture
•A3: extra-articular unifocal fracture with non-impacted metaphyseal fracture
Type B: extra-articular bifocal (both tuberosities +/- surgical
neck of the humerus or glenohumeral dislocation)
•B1: extra-articular bifocal fractures with impacted metaphyseal fracture
•B2: extra-articular bifocal fractures with non-impacted metaphyseal fracture
•B3: extra-articular bifocal fractures with glenohumeral joint dislocation
Type C: extra-articular (anatomical neck) but with compromise
to the vascular supply of the articular segment
•C1: anatomical neck fracture, minimally displaced
•C2: anatomical neck fracture, displaced and impacted
•C3: anatomical neck fracture with glenohumeral joint dislocation

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

6. NEER
Classification
Fracture lines involve 1-4 parts
None of the parts are displaced (i.E <1 cm and <45
degrees)
One-part
fracture
Fracture lines involve 2-4 parts
One part is displaced (i.E >1 cm or >45 degrees)
Two-part
fracture
Fracture lines involve 3-4 parts
Two parts are displaced (i.E >1 cm or >45 degrees)
Three-part
fracture
Fracture lines involve more than 4 parts
Three parts are displaced (i.E., >1 cm or >45 degrees) with
respect to the 4th
Four-part
fracture

7. Radiological
Parametric

8. Radiographs
• Complete trauma series
• True AP (grashey)
• Scapular Y
• Axillary
Scapular Y (normal)
True AP (grashey)
Axillary

9. Radiographs
• Additional views
• Apical oblique
• Velpeau
• West point axillary
Apical oblique Velpeau West point axillary

10. • Findings
• Combined cortical thickness (medial +
lateral thickness >4 mm)
• Studies suggest correlation with
increased lateral plate pullout strength
• Pseudosubluxation (inferior humeral head
subluxation) caused by blood in the
capsule and muscular atony

11. CT scan
• CT scans are not necessary for all proximal humerus fractures, especially if minimally displaced.
• They can be very helpful for assessing complex injuries, particularly involving the humeral head,
or with significant comminution.
• CT scans aid assessment of:
• Fracture morphology (including the number of fragments)
• Bone stock of the tuberosities and humeral head fragment
• Degree of comminution
• Size of fixable fragments
• Length of posteromedial metaphyseal extension

12. MRI
• Indications
• Rarely indicated
• Useful to identify associated
rotator cuff injury

13. Surgical Indication
• 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
• Outcomes
• Considerably 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

14. ORIF
•Indications
•Greater tuberosity displaced > 5mm
•Displaced 2-part fractures
•3-, and 4-part fractures in younger patients
•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

15. Intramedullary
nailing
• Indications
• Surgical neck fractures or 3-part
greater tuberosity fractures in
younger patients
• 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

16. Arthroplasty
Indications
• Hemiarthroplasty
• In 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
• Reverse total shoulder
• Low-demand elderly individuals with non-
reconstructible tuberosities and poor bone stock
• Older patients with fracture-dislocation

17. Arthroplasty
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°

18. Clavicle Fracture Classification
• Clavicle Shaft Fracture
Allman Classification
Type I Middle third (most common)
Type II
Distal to the
coracoclavicular ligaments
(lateral 1/3)
Type III Proximal (medial) third

19. Radiologic Parametric
views sitting/standing upright, standard AP view of
bilateral shoulders
15° cephalic tilt (ZANCA view) determine superior/inferior
displacement

20. Surgical Indication
• open reduction internal fixation
• indications
• controversial: adolescent fractures with significant shortening(>2cm)
• absolute
• open fxs
• displaced fracture with soft-tissue at risk from tenting
• subclavian artery or vein injury

21. Clavicle Fracture Classification (distal Clavicle)
• Neer Classification (type I)
• extraarticular fracture occurring lateral to CC ligaments
• conoid and/or trapezoid ligament remain intact
• minimal displacement
• stable

22. Clavicle Fracture Classification (distal Clavicle)
Type IIA Type IIB Type III
Type IV Type V

23. Radiologic Parametric
• upright AP of bilateral shoulders
• axillary lateral
• 15° cephalic tilt (zanca view)
• helps to determine superior/inferior displacement

24. Surgical Indication
• open reduction internal fixation
• Absolute
• open or impending open fractures
• subclavian artery or vein injury
• floating shoulder (distal clavicle and scapula neck fractures with > 10mm of displacement)
• symptomatic nonunion
• relative
• unstable fracture patterns (Neer Type IIA, IIB, V)
• brachial plexus injury (questionable because 66% have spontaneous return)
• closed head injury
• seizure disorder
• polytrauma patient

25. Clavicle Fracture Classification (midshaft clavicle)
• Neer Classification
• Nondisplaced -<100% displacement
• Displaced >100% displacement

26. Clavicle Fracture Classification (midshaft clavicle)

27. Radiologic Parametric
• upright AP of bilateral shoulders
• axillary lateral
• 15° cephalic tilt (zanca view)
• helps to determine superior/inferior displacement

28. Surgical Indication
• Closed reduction and intramedullary fixation vs. open
reduction internal fixation
• Absolute indication
• Open fractures
• Displaced fractures with skin tenting
• Subclavian artery or vein injury
• Floating shoulder
• Symptomatic nonunion
• Symptomatic malunion

29. Surgical Indication
• Closed reduction and intramedullary fixation vs. open
reduction internal fixation
• Relative and controversial indications
• Displaced with >2 cm shortening
• bilateral displaced clavicle fractures
• brachial plexus injury (questionable because 66% have spontaneous
return)
• closed head injury
• seizure disorder
• polytrauma patient

30. Scapular Fracture Classification
Classification is based on the location of the fracture and includes
• coracoid fractures
• acromial fractures
• glenoid fractures
• scapular neck fractures
• look for associated AC joint separation or clavicle fracture
• known as "floating shoulder"
• scapular body fractures
• described based on anatomic location
• scapulothoracic dissociation

31. Coracoid Fracture Classification

32. Acromial Fracture Classification

33. Ideberg Classification of Glenoid Fracture

35. Radiographs
recommended views
true AP, scapular Y and axillary lateral view

36. open reduction internal fixation
•Indications
•glenohumeral instability
• > 25% glenoid involvement with subluxation of humerus
• > 5mm of glenoid articular surface step off or major gap
• excessive medialization of glenoid
•displaced scapula neck fx
• with > 40 degrees angulation or 1 cm translation
•open fracture
•loss of rotator cuff function
•coracoid fx with > 1cm of displacement
•"double disruption" of the superior shoulder suspensory complex

37. ACROMIOCLAVICULAR JOINT
DISRUPTION

38. Classification
• Rockwood classification

39. Radiographs
• Required views
• bilateral anteroposterior (AP) view of AC joints
• axillary lateral view
• Zanca view

40. Radiographs
• Additional views
• cross-body adduction view (Basmania)
• weighted stress views

41. Surgical Indication
• CC interval restoration (ORIF vs. Ligament Reconstruction)
• Indication
• acute type IV, V or VI injuries
• acute type III injuries in laborers, elite athletes, patients with cosmetic
concerns
• chronic type III injuries that failed non-op treatment
• Contraindication
• patient unlikely to comply with postoperative rehabilitation
• skin problems over fixation approach site

42. THANK YOU