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Upper extremity (shoulder fracture
- 1. Upper Extremity Fracture Principle (SHOULDER) Marsa- Orthopaedi & Traumatologi Bandung
- 2. Proximal Humerus Fracture Classification A0 • Organizesfractures 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-articularunifocal (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 • Basedon 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 involve1-4 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
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- 8. Radiographs • Complete traumaseries • 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 • Combinedcortical 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 • CTscans 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 • Rarelyindicated • 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 • Surgicalneck 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 • Inyounger 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 resultsif • 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/standingupright, standard AP view of bilateral shoulders 15° cephalic tilt (ZANCA view) determine superior/inferior displacement
- 20. Surgical Indication • openreduction 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 • uprightAP of bilateral shoulders • axillary lateral • 15° cephalic tilt (zanca view) • helps to determine superior/inferior displacement
- 24. Surgical Indication • openreduction 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 • uprightAP of bilateral shoulders • axillary lateral • 15° cephalic tilt (zanca view) • helps to determine superior/inferior displacement
- 28. Surgical Indication • Closedreduction 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 • Closedreduction 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 Classificationis 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
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- 33. Ideberg Classification ofGlenoid Fracture
- 35. Radiographs recommended views true AP,scapular Y and axillary lateral view
- 36. open reduction internalfixation •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
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- 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 • CCinterval 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
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