1. DR.K KODANDAPANI
PROFESSOR OF ORTHOPAEDICS
OSMANIA MEDICAL COLLEGE
OSMANIA GENERAL HOSPITAL
HYDERABAD

2. Proximal Humeral Fxs
 Majority occur in the elderly ,
 minimally displaced and stable.
 osteoporotic and metaphyseal
fractures, with compromised
bone quality -optimal surgical
and functional outcomes are
limited.
 F- affected three times more
common
 Low energy trauma in elderly
and high energy trauma in
younger age group

3.  proximal humeral fractures account for 5%of all
skeletal fractures and 80 % of them are minimally
displaced or undisplaced which can be treated non
surgically with good results , they generally occur in
elderly patients , as a result of trivial and low energy
trauma , risk factors in the elderly include poor bone
quality, impaired vision, and balance , medical co-
morbidities

4.  irrespective of age , operative or non operative
, management, the premise of treatment is to achieve
a stable ,pain free range of movement of the
limb, thereby avoiding the late sequelae like
, refractory shoulder
stiffness, osteonecrosis, malunion, nonunion, and
heterotopic ossification

5.  In order to achieve this objective , it is imperative , to
pay utmost attention to the anatomical distortion and
disturbance of, shoulder joint ,that is inherent to
proximal humeral fractures
 At this juncture it is pertinent to look at the
anatomical profile of the proximal humerus, which has
a direct bearing on the diagnosis, work up, treatment
protocols and rehabilitation.

7. Proximal humerus comprises of
four major segments
The Articular head,
The greater tuberosity,
lesser tuberosity, and
the shaft. the muscle insertions
on these segments and the
magnitude and direction of the
forces causing injury, determine
the pattern of fracture lines
,displacement and angulation

8. Critical Anatomic Factors
The critical anatomic relationships of the articular
segment to the shaft and the tuberosities, and include
 retroversion,
 inclination angle, and
 translation of the head relative to the shaft, and the
 relationship of the head to the greater tuberosity
 Rotator cuff

9.  The articular head lies above the greater tuberosity, 3-
20 mm. Avg – 8mm
 The ascending branch of the anterior circumflex
humeral artery provides most of the blood flow to the
articular segment. If the medial calcar of the humerus
is spared by the fracture, the vessel is spared

10. Anatomic
Parameters
 Shoulder is a very unstable joint , Joint capsule ,though
strong is lax
 Stabilising factors – the labrum deepens the glenoid
cavity, scapular muscles hold the head in close
opposition , coraco acromial arch , fusion of the tendons
of the scapular muscles to the capsule and the muscles
attaching the humerus to the pectoral girdle
 Head of the humerus is larger than the glenoid cavity
deepened by the labrum
 The head is inclined 130 degrees to the shaft with 3mm
offset posteriorly and from the centre of the shaft
 Retroversion of the head varies from 18 to 40degrees
 Normal humeral retroversion places the humeral head
posterior to the humeral shaft
 The bone quality of greater tuberosity is marginal and is
often comminuted
 The bone quality of lesser tuberosity often better than
GT , particularly laterally near the bicipital groove
 Radius,of curvature of the average adult humeral head is
between 22 and 25 mm and is proportional to the
thickness of the humeral head

11. Clinical Features
 A complete history and physical examination
must be obtained about the mechanism of
injury and velocity of fracture and other
associated injuries - viz rib ,cervical, and
scapular fxs
 Patients are tender over the injured
shoulder, with swelling and
ecchymosis, echymoses appears 24 to 48 hrs
and may to arm ,forearm, ,chest
wall, , indicates t extensive soft tissue injury
 The patient will hold the arm in
internal,rotation
 Palpation over the shoulder and any attempted
movement of the extremity will elicit pain in
the shoulder
 Complete Neuro vascular asssessment is made

12. Pre op planning
Preoperative planning
Imaging—accurate
identification, of the size, location
and displacement of the fragments
is essential for Fracture
classification and formulation of
Rx Plan
Initial Radiographs , must be
Neer’s Trauma series
True AP
Scapular Lateral
Axillary
True AP View -- Identifies major
Fracture lines ,, Tuberosity ,and
humeral head displacement
Axillary view reveals the articular
surface , in relation to glenoid
, evaluates the degree of Tuberosity
displacement, surface defects, and
dislocations

13. Pre op Planning
 CT Scan
Delineates, Comminution, amount
of Tuberosity
displacement, humeral head
indentation Fractures, evaluates the
Head splitting Fractures and
assesses Glenoid Fxs , posterior
dislocations
 MRI Is rarely indicated in a trauma
setting , and is done to evaluate any
pre existing Shoulder problem , as a
corollary in Pathologic Fxs, and in
non unions
 Angiography,
 To assess vascular injury, specially in
two Part neck Fracture, because of
the tethering of the circum flex
anastomosis – is often associated
with severe medial shaft
displacement through Surgical
neck

14. Classification of
Proximal humeral
Fxs
 First systems dating back to 17th Century, classed them as Simple
closed versus Open
 Modern Times - 1896, -- Kocher Focused on the location of the
fracture and divided Proximal humerus Fractures into Supra
Tubercular, Peritubercular,infratubercular, and Sub Tubercular
 Codman Classified according to the Fracture pattern, he
described fractures along the lines of epiphyseal scars and
observed that fractures occur in several combinations of four
parts
 Watson Jones System , based on the Mechanism of injury
described PHF as Impacted adduction and Impacted abduction, a
contusion crack fracture, and a fracture of minimal displacement
 Dehne Classification
 DeAnquin and DeAnquin similar to the one used by Neer.
 AO /ASIF Classification – emphasises on the vascular supply of
the articular portion of the proximal humerus with 27 possible
subgroups based on Extra articular/articular
involvement, Focality, Dislocation and degree of comminution.
The vascular supply to the fragment is considered adequate , if
either of the tuberosity remains attached to the head



15. Neer’s(1970)
classification
 It is a Refinement of Codman’s System, incorporates ,the
concept of displacement and vascular isolation of the
articular segment and relates the anatomy and
biomechanical forces resulting in the displacement of
fragments to diagnosis and treatment
 Fractures are classified by evaluating the displacement of
the Parts (head, shaft, greater tuberosity, lesser
tuberosity) from each other
 To meet the Criteria of a part, the fragment must be
rotated 45 degrees or 1cm from another fragment
 Classifies as one part, Two part, three Part and Four part
Fractures
 Neer also categorized Fracture –Dislocation , which are
displaced proximal fractures – 2,3,or4 Part associated
with either anterior or posterior dislocation of the
articular segment
 Neer also described articular surface fractures of two
types, --1) Impression Fractures, of the articular surface
(seen in Chronic Dislocations 2 ) Head Splitting
Fractures is usually associated with other displaced fxs of
proximal humerus

16. Neer’s(1970) classification
 It is a Refinement of Codman’s System, incorporates
,the concept of displacement and vascular isolation of
the articular segment and relates the anatomy and
biomechanical forces resulting in the displacement of
fragments to diagnosis and treatment
 Fractures are classified by evaluating the displacement
of the Parts (head, shaft, greater tuberosity, lesser
tuberosity) from each other
 To meet the Criteria of a part, the fragment must be
rotated 45 degrees or 1cm from another fragment
 Classifies as one part, Two part, three Part and Four
part Fractures
 Neer also categorized Fracture –Dislocation , which
are displaced proximal fractures – 2,3,or4 Part
associated with either anterior or posterior dislocation
of the articular segment
 Neer also described articular surface fractures of two
types, --1) Impression Fractures, of the articular
surface (seen in Chronic Dislocations 2 ) Head
Splitting Fractures is usually associated with other
displaced fxs of proximal humerus


17. Indications
 Surgical options- Inthe absence  Specific Surgical indications for PHFXs is
poorly defined , any single surgical technique
of medical contraindications, all is not appropriate for all patients Treatment
must be tailored to each specific situation
displaced fractures must be  Significantly (>1cm )Displaced Greater Fxs
operated .results of surgery is Requires Repair, to avoid Rotator cuff
deficiency. and sub acromial impingement of
variable, the cuff . 0.5 cm displacement may lead to
pain or disability after fracture healing.
 Prognostic factors include ---  Displaced lesser Tuberosity – where
Fracture Pattern , Bone significant amount of articular head is
attached to the fragment , or Fxs that limit
quality, Quality of surgical internal rotation .
Reduction, stability of Fixation  Two part anatomic neck Fxs. In Young pts ,--
ORIF
, Age of the patient, Patient  Two part Surgical neck FXs
motivation, and reliability  Two Part tuberosity Fx Dislocation
, Surgeon experience and post  Fx - Dislocation , involving the Surgical neck
op Rehabilitation.


18. Varied Surgical options are
available and is to be
individualized to the fracture
pattern and class. , these include –
Closed reduction and
Percutaneous , pinning
Open reduction and Percutaneous
pinning
Good Bone Quality--Extra
medullary Fixation with – Tension
Band wiring , Blade Plate ,,Locking
compression periarticular plates
Poor Bone Quality – Intra
medullary Fixation with – Enders
nail
Hemiarthroplasty
Total shoulder replacement
Reverse shoulder arthroplasty

19. Percutaneous Pinning
 Percutaneous pinning – first  Contra indications -- Severe
advocated by Bohler - Termed comminution and osteopenia are
Biological Fixation absolute contraindications
 Less soft tissue dissection , and  Inability to reduce Fracture
disruption, Fragments
 vascularity of the humeral head is  Fracture Dislocation
preserved  Non Compliant patients
 incidence of osteonecrosis is
minimal
 PHFXs – without comminution, in
patients with good quality bone who
are willing to comply with serial
Radiographs and shoulder
immobilization for4 to 6 weeks
 The ideal Indication is Two Part
Surgical neck Fractures and can also
be done in 3 Part and 4 part
fractures

21. Contra indications -- Severe  The orientation and pin
comminution and osteopenia placement must be parallel and
are absolute contraindications avoid
 Inability to reduce Fracture 1)the Axillary nerve , which
Fragments courses 5cms distal to the lateral
 Fracture Dislocation edge of the Acromion from
 Non Compliant patients
posterior to anterior.
2)The Radial Nerve , Passing
around the spiral groove
3) Anteriorly ,- the long head
of Biceps must be avoided
4) Medially , the Anterior
circumflex humeral vessels
, along the medial cortex

26. Locking Humeral Plate
 Concept  Indications for use
 The development of the locking plate has  In the treatment of acute unstable 2, 3
changed the management of many and 4 part fractures and fracture
fractures.
dislocations.
 They have a number of advantages
including improved fixation in osteoporotic  Non-union of fractures especially at
bone, and the facilitation of reconstruction the neck of the humerus (combined
of comminuted irreducible fractures with bone grafting).
 The concepts behind its use are to provide:  Pathological fractures .
 Stable fixation of the unstable proximal 
humerus fracture until bony union.
 Early mobilisation of the shoulder and early
 Contraindications
active rehabilitation program.  Extensively comminuted humeral
 Good functional outcomes and a good head fractures which cannot be
restoration of the activities of daily living adequately reconstructed.
[5].  Fractures in immature patients.
 Local infection after previous surgery
[5].

27. Arthroplasty in PHFxs
 4-part fractures,
 fracture dislocations,
 head-splitting fractures,
 impaction fractures,
 humeral head fractures with
involvement of more than
50% of the articular
surface, and
 3-part fractures in elderly
patients with osteoporotic
bone. However, heterogeneity
of fracture patterns exists
within these groups

28. Reverse Shoulder Prostheses
 for acute complex fractures of the proximal
 humerus in elderly population with poor bone quality
and
 severe rotator deficiency, when an efficient and
reliable
 re-fixation of the tubercles is diffcult or impossible

29. Reverse shoulder prostheses

30. Reverse Shoulder Prostheses

31. Complications
 Humeral head necrosis
 Delayed union/non-union
 Screw cut out with intra-articular displacement
 Implant failure
 Varus displacement (>10˚)
 Infection
 Heterotopic bone formation

32. Complications
 Shoulder stiffness, osteonecrosis, malunion or nonunion.
 technical errors, such as inadequate reduction, incorrectly positioned
implants, screw penetration into the joint, loss of fixation, tuberosity
disruption, and nerve injury.
 The use of plates with angular stability, such as blade plates or plates
with locking screws, and/or augmentation of the fracture with
polymethylmethacrylate (PMMA) or calcium phosphate cement
lessens this risk.
 Osteonecrosis of the humeral head following fracture may be partial or
complete; the significance of this complication on outcome remains
controversial. Open reduction and internal fixation with plates
requires a more invasive approach and may be associated with an
increased risk of osteonecrosis. However, rigid fixation may promote
better and more rapid revascularization by creeping substitution of the
humeral head and may therefore lessen the risk of articular collapse

33. Thank you