DR.K KODANDAPANIPROFESSOR OF ORTHOPAEDICS OSMANIA MEDICAL COLLEGE OSMANIA GENERAL HOSPITAL HYDERABAD
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
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
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
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.
Proximal humerus comprises offour major segmentsThe Articular head,The greater tuberosity,lesser tuberosity, and the shaft. the muscle insertionson these segments and themagnitude and direction of theforces causing injury, determinethe pattern of fracture lines,displacement and angulation
Critical Anatomic FactorsThe 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
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
AnatomicParameters 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
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
Pre op planningPreoperative planningImaging—accurateidentification, of the size, locationand displacement of the fragmentsis essential for Fractureclassification and formulation ofRx PlanInitial Radiographs , must beNeer’s Trauma series True AP Scapular Lateral AxillaryTrue AP View -- Identifies majorFracture lines ,, Tuberosity ,andhumeral head displacementAxillary view reveals the articularsurface , in relation to glenoid, evaluates the degree of Tuberositydisplacement, surface defects, anddislocations
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
Classification ofProximal humeralFxs 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
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
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
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.
Varied Surgical options areavailable and is to beindividualized to the fracturepattern and class. , these include –Closed reduction andPercutaneous , pinningOpen reduction and Percutaneouspinning Good Bone Quality--Extramedullary Fixation with – TensionBand wiring , Blade Plate ,,Lockingcompression periarticular platesPoor Bone Quality – Intramedullary Fixation with – EndersnailHemiarthroplastyTotal shoulder replacementReverse shoulder arthroplasty
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
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
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. . Fractures in immature patients. Local infection after previous surgery .
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
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
Complications Humeral head necrosis Delayed union/non-union Screw cut out with intra-articular displacement Implant failure Varus displacement (>10˚) Infection Heterotopic bone formation
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