proximal humerus fractures principles of diagnosis, decision making and treatment christopher g....

Proximal HumerusProximal Humerus

FracturesFracturesPrinciples of Diagnosis,Principles of Diagnosis,

Decision Making and TreatmentDecision Making and TreatmentChristopher G. Finkemeier, MD, MBAChristopher G. Finkemeier, MD, MBA

Revised: May 2011Revised: May 2011

Acknowledgement: AO faculty lecture archive

Objectives

1. Learn the principles of 1. Learn the principles of diagnosisdiagnosis

2. Learn the principles of 2. Learn the principles of decision makingdecision making

3. Learn the 3. Learn the various treatment optionsvarious treatment options

EpidemiologyAll upper extremity fracturesAll upper extremity fractures

1. forearm fxs1. forearm fxs2. proximal humerus fxs2. proximal humerus fxs

All fractures in patients > 65 yrsAll fractures in patients > 65 yrs

1. hip fxs1. hip fxs2. “colles” fxs2. “colles” fxs3. proximal humerus fxs3. proximal humerus fxs

HUMERAL HEAD:precarious blood supplyAVN

LESSER TUBEROSITY:subscapularis insertion

GREATER TUBEROSITY:supra/infraspinatus

insertion

SURGICAL NECK/SHAFT:deltoid/pectoralis major

largely dictates fx behaviorcompression: stable

shear: unstable

4 Anatomic PartsDeforming forces determine fx displacementDeforming forces determine fx displacement

Vascular Supply

Lateral ascending branch of anterior

humeral circumflex artery

Damage may lead to AVN

Humeral Head VascularityHumeral Head Vascularity

Gerber et al., JBJS, 1990

Non shaded area is suppliedNon shaded area is suppliedby the lateral ascending branchby the lateral ascending branch of the anterior humeral circumflexof the anterior humeral circumflexartery.artery.

Humeral Head VascularityHumeral Head Vascularity

In the fractured humerus, the arcuate artery isIn the fractured humerus, the arcuate artery isgenerally interupted.generally interupted.

Recent anatomic and clinical findings confirmRecent anatomic and clinical findings confirmthat perfusion from the posterior circumflex vesselsthat perfusion from the posterior circumflex vesselsalonealone may be adequate for head survival. may be adequate for head survival.

Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001

True AP Transcapular “Y”

RadiographyRadiography

Axillary View

Lesser Tuberosity

CT Scan

Articular surface– Head splitting injury

Tuberosity displacement, especially lesser

tuberosity

Treatment80% of PHF are NONDISPLACED and can be

successfully treated NONOPERATIVELY

20% Displaced

Operative Nonoperative?Fx pattern

Head viabilityBone quality

Implant limitationsPatient age & comorbidities

Neer Classification

Codman’s 4 parts

> 1 cm> 1 cm45º45º

A-type: 2-partA-type: 2-part

B-type: 3-partB-type: 3-part

C-type: 4-part +C-type: 4-part + anatomic neckanatomic neck

AO Classification

Predictors of ischemia:

– Metaphyseal head extension (calcar) < 8 mm.

Hertel et al, J Shoulder Elbow Surg 2004;13:427

97%PPV

Loss of integrity of medial hinge Fracture Pattern (anatomic neck)

BEWARE of lateral displacement of head

Blood Supply Potentially Torn if medial hinged displaced

This head is likely NOT viable.

Metaphyseal head extension < 8mm

Medial Hinge notMedial Hinge not displaceddisplaced

Metaphyseal headMetaphyseal headExtension > 8mmExtension > 8mmThis head isThis head is

likely viablelikely viable

Bone QualityTingert et al, JBJS(B), 2003Tingert et al, JBJS(B), 2003

2 cm2 cmAA

DDCCBB

Mean cortical thicknessMean cortical thickness

A + B + C + DA + B + C + D

44

““A mean cortical thickness A mean cortical thickness < 4 mm< 4 mm is highly indicative of low is highly indicative of low BMD”BMD”

Predictable loss of fixation ?Predictable loss of fixation ?

Implant limitationsImplant limitations

Locking plates are less proneto failure due to the fixed-angled screws.

Conventional implantsPoorly control varus

collapse, screw looseningand screw back out.

Recognizing what implants areRecognizing what implants areappropriate for certain fractureappropriate for certain fracturetypes is a key decision making factor.types is a key decision making factor.

Operative Nonoperative?Fx pattern

Head viabilityBone quality

Implant limitationsPatient age & comorbidities

Putting it all togetherPutting it all together

Hospital for Special Surgeryprotocol

Nonoperative TxNonoperative Tx

Nonop tx = surgeryNonop tx = surgery

sling + ROMsling + ROM

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons

Court-Brown et al., JBJS(B), 2001

Jan 07Jan 07

Hospital for Special Surgeryprotocol

Hospital for Special Surgeryprotocol

Nonoperative TxNonoperative Tx

ElderlyElderlyNon-displacedNon-displacedor mod displacedor mod displaced

Nonop tx = surgeryNonop tx = surgery

sling + ROMsling + ROM

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons

Court-Brown et al., JBJS(B), 2001

Jan 07Jan 07

Treatment: Non-operativeKoval et al., JBJS, 1997

– 77% good or excellent; 13% fair, 10% poor results

– Functional recovery averaged 94%

– Sling with ROM exercises by 2 weeks

Treatment: Non-operativeCourt-Brown et al., JBJS(B), 2001

– Mean age 72 yrs

– Outcome determined by age and degree oftranslation

– Surgery did not improve outcomes regardlessof translation

Hospital for Special Surgeryprotocol

Poor bone qualityPoor bone qualityOperative TxOperative Tx

heavy sutureheavy suturethrough rotatorthrough rotatorcuff insertioncuff insertion

““significant displacement”significant displacement”>5mm GT >66% SN>5mm GT >66% SN

Locking plate

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

oror

Hospital for Special Surgeryprotocol

Operative TxOperative Tx

Satisfactory bone qualitySatisfactory bone quality

Closed reductionClosed reductionpercutaneous pinspercutaneous pins

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

Hospital for Special Surgeryprotocol

Operative TxOperative Tx

Satisfactory bone qualitySatisfactory bone quality

ORIFORIF

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

Hospital for Special Surgeryprotocol

Nonoperative TxNonoperative Tx

B1.1B1.1Poor bone qualityPoor bone quality

Court-Brown, JBJS(B), 2002Court-Brown, JBJS(B), 2002

Zyto et al, JBJS(B), 1997Zyto et al, JBJS(B), 1997

Non-op = surgeryNon-op = surgery

maybe bettermaybe better

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

Hospital for Special Surgeryprotocol

ORIFORIF

High failure rates withHigh failure rates withstandard platesstandard plates

Especially in patients Especially in patients with poor bonewith poor bone

Locking plates have Locking plates have dramatically improved dramatically improved fixationfixation

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

Hospital for Special Surgeryprotocol

HemiarthroplastyHemiarthroplasty

Highly displaced fxsHighly displaced fxs““3 or 4-part”3 or 4-part”

Poor bone qualityPoor bone quality

Not reconstructableNot reconstructable

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

HemiarthroplastyHemiarthroplasty

HemiarthroplasyHemiarthroplasy

Pain relief generally good

Good function depends on anatomic tuberosity placement

Despite all the advances, shoulder flexion above 90º is difficult to acheive

Hospital for Special Surgeryprotocol

Anatomic neck fxsAnatomic neck fxshave high rate ofhave high rate ofAVN (+/- 50%).AVN (+/- 50%).

Poor bonePoor bone HemiHemiGood boneGood bone FixFix

Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07

Unless able to fixUnless able to fixanatomically, better to anatomically, better to replace (hemi)replace (hemi)

Gerber et al.Gerber et al.JSES, 1998 JSES, 1998

Summary ofSummary ofDecision Making ProcessDecision Making Process

““Young” PatientsYoung” Patients<30yrs? <40yrs? <50 yrs?<30yrs? <40yrs? <50 yrs?

““Full court press”Full court press”

Hemiarthroplasty for non-reconstructable fxs Hemiarthroplasty for non-reconstructable fxs onlyonly

Preservation of function is primary objectivePreservation of function is primary objective

Anatomic reduction/soft tissue sparingAnatomic reduction/soft tissue sparingStable fixation Stable fixation

““good bone quality”good bone quality”

Elderly PatientsElderly Patients

Pain relief primary objectivePain relief primary objective

Non op RX if fracture stable and early motion possible

Lock

ing plate

““poor bone quality”poor bone quality”

If unstable:

ORIF if head viable and fracture reducible

Hemiarthroplasty if head not viable or fracture not repairable

CaveatCaveat

““A proximal humeral fracture that is at riskA proximal humeral fracture that is at riskfor AVN has to be reduced anatomicallyfor AVN has to be reduced anatomicallyif joint preserving treatment is selected. Ifif joint preserving treatment is selected. Ifanatomic reduction cannot be obtained,anatomic reduction cannot be obtained,other treatment options such as arthroplastyother treatment options such as arthroplastyshould be considered.”should be considered.”

Gerber et al.Gerber et al.The clinical relevance of posttraumatic avascularThe clinical relevance of posttraumatic avascularNecrosis of the humeral head. JSES, 1998 Necrosis of the humeral head. JSES, 1998

93 y/o male93 y/o maleRHDRHD

HealthyHealthyFellFell

Medial hinge intact

Metaphyseal spike> 8mm

GT fx +GT fx +Surgical neck fxSurgical neck fxwith extensionwith extension

6 weeks6 weeks

+ callus+ callus

FE 90FE 90

ReferencesReferences

Neer, CS. Displaced Proximal Humeral Fractures. Neer, CS. Displaced Proximal Humeral Fractures. JBJS 52-A: 1077-1089, 1970.JBJS 52-A: 1077-1089, 1970.

Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:1090-1103, 1970.1090-1103, 1970.

Gerber, C. et al. The Arterial Vascularization of the Humeral Head. Gerber, C. et al. The Arterial Vascularization of the Humeral Head. JBJS 72-A: 1486-1494, 1990.JBJS 72-A: 1486-1494, 1990.

Brooks, CH et al. Vascularity of the Humeral Head After Proximal HumeralBrooks, CH et al. Vascularity of the Humeral Head After Proximal HumeralFractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.Fractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.

Hertel, R et al. Predictors of Humeral Head Ischemia After IntracapsularHertel, R et al. Predictors of Humeral Head Ischemia After IntracapsularFracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004Fracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004

ReferencesReferences

Nho, SJ. et al. Nho, SJ. et al. Innovations in the Management of Displaced Proximal Humerus Innovations in the Management of Displaced Proximal Humerus FracturesFractures . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007. . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007.

Koval, KJ. et al. Koval, KJ. et al. Functional Outcome after Minimally Displaced Fractures Functional Outcome after Minimally Displaced Fractures of the Proximal Part of the Humerusof the Proximal Part of the HumerusJBJS 79-A: 79: 203 – 7, JBJS 79-A: 79: 203 – 7, 1997.1997.

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