Proximal Humerus DR.K KODANDAPANI

PROFESSOR OF ORTHOPAEDICS OSMANIA MEDICAL COLLEGE

OSMANIA GENERAL HOSPITAL HYDERABAD

Proximal Humeral FxsMajority 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 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

Critical Anatomic FactorsThe critical anatomic relationships of the

articular segment to the shaft and the tuberosities, and include

retroversion,inclination angle, andtranslation 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

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

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

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 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

   

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

of medical contraindications, all displaced fractures must be operated .results of surgery is variable,

Prognostic factors include --- Fracture Pattern , Bone quality, Quality of surgical Reduction, stability of Fixation , Age of the patient, Patient motivation, and reliability , Surgeon experience and post op Rehabilitation.

 

Specific Surgical indications for PHFXs is poorly defined , any single surgical technique is not appropriate for all patients Treatment must be tailored to each specific situation

Significantly (>1cm )Displaced Greater Fxs Requires Repair, to avoid Rotator cuff deficiency. and sub acromial impingement of the cuff . 0.5 cm displacement may lead to pain or disability after fracture healing.

Displaced lesser Tuberosity – where significant amount of articular head is attached to the fragment , or Fxs that limit internal rotation .

Two part anatomic neck Fxs. In Young pts ,-- ORIF

Two part Surgical neck FXs Two Part tuberosity Fx Dislocation Fx - Dislocation , involving the Surgical

neck

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 nailHemiarthroplastyTotal shoulder replacementReverse shoulder arthroplasty  

Percutaneous Pinning Percutaneous pinning – first

advocated by Bohler - Termed Biological Fixation

Less soft tissue dissection , and disruption,

vascularity of the humeral head is preserved

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 comminution and osteopenia are absolute contraindications

Inability to reduce Fracture Fragments

Fracture Dislocation Non Compliant

patients

Contra indications -- Severe comminution and osteopenia are absolute contraindications

Inability to reduce Fracture Fragments

Fracture DislocationNon Compliant

patients

The orientation and pin placement must be parallel and avoid

1)the Axillary nerve , which courses 5cms distal to the lateral edge of the Acromion from 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 The development of the locking plate has

changed the management of many fractures.

They have a number of advantages including improved fixation in osteoporotic bone, and the facilitation of reconstruction of comminuted irreducible fractures

The concepts behind its use are to provide:

Stable fixation of the unstable proximal humerus fracture until bony union.

Early mobilisation of the shoulder and early active rehabilitation program.

Good functional outcomes and a good restoration of the activities of daily living [5].

Indications for use In the treatment of acute unstable 2,

3 and 4 part fractures and fracture dislocations.

Non-union of fractures especially at the neck of the humerus (combined with bone grafting).

Pathological fractures .   Contraindications Extensively comminuted humeral

head fractures which cannot be adequately reconstructed.

Fractures in immature patients. Local infection after previous surgery

[5].

Arthroplasty in PHFxs4-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 Prosthesesfor acute complex fractures of the proximalhumerus in elderly population with poor bone

quality andsevere rotator deficiency, when an efficient

and reliablere-fixation of the tubercles is diffcult or

impossible

Reverse shoulder prostheses

Reverse Shoulder Prostheses

Complications

Humeral head necrosisDelayed union/non-unionScrew cut out with intra-articular

displacementImplant failureVarus displacement (>10˚)InfectionHeterotopic 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

Thank you