PROXIMAL HUMERUS FRACTURES

PROXIMAL HUMERUS FRACTURES

MODERATOR: DR.SUBRAMANIAN

PRESENTER: DR.RAMACHANDRA

INTRODUCTIONIt is the commonest # affecting shoulder girdle in adults.Proximal humeral # account for almost 7% of all # and 80% of all humeral #.In pts above the age of 65 years proximal humeral # are the 2nd most frequent upper extremity #.

ANATOMYShoulder has greatest range of motion of any articulation in body.It is due to shallow glenoid fossa that is only 25% of humeral head.Major contribution to stability is by soft tissue composed of muscle, capsule, & ligaments.Proximal humerus is retroverted 35 to 40 degrees relative to epicondylar axis.

Four osseous segments in proximal humerus are:

Humeral headLesser tuberosityGreater tuberosityHumeral shaft

Deforming muscular forces on osseous fragments:

Greater tuberosity is displaced by supraspinatus & external rotators.Lesser tuberosity is displaced by subscapularis.Humeral shaft displaced by pectoralis major.Deltoid insertion causes abduction of proximal fragment.

MECHANISM OF INJURYMost common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.Younger pts present following high energy trauma.Less common with excessive shoulder abduction, direct trauma, electric shock or seizures.

The proximal humerus can # as a consequence of 3 main loading modes:

Compressive loading of the glenoid onto the humeral head.Bending forces at the surgical neck.Tension forces of the rotator cuff at the greater & lesser tuberosities.

ASSOCIATED INJURIES The majority of proximal humeral # occur as isolated injuries.In polytrauma pts, proximal humeral # frequently exhibit comminution extending into the humeral shaft. In the presence of # dislocations, glenoid rim and neck # and avulsion # of the coracoid may occur.

The association of arterial injuries is rare and is reported in the literature as isolated case reports.Electromyographic evidence of neurologic injury can be present in as many as 67% of proximal humeral #. The most frequently affected nerves are the axillary nerve (58%) & suprascapular nerve (48%), with combined neurologic lesions being frequent.

The association of rotator cuff tears has been found to increase with age.

Full-thickness tears have been found in only 6% of proximal humerus pts under 60 years of age compared to 30% in those pts above 60 years of age.

CLINICAL EVALUATIONPts typically present with upper extremity held closely to chest by contralateral hand, pain, swelling & tenderness.Ecchymosis may or may not be present.Careful neurovascular exmn. is essential. mainly for Axillary nerve function.It is assessed by presence of sensation on lateral aspect of proximal arm overlying deltoid.

CLASSIFICATIONCODMANS CLASSIFICATION

NEER CLASSIFICATION

AO/OTA CLASSIFICATION

CODMANS CLASSIFICATIONA- Greater tuberosityB- Lesser tuberosityC- HeadD- Shaft

NEER CLASSIFICATIONMost commonly used classification is Neers classification.

Useful in guiding treatment.

Based on four part anatomy of proximal humerus : Humeral head, lesser & greater tuberosities, proximal shaft.

Criteria for displacement Greater than 1cm of seperation of a part or

Angulation of 45 degrees.

Osteonecrosis is most likely after displaced four part fractures.

NEER CLASSIFICATION

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AO/OTA CLASSIFICATION

RADIOGRAPH EVALUATION

X ray AP view of shoulder in plane of scapula.

Neer Lateral Y view of shoulder.

Axillary view of shoulder.

Computed TomographyCT of proximal humeral # is helpful in providing further understanding of fracture configuration.

Axial images can confirm displacement of the lesser and greater tuberosity fragments in the transverse plane.

Coronal images give more detail about the alignment of the humeral head & assessment of comminution at the level of the humeral calcar, the integrity of the inferomedial hinge, and extent of metaphyseal # extension.Sagittal images help in determining a flexion or extension deformity of the proximal humerus with regard to the shaft.

MANAGEMENTNON OPERATIVE TREATMENT

OPERATIVE TREATMENT

Immobilization of the arm to the chest using a simple collar and cuff sling

Gilchrist or Velpeau type shoulder immobilizer used.

At 2 weeks passive ROM exercises of the shoulder.

At 3 or 4 weeks radiographs are taken & gentle assistive exercises (pulley elevation, external rotation with a stick, extension with a stick) are begun.

At 6 weeks, rapid progression to terminal stretches and light resistive exercises is started

OUTCOMESPredictors for outcomes have been found to be age factor.Court-Brown et al. studied 131 two-part surgical neck #.At 1yr follow up pts able to return to houseworkNon operative treatment yielded results similar to those of surgical treatment even in # with translation of 66% or more.

Court-Brown et al. further assessed non operative treatment of four-part valgus-impacted # in elderly patients.

Good or excellent results were achieved in 81% of patients according to Neers criteria.

OPERATIVE TREATMENTThe treatment of displaced proximal humeral # is complex & requires careful assessment

Pt factors (age & activity level)

Fracture-related factors (bone quality, fracture pattern, degree of comminution, & vascular status).

The goal of treatment is a pain-free shoulder with restoration of pre-injury function.

Hertel CriteriaGood predictors of ischemia are:

Metaphyseal extension of the humeral head of 2 mm Ischemia of head:

The combination of metaphyseal extension of the humeral head.

Medial hinge disruption of >2 mmAnatomic neck # patternRadiographic criteria for perfusion of humeral head

Conservative vs Internal fixationOperative management is guided by fracture pattern & cortical thickness.Combined cortical thickness is the average of medial & lateral cortical thickness.A cortical thickness 4mm- internal fixation.

TREATMENT OPTIONS Transosseous Suture Fixation

IndicationsContraindications proximal humeral fractures that have at least 1 cm of displacement between the head and the shaft fragments

or 5 mm of displacement of the tuberosity fragment.previous attempt(s) at internal fixation

More than 6wks old #.

Four part comminuted #

RESULTSFlatow et al. reported isolated greater tuberosity # had good or excellent results with osseous union.78% of the pt had an excellent result according to the criteria of Neer et al. in 2 or 3 part #.

CLOSED REDUCTION & PERCUTANEOUS FIXATIONIndicationsgreater tuberosity # isolation or in conjunction with a surgical neck #.

three and four-part proximal humeral #.

four-part valgus impacted # or true four part #.severe osteopenia or osteoporosis.

Comminution of the medial portion of the calcar or proximal part of the humeral shaft.Contraindications

OPEN REDUCTION & INTERNALFIXATIONTwo surgical approaches are commonly used to perform open reduction and internal fixation (ORIF).

These are the

Delto pectoral approach Deltoid-splitting approach.

IndicationsContraindicationsAO type-B (bifocal)

AO type-C (anatomic neck)Fracture-dislocations

Head splitting fractures

Impression fractures that involve >40% of the articular surface

LOCKING PLATE The plate should be positioned directly on the middle of the lateral cortex and approximately 8 mm distal to the superior aspect of the greater tuberosity.

Humeral head preservation may be possible with locked-plate fixation supplemented with local bone graft or bone-graft substitute.

INTRAMEDULLARY NAILINGThe main indications for proximal humerus interlocking IMIL nailing are displaced two-part surgical neck # especially those with extension into the humeral diaphysis, and pathologic #.

Three-part greater tuberosity fractures may also be amenable to fixation with IM nailing

INTRAMEDULLARY NAILING

HEMIARTHROPLASTYIndicationsContraindicationsFour-part #, three-part # in older pts with osteoporotic bone.

Fracture-dislocations

Head-splitting fractures

That involve >40% of the articular surfaceActive infection of the shoulder joint and/or

Surrounding soft tissue

Delto pectoral approach proximal anatomy is restored by greater tuberosity cerclage sutures medial to the humeral neck and tie them around the greater tuberosity fragment.

A second set of sutures can then be passed into the lesser tuberosity and tied.

COMPLICATIONSOsteonecrosis: 3% to 14% of 3 part # , 4 to 14% of 4 part # & high rate in anatomical neck #.InfectionsNonunionMalunionShoulder stiffnessImplant failurePin tract infection

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Neurovascular injuryImpingement syndromeRotator cuff injury

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