proximal humerus fractures principles of diagnosis, decision making and treatment christopher g....
TRANSCRIPT
![Page 1: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/1.jpg)
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
![Page 2: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/2.jpg)
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
![Page 3: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/3.jpg)
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
![Page 4: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/4.jpg)
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
![Page 5: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/5.jpg)
Vascular Supply
Lateral ascending branch of anterior
humeral circumflex artery
Damage may lead to AVN
![Page 6: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/6.jpg)
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.
![Page 7: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/7.jpg)
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
![Page 8: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/8.jpg)
True AP Transcapular “Y”
RadiographyRadiography
![Page 9: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/9.jpg)
Axillary View
Lesser Tuberosity
![Page 10: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/10.jpg)
CT Scan
Articular surface– Head splitting injury
Tuberosity displacement, especially lesser
tuberosity
![Page 11: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/11.jpg)
Treatment80% of PHF are NONDISPLACED and can be
successfully treated NONOPERATIVELY
20% Displaced
Operative Nonoperative?Fx pattern
Head viabilityBone quality
Implant limitationsPatient age & comorbidities
![Page 12: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/12.jpg)
Neer Classification
Codman’s 4 parts
> 1 cm> 1 cm45º45º
![Page 13: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/13.jpg)
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
![Page 14: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/14.jpg)
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)
![Page 15: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/15.jpg)
BEWARE of lateral displacement of head
Blood Supply Potentially Torn if medial hinged displaced
This head is likely NOT viable.
Metaphyseal head extension < 8mm
![Page 16: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/16.jpg)
Medial Hinge notMedial Hinge not displaceddisplaced
Metaphyseal headMetaphyseal headExtension > 8mmExtension > 8mmThis head isThis head is
likely viablelikely viable
![Page 17: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/17.jpg)
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 ?
![Page 18: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/18.jpg)
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.
![Page 19: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/19.jpg)
Operative Nonoperative?Fx pattern
Head viabilityBone quality
Implant limitationsPatient age & comorbidities
Putting it all togetherPutting it all together
![Page 20: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/20.jpg)
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
![Page 21: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/21.jpg)
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
![Page 22: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/22.jpg)
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
![Page 23: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/23.jpg)
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
![Page 24: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/24.jpg)
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
![Page 25: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/25.jpg)
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
![Page 26: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/26.jpg)
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
![Page 27: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/27.jpg)
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
![Page 28: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/28.jpg)
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
![Page 29: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/29.jpg)
![Page 30: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/30.jpg)
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
![Page 31: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/31.jpg)
HemiarthroplastyHemiarthroplasty
![Page 32: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/32.jpg)
HemiarthroplasyHemiarthroplasy
Pain relief generally good
Good function depends on anatomic tuberosity placement
Despite all the advances, shoulder flexion above 90º is difficult to acheive
![Page 33: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/33.jpg)
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
![Page 34: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/34.jpg)
Summary ofSummary ofDecision Making ProcessDecision Making Process
![Page 35: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/35.jpg)
““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”
![Page 36: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/36.jpg)
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
![Page 37: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/37.jpg)
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
![Page 38: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/38.jpg)
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
![Page 39: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/39.jpg)
![Page 40: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/40.jpg)
![Page 41: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/41.jpg)
6 weeks6 weeks
+ callus+ callus
FE 90FE 90
![Page 42: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/42.jpg)
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
![Page 43: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/43.jpg)
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.
![Page 44: Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:](https://reader035.vdocuments.mx/reader035/viewer/2022081516/56649d0a5503460f949dc4e6/html5/thumbnails/44.jpg)
Thank you!
Return to Return to Upper ExtremityUpper Extremity
IndexIndex
E-mail OTA E-mail OTA about about
Questions/CommentsQuestions/Comments
If you would like to volunteer as an author for the If you would like to volunteer as an author for the Resident Slide Project or recommend updates Resident Slide Project or recommend updates
to any of the following slides, please send to any of the following slides, please send an e-mail to [email protected] e-mail to [email protected]