Fractures of the proximal humerus
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Proximal humerus fractures are the third most common upper extremity fractures, often caused by low-energy falls in elderly patients. Treatment options include non-operative management, closed reduction percutaneous pinning, ORIF, intramedullary nailing, and various types of shoulder arthroplasty, with no single approach suitable for all cases. The outcomes of surgical treatments in elderly patients have shown limited improvement in functional status and a higher incidence of complications compared to conservative management.
Fractures of the proximal humerus
- 1. Fractures of the Proximal Humerus
- 2. Epidemiology Third most common upper extremity fracture (distal radial & hand ) Most common mechanism: simple low energy fall in an elderly patient 80 % of all humeral #above 60 7 % of all #.. • Young Pts – High energy trauma • Severe soft tissue disruption always require surgical intervention
- 3. Common mechanism in elderly patients
- 4. Anatomy • Articular segment almost spherical diameter of curvature ranging from 37-57 mm • Head shaft angle averages 130 degrees • Retroversion varies 18 - 40 degrees
- 5. Deforming forces of PHF
- 6. Vascular anatomy • Ascending branch of anterior humeral circumflex ( Arcuate artery of Liang) • Recent studies post humeral circumflex is the main blood supply to HH
- 7. Study on Twenty-four fresh-frozen cadaver shoulders with Gadolinium MRI Posterior humeral circumflex artery 64% of Blood Supply to Humeral Head
- 8. Risk of head ischemia • Vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
- 9. Hertel et al…2004 • Three most accurate predictors of humeral head ischemia are: < 8mm of calcar length attached to articular segment Disrupted medial hinge ≥ 2mm Fracture through anatomical neck
- 10. Complex proximal humeral fractures: Hertel′s criteria reliability to predict head necrosis Conclusions: Hertel’s criteria are important in the surgical planning, but they are not sufficient. An accurate evaluation of the calcar area fracture in three planes is required. All fractures involving calcar area should be studied with CT
- 11. CLASSIFICATION • KOCHERS: based on different anatomic levels. Anatomic neck Epiphyseal region Surgical neck. Did not included #s at multiple level, degree of displacement, dislocations, mechanism. Codmann”s based on physeal lines Identifies four possible #s GT ,LT ,anatomic head, shaft
- 12. NEER’S CLASSIFICATION (5-types) • The most commonly used classification was developed in 1970 by Dr charles neer. • The basis of the system according to Displacement Anatomical lines of epiphyseal union
- 13. Neer Classification • Considered a separate part if Displacement > 5mm 45 degee angulation
- 15. Imaging • X-Rays True AP (Grashey) Scapular Y Axillary/ Velpeau • CT Articular surface Tuberosity displacement Occult medial calcar fracture 3D reconstruction
- 16. Treatment Non-operative Most fractures of the proximal humerus have a stable configuration and heal functionally with non-operative treatment Operative CRPP ORIF Intra-medullary nailing Arthroplasty Hemiarthroplasty RTSA
- 17. Non-Operative Treatment • Sling immobilization followed by progressive rehab • Indications Minimally displaced fractures GT fractures displaced < 5mm Patients who are not surgical candidates • Other variables to consider Age Hand dominance Bone quality General medical condition The shoulder is very forgiving when one doesn’t operate, but can be very unforgiving when one DOES operate
- 18. • 70 consecutive patients • 60-85 years old • Treated conservatively • Conservative treatment > 75 yrs provides good pain relief with limited functional outcome. • Despite limited functional outcome, this appears to have no effect on the quality-of-life perception in the population studied.
- 19. • 650 patients • Mean age 65 • “High rates of radiographic healing, good functional outcomes, and a modest complication rate”
- 20. Total 518 patients (average age 70.93) met inclusion criteria. Patients were followed up for at least 1 year in all the studies. Conclusion Operative treatments did not significantly improve the functional outcome and healthy-related quality of life in elderly patients. Instead, Operative treatment for CPHFs led to higher incidence of postoperative complications.
- 21. Closed Reduction Percutaneous Pinning • Indications Good bone quality Minimal metaphyseal comminution Intact medial calcar Outcomes It has theoretical advantage of minimizing soft tissue trauma, thereby promoting healing and reducing the risk of AVN of the humeral head.
- 22. • To avoid injury to the axillary nerve, • lateral pins should enter the humeral cortex at a point at least twice the distance from the upper aspect of the head to the inferior head margin with the wire angulated approximately 45 degrees to the cortical surface. • The end point for the greater tuberosity pin should be >2 cm from the inferior most margin of the humeral head.
- 23. Contraindications Severe comminution and osteopenia Inability to reduce Fracture Fragments Fracture Dislocation Non Compliant patients
- 24. ORIF • Indications Greater tuberosity displaced > 5mm 2-,3- and 4-part fractures in younger patients Head splitting fractures in younger patients Medial support is necessary for fractures with posteromedial comminution so Calcar screw is the most important
- 25. ORIF • Surgical pearls Non-absorbable sutures to rotator cuff tendons Avoid subchondral screws Avoid varus reductions Restore medial contact Infero-medial screw! Be prepared for ORIF and arthroplasty
- 26. Intramedullary Nailing • Indications Surgical neck or 3-part fractures in younger patients Combined proximal humerus and humeral shaft fractures • Outcomes compared to ORIF Biomechanically inferior with torsional stress Favorable rates of fracture healing and ROM
- 27. Shoulder Arthroplasty • Older patients with 4-part fracture dislocations Head splitting components Anatomical neck fractures
- 28. • Boyle et al, JSES 2013 Acute proximal humerus fractures 55 RSA, 313 shoulder hemi Significantly better 5-year Oxford Shoulder Score in RSA group
- 29. Debate…..? Leave it, fix it or replace it??
- 30. Decision Making • Non-operative? Majority of fracture cases…. • ORIF? Viable head, good bone quality…. • Hemiarthroplasty? Nonviable head, good bone quality…. • Reverse arthroplasty? Nonviable head, poor bone quality…. THERE IS NO SINGLE TREATMENT OPTION THAT WILL WORK FOR ALL PATIENTS!!
- 31. Decision Making Patient Factors • Age (operative treatment rarely indicated > 85) • Nonfunctional limb • Severe medical comorbidity • Severe osteoporosis • Smoking • DM • RA Poor outcomes Surgeon Factors Choice of treatment Technical expertise
- 32. Decision Making Injury Factors No entirely satisfactory classification to guide modern treatment and predict outcome Neer one-part fractures Impacted two-part fractures of surgical neck with minimal angulation Non-operative
- 33. Complications of Proximal Humerus Fractures • Posttraumatic shoulder stiffness • AVN • Malunion • Nonunion • Infection • Complications unique to arthroplasty Tuberosity redisplacement, nonunion or resorption Instability/dislocation Prosthetic loosening Periprosthetic fracture