Proximal humerus fractures
- 1. PROXIMAL HUMERUS FRACTURES Dr Muhammed Shamseer C
- 2. PROXIMAL HUMERUS FRACTURES • Defined as fractures occurring at or proximal to surgical neck of humerus • m/c humerus fracture-45% • Age > 65- 2nd M/C Fs of upper extremity • Incidence increases with age • F:M- 3:1 • Most of Pts are osteoporotic post menopausal woman • Most fractures are nondisplaced(85%), good prognosis • < 5% of paediatric fractures
- 3. ANATOMY • 4 parts • Head of humerus • Greater tuberosity • Lesser tuberosity • Shaft • 3 ossification centre's - humeral head, GT, LT
- 4. ANATOMY • GT-Supraspinatus, Infraspinatus & teres minor • LT- Subscapularis • intertubercular sulcus/ bicipital groove-tendon of the long head of the biceps brachii • “a lady between two majors” • Surgical neck-axillary nerve and circumflex humeral vessels
- 5. ANATOMY • Axillary nerve- Deltoid, teres mionor, • Abduction • Regimental badge area • just antero inferior to glenohumoral joint. It is at risk of traction injury and injury while anterior fracture-dislocation
- 6. ANATOMY • Arcuate artery of Liang- supplies head • Ascending branch of ACHA(anterior circumflex humeral artery) supplies most of blood to articular segment • Posterior circumflex humeral artery- blood supply to humeral head
- 7. MECHANISM OF INJURY • Fall on outstretched arm • Direct trauma • Older Pt- low energy trauma(FOOSH) • Young Pt-high energy trauma • Indirect cause- seizures & electric shock • Pathological- malignant/ benign lesions
- 8. DEFORMING FORCES • GT is pulled posteromedially by supraspinatus and infraspinatus tendons • LT is pulled anteriorly and medially by Subscapularis tendons • The shaft segment is pulled anteromedially by Pect. Major tendon • Deltoid abducts the proximal fragment
- 9. CLINICAL FEATURES • Pain may not be severe, as the fracture may be deeply impacted • Signs of axillary nv/brachial plexus injury •
- 10. IMAGING • AP/Grashey view-taken in neutral arm rotation with torso rotated 30-45 degrees
- 11. • Neer view( Scapula Y view)-scapula is imaged perpendicular to Grashey view
- 12. • Axillary view • may be difficult because of pain
- 13. Velpeau axillary view • 45 degree obliquity
- 14. CT scan with 3D reconstruction • planning of treatment • articular involvement • degree of fracture displacement • impression fractures • glenoid rim fractures MRI • to assess rotator cuff integrity
- 15. CLASSIFICATION :- • Neer classification • AO classification • LEGO system by Hertel et al • HGLS classification system
- 16. NEER CLASSIFICATION(1970) • based on xray • A part- > 1 cm of fracture displacement, or > 45 degrees of angulatio
- 17. ONE PART FRACTURES • No displaced fragments regardless of no of fracture lines.
- 18. TWO PART FRACTURES • anatomical neck • Surgical neck • GT • LT
- 19. THREE PART FRACTURES • It may be • Surgical neck with GT • Surgical neck with LT
- 20. FOUR PART FRACTURE:- • All the 3 major parts are displaced
- 21. FRACTURE DISLOCATION • head is dislocated • can be 2 part, 3 part 4 parts
- 29. LEGO SYSTEM BY HERTEL ET AL (BINARY SYSTEM) • Lego blocks • 5 yes-or-no questions had to be answered concerning the 5 basic fracture planes: • (1) Is there a fracture plane between the head and greater tuberosity? • (2) Is there a fracture plane between the greater tuberosity and shaft? • (3) Is there a fracture plane between the head and lesser tuberosity? • (4) Is there a fracture plane between the lesser tuberosity and shaft? • (5) Is there a fracture plane between the greater tuberosity and lesser tuberosity? Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13:427-33. http://dx.doi.org/10.1016/j. jse.2004.01.034
- 30. LEGO SYSTEM • assessed the humeral head vascularity in the context of different fracture plane locations • Hertel et al emphasized the importance of the location of fracture planes, rather than the specific number of fracture fragments
- 31. HGLS CLASSIFICATION SYSTEM:-( CODMAN'S MODIFICATION OF HERTEL' S SYSTEM) • A fracture plane is represented by a hyphen (-) Codman E. Fractures in relation to the subacromial bursa. In: Codman E,
- 32. TREATMENT Minimally displaced fractures- One part fractures • Non-operative • Sling immobilization/swathe for comfort • Early range of motion when pain permits(usually after 1-2weeks) • Pendulum exercises and gentle isometric strengthening of biceps and triceps to compress fracture fragments • After 3-4 weeks-supine passive flexion and external rotation exercises may be added • 4-5 weeks-overhead pulley exercises • 6-8 weeks- strengthening • Resistive exercises started b/w 6-12 weeks • Full ROM and function is expected outcome by 1 year
- 33. TWO PART FRACTURES :- • Anatomic neck fractures • Rare • Difficult to treat by closed reduction • For younger Pt- ORIF • For older Pt- Hemiarthroplasty due to risk of avascular necrosis of humeral head
- 34. TWO PART FRACTURES (SURGICAL NECK FRACTURES) • Non operative- • Angulated/displaced surgical neck fractures which are stable( move as a unit) • In lower demand Pt • Severely debilitated pt • Those who can not tolerate surgery • Closed reduction and percutaneous pin
- 35. TWO PART FRACTURES (SURGICAL NECK FRACTURES) • Closed reduction and percutaneous pin • Indications- • Pt with good bone quality • Noncomminuted/ minimally comminuted fractures that can be reduced by closed means • Contraindications- • Severe comminution • Osteopenia
- 36. TWO PART FRACTURES (SURGICAL NECK FRACTURES) • Advantages • Avoidance of devascularisation of fracture fragments • Minimization of injury to blood supply of humeral head • Reduced operative morbidity • Disadvantage- • Risk of nerve injury- axillary • Pin loosening • Pin migration • Inability to move the arm • Risk of pin migration • Loss of reduction
- 37. TWO PART FRACTURES (SURGICAL NECK FRACTURES) • ORIF • IM device • Plate and screws • Prosthetic replacement • For PT with extreme osteopenia • May be hemiarthroplasty, total shoulder, or reverse shoulder prosthesis
- 38. TWO PART FRACTURES (GT FRACTURES) • often associated with anterior dislocation • Reduces to good position once the shoulder is relocated • If it does not reduce, the fragment can be reattached through a small incision interosseous sutures, or in young hard bone- cancellous screws • ORIF with /without rotator cuff repair is indicated for GT fractures which are displaced >5-10 mm • Otherwise, they may develop non union/ subacromial impingement
- 39. TWO PART FRACTURES (LT FRACTURES) • Must rule out associated Posterior dislocation • May be treated closely unless displaced fragment blocks internal rotation
- 40. THREE PART FRACTURES • Usually involve displacement of surgical neck and GT • Unstable due to opposing muscle forces- so closed reduction and its maintenance is often difficult. • In active Pts it is best managed by ORIF • Younger Pt- attempt ORIF using plate and srews • replacement- indicated in elderly
- 41. FOUR PART FRACTURES • Very severe injuries with a high risk of complications like • Vascular injury • Brachial plexus damage • Injuries of chest wall • (later) Avascular necrosis of humeral head • In younger Pts, an attempt should be made at reconstruction by ORIF if head is within glenoid fossa and there appears to be soft tissue continuity • Fixation can be done with locking plate and screws, sutures and /or wire fixation • Primary prosthetic replacement- indicated in elderly
- 42. FRACTURE-DISLOCATIONS • Fracture-dislocations:- • 2 part FD:- • May be treated closed after shoulder reduction • 3 and 4 part- • ORIF in younger • Prosthetic replacement in older • Brachial plexus and axillary artery are in proximity to humeral head fragment with anterior fracture dislocation • Recurrent dislocation is rare following fracture union • Prosthetic replacement of anatomic neck fracture dislocation is recommended because of high incidence of osteonecrosis • May be associated with increased incidence of Myositis ossificans with repeated attempts at closed reduction
- 43. ARTICULAR SURFACE FRACTURES • Hill-sach's and reverse Hill sach's • Pt with > 40% of humeral head involvement - may require replacement • <40 years - ORIF should be considered initially, if possible
- 44. • Studied 231 pt • >16 years • Follow up- 2 years • Results- • No significant difference b/w surgical treatment compared with nonsurgical treatment Rangan, Amar, et al. "Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial." Jama 313.10 (2015): 1037-1047.
- 45. • 50 patients • 22 males and 28 females • NEER’S classification. • follow-up at 1 month, 3 months, 6 months, 9 months and 1 year Results • average age-55.6 years • 56% were female. • Domestic fall was the most common mode of injury (64% patients). • Two part surgical neck fractures (Neer’s) accounted maximum number of the patients (34%). • All One parts and most of the two part fractures treated conservatively. Most of the three part fracture treated with Open reduction and proximal humerus anatomical locking plates. • Most common complication was malunion whereas one patient had implant loosening as complication. ISSN: 2395-1958 IJOS 2018; 4(1): 41-44 © 2018 IJOS www.orthopaper.com Received: 16-11-2017 Accepted: 17-12-2017
- 46. • Constant and Murley score • excellent (score 86-100), good (score 71-85), fair (score 56-70) and poor (0-55). • conservatively treated patients- 75.69 • close reduction and percutaneous K wire fixation -82.79 • open reduction and internal fixation with anatomical locking plate -73.6.
- 47. SURGICAL CONSIDERATIONS • Pt position- • Supine • beach chair position • Allows weight of arm to facilitate fracture reduction • Prosthetic replacement is usually performed
- 48. SURGICAL CONSIDERATIONS • Surgical approach- • Deltopectoral • Allows for extensile approach to proximal humerus • ORIF/ arthroplasty is well performed through this approach • Deltoid split:- • Allows for easier plate placement on GT and requires fewer assistants to retract deltoid muscle
- 49. COMPLICATIONS • Vascular injury • Infrequent(5-6%) • m/c sit- axillary artery(proximal to ACHA) • Incidence high in older individuals due to atherosclerosis and loss of vessel elasticity • Neural injury • Brachial plexus injury- 6% • Axillary nv injury- • Vulnerable with anterior fracture dislocation, because the nerve nv courses on the inferior capsule and is prone to traction injury or laceration
- 50. COMPLICATIONS • Chest injury • Intrathoracic dislocation may occur with surgical neck fracture- dislocations • Pneumothorax • Haemothorax • Myositis ossificans:- • Uncommon • Ass with chronic unreduced fracture dislocations, repeated attempts at closed reductions • May also be related to timing of surgery and deltoid split approaches
- 51. COMPLICATIONS • Shoulder stiffness • May be minimized with an aggressive, supervised physical therapy regimen and may require open lysis of adhesions for recalcitrant cases • Avascular necrosis- • 10-30% in 3 part fractures • 10-50% in 4 part fractures • High in anatomic neck fractures • Hertel criteria • Metaphyseal extension of humeral head < 8mm 97% predictive value • Medial hinge disruption of > 2mm, and
- 52. COMPLICATIONS
- 53. COMPLICATIONS
- 54. COMPLICATIONS • Nonunion • 2 part surgical neck fractures with soft tissue interposition • Excessive traction • Severe fracture displacement • Poor bone quality • Inadequate fixation • Infection • m/m • ORIF with or without bone graft / prosthetic replacement
- 55. COMPLICATIONS • Malunion • Inadequate closed reduction • Failed ORIF • May cause impingement of GT on acromion- restriction motion