Proximal humerus fractures
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- Humeral fractures are common, especially in older adults, with the surgical neck being the most common site. Most fractures are nondisplaced and can be treated nonsurgically. - Displaced fractures, fractures with rotator cuff injuries, and those in poor bone quality patients may require surgical treatment like open reduction and internal fixation using plates or pins. - Complications can include malunion, nonunion, avascular necrosis, and arthritis, so careful follow up is needed after surgical treatment of humeral fractures.
![ Old Pts low energy trauma. [FOOSH]
Most # are nondisplaced, good prognosis –
nonsurgical
Risk factors: Poor quality bone impaired vision &
balance, medical comorbidities, decreased muscle
tone.
Young Pts – High energy trauma.
Severe soft tissue disruption always require
surgical intervention
Seizures & electric shock – indirect causes.](https://image.slidesharecdn.com/proximalhumerusfractures-130423124129-phpapp02/85/Proximal-humerus-fractures-3-320.jpg)
![ Scapular AP, Y- lateral, abducted & Velpeau
axillary view.
CT – to assess glenoid #, dislocation,
communition, & posteriorly displaced GT or
medially displaced LT fragments.
MRI: Pt had preinjury shoulder problem [cuff tear],
pathological #, nonunion.](https://image.slidesharecdn.com/proximalhumerusfractures-130423124129-phpapp02/85/Proximal-humerus-fractures-11-320.jpg)
![ Edwin smith papyrus: closed / open.
Kocher [1896]: location of #, supratubercular,
periT, infraT, subT.
Codman: 11 different types, described # along the
lines of epiphyseal scars.
Watson & Jones: based on mechanism of injury
AO – 27 possible subgroups, emphasizes on
vascular supply of articular portion of PH.](https://image.slidesharecdn.com/proximalhumerusfractures-130423124129-phpapp02/85/Proximal-humerus-fractures-12-320.jpg)
![ Most # [>80%] can be treated conservatively.
Two part nondisplaced is the most common
variant.
3 & 4 part # represent 13-16% of PH%.
Good outcome doesn’t require anatomic
reduction.
Considerations: assessment of #, bone quality,
status of rotator cuff. Pt age, activity level,
preinjury health.](https://image.slidesharecdn.com/proximalhumerusfractures-130423124129-phpapp02/85/Proximal-humerus-fractures-18-320.jpg)
Proximal humerus fractures
- 2. 2-4 % of upper extremity # 5% of all #. second most common fracture of the upper extremity. Pt > 65 yrs – third most common # 65% of # occur in Pt’s > 60 yrs F:M – 3:1 Incidence increases with age.
- 3. Old Pts low energy trauma. [FOOSH] Most # are nondisplaced, good prognosis – nonsurgical Risk factors: Poor quality bone impaired vision & balance, medical comorbidities, decreased muscle tone. Young Pts – High energy trauma. Severe soft tissue disruption always require surgical intervention Seizures & electric shock – indirect causes.
- 4. Articular head, G.T, L.T, for insertion for rotator cuff & shaft. Metaphyseal flare – surgical neck most common site of # Anatomic neck. Articular segment is almost spherical, with a diameter of curvature averaging 46 mm (ranging from 37 to 57 mm) Inclination of the humeral head relative to the shaft averages 130 degrees
- 5. Humeral retroversion – 18*-40* Bone density of subchondral bone is strongest. Greater tuberosity has three regions into which the supraspinatus, infraspinatus, and teres minor insert Subscapularis tendon lesser tuberosity, which is separated from the greater tuberosity by the bicipital groove.
- 6. PH is formed by 3 ossification centres Fusion of these ossification centers at the physis creates a weakened area that is susceptible to fracture . Primary deforming forces – pectoralis major & rotator cuff. Blood supply: distal branches of axillary artery. Arcuate artery of Liang – supplies H. head. Tethered trifucation – at the level of surgical neck – vascular injury.
- 9. Ecchymosis appears 24-48 hrs. Look for rib, scapular, cervical # in high energy trauma. Concurrent brachial plexus injury 5% Axillary nerve is susceptible in anterior # dislocation. Gentle rotation of arm & palpation of # - guide for # stability .
- 11. Scapular AP, Y- lateral, abducted & Velpeau axillary view. CT – to assess glenoid #, dislocation, communition, & posteriorly displaced GT or medially displaced LT fragments. MRI: Pt had preinjury shoulder problem [cuff tear], pathological #, nonunion.
- 12. Edwin smith papyrus: closed / open. Kocher [1896]: location of #, supratubercular, periT, infraT, subT. Codman: 11 different types, described # along the lines of epiphyseal scars. Watson & Jones: based on mechanism of injury AO – 27 possible subgroups, emphasizes on vascular supply of articular portion of PH.
- 13. DePalma and Cautilli emphasized the difference between fractures with and without dislocation of the joint surfaces Neer classification: # classified by evaluating the displacement of parts from each other. Criteria to consider as a part, fragment must be rotated 45* or 1 cm from the another fragment.
- 15. Articular surface # are two types Impression # mostly occurs in association with chronic dislocations. Head splitting # are associated with other # in which splitting of AS is significant component. Neer -Commonly used because it based on the regional anatomy & emphasis on degree of diplacement.
- 16. almost exclusively in older people tend to develop periarthritis about the shoulder, these fractures should be treated by methods that allow early motion and early restoration of function
- 18. Most # [>80%] can be treated conservatively. Two part nondisplaced is the most common variant. 3 & 4 part # represent 13-16% of PH%. Good outcome doesn’t require anatomic reduction. Considerations: assessment of #, bone quality, status of rotator cuff. Pt age, activity level, preinjury health.
- 19. Non-displaced # - < 5mm of superior or 10 mm of posterior GT displacement in active Pts & < 10 mm of superior displacement in nondominant arm in sedentary pt. Surgical neck # - any bone contact in elderly pt, in young pt <50% shaft diameter displacement & <45* angulation in dominant arm.
- 20. Reduced demand: Pt willing to accept stiffness Poor health: pt unable to tolerate surgery & anaesthesia. Poor rehabilitation candidate.
- 21. Principle: early protection & combined with gradual mobilization. Early sling immobilisation for 7-10 days. Active finger, wrist, elbow movts By 2 wks, gentle active assisted ROM ex By 6 wks, light resistive ex By 3 months, shoulder strengthening ex.
- 22. most commonly occur as a result of seizures or secondary to glenohumeral dislocations. These often reduce anatomically with reduction of the humeral head and can be managed nonoperatively. displaced more than 1 cm, open reduction and internal fixation are required fixation with screws, wire, or suture as dictated by the size of the fragment, the comminution, or the quality of the bone
- 23. If tuberosity has been displaced and retracted, a significant tear in the rotator cuff mechanism exists also, Careful identification and repair of the rotator cuff defect are required
- 25. Two-part # involving the anatomical neck render the articular fragment avascular and may require prosthetic replacement. Involving the surgical neck usually can be treated by a sling, hanging arm cast, or other conservative measures. Indications for operative treatment of two-part fractures include open fractures, the inability to obtain or maintain an acceptable closed reduction, injury to the axillary artery, and selected multiple trauma patients
- 26. Indications for CRPF # without significant communition in pt with good quality bone. Pt should be willing to comply with postop care plan. Contraindications: Severe communition & osteopenia. Inability to reduce the #.
- 28. The safe starting point for the proximal lateral pins and the end point for the greater tuberosity pins. X = distance from the superiormost aspect of the humeral head to the inferiormost aspect of the humeral head. 2X = the starting point for the proximal lateral pin. The end point for the greater tuberosity pin should be >2 cm from the inferior most margin of the humeral head.
- 29. Shoulder immobilised for 4 wks Pt were reviewed every wk for checking the pins position, Pins can be removed by 4-6 wks time, begin assisted motion.
- 30. If open reduction is necessary, internal fixation with a combination of intramedullary rod fixation and tension band technique or intramedullary rod fixation with a proximal locking screw. A hand-bent semitubular plate used as a blade- plate device also is satisfactory in osteopenic bone. In younger patients, an AO buttress plate with screws also is useful.
- 32. ORIF one of the tuberosities remains with the articular head fragment, thereby retaining its vascularity
- 34. Rationale: injury caused avascularity of articular segment which even with a satisfactory reduction & fixation would eventually collapse – posttraumatic arthritis. Indications: 1. four part# & # dislocations, 2. three part # & # dislocations in elderly pts with osteopenic bone, anatomic neck 3. Head splitting # 4. Anatomic neck # that can not be R & F. 5. Chronic dislocation with impression # involving >40% articular surface.
- 35. More likely after surgical than nonoperative # care. Careful postop followup is necessary. 1) INSTABILITY Glenoid # , rotator cuff tear, muscle atony. ORIF glenoid, repair of cuff, isometric ex. 2) MALUNION Incorrect diagnosis, poor reduction, inadequate fixation. Release of adhesions, with or with out osteotomy Vs trim of prominence.
- 36. 3) NONUNION Motion too early, poor bone. Preserved head – ORIF & BG Cavitated head – HHR 4) AVASCULAR NECROSIS: Four part # & dislocation HHR 5) NEUROVASCULAR INJURY Four part with head in axilla If nerve injury + at the time of closed injury, prognosis is good.
- 37. 6) INFECTION: Immune compromise & extensive soft tissue loss Hard ware removal & debridement. 7) ARTHRITIS Hardware penetrating the jt 8) Refractory shoulder stiffness 9) CHARCOT SHOULDER: unusual fragmentation occurs after # 10) Heterotopic bone formation. Soft tissue injury, repeated manipulation, delayed reduction beyond 7 days.
- 39. NEER CLASSIFICATION: Classified according to the amount of displacement. Grade I fracture is displaced less than 5 mm. Grade IV fracture involves total displacement.
- 40. Open reduction indicated for 1) the rare displaced Salter-Harris types III and IV fractures, 2) interposition of the biceps tendon in the fracture site, 3) fracture-dislocations 4) open fractures