Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture

 

>65

- third most common fracture after hip and distal radius

 

Anatomy

 

Neck shaft angle

- 130o

 

Head retroverted

- 20o relative to shaft

 

Anatomical neck

- junction of head and metaphysis

 

Surgical neck

- junction of diaphysis and metaphysis

 

Blood supply 

 

Gerber JBJS Am 1990 December

Anatomical cadaver study

 

1.  Anterior humeral circumflex

 

Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis

 

Nearly always disrupted in fractures

 

2.  Posterior Humeral circumflex

 

Small contribution posterior head

- allows head to survive with both tuberosities fractured

 

3.  RC

- supplies blood to tuberosities in fractures

 

Neer Classification 1970

 

Displaced 

-  any fragment > 1cm or > 45o

 

Number of displaced fragments

- 2 part (head/shaft, GT, LT)

- 3 part (head/shaft/GT, head/shaft/LT)

- 4 part (head/shaft/GT/LT)

 

Fracture / dislocation

 

Shoulder Fracture DislocationProximal Humerus Fracture DislocationShoulder Fracture Dislocation AnteriorPosterior Shoulder Fracture Dislocation

 

Head splitting fracture

 

SNOH Head Split CTProximal Humerus Head Split CT

 

Anatomical Neck Fracture

 

Humerus Anatomical Neck Fracture

 

AVN

 

SNOH AVN

 

In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- increases with amount of displacement

 

Rates AVN

 

4 part fracture 30%

 

3 part fracture 15%

 

Hertel Radiographic criteria

 

Hertel et al J Should Elbow Surg 2004

 

2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm

 

97% positive predictive of ischaemia if both factors present

 

Aetiology

 

FOOSH

- mostly elderly patients with osteoporotic

 

Young 

- high energy MVA

 

Deforming Forces

 

2 part fracture

- P. major displaces shaft medially

- head internally rotated by SSC

 

SNOH Fracture Displaced

 

GT fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor

 

Displaced Greater Tuberosity Fracture APDisplaced Greater Tuberosity Fracture LateralShoulder CT Displaced GT Fracture

 

LT fracture

- medially by SSC

 

Lesser Tuberosity FractureLesser Tuberosity Fracture 2

 

X-rays

 

AP / Scapula Lateral / Axillary lateral

 

CT 

 

Indication

- delineate no of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF / in elderly

 

Surgical Neck of Humerus CT 4 Part CoronalSurgical Neck of Humerus CT 4 Part SagittalSNOH CT 3 Parts

 

Associated Injuries

 

Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid

 

Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand

 

Management

 

Non operative 

 

Indications

- undisplaced

- elderly

 

NHx

 

85% are undisplaced and do not require surgery

 

Technique

 

Sling for 2/52 then mobilise

 

Results

 

Koval et al JBJS Am 1997

- 104 patients minimally displaced fracture as per Neer

- < 1cm displacement and <45o

- 90% no pain, 77% good or excellent result

- ROM approximately 90% of the other side

- 10% moderate pain and 10% poor result

- poor function and ROM associated with phyio started > 14 days after injury

- poor function associated with pre-existing cuff problems

 

Olerudet al JSES 2011

- RCT nonop v hemiarthroplasty for displaced 4 part

- 55 patients, average age 77

- 2 year follow up

- significant advantage of hemiarthroplasty

 

Operative Management

 

1.  2 Part Fractures

 

A.  SNOH

 

Indications

- >1 cm or > 45o

 

Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP

 

Options

- percutaneous wires / screws

- intra-osseous sutures

- proximal humeral nail

- locking plate

 

B.  GT 

 

Issues

- > 5mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step

 

Displaced Greater Tuberosity Fracture LateralCT Coronal Greater Tuberosity FractureCT GT Fracture Sagittal

 

Technique

- deltoid splitting approach

- young patient can ORIF with screw

- in elderly insert Mason Allen no 2 suture in cuff and tie over screw

- repair rotator cuff

 

 ORIF Greater Tuberosity FractureGreater tuberosity Tie over screw

 

Consequences Nonoperative Treatment

 

SNOH MalunionSNOH Malunion 2

 

C. LT Fractures

 

Soft tissue washer and screw

 

LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF

 

LT ORIFLT ORIF

 

2.  3 & 4 Part fractures

 

A.  ORIF with plate

 

SNOH Plate

 

Indications

- need sufficient bone quality

- always attempt in young

 

Results

 

Moonot et al JBJS Br 2007

- 32 patients with 3 or 4 part treated with Philos plate

- 31 of 32 united

- 27/32 (86%) excellent or satisfatory results

- 5/32 (16%) poor results

- 1 patient AVN and non union

 

Yang et al J Orthop Trauma 2010

- 64 patients treated with proximal humeral plate

- screw penetration into joint most common complication 5/64

- deep wound infection 2/64

- AVN 2/64

- 3 fixation failures requiring revision

- half good and half moderate shoulder scores, few excellent or poor

- all complications in 4 part fractures

- tuberosity malunion associated with poor outcome

 

B.  IM Nail

 

Results

 

Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions

 

C.  Hemiarthroplasty

 

Shoulder Trauma HemiarthroplastyShoulder Trauma Hemiarthroplasty

 

Indications

- unreconstructable

- elderly

- 4 part fractures

- head splitting fractures

- anatomical neck

- head impression > 40% articular surface

 

Proximal Humerus Unreconstructable

 

Problem

- only good ROM if tuberosities heal

 

Timing

- best to do in first three weeks

- whilst GT / LT still easy to mobilise

 

Results

 

ROM often poor

- better if anatomical union tuberosities

- early ROM gives better results (<2/52)

- rarely > 90o

 

SNOH Hemi 1SNOH Hemi 2

 

Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100o

- 16% moderate or severe pain

 

Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty

 

D.  Reverse total shoulder

 

Indication

- elderly patient

- poor cuff

- poor chance of tuberosity healing

 

Problems

- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding

 

Results

 

Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90o v 60o) and abduction (90o v 53o) better in reverse

- rotation better in hemiarthroplasty

 

ORIF Locking Plate

 

SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CT

 

Proximal Humerus 4 Part Head Splitting ORIF APProximal Humeral 4 Part Head Splitting ORIF Lateral

 

Technique

 

Set up

- GA, IV ABx, lazy beach chair

- mark anatomy

- II (patient either in middle of radiolucent table or remove lateral aspect shoulder table) 

 

Deltopectoral approach 

- cephalic usually taken lateral

- take part of pec major off to facilitate exposure

- Hawkins Bell retractor (shoulder charnley retractor) / non pointed double gelpies 

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractor deep to tendon

 

Dangers

- protect MCN under conjoint, minimal retraction

- find and protect the axillary nerve on inferior border of SSC, sweep finger inferiorly

 

Deep dissection

- clear sup deltoid bursa

- must elevate deltoid from head

- place a homan retractor over head to elevate deltoid

 

Identify structures

- remove callous

- reduce head onto shaft

- head is displaced posteriorly

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check for head splitting fractures

 

Find tuberosities

- secure with Mason Allen

- no 5 non absorbable

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check II now to avoid having plate too high

- must not leave head in varus

 

SNOH ORIF

 

Fixation

- to prevent cutout must have head out of varus

- long inferomedial screws / kickstand screws

- similar concepts to NOF (don't want screws high in the head)

 

Closure over drain

 

Rehab

- sling 6/52 with pendulars

- ROM 6/52

 

Complications

 

Non-union

- uncommon

- associated with AVN

 

 

 

Malunion

 

SNOH Malunion

 

Cutout

- medial support very important

- must avoid varus malreduction

 

Plate impingement

- need to ensure place plate low on the head

 

Screw perforation of humeral head

- most common complication

 

AVN

- fortunately uncommon

 

Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral

 

SNOH ORIF AVN

 

Vascular Injury

 

Axillary / MCN / Brachial Plexus

 

OA

- from signficant deformity

- TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy

 

Hemiarthroplasty

 

Proximal Humerus 4 Part Fracture In Elderly

 

Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2TSR Post OA

 

 

Technique

 

Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height

 

Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades

 

Deltopectoral approach

 

Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities

 

Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation

 

Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities

 

Need retroversion of 30o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30o

 

Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets

 

Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture

 

Place on head with 12/14 taper

 

Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole

 

Biceps tenodesis

 

Close over drain, rehab as above

 

Complications

 

Malunion / Non union tuberosities

 

Causes

- increased in women

- increased with initial malposition

- excessive height or retroversion of humeral head

 

Incidence

- 4-50%

 

Heterotropic ossification

- 10%

 

Glenoid degeneration

- 8% at 3 years

 

Prosthetic loosening

- 3-6%

 

Nerve injury

- AXN, MCN

 

Infection

- 1-2%

 

Stiffness

- need realistic goals

- aim to achieve function at shoulder height