Proximal Humerus Fracture

Proximal humerus off ended

 

Epidemiology                                                                                                                    

 

>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.  Rotator cuff

 

Supplies blood to tuberosities in fractures

 

Neer Classification 1970

 

Displaced 

 

Any fragment

- > 1cm displaced

- > 45o angulated

 

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

 

Avascular necrosis

 

SNOH AVN

 

Risk AVN

 

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

- posterior circumflex artery is sufficient

- risk increases with amount of displacement

 

4 part fracture 30%

 

3 part fracture 15%

 

Hertel Radiographic criteria

 

Hertel et al J Should Elbow Surg 2004

https://pubmed.ncbi.nlm.nih.gov/15220884/

 

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 patients - high energy MVA

 

Deforming Forces

 

2 part fracture

- pectoralis major displaces shaft medially

- head internally rotated by SSC

 

SNOH Fracture Displaced

 

Greater tuberosity fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor

 

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

 

Lesser tuberosity fracture

- displaced medially by subscapularis

 

Lesser Tuberosity FractureLesser Tuberosity Fracture 2

 

X-rays

 

AP / Scapula Lateral / Axillary lateral

 

CT 

 

Assess

- number of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF?

 

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

 

Minimally displaced

Elderly / low functioning patients

 

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

 

Complications of nonoperative treatment

 

Non-union

 

Uncommon

- associated with AVN

 

 

Malunion OA

 

SNOH MalunionSNOH Malunion

 

TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy

 

Operative Management

 

1.  Two Part Fractures

 

A.  Surgical neck of humerus

 

Indications

- >1 cm displaced or > 45o angulation

 

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

 

ORIF with proximal humerus plate

 

B.  Displaced fractures of the greater tuberosity

 

Issues

- > 5 mm 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

 

GT displaced 1GT displaced 2GT displaced 3

 

Options

 

Suture and repair over distal screw

Lateral plate

 

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

 

C. Lesser tuberosity fractures

 

Soft tissue washer and screw

 

LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF

 

LT ORIFLT ORIF

 

2.  Three and Four part fractures

 

Options

 

ORIF

IM nail

Hemiarthroplasty

Reverse TSR

 

ORIF with plate

 

SNOH Plate

 

Indications

 

Young patient

Sufficient bone quality

 

Results

 

Surgical technique

 

SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CTProximal humerus ORIF 1Proximal humerus ORIF 2

 

Set up

- GA, IV antibiotics, lazy beach chair

- mark anatomy

- ensure adequate flouroscopy images

 

Deltopectoral approach 

- cephalic usually taken laterally

- Hawkins Bell retractor/ blunt gelpies

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractors deep to tendon

- release adhesions from undersurface of deltoid

 

Extensile approach

- release CA ligament

- release proximal pectoralis major

- can release anterior deltoid insertion from clavicle if needed (intra-osseous repair latera)

 

Dangers

- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially

 

Identify structures

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

- remove hematoma

- reduce head onto shaft (head is displaced posteriorly)

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check provisonal fixation with fluoroscopy

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check fluoroscopy aain to avoid having plate too high

- keep head out of varus to avoid cutout

- long inferomedial screws / kickstand screws

 

SNOH ORIF

 

Complications ORIF

 

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 AVNTSR Post OA

 

Vascular Injury

 

Axillary / MCN / Brachial Plexus

 

B.  Intramedullary 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 / Reverse TSR

 

Indications

 

Unreconstructable

Elderly

4 part fractures

Head splitting fractures

 

Proximal Humerus 4 Part Fracture In Elderly

Proximal Humerus Unreconstructable

 

 

Hemiarthroplasty

 

SNOH Hemi 2SNOH Hemi 1

 

Issues

 

Must ensure tuberosities heal

ROM often poor / rarely > 90o

 

ROM

 

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

 

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

 

Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2

 

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