Proximal Humerus Fractures

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Proximal Humerus Fractures

• 2008 Southeastern Fracture Symposium
• Charleston, South Carolina

Cay M Mierisch, MD Cesar J. Bravo, MD Cassandra
Mierisch, MD Hand and Upper Extremity
Division Carilion Clinic Bone And Joint Center
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Proximal Humerus Fractures

• Common injuries
• 4-6 of all fractures
• 2/3 female
• Prevalence increases with age
• Court-Brown CM, Caesar B. Injury 2006
• Significant functional impairment
• Large number of treatment options available
• No accepted standard

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Anatomy

• Neck shaft angle 130
• Retroversion 19-22
• Greater tuberosity 7-10 mm below highest point of
  the articular surface
• Consider muscle forces
• Blood supply
• Anterior humeral circumflex artery

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Classfication

• Neer Classification
• Number of fragments
• Displacement gt 1cm
• Angulation gt 45
• AO/OTA
• morphologic
• Surgical neck
• impaction, angulation, translation
• Hertel
• Predictors of ischemia
• Medial hinge disruption gt 2mm
• Metaphyseal head extension lt 8mm
• J shoulder and elbow surg. 2004

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Classification

• Poor reproducibility and reliability
• Radiographic displacement difficult to determine
• Biological factors not considered
• Age
• Bone quality

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Imaging

• Shoulder AP
• Scapular AP
• Axillary view
• Scapular Y
• CT scan
• 3 D
• Improved assessment of displacement
• Involvement of articular surface
• MRI
• Assess rotator cuff

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Treatment

• Non-operative
• Indication
• Minimal displacement
• Surgical neck may tolerated a lot of displacement
• Tuberosity displacement not well tolerated (lt5mm)
• 2 part fractures
• Court-Brown CM, Caesar B. Injury 2006
• Early mobilization
• Follow closely with x-rays
• Complications
• Stiffness
• Malunion/nonunion
• Posttraumatic arthritis
• Persistent nerve injury

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Treatment

• Operative treatment
• Indications
• Tuberosity displacement gt 5mm
• Shaft displacement gt 2/3
• Angulation greater 45
• 3-4 part fx

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Options

• IM nailing
• Closed reduction percutaneous pinning
• Open reduction and internal fixation
• Conventional plates
• Transosseous sutures
• Locking plates
• Arthroplasty

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Considerations

• Fracture pattern
• Bone quality
• Combined cortical thickness gt 4mm required to
  support plate fixation
• Associated injuries
• Nerve injury
• RTC
• Preexisting RTC disease

Tingart MS et al J Bone Joint Surg Br 2003
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IM nailing

• Less soft tissue dissection
• Antegrade
• Cuff problems
• Retrograde
• Only 2-part fx
• Not widely used

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Closed reduction and Percutaneous pinning

• Minimizes surgical dissection
• Requires good bone quality for cortical purchase
• 0.62 terminally threaded K-wires or cannulated
  screws
• Successfully used in 2-, 3-, and 4-part fractures
• Resch H et al. J Bone Joint Surg Br 1997
• 3 and 4 part fractures 90 good and
  excellent
• Complications 11 AVN in 4 parts
• Chen CY et al. J Trauma 1998
• 2 and 3-part fractures
• 85 good and excellent
• Calvo E et al. J Shoulder and Elbow Surg 2007
• 2-4 part fractures
• Recommend pinning only for 2 part fractures
• Pediatric proximal humerus fx

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Open Reduction and Internal fixation

• Transosseous suture
• Poor bone quality
• Older patients
• Park MC et al. J Orthop Trauma 2003
• 2-3 part fractures
• 78 excellent, 11 satisfactory
• Less commonly used after advent of locking plates

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Open reduction and internal fixation

• Conventional plate fixation
• High failure rate
• Factors
• Age
• Poor bone quality
• Metaphyseal comminution

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Open reduction and internal fixation

• Locking plate
• Fixed angle device
• improved stability
• Combine with bone graft materials
• Clinical experience limited

• Agudelo J. et al. J Orthop Trauma. 2007
  Nov-Dec21(10)676-81
• Varus malreduction may lead to construct failure
• Dietrich et al. Chirurg. 2007 Nov 28 German.
• 52 patient 3-4 part fx . PHLP better than HA
• Fankhauser F et al. Clin Orthop Relat Res 2005
  430 176-181.
• 29 patient Type A 2 Type B 15 type C 9
• 1 year FU constant score of 75
• Strohm et al. Techniques in Shoulder Elbow
  Surgery 2005 6 8-13.
• 64 very good and good results

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Locking Plate2 part fracture
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Locking Plate
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Locking Plate3-4 part fractures
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Locking Plate
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Arthroplasty

• Indications
• Head splitting fracture
• Fracture dislocations
• 3-4 part fracture
• If stable fixation cannot be accomplished
• Poor bone stock
• Impression fractures
• gt 40 involvement of articular surface
• Avoids complication of AVN

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Implant choices

• Hemiarthroplasty with fracture stem
• Reverse Total shoulder replacement
• Total shoulder replacement

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Hemiarthroplasty

• Outcomes
• Pain relief most predictable 61-97
• Function inconsistently reported
• Only 50 use hand above shoulder level

• Prognostic factors
• Age
• Gender
• Female worse
• Time to surgery
• Nerve injury
• GT Tuberosity malunion/nonunion

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Shoulder Hemiarthroplasty
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Reverse Total shoulder

• Indications still evolving
• Pre-existing RTC disease
• Revision of failed hemiarthroplasty
• Older patients with poor bone quality
• Poor outcome of HA in female gt 75
• Boileau P et al. J Shoulder Elbow Surg
• Tuberosity displacement
• Tanner MW et al. Clin Orthop Relat Res
• Bufquin T et al. J Bone Joint Surg Br. 2007
• 43 cases
• 97 degrees of abduction
• Tuberosity healing did not affect outcome

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Reverse Total Shoulder

• 78 y female
• Ground level fall
• Ipsilateral IT hip fx

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Reverse Total Shoulder
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Reverse Total Shoulder

• 70 y male rheumatoid
• Pre-existing shoulder problems

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Reverse Total Shoulder
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Total Shoulder for locked posterior dislocation
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Summary

• PHF on the rise
• Older patient
• More complex patterns
• No accepted standard for treatment
• Locking plates may allow ORIF in older patients
• bone graft materials
• Successful tuberosity union for improved outcomes
• Role of reverse total shoulder evolving

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Thank You
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Greater Tuberosity

• Younger patients
• Anterior shoulder dislocations or direct impact
• Treatment
• Non-surgical for minimally and non-displaced fx
• Surgical for displacement gt 5mm
• ORIF
• arthroscopic