Humeral fractures in proximal part Flashcards
what is the cause of proximal humeral fractures ?
low energy falls on an outstretched arm.of elderly with osteoporotic bones
high energy trauma in young individuals
any fracture to the greater tuberosity has what orientation ?
greater tuberosity located posteriorly and the insertion point for :
the supraspinatus , infraspinatus and teres minor causes the greater tuberosity to go posteriorly and internally rotate medially
which neck is more involved in fractures of the humerus ?
the surgical neck
anatomic neck represents the old epiphyseal plate
what are the blood vessels which supplies the head of the humerus ?
anterior humeral circumflex artery from the axillary artery - from that anterolateral ascending brach
and arcuate branch - main artery which gets generally disrupted
posterior humeral circumflex artery - another branch of axillary artery - main SUPPLY
most of the proximal humeral fractures are ?
minimally displaced
the classification of of proximal humeral head only describes ?
displaced segments which are defined as 1cm or 45 degree angulation
describe the classification of the proximal humeral head fracture ?
neer classification
minimally displaced - minimally displaced anatomical neck (humeral head) surgical neck (shaft) greater tuberosity lesser tuberosity
in fractures existing in any these places no fracture segments are displaced by 1cm or angulates by 45 degrees
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2 part - one part of the fracture is significantly displaced by 1cm or 45 degrees
again anatomical neck
surgical neck - MOST COMMON
greater tuberosity
lesser tuberosity
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3 part
where two segments are significantly displaced
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4 part
3 segments are displaced by 1cm or 45 degree angulation
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articular surface fracture - head splitting
which fracture displacement has a higher chance of avascular necrosis ?
fracture of the anatomical neck
predictors of humeral head ischemia (Hertel criteria) :
<8 mm of calcar length attached to articular segment disrupted medial hinge increasing fracture complexity displacement >10mm angulation >45°
a fracture in the lesser tuberosity will have what orientation
insertion of subscapularis - goes medially
which orientation does the shaft of the humerus have a tendency to go if there is a fracture in the surgical neck or shaft ?
internal rotation anteriorly and medially because of the insertion of deltoid muscle and pectorals major
the arms is internally rotated
indications for non operative methods for proximal humeral fractures
most proximal humerus fractures can be treated nonoperatively including
minimally displaced surgical and anatomic neck fractures
greater tuberosity fracture displaced < 5mm
what are the non operative method for proximal humeral fractures ?
non operative - sling immobilisation - ROM at 14 days
how to treate type two part fractures ?
surgical neck -MOST COMMON PATTERN - non operative closed reduction is often possible with sling - GILCHRIST BANDAGE
operative - by CRPP closed reduction percutaneous pinning
plate
IM nailing
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greater tuberosity
more than 5mm = ORIF by isolated screw in young
nonabsorbable suture technique for osteoporotic bone (avoid hardware
or tension band wiring
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lesser tuberosity = ORIF
if large frag - isolated screw
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anatomical neck
young - ORIF
old - ORIF / hemiarthroplasty / reverse shoulder arthroplasty in elderly
technique for CRPP in surgical neck ?
The arm should first be placed along the patient’s side to relax the pectoralis major. If the fragments are impacted, axial traction is performed to disimpact the fracture.
Next, a gentle posteriorly and laterally directed force is applied as the shaft is flexed and brought underneath the head.
Once the reduction is confirmed, the arm is prepared in a sterile fashion and fixation pins are placed under image-intensification control.
Post operatively 2 part
Patient wears shoulder immobilizer four to six weeks.
Begin pendulum exercises immediately.
how do we treat a 3 part fracture ?
surgical neck and GT fracture
non operative - GT <5mm , articular segment 1 cm <45 degrees
operative - on young patients
percutaneous pinning
Im fixation - violates cuff
locking plates - poor results and high rate of AVN
operative on elderly - hemiarthroplasty with rotator cuff repair or tuberosity repair
or
reverse total shoulder arthroplasty
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surgical neck and LT
trend towards non operative management given high complications with ORIF
Young patient
- percutaneous pinning (good results, protect axillary nerve)
- IM fixation (violates cuff)
- locking plate (poor results with high rate of AVN, impingement, infection, and malunion)
• Elderly patient
- hemiarthroplasty with RC
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young patients :
CRPP
IM
locking plate not used
old patients especially involving anatomical neck - hemiarthroplasty (no replacement of glenoid but proximal humeral prosthesis )
reverse total shoulder replacement - humeral cup and glenosphere
