proximal humerus fracture Flashcards
Epidemiology
- incidence
- 4-6% of all fractures
- third most common non-vertebral fracture pattern seen in the elderly (>65 years old)
- demographics
- 2:1 female to male ratio
- increasing age associated with more complex fracture types
mechanism
mechanism
- low-energy falls
- elderly with osteoporotic bone
- high-energy trauma
- young individuals
- concomitant soft tissue and neurovascular injuries
pathoanatomy
- pectoralis major displaces shaft anteriorly and medially
- supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity
- subscapularis interally rotates articular segment or lesser tuberosity
- vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
Vascular anatomy
-
anterior humeral circumflex artery
- large number of anastamoses with other vessels in the proximal humerus
- branches
- anterolateral ascending branch
- is a branch of the anterior humeral circumflex artery
- arcuate artery
- is the terminal branch and main supply to greater tuberosity
- anterolateral ascending branch
-
posterior humeral circumflex artery
- recent studies suggest it is the main blood supply to humeral head
Classification
Imaging
- Radiographs
- recommended views
- complete trauma series
- true AP (Grashey)
- scapular Y
- axillary
- additional views
- findings
- complete trauma series
- recommended views
- CT scan
- indications
- preoperative planning
- humeral head or greater tuberosity position uncertain
- intra-articular comminution
- indications
Nonoperative
-
sling immobilization followed by progressive rehab
- technique
start early range of motion within 14 days
indications of Nonop treatement
additional variables to consider for Nonop Rx
- age
- fracture type
- fracture displacement
- bone quality
- dominance
- general medical condition
- concurrent injuries
Operative
- CRPP (closed reduction percutaneous pinning)
- ORIF
- intramedullary nailing
- arthroplasty
CRPP (closed reduction percutaneous pinning)
indications and outcomes
-
indications
- 2-part surgical neck fractures
- 3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar
-
outcomes
- considerably higher complication rate compared to ORIF, HA, and RSA
ORIF
intramedullary nailing
- indications
- surgical neck fractures or 3-part greater tuberosity fractures
- in younger patients
- combined proximal humerus and humeral shaft fractures
- outcomes
- biomechanically inferior with torsional stress compared to plates
- favorable rates of fracture healing and ROM compared to ORIF
arthroplasty
indications
-
hemiarthroplasty
- controversial when considering hemiarthroplasty versus RSA
- younger patients (40-65) with complex fractures or head-splitting components likely to have complications with ORIF
- recommended use of convertible stems to permit easier conversion to RSA if necessary in future
-
reverse total shoulder
- low-demand elderly individuals with non-reconstructible tuberosities and poor bone stock
- low-demand patients with fracture dislocation
outcomes
Treatment by Fracture Type
- Two-Part Fracture
- Three-Part Fracture
- Four-Part Fracture
Two-Part Fracture
Surgical Neck
- Most common fx pattern
- Nonoperative • Closed reduction often possible • Sling
- Operative
- controversial
- technique
- CRPP
- Plate fixation
- IM device
- technique
- controversial
Functional outcomes after nonoperative management of fractures of the proximal humerus.
Hanson B
difficult to demonstrate a significant advantage of surgical over nonoperative treatment in patients with proximal humeral fractures.
Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial
Lefevre-Colau MM
Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy
Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment
Surgical treatment of displaced greater tuberosity fractures revealed good functional and radiographic results. Reduction and fixation of those fractures is recommended because patients with nonoperative treatment showed significantly worse results. Similar results can be achieved for open reduction and internal fixation, or closed reduction and percutaneous fixation.
Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up
Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly
Innovations in the management of displaced proximal humerus fractures
Proximal humerus fractures must be evaluated on an individual basis, with treatment tailored according to patient and fracture characteristics.
The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients.
This fracture was relatively common in the elderly population and non-operative treatment sometimes resulted in increased varus angulation. Decreased shoulder function was associated with increasing age but not with increasing varus angulation. After nonoperative management the outcome was good, regardless of the degree of varus, 1 year after fracture. Age was the main predictor of outcome. Physiotherapy did not improve outcome.
Functional outcome after minimally displaced fractures of the proximal part of the humerus.
Koval KJ
The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.
Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures.
Goldman RT
This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable
Two-Part Fracture
Greater tuberosity
Nonoperative
• indicated for GT displaced < 5 mm
Operative
• indicated for GT displacement > 5 mm
- isolated screw fixation only in young with good bone stock
- nonabsorbable suture technique for osteoporotic bone (avoid hardware due to impingement)
- tension band wiring
Two-Part Fracture Lesser tuberosity
Nonoperative
• Minimally or non-displaced
Operative
- ORIF if large fragment
- excision with RCR if small
- COPY
two part Anatomic neck
Rare
Nonoperative
• Minimally or non-displaced
Operative
• ORIF in young
• ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly
Three-Part Fracture
Surgical neck and GT
Nonoperative if:
• Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees)
• Poor surgical candidate
Operative:
• 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 RCR or tuberosity repair vs. reverse total shoulder arthroplasty
Three-Part Fracture
Surgical neck and LT
•Trend towards nonoperative 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 RCR or tuberosity repair vs. reverse total shoulder arthroplasty
Four-Part Fracture
Valgus impactedfracture
• Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply
• Surgical technique
1. raise articular surface and fill defects
2. repair tuberosities
Four-Part Fracture
4-part with head-splitting fracture
- *Young patient**
- ORIF vs. hemiarthroplasty (hemiarthroplasty favored for nonreconstructible articular surface, severe head split, extruded anatomic neck fracture)
- *• Elderly patient**
- hemiarthroplasty v. reverse total shoulder arthroplasty
- COP
Rehabilitation
- Important part of management
- Best results with guided protocols (3-phase programs)
- early passive ROM
- active ROM and progressive resistance
- advanced stretching and strengthening program
- Prolonged immobilization leads to stiffness
Complications
Malunion
- usually varus apex-anterior or malunion of GT
- results inferior if converting from varus malunited fracture to TSA
- use reverse TSA instead
Nonunion
- usually with surgical neck and tuberosity fx
- treatment of chronic nonunion/malunion in the elderly should include arthroplasty
- lesser tuberosity nonunion leads to weakness with lift-off testing
- greater tuberosity nonunion leads to lack of active shoulder elevation
- greatest risk factors for non-union are age and smoking
General points need to be taken into consideration:
- 80% of proximal humeral fractures are undisplaced, and can be treated conservatively
- Three and four-part fractures are notoriously difficult to manage and yield poor results – but one in fact uncommon injuries, with very small series reported in the literature
- The commonest fracture pattern seen is the two-part fractures of the surgical neck.
DECISION MAKING
- Fracture configuration
- Neer
- Hertel
- Lateral shift
- Capsular attachments
- Head vascularity
- Osteoporosis augmented fixation
- Age of patient
- Hemiarthroplasty
- RSA
Treatment Plan
- Decide on fixation or replacement
- Fixation then assess medial cortex if intact and cortical thickness >4mm, no augmentation
- Medial cortex intact <4mm then fixation plus calcium phosphate or cancellous bone
- Medial cortex not intact, then fibular strut graft.
ARTHROPLASTY FOR FRACTURE
Hemiarthroplasty for fractures has been shown to demonstrate good pain relief, but poorer functional outcomes compared to replacement arthroplasty for osteoarthritis.
Important to restore humeral height, humeral version and tuberosity reconstruction.
Pascal Boileau(2002) described the “unhappy triad”
Excessive height of prosthesis
Excessive retroversion of prosthesis
Greater tuberosity positioned too low
Poor functional results and persistent pain and stiffness
RSA Advantages
More favourable and predictable results than HA
Much better ROM particularly AFE and Abduction
Lower postoperative pain
Earlier initiation of rehabilitation
RSA Disadvantages
Scapular notching
Decreased Active external rotation
Acromial fractures
Instability
But with lateralization of glenosphere with RSA there is less notching, greater AER and AIR and much less instability
Florian Grubhofer
Many studies in recent years support the use of RSA for displaced proximal humeral fractures in the elderly.
must know
- Proximal humeral fractures are common and can have a significant effect on quality of life in the elderly if not appropriately treated.
- Each fracture must be assessed on its own merit. There is no single correct treatment option.
- All current treatment options have limitations and there is still an unacceptably high failure rate with both fixation and arthroplasty.
- We must provide one operation for patients.
