Proximal Humerus Fracture Nonunion & Malunion

Question 1

fracture characteristics that increase risk for nonunion

Answer 1

2-part (surgical neck) fracture patterns
humeral head split
displaced tuberosity fractures

Question 2

patient factors that increase risk for nonunion

Answer 2

osteoporosis
chronic renal disease
chronic alcohol or steriod use
smoking

Question 3

origin of malunion:

Answer 3

initial fracture displacement
secondary displacement after loss of reduction
failure of internal fixation

Question 4

humeral head malunion:

Answer 4

initial fracture displacement
secondary displacement after loss of reduction
failure of internal fixation

Question 5

greater tuberosity malunion
usually displaced posterior, superior and _____

Answer 5

externally rotated

Question 6

____ tuberosity malunion
usually displaced posterior, superior and externally rotated

Answer 6

greater

Question 7

_____ tuberosity malunion
usually displaced medial

Answer 7

lesser

Question 8

lesser tuberosity malunion
usually displaced ____

Answer 8

medial

Question 9

associated conditions

Answer 9

rotator cuff tearing
osteonecrosis of humeral head
glenohumeral joint issues

Question 10

associated glenohumeral joint issues may include:

Answer 10

stiffness
post-traumatic arthritis
subluxation or dislocation
subacromial impingement

Question 11

average humeral head diameter

Answer 11

43 mm

Question 12

humeral head is retroverted _____° from transepicondylar axis of the distal humerus

Answer 12

30

Question 13

humeral neck-shaft angle usually ____

Answer 13

130-140 degrees

Question 14

position important for rotator cuff muscle fuction

Answer 14

greater tuberosity

Question 15

medial edge of greater tuberosity is _____ mm lateral to humeral canal axis

Answer 15

10

Question 16

medial edge of tuberosity is 10mm lateral to _____

Answer 16

humeral canal axis

Question 17

superior edge of greater tuberosity is _____ mm inferior to upper edge of humeral head

Answer 17

6

Question 18

superior edge of greater tuberosity is 6mm inferior to _____

Answer 18

upper edge of humeral head

Question 19

physical exam inspection:

Answer 19

features of systemic disease
muscle atrophy
diffuse tenderness

Question 20

_____ malunion = apprehension test

Answer 20

humeral head

Question 21

humeral head malunion = _____ test

Answer 21

apprehension

Question 22

_____ malunion = weakness with abduction, external rotation

Answer 22

greater tuberosity

Question 23

greater tuberosity malunion = weakness with _____

Answer 23

abduction and ER

Question 24

_____ malunion = weakness with internal rotation

Answer 24

lesser tuberosity

Question 25

lesser tuberosity malunion = weakness with _____

Answer 25

internal rotation

Question 26

radiographic views

Answer 26

true AP, scapular Y, axillary

Question 27

radiographic findings

Answer 27

neck-shaft angle = varus or valgus
greater tuberosity = superiorly and posteriorly displaced, externally rotated
lesser tuberosity = medialized

Question 28

humeral head radiographic measurements

Answer 28

> 45° of deformity in any plane
symptomatic articular incongruity
neck-shaft angle <120° or >150°

Question 29

greater or lesser tuberosity radiographic findings

Answer 29

> 1 cm from native anatomical position

Question 30

CT indications

Answer 30

preoperative planning
assess bone stock, orientation and articular surface

Question 31

CT findings

Answer 31

humeral head and greater tuberosity displacement
glenoid version and glenoid bone stock
articular injury

Question 32

MRI indications

Answer 32

preoperative planning
soft-tissue structures

Question 33

MRI findings

Answer 33

rotator cuff or labral injury
deltoid atrophy secondary to axillary nerve injury
long-head biceps injury
osteonecrosis

Question 34

labs to obtain

Answer 34

CBC, ESR, CRP, blood cultures to rule out infection

Question 35

non op treatment modalities:

Answer 35

NSAIDS, physical therapy, occasional corticosteroid injection

Question 36

non op indications

Answer 36

low-demand patient
painless shoulder limitations
unable to comply with the rehabilitation protocol

Question 37

non op outcomes

Answer 37

return to 90% of normal function

Question 38

operative options

Answer 38

ORIF +/- osteotomy, subacromial decompression, and soft tissue technique
shoulder arthroplasty

Question 39

ORIF indications

Answer 39

symptomatic malunion following
nonoperative treatment
failed internal fixation

Question 40

anatomic requirements for ORIF

Answer 40

adequate bone stock for fixation
preserved articular surface
intact blood supply to humeral head

Question 41

complication rates associated with surgical management of malunions are _____ than those associated with acute fractures

Answer 41

higher

Question 42

shoulder arthroplasty indications

Answer 42

symptomatic malunion following
nonoperative treatment
failed internal fixation

Question 43

anatomic requirements for shoulder arthroplasty

Answer 43

inadequate bone stock for fixation techniques
articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split)
compromised blood supply
chronic dislocation

Question 44

greater improvement in functional outcome scores than hemiarthroplasty
lower complication rates than hemiarthroplasty

Answer 44

reverse total shoulder

Question 45

ORIF-minor deformity techniques

Answer 45

open/arthroscopic tuberoplasty
+/- acromioplasty
+/- capsular release
+/- bursectomy

Question 46

ORIF severe deformity techniques

Answer 46

varus/valgus osteotomy
+/- rotational osteotomy and lateral plate fixation

Question 47

greater tuberosity deformities
<1.5 cm displacement what to do in ORIF

Answer 47

arthroscopic subacromial decompression +/- rotator cuff repair

Question 48

greater tuberosity deformities >1.5 cm displacement what to do in ORIF

Answer 48

open/arthroscopic tuberosity osteotomy +/- subacromial decompression

Question 49

complications

Answer 49

Persistent pain and weakness
Stiffness
Loss of fixation
Infection
Bleeding