Proximal Humerus Fractures Flashcards
Reliability of the Neer Classification:
30% interobserver reliability (HJD, JDZ)
Can you tension band wire proximal humerus fractures?
You can, but high rates of loss of fixation (HJD, Koval/JDZ)
Outcomes of hemiartrhoplasty for 3- and 4-part proximal humerus fractures:
generally achieve a pain free shoulder ROM and functional outcomes are variable - - FE 110 - ER 31 - IR to L2
Tuberosity management during hemiarthroplasty for fracture?
- needs reapproximation
- need appropriate soft tissue tensioning
- need secure tuberosity fixation
What’s the functional outcome expected 1 year after minimally displaced 1-part proximal humerus fractures:
- 90% with either no or mild pain
- 94% with good functional outcome
- most returned to baseline function
- nearly 90% of the ROM compared to the contralateral shoulder
- starting early PT within 14 days improves outcomes
Is the axillary lateral view reliable for measuring angulation of proximal humerus fractures?
no
- multiple angles can be measured based on humeral rotation and this is not a reliable thing to do. (HJD, JDZ)
complications of proximal humerus locking plate:
- screw penetration is most common (16%)
- secondary loss of fixation
should you use calcium phosphate cement when performing ORIF of proximal humerus fracture?
yes, calcium phosphate cement has less settling compared with patients who receive no augmentation or augmentation with cancellous chips
- significantly less screw penetration with calcium phosphate cement
IMN for humerus fracture
no difference in functional outcomes or ROM
- some series, no difference in complications
- other series, higher rates of subacroimial impingement and rotator cuff issue
What is the problem with varus displacement of proximal humerus fracture
similar functional outcomes as patients without varus displacement
- 40% complication rate - including AVN and secondary varus displacement
what is the primary determinant of successful hemiarthroplasty?
healing and placement of the tuberosities
- resorption, malunion, nonunion yields inferior outcomes
- functioning rotator cuff is essential
comparing ORIF vs hemiarthroplasty:
better functional outcomes in ORIF but a higher complication rate including
- AVN (50%)
- screw penetration (5-20%)
- varus collapse
Age limitations for rTSA in proximal humerus fractures
should be reserved for those >70 years
Relative contraindications for reverse?
- deltoid deficiency
- glenoid fracture
- scapular spine fracture
- glenoid deficiency
is tuberosity resorption common?
it is common if the stem is cemented in rTSA or in hemi, presumably because of the effect of stress shielding
Hertel’s morphologic risk factors for humeral head ischemia:
<8mm (short) posteromedial metaphyseal extension of the head fragment
- disruption of the medial calcar
Rates of concomitant rotator cuff injury
~40%
- increasing risk with increasing Neer grade
- increasing risk with >5mm GT displacement
Does initial degree of fracture varus influence surgical management?
yes.
if >20 deg varus initially, should go arthroplasty option
reason is that locking plates in this context are high risk to lose reduction, have intra-articular screw penetration, and osteonecrosis
How much residual greater tuberosity displacement is acceptable?
<5mm in normal people
<3mm in those who engage in overhead activities
displacement greater than this will alter rotator cuff mechanics and can cause impingement
what is the accepted “combined cortical thickness” implying adequate bone stock for internal fixation of proximal humerus fractures
> 4mm
PMID 17213379
what is expected outcome of 1 part proximal humerus fracture treated non-op?
similar functional status prior to injury
decreased ROM compared to contralateral uninjured side
does smoking affect nonunion in varus displaced proximal humerus fractures?
yes smoking can increase nonunion risk by 5.5x
