Proximal Humerus Fractures

Question 1

Reliability of the Neer Classification:

Answer 1

30% interobserver reliability (HJD, JDZ)

Question 2

Can you tension band wire proximal humerus fractures?

Answer 2

You can, but high rates of loss of fixation (HJD, Koval/JDZ)

Question 3

Outcomes of hemiartrhoplasty for 3- and 4-part proximal humerus fractures:

Answer 3

generally achieve a pain free shoulder
ROM and functional outcomes are variable - 
- FE 110
- ER 31
- IR to L2

Question 4

Tuberosity management during hemiarthroplasty for fracture?

Answer 4

• needs reapproximation
• need appropriate soft tissue tensioning
• need secure tuberosity fixation

Question 5

What’s the functional outcome expected 1 year after minimally displaced 1-part proximal humerus fractures:

Answer 5

• 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

Question 6

Is the axillary lateral view reliable for measuring angulation of proximal humerus fractures?

Answer 6

no

- multiple angles can be measured based on humeral rotation and this is not a reliable thing to do. (HJD, JDZ)

Question 7

complications of proximal humerus locking plate:

Answer 7

• screw penetration is most common (16%)

- secondary loss of fixation

Question 8

should you use calcium phosphate cement when performing ORIF of proximal humerus fracture?

Answer 8

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

Question 9

IMN for humerus fracture

Answer 9

no difference in functional outcomes or ROM

• some series, no difference in complications
• other series, higher rates of subacroimial impingement and rotator cuff issue

Question 10

What is the problem with varus displacement of proximal humerus fracture

Answer 10

similar functional outcomes as patients without varus displacement

• 40% complication rate - including AVN and secondary varus displacement

Question 11

what is the primary determinant of successful hemiarthroplasty?

Answer 11

healing and placement of the tuberosities

• resorption, malunion, nonunion yields inferior outcomes
• functioning rotator cuff is essential

Question 12

comparing ORIF vs hemiarthroplasty:

Answer 12

better functional outcomes in ORIF but a higher complication rate including

• AVN (50%)
• screw penetration (5-20%)
• varus collapse

Question 13

Age limitations for rTSA in proximal humerus fractures

Answer 13

should be reserved for those >70 years

Question 14

Relative contraindications for reverse?

Answer 14

• deltoid deficiency
• glenoid fracture
• scapular spine fracture
• glenoid deficiency

Question 15

is tuberosity resorption common?

Answer 15

it is common if the stem is cemented in rTSA or in hemi, presumably because of the effect of stress shielding

Question 16

Hertel’s morphologic risk factors for humeral head ischemia:

Answer 16

<8mm (short) posteromedial metaphyseal extension of the head fragment
- disruption of the medial calcar

Question 17

Rates of concomitant rotator cuff injury

Answer 17

~40%

• increasing risk with increasing Neer grade
• increasing risk with >5mm GT displacement

Question 18

Does initial degree of fracture varus influence surgical management?

Answer 18

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

Question 19

How much residual greater tuberosity displacement is acceptable?

Answer 19

<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

Question 20

what is the accepted “combined cortical thickness” implying adequate bone stock for internal fixation of proximal humerus fractures

Answer 20

> 4mm

PMID 17213379

Question 21

what is expected outcome of 1 part proximal humerus fracture treated non-op?

Answer 21

similar functional status prior to injury

decreased ROM compared to contralateral uninjured side

Question 22

does smoking affect nonunion in varus displaced proximal humerus fractures?

Answer 22

yes smoking can increase nonunion risk by 5.5x