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Proximal Humerus. Fractures. Principles of Diagnosis, Decision Making and Treatment. Christopher G. Finkemeier, MD, MBA Revised: May 2011. Acknowledgement: AO faculty lecture archive. Objectives. 1. Learn the principles of diagnosis. 2. Learn the principles of decision making.

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Proximal humerus

Proximal Humerus

Fractures

Principles of Diagnosis,

Decision Making and Treatment

Christopher G. Finkemeier, MD, MBA

Revised: May 2011

Acknowledgement: AO faculty lecture archive


Objectives

Objectives

1. Learn the principles of diagnosis

2. Learn the principles of decision making

3. Learn the various treatment options


Epidemiology

Epidemiology

All upper extremity fractures

1. forearm fxs

2. proximal humerus fxs

All fractures in patients > 65 yrs

1. hip fxs

2. “colles” fxs

3. proximal humerus fxs


4 anatomic parts

HUMERAL HEAD:

precarious blood supply

AVN

GREATER TUBEROSITY:

supra/infraspinatus

insertion

SURGICAL NECK/SHAFT:

deltoid/pectoralis major

largely dictates fx behavior

compression: stable

shear: unstable

LESSER TUBEROSITY:

subscapularis insertion

4 Anatomic Parts

Deforming forces determine fx displacement


Vascular supply

Vascular Supply

  • Lateral ascending branch of anterior humeral circumflexartery

  • Damage may lead to AVN


Proximal humerus

Gerber et al.,

JBJS, 1990

Humeral Head Vascularity

Non shaded area is supplied

by the lateral ascending branch

of the anterior humeral circumflex

artery.


Proximal humerus

Recent anatomic and clinical findings confirm

that perfusion from the posterior circumflex vessels

alone may be adequate for head survival.

Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001

Humeral Head Vascularity

In the fractured humerus, the arcuate artery is

generally interupted.


Proximal humerus

Radiography

True AP

Transcapular “Y”


Axillary view

Lesser Tuberosity

Axillary View


Ct scan

CT Scan

  • Articular surface

    • Head splitting injury

  • Tuberosity displacement, especially lesser tuberosity


Treatment

?

Operative

Nonoperative

Fx pattern

Head viability

Bone quality

Implant limitations

Patient age & comorbidities

Treatment

  • 80% of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY

20% Displaced


Neer classification

Neer Classification

> 1 cm

45º

Codman’s

4 parts


Ao classification

AO Classification

A-type: 2-part

B-type: 3-part

C-type: 4-part +

anatomic neck


Proximal humerus

97%

PPV

  • Loss of integrity of medial hinge

Predictors of ischemia:

  • Metaphyseal head extension (calcar) < 8 mm.

  • Fracture Pattern (anatomic neck)

Hertel et al, J Shoulder Elbow Surg 2004;13:427


Proximal humerus

  • BEWARE of lateral displacement of head

Metaphyseal

head extension < 8mm

Blood Supply Potentially Torn if medial hinged displaced

 This head is likely NOT viable.


Proximal humerus

Medial Hinge not

displaced

Metaphyseal head

Extension > 8mm

This head is

likely viable


Bone quality

Bone Quality

Tingert et al, JBJS(B), 2003

Mean cortical thickness

A

B

2 cm

A + B + C + D

C

D

4

“A mean cortical thickness < 4 mm is highly indicative of low BMD”

Predictable loss of fixation ?


Proximal humerus

Locking plates are less prone

to failure due to the fixed-

angled screws.

Implant limitations

Recognizing what implants are

appropriate for certain fracture

types is a key decision making factor.

Conventional implants

Poorly control varus

collapse, screw loosening

and screw back out.


Proximal humerus

?

Operative

Nonoperative

Fx pattern

Head viability

Bone quality

Implant limitations

Patient age & comorbidities

Putting it all together


Proximal humerus

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Hospital for Special Surgery

protocol

Nonoperative Tx

sling + ROM

Nonop tx = surgery

Court-Brown et al., JBJS(B), 2001


Proximal humerus

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Elderly

Non-displaced

or mod displaced

Nonoperative Tx

sling + ROM

Nonop tx = surgery

Court-Brown et al., JBJS(B), 2001


Treatment non operative

Treatment: Non-operative

  • Koval et al., JBJS, 1997

    • 77% good or excellent; 13% fair, 10% poor results

    • Functional recovery averaged 94%

    • Sling with ROM exercises by 2 weeks


Treatment non operative1

Treatment: Non-operative

  • Court-Brown et al., JBJS(B), 2001

    • Mean age 72 yrs

    • Outcome determined by age and degree oftranslation

    • Surgery did not improve outcomes regardlessof translation


Proximal humerus

Operative Tx

heavy suture

through rotator

cuff insertion

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

“significant displacement”

>5mm GT >66% SN

Poor bone quality

or

Locking plate


Proximal humerus

Closed reduction

percutaneous pins

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Satisfactory bone quality

Operative Tx


Proximal humerus

ORIF

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Satisfactory bone quality

Operative Tx


Proximal humerus

Nonoperative Tx

B1.1

Poor bone quality

Court-Brown, JBJS(B), 2002

Zyto et al, JBJS(B), 1997

Non-op = surgery

maybe better

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol


Proximal humerus

High failure rates with

standard plates

Especially in patients

with poor bone

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

ORIF

Locking plates have

dramatically improved

fixation


Proximal humerus

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Hemiarthroplasty

Highly displaced fxs

“3 or 4-part”

Poor bone quality

Not reconstructable


Proximal humerus

Hemiarthroplasty


Proximal humerus

Hemiarthroplasy

  • Pain relief generally good

  • Good function depends on anatomic

    tuberosity placement

  • Despite all the advances, shoulder

    flexion above 90º is difficult to acheive


Proximal humerus

Unless able to fix

anatomically, better to

replace (hemi)

Gerber et al.

JSES, 1998

Hemi

Poor bone

Fix

Good bone

Jan 07

Journal of the American Academy of Orthopedic Surgeons

Hospital for Special Surgery

protocol

Anatomic neck fxs

have high rate of

AVN (+/- 50%).


Proximal humerus

Summary of

Decision Making Process


Proximal humerus

“Young” Patients

<30yrs? <40yrs? <50 yrs?

“good bone quality”

Preservation of function is primary objective

“Full court press”

Anatomic reduction/soft tissue sparing

Stable fixation

Hemiarthroplasty for non-reconstructable fxs only


Proximal humerus

Elderly Patients

“poor bone quality”

Pain relief primary objective

Non op RX if fracture stable and early motion possible

  • If unstable:

    • ORIF if head viable and fracture reducible

    • Hemiarthroplasty if head not viable or fracture not repairable

Locking plate


Proximal humerus

Caveat

“A proximal humeral fracture that is at risk

for AVN has to be reduced anatomically

if joint preserving treatment is selected. If

anatomic reduction cannot be obtained,

other treatment options such as arthroplasty

should be considered.”

Gerber et al.

The clinical relevance of posttraumatic avascular

Necrosis of the humeral head. JSES, 1998


Proximal humerus

GT fx +

Surgical neck fx

with extension

Medial

hinge intact

Metaphyseal spike

> 8mm

93 y/o male

RHD

Healthy

Fell


Proximal humerus

6 weeks

+ callus

FE 90


Proximal humerus

References

Neer, CS. Displaced Proximal Humeral Fractures.

JBJS 52-A: 1077-1089, 1970.

Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:

1090-1103, 1970.

Gerber, C. et al. The Arterial Vascularization of the Humeral Head.

JBJS 72-A: 1486-1494, 1990.

Brooks, CH et al. Vascularity of the Humeral Head After Proximal Humeral

Fractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.

Hertel, R et al. Predictors of Humeral Head Ischemia After Intracapsular

Fracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004


Proximal humerus

References

Nho, SJ. et al. Innovations in the Management of Displaced Proximal Humerus

Fractures . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007.

Koval, KJ. et al. Functional Outcome after Minimally Displaced Fractures

of the Proximal Part of the HumerusJBJS 79-A: 79: 203 – 7, 1997.


Thank you

Thank you!

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