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Proximal humerus fractures
1.
2. 2-4 % of upper extremity #
5% of all #.
second most common fracture of the upper
extremity.
Pt > 65 yrs – third most common #
65% of # occur in Pt’s > 60 yrs
F:M – 3:1
Incidence increases with age.
3. Old Pts low energy trauma. [FOOSH]
Most # are nondisplaced, good prognosis –
nonsurgical
Risk factors: Poor quality bone impaired vision &
balance, medical comorbidities, decreased muscle
tone.
Young Pts – High energy trauma.
Severe soft tissue disruption always require
surgical intervention
Seizures & electric shock – indirect causes.
4. Articular head, G.T, L.T, for insertion for rotator
cuff & shaft.
Metaphyseal flare – surgical neck most
common site of #
Anatomic neck.
Articular segment is almost spherical, with a
diameter of curvature averaging 46 mm (ranging
from 37 to 57 mm)
Inclination of the humeral head relative to the
shaft averages 130 degrees
5. Humeral retroversion – 18*-40*
Bone density of subchondral bone is strongest.
Greater tuberosity has three regions into which
the supraspinatus, infraspinatus, and teres minor
insert
Subscapularis tendon lesser tuberosity, which
is separated from the greater tuberosity by the
bicipital groove.
6. PH is formed by 3 ossification centres
Fusion of these ossification centers at the physis
creates a weakened area that is susceptible to
fracture .
Primary deforming forces – pectoralis major &
rotator cuff.
Blood supply: distal branches of axillary artery.
Arcuate artery of Liang – supplies H. head.
Tethered trifucation – at the level of surgical neck
– vascular injury.
7.
8.
9. Ecchymosis appears 24-48 hrs.
Look for rib, scapular, cervical # in high energy
trauma.
Concurrent brachial plexus injury 5%
Axillary nerve is susceptible in anterior #
dislocation.
Gentle rotation of arm & palpation of # - guide for
# stability .
12. Edwin smith papyrus: closed / open.
Kocher [1896]: location of #, supratubercular,
periT, infraT, subT.
Codman: 11 different types, described # along the
lines of epiphyseal scars.
Watson & Jones: based on mechanism of injury
AO – 27 possible subgroups, emphasizes on
vascular supply of articular portion of PH.
13. DePalma and Cautilli emphasized the difference
between fractures with and without dislocation of
the joint surfaces
Neer classification: # classified by evaluating the
displacement of parts from each other.
Criteria to consider as a part, fragment must be
rotated 45* or 1 cm from the another fragment.
14.
15. Articular surface # are two types
Impression # mostly occurs in association with
chronic dislocations.
Head splitting # are associated with other # in
which splitting of AS is significant component.
Neer -Commonly used because it based on the
regional anatomy & emphasis on degree of
diplacement.
16. almost exclusively in older people
tend to develop periarthritis about the shoulder,
these fractures should be treated by methods that
allow early motion and early restoration of function
17.
18. Most # [>80%] can be treated conservatively.
Two part nondisplaced is the most common
variant.
3 & 4 part # represent 13-16% of PH%.
Good outcome doesn’t require anatomic
reduction.
Considerations: assessment of #, bone quality,
status of rotator cuff. Pt age, activity level,
preinjury health.
19. Non-displaced # - < 5mm of superior or 10 mm of
posterior GT displacement in active Pts & < 10
mm of superior displacement in nondominant arm
in sedentary pt.
Surgical neck # - any bone contact in elderly pt, in
young pt <50% shaft diameter displacement &
<45* angulation in dominant arm.
20. Reduced demand: Pt willing to accept stiffness
Poor health: pt unable to tolerate surgery &
anaesthesia.
Poor rehabilitation candidate.
21. Principle: early protection & combined with
gradual mobilization.
Early sling immobilisation for 7-10 days.
Active finger, wrist, elbow movts
By 2 wks, gentle active assisted ROM ex
By 6 wks, light resistive ex
By 3 months, shoulder strengthening ex.
22. most commonly occur as a result of seizures or
secondary to glenohumeral dislocations.
These often reduce anatomically with reduction of
the humeral head and can be managed
nonoperatively.
displaced more than 1 cm, open reduction and
internal fixation are required
fixation with screws, wire, or suture as dictated by
the size of the fragment, the comminution, or the
quality of the bone
23. If tuberosity has been displaced and retracted, a
significant tear in the rotator cuff mechanism
exists also,
Careful identification and repair of the rotator cuff
defect are required
24.
25. Two-part # involving the anatomical neck render
the articular fragment avascular and may require
prosthetic replacement.
Involving the surgical neck usually can be treated
by a sling, hanging arm cast, or other conservative
measures.
Indications for operative treatment of two-part
fractures include open fractures, the inability to
obtain or maintain an acceptable closed reduction,
injury to the axillary artery, and selected multiple
trauma patients
26. Indications for CRPF
# without significant communition in pt with good
quality bone.
Pt should be willing to comply with postop care
plan.
Contraindications: Severe communition &
osteopenia.
Inability to reduce the #.
27.
28. The safe starting point for the proximal lateral
pins and the end point for the greater tuberosity
pins.
X = distance from the superiormost aspect of the
humeral head to the inferiormost aspect of the
humeral head.
2X = the starting point for the proximal lateral pin.
The end point for the greater tuberosity pin
should be >2 cm from the inferior most margin of
the humeral head.
29. Shoulder immobilised for 4 wks
Pt were reviewed every wk for checking the pins
position,
Pins can be removed by 4-6 wks time, begin
assisted motion.
30. If open reduction is necessary, internal fixation
with a combination of intramedullary rod fixation
and tension band technique or intramedullary rod
fixation with a proximal locking screw.
A hand-bent semitubular plate used as a blade-
plate device also is satisfactory in osteopenic
bone.
In younger patients, an AO buttress plate with
screws also is useful.
31.
32. ORIF
one of the tuberosities remains with the articular
head fragment, thereby retaining its vascularity
33.
34. Rationale: injury caused avascularity of articular
segment which even with a satisfactory
reduction & fixation would eventually collapse –
posttraumatic arthritis.
Indications:
1. four part# & # dislocations,
2. three part # & # dislocations in elderly pts with
osteopenic bone, anatomic neck
3. Head splitting #
4. Anatomic neck # that can not be R & F.
5. Chronic dislocation with impression # involving
>40% articular surface.
35. More likely after surgical than nonoperative #
care.
Careful postop followup is necessary.
1) INSTABILITY
Glenoid # , rotator cuff tear, muscle atony.
ORIF glenoid, repair of cuff, isometric ex.
2) MALUNION
Incorrect diagnosis, poor reduction, inadequate
fixation.
Release of adhesions, with or with out
osteotomy Vs trim of prominence.
36. 3) NONUNION
Motion too early, poor bone.
Preserved head – ORIF & BG
Cavitated head – HHR
4) AVASCULAR NECROSIS:
Four part # & dislocation
HHR
5) NEUROVASCULAR INJURY
Four part with head in axilla
If nerve injury + at the time of closed injury,
prognosis is good.
37. 6) INFECTION:
Immune compromise & extensive soft tissue
loss
Hard ware removal & debridement.
7) ARTHRITIS
Hardware penetrating the jt
8) Refractory shoulder stiffness
9) CHARCOT SHOULDER:
unusual fragmentation occurs after #
10) Heterotopic bone formation.
Soft tissue injury, repeated manipulation,
delayed reduction beyond 7 days.
38.
39. NEER CLASSIFICATION:
Classified according to the amount of
displacement.
Grade I fracture is displaced less than 5 mm.
Grade IV fracture involves total displacement.
40. Open reduction indicated for
1) the rare displaced Salter-Harris types III and IV
fractures,
2) interposition of the biceps tendon in the fracture
site,
3) fracture-dislocations
4) open fractures
