PROXIMAL HUMERUS FRACTURES

1. MODERATOR: DR.SUBRAMANIAN
PRESENTER: DR.RAMACHANDRA

2. It is the commonest # affecting shoulder
girdle in adults.
Proximal humeral # account for almost 7%
of all # and 80% of all humeral #.
In pts above the age of 65 years proximal
humeral # are the 2nd most frequent upper
extremity #.

3. Shoulder has greatest range of motion of
any articulation in body.
It is due to shallow glenoid fossa that is
only 25% of humeral head.
Major contribution to stability is by soft
tissue composed of muscle, capsule, &
ligaments.
Proximal humerus is retroverted 35 to 40
degrees relative to epicondylar axis.

4. Four osseous segments in proximal
humerus are:
Humeral head
Lesser tuberosity
Greater tuberosity
Humeral shaft

8.  Greater tuberosity is
displaced by
supraspinatus &
external rotators.
 Lesser tuberosity is
displaced by
subscapularis.
 Humeral shaft displaced
by pectoralis major.
 Deltoid insertion
causes abduction of
proximal fragment.

9. Most common is fall onto outstretched
upper extremity from a standing height, in
older & osteoporotic woman.
Younger pts present following high energy
trauma.
Less common with excessive shoulder
abduction, direct trauma, electric shock or
seizures.

11. The proximal humerus can # as a
consequence of 3 main loading modes:
Compressive loading of the glenoid onto
the humeral head.
Bending forces at the surgical neck.
Tension forces of the rotator cuff at the
greater & lesser tuberosities.

12. The majority of proximal humeral # occur
as isolated injuries.
In polytrauma pts, proximal humeral #
frequently exhibit comminution extending
into the humeral shaft.
 In the presence of # dislocations, glenoid
rim and neck # and avulsion # of the
coracoid may occur.

13.  The association of arterial injuries is rare and
is reported in the literature as isolated case
reports.
 Electromyographic evidence of neurologic
injury can be present in as many as 67% of
proximal humeral #.
 The most frequently affected nerves are the
axillary nerve (58%) & suprascapular nerve
(48%), with combined neurologic lesions
being frequent.

14. The association of rotator cuff tears has
been found to increase with age.
Full-thickness tears have been found in
only 6% of proximal humerus pts under 60
years of age compared to 30% in those pts
above 60 years of age.

15. Pts typically present with upper extremity
held closely to chest by contralateral hand,
pain, swelling & tenderness.
Ecchymosis may or may not be present.
Careful neurovascular exmn. is essential.
mainly for Axillary nerve function.
It is assessed by presence of sensation
on lateral aspect of proximal arm overlying
deltoid.

16. CODMAN’S CLASSIFICATION
 NEER CLASSIFICATION
AO/OTA CLASSIFICATION

17.  A- Greater tuberosity
 B- Lesser tuberosity
 C- Head
 D- Shaft

18. Most commonly used classification is
Neer’s classification.
Useful in guiding treatment.
Based on four part anatomy of proximal
humerus : Humeral head, lesser & greater
tuberosities, proximal shaft.

19. Criteria for displacement
Greater than 1cm of seperation of a part or
Angulation of 45 degrees.
Osteonecrosis is most likely after displaced
four part fractures.

22.  X ray AP view of
shoulder in plane of
scapula.

23.  Neer Lateral Y view
of shoulder.

24.  Axillary view of
shoulder.

27. CT of proximal humeral # is helpful in
providing further understanding of fracture
configuration.
Axial images can confirm displacement of
the lesser and greater tuberosity
fragments in the transverse plane.

28. Coronal images give more detail about the
alignment of the humeral head &
assessment of comminution at the level of
the humeral calcar, the integrity of the
inferomedial hinge, and extent of
metaphyseal # extension.
Sagittal images help in determining a
flexion or extension deformity of the
proximal humerus with regard to the shaft.

31. NON OPERATIVE TREATMENT
OPERATIVE TREATMENT

33. Immobilization of the arm to the chest
using a simple collar and cuff sling
Gilchrist or Velpeau type shoulder
immobilizer used.
At 2 weeks passive ROM exercises of the
shoulder.

34.  At 3 or 4 weeks
radiographs are taken &
gentle assistive exercises
(pulley elevation, external
rotation with a stick,
extension with a stick) are
begun.
 At 6 weeks, rapid
progression to terminal
stretches and light resistive
exercises is started

35. Predictors for outcomes have been found
to be age factor.
Court-Brown et al. studied 131 two-part
surgical neck #.
At 1yr follow up pts able to return to
housework
Non operative treatment yielded results
similar to those of surgical treatment even
in # with translation of 66% or more.

36. Court-Brown et al. further assessed non
operative treatment of four-part valgus-
impacted # in elderly patients.
Good or excellent results were achieved
in 81% of patients according to Neer’s
criteria.

37.  The treatment of displaced proximal humeral
# is complex & requires careful assessment
 Pt factors (age & activity level)
 Fracture-related factors (bone quality, fracture
pattern, degree of comminution, & vascular
status).
 The goal of treatment is a pain-free shoulder
with restoration of pre-injury function.

38. Good predictors of
ischemia are:
 Metaphyseal extension
of the humeral head of
<8 mm
 Medial hinge disruption
of >2 mm
Ischemia of head:
 The combination of
metaphyseal extension
of the humeral head.
 Medial hinge disruption
of >2 mm
 Anatomic neck #
pattern
Radiographic criteria for perfusion of humeral head

41. Operative management is guided by
fracture pattern & cortical thickness.
Combined cortical thickness is the average
of medial & lateral cortical thickness.
A cortical thickness <4mm- sling,
osteosuture & hemiarthroplasty.
A cortical thickness >4mm- internal
fixation.

43. INDICATIONS CONTRAINDICATIONS
 proximal humeral fractures
that have at least 1 cm of
displacement between the
head and the shaft
fragments
 or 5 mm of displacement of
the tuberosity fragment.
 previous attempt(s) at
internal fixation
 More than 6wks old #.
 Four part comminuted #

44.  Flatow et al. reported
isolated greater
tuberosity # had good
or excellent results
with osseous union.
 78% of the pt had an
excellent result
according to the
criteria of Neer et al.
in 2 or 3 part #.

45. INDICATIONS
 greater tuberosity #
isolation or in conjunction
with a surgical neck #.
 three and four-part proximal
humeral #.
 four-part valgus impacted #
or true four part #.
 severe osteopenia or
osteoporosis.
 Comminution of the medial
portion of the calcar or
proximal part of the humeral
shaft.
CONTRAINDICATIONS

47. Two surgical approaches are commonly
used to perform open reduction and
internal fixation (ORIF).
These are the
Delto pectoral approach
Deltoid-splitting approach.

48. INDICATIONS CONTRAINDICATIONS
 AO type-B (bifocal)
 AO type-C (anatomic neck)
 Fracture-dislocations
 Head splitting fractures
 Impression fractures that
involve >40% of the articular
surface

49.  The plate should be positioned directly on
the middle of the lateral cortex and
approximately 8 mm distal to the superior
aspect of the greater tuberosity.
Humeral head preservation may be
possible with locked-plate fixation
supplemented with local bone graft or
bone-graft substitute.

52. The main indications for proximal humerus
interlocking IMIL nailing are displaced two-
part surgical neck # especially those with
extension into the humeral diaphysis, and
pathologic #.
Three-part greater tuberosity fractures may
also be amenable to fixation with IM nailing

54. INDICATIONS CONTRAINDICATIONS
 Four-part #, three-part # in
older pts with osteoporotic
bone.
 Fracture-dislocations
 Head-splitting fractures
 That involve >40% of the
articular surface
 Active infection of the
shoulder joint and/or
 Surrounding soft tissue

55.  Delto pectoral
approach
 proximal anatomy is
restored by
 greater tuberosity
cerclage sutures
medial to the humeral
neck and tie them
around the greater
tuberosity fragment.

57.  A second set of
sutures can then be
passed into the lesser
tuberosity and tied.

59. Osteonecrosis: 3% to 14% of 3 part # , 4 to
14% of 4 part # & high rate in anatomical
neck #.
Infections
Nonunion
Malunion
Shoulder stiffness
Implant failure
Pin tract infection

60. Neurovascular injury
Impingement syndrome
Rotator cuff injury

63. DHANYAVAAD