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Introduction
  • Epidemiology
    • incidence
      • 4-6% of all fractures
      • third most common fracture pattern seen in elderly
    • demographics
      • 2:1 female to male ratio
      • increasing age correlates with increasing fracture risk in women
  • Pathophysiology
    • mechanism
      • low-energy falls
        • elderly with osteoporotic bone
      • high-energy trauma
        • young individuals
        • concomitant soft tissue and neurovascular injuries
    • pathoanatomy
      • vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
  • Associated conditions
    • nerve injury
      • axillary nerve palsy most common
    • fracture-dislocations
      • more commonly associated with nerve injuries
Anatomy
  • Osteology 
    • anatomic neck 
      • represents the old epiphyseal plate
    • surgical neck 
      • represents the weakened area below 
  • Vascular anatomy 
    • anterior humeral circumflex artery 
      • one of primary blood supplies to the humeral head
      • branches
        • anterolateral ascending branch
          • is a branch of the anterior humeral circumflex artery
        • arcuate artery
          • is the terminal branch 
      • course
        • runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove
        • has an interosseous anastomosis
    • posterior humeral circumflex artery 
      • recent studies suggest it is the main blood supply to humeral head  
Classification
  • Valgus impacted
    • not true 4-part fractures
    • have preserved posterior medial capsular vascularity to the articular segment
  • AO/OTA 
    • organizes fractures into 3 main groups and additional subgroups based on 
      • fracture location
      • status of the surgical neck
      • presence/absence of dislocation
  • Neer classification   
    • based on anatomic relationship of 4 segments 
      • greater tuberosity
      • lesser tuberosity
      • articular surface
      • shaft
    • considered a separate part if
      • displacement of > 1 cm
      • 45° angulation
Evaluation
  • Symptoms
    • pain and swelling
    • decreased motion
  • Physical exam
    • inspection
      • extensive ecchymosis of chest, arm, and forearm
    • neurovascular exam
      • 45% incidence of nerve injury (axillary most common)
        • distinguish from early deltoid atony and inferior subluxation of humeral head
      • arterial injury may be masked by extensive collateral circulation preserving distal pulses
Imaging
  • Radiographs
    • recommended views
      • complete trauma series
        • true AP
        • scapular Y
        • axillary
      • additional views
        • apical oblique 
        • Velpeau 
        • West Point axillary 
      • findings
        • combined cortical thickness (>4 mm)
          • studies suggest correlation with increased lateral plate pullout strength
  • CT scan
    • indications
      • preoperative planning
      • humeral head or greater tuberosity position uncertain
      • intra-articular comminution
  • MRI
    • indications
      • rarely indicated
      • useful to identify associated rotator cuff injury
Treatment
  • Nonoperative
    • sling immobilization followed by progressive rehab
      • indications 
        • 85% of proximal humerus fractures are minimally displaced and can be treated nonoperatively including 
          • minimally displaced surgical neck fracture (1-, 2-, and 3-part)
          • greater tuberosity fracture displaced < 5mm
          • fractures in patients who are not surgical candidates
        • additional variables to consider
          • age
          • fracture type
          • fracture displacement
          • bone quality
          • dominance
          • general medical condition
          • concurrent injuries
      • technique
        • start early range of motion within 14 days
  • Operative
    • CRPP (closed reduction percutaneous pinning)
      • indications
        • 2-part surgical neck fractures
        • 3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar
    • ORIF
      • indications
        • greater tuberosity displaced > 5mm   
        • 2-,3-, and 4-part fractures in younger patients 
        • head-splitting fractures in younger patients
    • intramedullary rodding
      • indications
        • surgical neck fractures or 3-part greater tuberosity fractures in 
        • younger patients
        • combined proximal humerus and humeral shaft fractures
      • outcomes
        • 85% success rate in younger patients
    • hemiarthroplasty 
      • indications  
        • anatomic neck fractures in elderly (initial varus malalignment >20 degrees) or those that are severely comminuted
        • 4-part fractures and fracture-dislocations (3-part if stable internal fixation unachievable)
        • rotator cuff compromise
        • glenoid surface is intact and healthy
        • chronic nonunions or malunions in the elderly
        • head-splitting fractures with incongruity of humeral head
        • humeral head impression defect of > 40% of articular surface
        • detachment of articular blood supply (most 3- and 4-part fractures)
      • outcomes
        • improved results if
          • performed within 14 days
          • accurate tuberosity reduction
          • cerclage wire passed through hole in prosthesis and tuberosities
        • poor results with
          • tuberosity malunion 
          • proud prosthesis
          • retroversion of humeral component > 40°
    • total shoulder arthroplasty
      • indications
        • rotator cuff intact
        • glenoid surface is compromised (arthritis, trauma)
    • reverse shoulder arthroplasty 
      • indications
        • elderly individuals with nonreconstructible tuberosities
Treatment by Fracture Type
 
One-Part Fracture (most common)

Surgical Neck fx

• Most common type
• if stable then early ROM
• if unstable then period of immobilization followed by ROM once moves as a unit

Anatomic Neck fx

  • ORIF in young patient
• ORIF vs. hemiarthroplasty in elderly patient
• hemiarthroplasty if severely comminuted
Two-Part Fracture

Surgical Neck

• Most common fx pattern (85%)
• Deforming forces:
1) pectoralis pulls shaft anterior and medial 2) head and attached tuberosities stay neutral
• Posterior angulation tolerated better than anterior and varus angulation

Nonoperative
Closed reduction often possible
• Sling
Operative
• indicated for >45° angulation
• technique
- CRPP
- Plate fixation
- Enders rods with tension band
- IM device

Greater tuberosity

• Often missed 
• Deforming forces: GT pulled superior and posterior by SS, IS, and TM
• Can only accept minimal displacement or else it will block ER and ABD

Nonoperative
• indicated for GT displaced < 5 mm
Operative
• indicated for GT displacement > 5 mm
•AP radiograph of a left shoulder demonstrates a 2-part proximal humerus fracture at the surgical neck.
- isolated screw fixation only in young with good bone stock
- nonabsorbable suture technique for osteoporotic bone (avoid hardware due to impingement)
tension band wiring 

Lesser tuberosity

• Assume posterior dislocation until proven otherwise

Operative
• ORIF if large fragment 
• excision with RCR if small

Anatomic neck • Rare

Operative
 ORIF in young
• ORIF vs. hemiarthroplasty in elderly patient

Three-Part Fracture
Surgical neck and GT
 

• Subscap will internally rotate articular segment
• Often associated with longitudinal RCT

 
Surgical neck and LT

• Unopposed pull of external rotators lead to articular surface to point anterior
• Often associated with longitudinal RCT

• Trend towards nonoperative management with high complications with ORIF
• Young patient
- percutaneous pinning (good results, protect axillary nerve)
- blade plate / fixed angle device
- IM fixation (violates cuff)
- T plate (poor results with high rate of AVN, impingement, infection, and malunion)
• Elderly patient
- hemiarthroplasty with RCR or tuberosity repair

Four-Part Fracture
Valgus impacted 3- and 4-part fracture
 

• Radiographically will see alignment between medial shaft and head segments

• 74% good results with ORIF
• Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply
• Surgical technique
1. raise articular surface and fill defects
2. repair tuberosities

4-part with articular surface and head-splitting fracture

• Characterized by removal of soft tissue from fracture fragment leading to high risk of AVN (21-75%) 
• Deforming forces: 1) shaft pulled medially by pectoralis

• Young patient
- ORIF vs. hemiarthroplasty (nonreconstructible articular surface, severe head split, extruded anatomic neck fracture)

• Elderly patient
- hemiarthroplasty

 
Techniques
  • CRPP (closed reduction percutaneous pinning) 
    • approach
      • percutaneous
    • technique
      • use threaded pins but do not cross cartilage
      • externally rotate shoulder during pin placement
      • engage cortex 2 cm inferior to inferior border of humeral head
    • complications
      • with lateral pins
        • risk of injury to axillary nerve 
      • with anterior pins
        • risk of injury to biceps tendon, musculocutaneous n., cephalic vein 
      • possible pin migration
  • ORIF 
    • approach
      • shoulder anterior approach (deltopectoral) 
      • shoulder lateral (deltoid-splitting) approach 
        • indicated for GT and valgus-impacted 4-part fractures
        • increased risk of axillary nerve injury
    • technique
      • heavy nonabsorbable sutures
        • (figure-of-8 technique) should be used for greater tuberosity fx reduction and fixation (avoid hardware due to impingement)
      • isolated screw
        • may be used for greater tuberosity fx reduction and fixation in young patients with good bone stock
      • locking plate
        • has improved our ability to fix these fractures
        • screw cut-out (up to 14%) is the most common complication following fixation of 3- and 4- part proximal humeral fractures and fractures treated with locking plates  
        • more elastic than blade plate making it a better option in osteoporotic bone
        • place plate lateral to the bicipital groove and pectoralis major tendon to avoid injury to the ascending branch of anterior humeral circumflex artery 
        • placement of an inferomedial calcar screw can prevent post-operative varus collapse, especially in osteoporotic bone 
  • Intramedullary rodding  
    • approach
      • superior deltoid-splitting approach
    • technique
      • lock nail with trauma or pathologic fractures
    • complications
      • rod migration in older patients with osteoporotic bone is a concern
      • shoulder pain from violating rotator cuff
      • nerve injury with interlocking screw placement
  • Hemiarthroplasty  
    • approach
      • shoulder anterior approach (deltopectoral) 
    • technique for fractures
      • cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability
      • place greater tuberosity 10 mm below articular surface of humeral head (HTD = head to tuberosity distance) 
        • impairment in ER kinematics and 8-fold increase in torque with nonanatomic placement of tuberosities
      • height of the prosthesis best determined off the superior edge of the pectoralis major tendon  
      • post-operative passive external rotation places the most stress on the lesser tuberosity fragment 
  • Total shoulder arthroplasty 
  • Reverse shoulder arthroplasty 
Rehabilitation
  • Important part of management
  • Best results with guided protocols (3-phase programs)
    • early passive ROM for first 6 weeks
    • active ROM and progressive resistance
    • advanced stretching and strengthening program
  • Prolonged immobilization leads to stiffness
Complications
  • Screw penetration
    • most common complication after locked plating fixation (up to 14%)
  • Avascular necrosis  
    • risk factors
      • 4 part fractures
      • head split
      • short calcar segments
      • disrupted medial hinge
    • no relationship to type of fixation (plate or cerclage wires)
  • Nerve injury
    • axillary nerve injury (up to 58%)
      • increased risk with anterolateral acromial approach
      • axillary nerve is found 7cm distal to the tip of the acromion 
    • suprascapular nerve (up to 48%)
  • Malunion 
    • usually varus apex-anterior or malunion of GT
    • results inferior if converting from varus malunited fracture (with GT in varus necessitating osteotomy) to TSA
      • use reverse TSA instead
  • Nonunion
    • usually with surgical neck and tuberosity fx
    • treatment of chronic nonunion/malunion in the elderly should include arthroplasty  
    • lesser tuberosity nonunion leads to weakness with lift-off testing
    • greater tuberosity nonunion leads to lack of active shoulder elevation
    • greatest risk factors for non-union are age and smoking 
  • Rotator cuff injuries and dysfunction
  • Missed posterior dislocation
  • Adhesive capsulitis
  • Posttraumatic arthritis
  • Infection
 

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