Surgical Neck fx
Anatomic Neck fx
• 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
• 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
• Assume posterior dislocation until proven otherwise
Operative• ORIF if large fragment • excision with RCR if small
Operative • ORIF in young • ORIF vs. hemiarthroplasty in elderly patient
• Subscap will internally rotate articular segment• Often associated with longitudinal RCT
• 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
• 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 technique1. raise articular surface and fill defects2. repair tuberosities
• 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
Please rate topic.
Average 4.3 of 84 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 44-year-old male is struck by a vehicle while riding his bike. In the trauma bay, he complains of right shoulder pain . Upper extremity physical exam reveals no neurologic deficits, and an initial radiograph of the shoulder is shown in Figure A. A CT scan of the shoulder shows 1cm of posterior displacement of the tuberosity fragment. Which of the following is true regarding this injury?
It is usually associated with a posterior shoulder dislocation
The subscapularis muscle is the main deforming force
Non-operative treatment of this displaced injury results in good long term shoulder function
Open reduction and internal fixation is the treatment of choice
Associated rotator cuff tears are uncommon
Select Answer to see Preferred Response
The radiograph in Figure A demonstrates a posteriorly displaced greater tuberosity fracture. These injuries are often associated with anterior shoulder dislocations, and concomitant rotator cuff tears. The subscapularis attaches to the lesser tuberosity, and is not a deforming force. Open reduction and internal fixation (ORIF) is usually the treatment of choice, and it is well accepted that more than 5mm of displacement is an indication for surgery in patients that require overhead function of the arm.
Flatow et al evaluated 12 patients who were an average of five years status post ORIF of displaced greater tuberosity fractures. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result.
Platzer et al retrospectively analyzed functional and radiographic results of 52 patients with operative treatment of displaced greater tuberosity fractures at an average time of 5.5 years from surgery compared to 9 patients with equivalent injuries treated non-operatively. Evaluation of the results of the surgical study group and the nonoperative control group, patients with reduction and fixat ion of greater tuberosity fractures had significantly better results on shoulder function than did those with conservative treatment.
Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU.
J Bone Joint Surg Am. 1991 Sep;73(8):1213-8. PMID: 1890123 (Link to Abstract)
Flatow, JBJS 1991
Platzer P, Thalhammer G, Oberleitner G, Kutscha-Lissberg F, Wieland T, Vecsei V, Gaebler C
J Trauma. 2008 Oct;65(4):843-8. PMID: 18349710 (Link to Abstract)
Platzer, JT 2008
HPI - 34 year old female, was incarcerated when she had a seizure 4 months ago. Her shoulder was reduced and she was seen by another doctor for several months. Comes to my clinic with complaints of pain and inability to use her right arm.
How would you approach her care?
Title: Innovation in Proximal Humerus Fixation Presenter: Andrew Schmidt, MDColu...
Please rate question.
Average 3.0 of 23 Ratings
When utilizing the pectoralis major tendon as a reference for restoring humeral height during shoulder hemiarthroplasty, at what level cephalad to the proximal edge of the tendon should the top of the prosthesis sit?
The pectoralis major tendon is a reproducible structure from which the humeral height during shoulder arthroplasty can be based upon, even in fracture situations where the anatomy is distorted. The superior edge of the pectoralis major tendon at its insertion on the humerus is 5.6 cm below the top of the humeral head.
The referenced study by Torrens et al is a cadaveric evaluation of the pectoralis major tendon and proximal humeral anatomy. They reported that the top of the head sits 5.6cm proximal to the superior border of the pectoralis major tendon.
The referenced study by Greiner et al is a retrospective review of shoulder hemiarthroplasty; improved radiographic and clinical outcomes were reported when the pectoralis major tendon was used as a reference for humeral height. Improved outcomes were also reported with successful tuberosity healing and centering of the humeral head in the glenoid.
The referenced study by Murachovsky et al is another cadaveric study that found the pectoralis major tendon is a reproducible means from which to base the humeral height. The distance reported was 5.6 +/- 0.5 cm in 40 shoulders.
Torrens C, Corrales M, Melendo E, Solano A, Rodríguez-Baeza A, Cáceres E.
J Shoulder Elbow Surg. 2008 Nov-Dec;17(6):947-50. Epub 2008 Sep 6. PMID: 18774736 (Link to Abstract)
Torrens, JSES 2008
Greiner SH, Kääb MJ, Kröning I, Scheibel M, Perka C
J Shoulder Elbow Surg. 2008 Sep-Oct;17(5):709-14. PMID: 18621554 (Link to Abstract)
Greiner, JSES 2008
Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ.
J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):675-8. Epub 2006 Oct 19. PMID: 17055748 (Link to Abstract)
Murachovsky, JSES 2006
Average 3.0 of 36 Ratings
A 64-year-old woman is thrown off a horse, sustaining the injury shown in Figures A and B. She undergoes surgical fixation as seen in Figures C through E. What is the most commonly reported complication of this procedure?
Axillary nerve injury
Valgus migration of the fracture
The patient in the scenario has a 2-part proximal humerus fracture treated with a locking plate as seen in Figures A-E. The most common complication with the use of this implant is screw penetration. The terms screw cut out and penetration are often used interchangeably in the literature with cut out appearing more frequently in reports regarding intertrochanteric fractures.
Owsley et al retrospectively reviewed 53 proximal humerus fractures treated with locking plates and the same post-operative protocol. The most common complication was screw cut out or penetration, followed by varus displacement. They concluded that 3 and 4-part fractures in patients over 60 years have a higher incidence of failure.
Agudelo et al retrospectively reviewed 153 patients at a level-one trauma center treated with proximal humerus locking plates, investigating modes of failure for the implant. They determined that varus malreduction (head-shaft angle<120 degrees) was the most common mode of failure in their group.
Owsley KC, Gorczyca JT
J Bone Joint Surg Am. 2008 Feb;90(2):233-40. PMID: 18245580 (Link to Abstract)
Owsley, JBJS 2008
Agudelo J, Schürmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W.
J Orthop Trauma. 2007 Nov-Dec;21(10):676-81. PMID: 17986883 (Link to Abstract)
Agudelo, JOT 2007
Average 3.0 of 20 Ratings
A 46-year-old male is involved in a motor vehicle accident and suffers a proximal humerus fracture. Operative treatment is recommended, and plate fixation is performed through an extended anterolateral acromial approach. Which of the following structures is at increased risk of injury using this surgical exposure compared to the deltopectoral approach?
Posterior humeral circumflex artery
Anterior humeral circumflex artery
The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior deltoid raphe is utilized, and the axillary nerve is at particular risk of injury and must be identified and protected. With this approach, anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed.
Gardner et al evaluated 23 patients who had acute displaced fractures of the proximal humerus treated with the anterolateral acromial approach and either a locking plate or an intramedullary nail. At one year post-op, there were no axillary nerve deficits, and they found that the approach allowed direct access to the lateral fracture planes for fracture reduction and plate placement or safe nail and interlocking screw placement.
Gardner et al, in another study, performed cadveric dissection using the extended anterolateral acromial approach and measured multiple parameters regarding the axillary nerve. The nerve was predictably found approximately 35 mm from the prominence of the greater tuberosity.
Morgan et al performed a cadaveric study to describe the anatomic insertion point of the deltoid onto the proximal humerus. They found that the deltoid insertion is long and broad, and that placement of 4.5-mm plate would result in detaching 13.5 mm of its insertional footprint. This would leave half of the insertion still attached to the humerus.
Illustration A shows the position of the axillary nerve in relation to the approach.
Gardner MJ, Boraiah S, Helfet DL, Lorich DG.
J Orthop Trauma. 2008 Feb;22(2):132-7. PMID: 18349783 (Link to Abstract)
Gardner, JOT 2008
Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG.
Clin Orthop Relat Res. 2005 May;(434):123-9. PMID: 15864041 (Link to Abstract)
Gardner, CORR 2005
Morgan SJ, Furry K, Parekh AA, Agudelo JF, Smith WR.
J Orthop Trauma. 2006 Jan;20(1):19-21. PMID: 16424805 (Link to Abstract)
Morgan, JOT 2006
Average 4.0 of 21 Ratings
A 73-year-old female presents with persistent right shoulder pain 3 months after undergoing open reduction and internal fixation for a right proximal humerus fracture. Which of the following could have best prevented the complication shown in the current radiograph shown in Figure A?
Insertion of both cortical and locking screws into the humeral head
Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity
Treatment of the fracture with closed reduction and percutaneous k-wire fixation
Addition of an inferomedial locking screw within the calcar
Intramedullary nailing of the fracture
Figure A shows varus collapse and intra-articular joint penetration of the the proximal locking screws. This could have potentially been prevented by the addition of an inferomedial calcar screw, which would have provided greater strength to the fixation construct and resistance to fracture collpase. Illustration A is an immediate post-operative fluoro image of the fracture and shows the proximal humerus to be near anatomically aligned. The illustration also demonstrates simulated overlay of where the recommended inferomedial locking screw would be placed. Illustration B shows ORIF of a different proximal humerus fracture with placement of an inferomedial calcar screw.
Konrad et al present a prospective, multicenter, observational study to evaluate the functional outcome and the complication rate after ORIF of proximal humeral fractures with use of a locking proximal humeral plate. At 1 year follow-up, they found an overall complication rate of 34%: most commonly due to screw perforation through the humeral head. Nineteen percent of the patients required re-operation within 1 year of their index surgery.
Gardner et al discuss a technique of using a segment of fibula allograft, placed endosteally and incorporated into the locking construct, to aid in the reduction and restoration of the mechanical integrity of the medial column of the proximal humerus. An example of this fixation construct is shown in Illustration C.
Gardner et al, in another study, sought determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support. They found that achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.
Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kaab M, Luo C, Plecko M, Wendt K, Kostler W, Sudkamp N
J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:85-95. PMID: 20194347 (Link to Abstract)
Konrad, JBJS 2010
Gardner MJ, Boraiah S, Helfet DL, Lorich DG.
J Orthop Trauma. 2008 Mar;22(3):195-200. PMID: 18317054 (Link to Abstract)
Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG.
J Orthop Trauma. 2007 Mar;21(3):185-91. PMID: 17473755 (Link to Abstract)
Gardner, JOT 2007
Average 4.0 of 20 Ratings
What structure is 7cm from the acromion and at greatest risk of injury during a deltoid splitting approach for a proximal humerus fracture?
The axillary nerve is located approximately 7cm from the tip of the acromion. The axillary nerve comes off the of the brachial plexus (middle trunk, posterior division, posterior cord) carrying fibers from C5 and C6. The axillary nerve travels through the quadrangular space with the posterior circumflex humeral artery and vein to innervate the teres minor and deltoid muscles and supply sensation over the lateral shoulder.
Based on the knowledge of the course of the axillary nerve, and potential complications regarding the vascular supply to the humeral head with the delto-pectoral approach, some authors are suggesting deltoid-splitting approach to the proximal humerus for reduction and fixation of proximal humeral fractures.
Cetik et al evaluated 24 cadaver shoulders to better identify the course of the axillary nerve and identify the "safe zones" for deltoid-splitting incisions. They found the distance from the tip of the acromion to the axillary nerve varied depending on patient specific factors like arm length and they identified a "safe area" where dissection was free of injury to the axillary nerve (Illustrations A and B).
Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H.
J Bone Joint Surg Am. 2006 Nov;88(11):2395-9. PMID: 17079396 (Link to Abstract)
Cetik, JBJS 2006
A 78-year-old female falls and sustains the fracture seen in Figure A. Surgical treatment is pursued with open reduction internal fixation with a lateral locking plate. Postoperative radiographs are provided in Figure B. What is the most common complication with this mode of fixation?
Axillary artery injury
Screw cut-out is the most common complication following open reduction and internal fixation of 3 and 4 part proximal humerus fractures. A radiograph of this phenomenon in this patient at 5 months is shown in illustration A. This complication ultimately results from fracture settling and axial compression allowing the screws to penetrate the joint.
Owsley and Gorczyca evaluated a single surgeon's experience treating 53 patients with displaced proximal humeral fracture with a standard post-op regime. They found that screw cut-out was the most common complication following fixation of 3 and 4 part fractures with locking plate technology.
Frankhauser et al. describe their results with a "new" proximal humeral locking plate (AO/ASIF technology) in 28 patient with 29 fractures. They describe good to excellent clinical/radiographic results by following radiographs and patient related Constant scores.
Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R.
Clin Orthop Relat Res. 2005 Jan;(430):176-81. PMID: 15662321 (Link to Abstract)
Fankhauser, CORR 2005
A comminuted proximal humerus fracture is treated with a shoulder hemiarthroplasty as shown in Figure A. The superior border of the pectoralis major tendon can be used to determine accurate restoration of which of the following?
Humeral prosthesis height and retroversion
Humeral prosthesis offset and retroversion
Humeral prosthesis head-neck angle and height
Humeral prosthesis stem width and height
Humeral prosthesis stem length and retroversion
The height of the prosthesis is best determined by the superior border of the pectoralis major insertion (PMI), which has been shown in several clinical and cadaveric studies to be the most reliable instrument to assess humeral prosthesis height. In addition, the PMI can be used to position the implant in regards to retroversion, as the distance and angle of the PMI to the posterior fin of the implant has been investigated and reported (see second reference below). No evidence exists to differentiate this against using the forearm as a landmark for retroversion, however.
The referenced study by Murchavosky et al found that in cadaveric dissection, pectoralis major tendons inserted 5.6 cm distal to the superior aspect of the humeral head.
The referenced study by Torrens et al also found that the insertion point was 5.6 cm distal to the superior aspect of the humeral head and very reproducible regarding its relationship to retroversion. The mean distance of the PMI to the posterior fin of the prosthesis was 1.06 cm. The mean angle between the PMI and the posterior fin of the prosthesis was 24.65 degrees.
The referenced study by Greiner et al found that clinical results from utilizing this reference in fracture cases improved radiographic and clinical outcomes; they also reported that clinical outcomes primarily depended on tuberosity healing.
Figure A shows a shoulder hemiarthroplasty.
Average 3.0 of 31 Ratings
A 60-year-old woman is undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A?
Anterior branch of the axillary nerve
Long head of the biceps tendon
Certain anatomic structures are at risk with percutaneous pinning of proximal humerus fractures. The red arrow in Figure A marks a proximal lateral pin that would place the anterior branch of the axillary nerve at risk.
Rowles and McGrory performed an anatomic study of the structures at risk with closed reduction and percuatneous pinning of the proximal humerus and found that proximal lateral pins were a mean of 3mm from the anterior branch of the axillary nerve. Pins placed through the anterior cortex and directed into the humeral head fragment were a mean of 2mm from the long head of the biceps tendon and greater tuberosity pins were found to be 8mm from the posterior humeral circumflex and 10mm from the main trunk of the axillary nerve as they penetrated the medial cortex of the humerus.
Jaberg et al retrospectively reviewed the clinical and radiographic results of 48 patients at an average of 3 years after undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. 70% good to excellent results with their described technique, and the authors caution that radiographic malunion did not correlate with patient function.
Answer 2: The posterior humeral circumflex artery (PHCA) is at risk from a greater tuberosity pin as it penetrates the medial cortex. In the anatomic study by Rowles and McGrory, the distance between the pin and the PHCA/axillary nerve was decreased with internal rotation and increased with external rotation.
Answer 3: The long head of the biceps tendon would be at risk from a pin placed through the anterior cortex and directed into the humeral head and was perforated by three pins in the study by Rowles and McGrory.
Answer 4: The cephalic vein is at risk with anterior pins (mean of 11mm in the referenced study)
Answer 5: The musculocutaneous nerve is at risk with anterior pins (mean of 17mm in the referenced study)
Rowles DJ, McGrory JE.
J Bone Joint Surg Am. 2001 Nov;83-A(11):1695-9. PMID: 11701793 (Link to Abstract)
Rowles, JBJS 2001
Jaberg H, Warner JJ, Jakob RP.
J Bone Joint Surg Am. 1992 Apr;74(4):508-15. PMID: 1583045 (Link to Abstract)
Jaberg, JBJS 1992
A 68-year-old woman undergoes a hemiarthroplasty for a proximal humerus fracture through a deltopectoral approach. What range of motion exercise should not be utilized in the immediate postoperative period due to concerns about lesser tuberosity fixation?
Active-assisted internal rotation of the shoulder to the plane of the body
Active forearm supination
Passive external rotation of the shoulder past 30 degrees
Passive internal rotation of the shoulder to the plane of the body
Frankle et al found that passive external rotation of the shoulder placed the most stress on the lesser tuberosity fixation. The subscapularis tendon inserts on the lesser tuberosity and is the deforming force when placed under tension during external rotation. They also found that non-anatomic tuberosity reduction of 4-part proximal humerus fractures treated with hemiarthroplasty increased torque and impaired external rotation kinematics.
Frankle MA, Greenwald DP, Markee BA, Ondrovic LE, Lee WE
J Shoulder Elbow Surg. 2001 Jul-Aug;10(4):321-6. PMID: 11517361 (Link to Abstract)
Frankle, JSES 2001
Frankle MA, Mighell MA.
J Shoulder Elbow Surg. 2004 Mar-Apr;13(2):239-47. PMID: 14997108 (Link to Abstract)
Frankle, JSES 2004
Average 3.0 of 18 Ratings
A 45-year-old laborer sustained a fall onto his nondominant shoulder while skiing. His sensation is intact throughout the extremity but he is unable to flex the arm above 90 degrees. A radiograph of his shoulder obtained the next day in the emergency room is shown in Figure A. What is the best treatment option?
Sling and swathe for 6 weeks then physical therapy
Reverse total shoulder arthroplasty
ORIF of proximal humerus
Closed reduction and percutaneous pinning of the greater tuberosity
The radiograph shows a valgus impacted 4-part proximal humerus fracture. Due to the patient's young age, active lifestyle, and the displacement of the greater tuberosity operative management is necessary. Open reduction internal fixation has been shown in multiple studies to provide the best long term outcome in this patient population. ORIF allows for restoration of anatomical alignment, reducing the possibility of impingement and weakness from the greater tuberostiy malunion.
The Robinson article reviewed series of 25 severely impacted proximal humerus fractures that all underwent ORIF and went on to union.
Wijgman et al reviewed the results of 60 patients with 3 or 4 part fractures who underwent ORIF with a T-plate or cerclage wires and found 87% had good/excellent results based on the Constant score. Interestingly 22 pts (37%) had AVN, yet 17 of these 22 (77%) patients had excellent/good Constant scores.
Robinson CM, Page RS.
J Bone Joint Surg Am. 2003 Sep;85-A(9):1647-55. PMID: 12954821 (Link to Abstract)
Robinson, JBJS 2003
Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK.
J Bone Joint Surg Am. 2002 Nov;84-A(11):1919-25. PMID: 12429749 (Link to Abstract)
Wijgman, JBJS 2002
Average 4.0 of 22 Ratings
A cadaveric study in 1990 established much of the orthopaedic literature on humeral head vascularity for two decades until recent experiments have provided new data. This original study in 1990 concluded that the anterolateral branch of the anterior circumflex artery supplies blood to what aspect of the proximal humerus?
Anterior portion of humeral head
Entire humeral head except posteroinferior portion of lesser tuberosity and head
Entire humeral head except posteroinferior portion of greater tuberosity and head
Entire humeral head except entire greater tuberosity
The anterolateral branch of the anterior circumflex artery, called the arcuate artery terminally, provides blood supply to the entire humeral head, lesser tuberosity and greater tuberosity except for a small posterior area. The posterior portion of the greater tuberosity and a small posteroinferior portion of the humeral head are supplied by the posterior circumflex artery.
Gerber et al performed an anatomical study of the arteries of the humeral head to determine their intraosseous distributions. They injected a radiopaque suspension into the anterior circumflex, posterior circumflex, suprascapular, thoracoacromial, or subscapular artery and then analyzed the specimens macroscopically and radiographically. The humeral head was shown to have been perfused by the anterolateral ascending branch of the anterior circumflex artery in all specimens. The posterior circumflex artery vascularized only the posterior portion of the greater tuberosity and a small posteroinferior part of the head.
While previous literature suggested that the anterior humeral circumflex artery provided the main blood supply to the humeral head, more current literature supports the posterior circumflex humeral artery as the predominant blood supply. Despite the anterior humeral circumflex artery being disrupted in approximately 80% of proximal humeral fractures, the occurrence of resultant osteonecrosis is still infrequent. This inconsistency also suggests a greater role for the posterior humeral circumflex artery.
Hettrich et al. performed a cadaveric study assessing the vascularity of the proximal part of the humerus. They injected gadolinium into the axillary artery proximally, and then either the anterior humeral circumflex artery or the posterior humeral circumflex artery was ligated. MRI was then performed and the specimens were dissected to determine the dominant blood supply. They found that the posterior humeral circumflex artery provided 64% of the blood supply to the humeral head, whereas the anterior humeral circumflex artery supplied 36%. The posterior humeral circumflex artery also provided significantly more of the blood supply in three of the four quadrants of the humeral head.
Illustration A depicts the humeral head vascular supply with #2 being the posterior circumflex, #3 being the anterior circumflex arteries, and #4 being the anterolateral humeral circumflex artery.
Gerber C, Schneeberger AG, Vinh TS.
J Bone Joint Surg Am. 1990 Dec;72(10):1486-94. PMID: 2254356 (Link to Abstract)
Gerber, JBJS 1990
Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG.
J Bone Joint Surg Am. 2010 Apr;92(4):943-8. PMID: 20360519 (Link to Abstract)
Hettrich, JBJS 2010
Average 2.0 of 58 Ratings
A 69-year-old woman falls while getting out of her car and lands on her right shoulder sustaining a 4-part proximal humerus fracture. She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. Which of the following is the most likely cause of this limitation?
Retroversion of the prosthesis
Greater tuberosity malunion
The radiograph demonstrates a humeral hemiarthroplasty. Malunion of the greater tuberosity is a known complication of this procedure, and the most likely cause for loss of shoulder elevation.
Frankle et al in 2004 reported a 25% rate of greater tuberosity malunion. They discuss surgical techniques to improve fixation of the tuberosities following hemiarthroplasty for proximal humerus fractures.
Frankle et al in 2002 evaluated 5 different techniques to reattach the tuberosities following shoulder hemiarthroplasty in human cadavers. Findings suggested that a circumferential medial cerclage should be placed around the tuberosities to enhance the stability of the tuberosity repair.
Bosch et al reviewed 39 consecutive 3 or 4 part proximal humerus fractures that were treated with either primary hemiarthroplasty or secondary hemiarthroplasty following a primary ORIF. Patients who underwent primary hemiarthroplasty reported better clinical outcomes. The authors concluded that elderly patients with 3 or 4 part humerus fractures are best treated with early arthroplasty.
Frankle MA, Ondrovic LE, Markee BA, Harris ML, Lee WE 3rd.
J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):413-20. PMID: 12378158 (Link to Abstract)
Frankle, JSES 2002
Bosch U, Skutek M, Fremerey RW, Tscherne H.
J Shoulder Elbow Surg. 1998 Sep-Oct;7(5):479-84. PMID: 9814926 (Link to Abstract)
Bosch, JSES 1998
A 72-year-old female presents to your office with a 12-month old painful nonunion of a 2-part (surgical neck) fracture of the proximal humerus. She denies prior shoulder pain, and has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. X-Rays show no shoulder arthritis. The current recommended treatment for this injury is which of the following?
Closed reduction and percutaneous pinning
Rotator cuff repair with possible latissimus dorsi tendon transfer
Open reduction and internal fixation with possible bone grafting
Open bone grafting
Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with fixation when possible. Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, rotator cuff repair (when needed), and treatment of soft tissue contractures. Attempts at arthroplasty are generally recommended only when the fracture has eroded enough to prevent successful fixation, if the tuberosities have resorbed, if the rotator cuff has a pre-existing tear, or other findings are present that would limit the success rate of fixation.
The referenced article by Cheung et al reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain relieving procedure.
Dines reported a case series of 20 chronic post-traumatic proximal humerus fractures including nonunions that were treated with shoulder arthroplasty achieving fair to excellent results in 90% at mid-term follow-up.
Cheung EV, Sperling JW.
Orthop Clin North Am. 2008 Oct;39(4):475-82, vii. PMID: 18803977 (Link to Abstract)
Cheung, CORR 2008
Average 3.0 of 28 Ratings
A 74-year-old female trips over the curb in a parking lot and sustains the shoulder injury shown in Figures A and B. An open reduction and humeral hemiarthroplasty is performed. A postoperative radiograph is provided in Figure C. This patient is most at risk for which of the following complications?
Loss of sensation over the lateral shoulder
Reduced shoulder elevation and abduction
Ulnar nerve palsy
The radiographs demonstrate a 3-part proximal humerus fracture with an intra-articular split. The postoperative radiograph shows a humeral hemiarthroplasty with the humeral head resting just below the top of the greater tuberosity. This puts the shoulder at risk of impingement and loss of abduction and elevation. The remaining answer choices are all possible, but much less likely complications.
Zuckerman et al review 26 hemiarthroplasties performed for 3 and 4 part proximal humerus fractures. The procedure reliably produced pain free shoulders, but the function was much less predictable with up to 25% demonstrating some loss of daily function.
In an Instructional Course Lecture, Bigliani et al review techniques for humeral arthroplasty and soft tissue preservation. Of note, the humeral head should rest above the level of the greater tuberosity to prevent impingement. Closure of the rotator interval is not necessary during this procedure and can over-tighten the anterior soft tissue restraints causing loss of external rotation.
Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD.
J Shoulder Elbow Surg. 1995 Mar-Apr;4(2):81-6. PMID: 7600169 (Link to Abstract)
Goldman, JSES 1995
Bigliani LU, Bauer GS, Murthi AM.
Instr Course Lect. 2002;51:11-20. PMID: 12064095 (Link to Abstract)
Average 4.0 of 29 Ratings
Title: Proximal Humerus Fractures- How Should They be Fixed?Duration: 14:37 Pres...
Title: Welcome and Opening Remarks Presenter: Melvin P. Rosenwasser, MDColumbia...
Case Presentations & Panel Discussion: Mark A. Mighell, MD(CSSE #26, 2017)
Complications of Internal Fixation: What Now?: Thomas Wright, MD(CSSE #24, 2017)
Innovative Plating Techniques for Proximal Humerus Fractures: William T. Obremsk...
Proximal Humerus Fractures: Where Are We?: Michael D. McKee, MD(CSSE #20, 2017)
Which Fractures Require Internal Fixation: Thomas "Quin" Throckmorton, MD(CSSE #...
Title: Proximal Humeral Fractures Author: Michael D. McKee, MD, FRCS(C) Duration...
HPI - A 14 year old patient present after she had idiopathic left humeral head and shaft avascular necrosis (AVN) 6 years ago. At that stage, a fibular autograft was used to treat the AVN and fixed with a flexible nail.
After a period of time, the grafted bone underwent AVN again.
No neurological deficit, distal pulses normal.
What is the next treatment option?
HPI - A 30 year old male patient presents with the chief complaint of limited abduction of his right arm after a fall approximately 10 weeks ago.
At the time of the fall, the patient was admitted to the ER and treated as an anterior shoulder dislocation with a greater tuberosity fracture. The dislocation was reduced at time of the injury by the ER staff and the patient was advised to keep his right arm in a sling.
He presents to clinic seeking for medical advise about his condition whith the primary complaint of a limitation of abduction to approximately 80 degree .
How would you manage this patient?
HPI - 81F presents with Left shoulder pain after falling while gardening.
How would you manage this fracture?
HPI - Fall on outstretched left hand. Nondominant side, relatively high functioning lady for her age.
How would you treat this injury?
HPI - fall on side of left shoulder... 03 days
How would you treat this fracture?
HPI - Fall on outstretched hand
What is the best treatment?
HPI - s/p MVC on Thanksgiving, transferred from outside hospital with proximal humerus injury.
How would you operatively treat this fracture?
HPI - Fall from standing height
HPI - Electric shock followed by direct fall on the left shoulder
Where would you perform the closed reduction and what type of sedation would you use?
HPI - RHD, retired independent woman.
12/22/14 - slipped on the floor at home.
Pain in the left shoulder.
HPI - 89 year old right hand dominant female fell while at home. She hit her head hardest then landed on her left shoulder and elbow. Patient refused CT of the head. She walks without assistive device but does use the walls and railings. Her two daughters live with her at home.
How would you treat this patient?
HPI - Non dominant hand . No medical problem . Patient is a taxi driver
HPI - History of Motor Vehicle Collision, Pain, swelling and deformity right arm,
isolated fracture, no other fractures
HPI - patient was lying down in the afternoon when he developed seizures following which pain inability to move shoulders.
emergent closed reduction of both shoulders under GA were done. (right shoulder associated fracture greater tuberosity large fragment)
What is your preferred treatment for the left proximal humerus fracture?
HPI - h/o fall injury to rt shoulder. Pain and inability to move rt shoulder
what kind of surgery
HPI - Fall on outstretched arm. Unable to move the right shoulder. Swelling and Pain
HPI - road traffic accident
What further imaging if necessary would you obtain?
HPI - Motorcycle accident 9 days ago
What is the recommended treatment?
HPI - 35 yo RHD f presenting after a mechanical fall while intoxicated
HPI - fall at home .pain inabilty to move the left shoulder
HPI - attacked by bear while cutting woods in forest
what would be your plan of management
HPI - Fall from standing height 3 week ago
HPI - 56 y/o male with continued left shoulder pain. Three months after injury in the Fall of 2011, patient underwent ORIF of left humerus after a three month delay and trial of non-operative management. Patient did well post op and denied any pain or issues. Began to do heavy lifting and move furniture. Presented with continued pain in left shoulder. Was given bone stimulator, CT scan performed which showed minimal healing. Broken screws were noticed proximally. Now one year out from injury and 9 months from ORIF.
What would you do now?
HPI - case odf nonunion rt prox humerus, since 20yrs, able to do routine activities with limited movement at the non union site.had a fall and injury to rt shoulder with disruption at nonunion site.
post fall treatment conservative or orif with bone graft
HPI - 53 F with left shoulder pain after fall. Patient suffers from bipolar disorder. This is her nondominant arm. She was initially treated elsewhere with a hanging arm cast. She continues to have significant pain and deformity. She is currently 4 weeks from her injury.
How would you treat this injury
HPI - 29 yr male. Hx of seizures but never had frank posterior shoulder dislocation. Presents with chronic left shoulder pain for past 2 years.
What shoulde be done for this patient?
HPI - 32 y/o hurt his shoulder in 2010 earth quake no treatment since then
HPI - fall from 10 ft ht on the shoulder.pt is manual labourer
What is your preferred method of fixation?
HPI - Right handed patient fell at home and was brought to emergency department complaining of left shoulder pain. No neurovascular damage.