Proximal Humerus Fractures

Author: Deborah Allen

Topic updated on 06/10/13 5:59am

Introduction

Third most common fracture pattern seen in elderly
Epidemiology
- demographics
  - incidence
    - 4-6% of all fractures
  - 2:1 female to male ratio
  - increasing age correlates with increasing fracture risk in women
Mechanism
- low-energy falls
  - elderly with osteoporotic bone
- high-energy trauma
  - young individuals
  - concomitant soft tissue and neurovascular injuries
Associated conditions
- 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
- anterolateral ascending branch of the anterior humeral circumflex artery (of which the terminal branch is the arcuate artery)
  - one of primary blood supplies to the humeral head
  - runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove
  - interosseous anastomosis
  - beware not to injure when plating proximal humerus fractures
- posterior humeral circumflex artery
  - most current literature supports this as providing the main blood supply to humeral head
- vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment

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

History
- injury mechanism
- pre-injury functional level
- associated extremity paresthesias/numbness
- history of prior dislocation
  - seizure disorder should alert to posterior dislocations
Symptoms
- pain and swelling
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
  - required
    - must include complete trauma series
      - true AP
      - scapular Y
      - axillary
  - additional views
    - apical oblique
    - velpeau
    - west point axillary
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 nondisplaced or minimally displaced and can be treated with initial immobilization and early passive motion
    - surgical neck fracture (1-, 2-, and 3-part)
    - greater tuberosity fracture displaced < 5mm
    - patient able to move shoulder within 14 days of injury
    - when surgical treatment is contraindicated
  - additional variables to consider
    - age
    - fracture type
    - fracture displacement
    - bone quality
    - dominance
    - general medical condition
    - concurrent injuries
Operative
- CRPP (closed reduction percutanous pinning)
  - indications
    - 2-part surgical neck fractures
    - some 3-part and valgus-impacted 4-part fractures
    - good bone quality with minimal metaphyseal comminution
    - stable closed reduction
    - intact medial calcar
    - cooperative patient
- ORIF
  - indications
    - ORIF of greater tuberosity fx if GT displaced > 5mm
    - 2-,3-, and 4-part fractures in younger patients
      - may be able to treat these fracture patterns in older patients as well
    - head-splitting fractures in younger patients
- intramedullary rodding
  - indications
    - younger patients
    - surgical neck fractures or 3-part greater tuberosity fractures
    - combination proximal humerus and humeral shaft fractures
  - outcomes
    - 85% success rate in younger patients
- hemiarthroplasty
  - indications
    - anatomic neck fractures in elderly 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 with
      - cerclage wire passed through hole in prosthesis and tuberosities improves fracture stability
      - better results if performed within 14 days
      - better results with accurate tuberosity reduction
    - 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 • technique - 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 percutanous 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
ORIF
- approach
  - shoulder anterior approach (deltopectoral)
  - superior 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 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

Avascular necrosis
- 21-75% AVN rate with 4-part fractures
- 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
- treated with corrective osteotomy/fixation if patient is young or active
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
Rotator cuff injuries and dysfunction
Missed posterior dislocation
Adhesive capsulitis
Posttraumatic arthritis
Infection

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Qbank (16 Questions)

TAG

(SBQ07.16) The anterolateral branch of the anterior circumflex artery supplies blood to what aspect of the proximal humerus? Topic

Review Topic

1. Anterior portion of humeral head
2. Lesser tuberosity
3. Entire humeral head except posteroinferior portion of lesser tuberosity and head
4. Entire humeral head except posteroinferior portion of greater tuberosity and head
5. Entire humeral head except entire greater tuberosity

PREFERRED RESPONSE ▶

DISCUSSION: 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. This was supported by a cadaveric study by Gerber et al who 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. 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.

Illustrations: A

REFERENCES:

1. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 267-274.

2. Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494. PMID:2254356 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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(OBQ11.14) 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? Topic

Review Topic

FIGURES: A

1. It is usually associated with a posterior shoulder dislocation
2. The subscapularis muscle is the main deforming force
3. Non-operative treatment of this displaced injury results in good long term shoulder function
4. Open reduction and internal fixation is the treatment of choice
5. Associated rotator cuff tears are uncommon

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991 Sep;73(8):1213-8. PMID:1890123 (Link to Abstract)

2. Platzer P, Thalhammer G, Oberleitner G, Kutscha-Lissberg F, Wieland T, Vecsei V, Gaebler C. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma. 2008 Oct;65(4):843-8. PMID:18349710 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Jan Szatkowski MD, Dave Marcu MD,

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Related Cases

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Greater Tuberosity Fracture (C1383)

Trauma - Treatment Consult - Proximal Humerus Fractures

HPI - 34 year old female, was incarcerated when she had a seizure 4 months ago. Her s...

How would you approach her care?

1/10/2013

922 responses

TAG

(OBQ11.73) 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? Topic

Review Topic

1. 1.0 cm
2. 2.4 cm
3. 3.8 cm
4. 5.6 cm
5. 6.5 cm

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Torrens C, Corrales M, Melendo E, Solano A, Rodríguez-Baeza A, Cáceres E. The pectoralis major tendon as a reference for restoring humeral length and retroversion with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2008 Nov-Dec;17(6):947-50. PMID:18774736 (Link to Abstract)

2. Greiner SH, Kääb MJ, Kröning I, Scheibel M, Perka C. Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2008 Sep-Oct;17(5):709-14. PMID:18621554 (Link to Abstract)

3. Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):675-8. PMID:17055748 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Jan Szatkowski MD,

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TAG

(OBQ11.84) 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? Topic

Review Topic

FIGURES: A

1. Axillary nerve injury
2. Valgus migration of the fracture
3. Nonunion
4. Hardware failure
5. Screw penetration

PREFERRED RESPONSE ▶

DISCUSSION: 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 with 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.

REFERENCES:

1. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008 Feb;90(2):233-40. Erratum in: J Bone Joint Surg Am. 2008 Apr;90(4):862. PMID:18245580 (Link to Abstract)

2. Agudelo J, Schürmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007 Nov-Dec;21(10):676-81. PMID:17986883 (Link to Abstract)

Question Authors:

Ben Taylor MD, Ben Taylor MD, Dave Marcu MD,

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TAG

(OBQ11.96) 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? Topic

Review Topic

1. Musculocutaneous nerve
2. Posterior humeral circumflex artery
3. Axillary nerve
4. Cephalic vein
5. Anterior humeral circumflex artery

PREFERRED RESPONSE ▶

DISCUSSION: 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 identifies the location of the incision for the anterolateral acromial exposure , and Illustration B shows the position of the axillary nerve in relation to the approach.

Illustrations: A

REFERENCES:

1. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008 Feb;22(2):132-7. PMID:18349783 (Link to Abstract)

2. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005 May;(434):123-9. PMID:15864041 (Link to Abstract)

3. Morgan SJ, Furry K, Parekh AA, Agudelo JF, Smith WR. The deltoid muscle: an anatomic description of the deltoid insertion to the proximal humerus. J Orthop Trauma. 2006 Jan;20(1):19-21. PMID:16424805 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Dave Marcu MD,

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(OBQ11.218) 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? Topic

Review Topic

FIGURES: A

1. Insertion of both cortical and locking screws into the humeral head
2. Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity
3. Treatment of the fracture with closed reduction and percutaneous k-wire fixation
4. Addition of an inferomedial locking screw within the calcar
5. Intramedullary nailing of the fracture

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:85-95. PMID:20194347 (Link to Abstract)

2. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008 Mar;22(3):195-200. PMID:18317054 (Link to Abstract)

3. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007 Mar;21(3):185-91. PMID:17473755 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Jan Szatkowski MD,

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(OBQ11.230) What structure is 7cm from the acromion and at greatest risk of injury during a deltoid splitting approach for a proximal humerus fracture? Topic

Review Topic

1. Radial nerve
2. Suprascapular nerve
3. Axillary nerve
4. Axillary artery
5. Axillary vein

PREFERRED RESPONSE ▶

DISCUSSION: 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).

Illustrations: A

REFERENCES:

1. Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J Bone Joint Surg Am. 2006 Nov;88(11):2395-9. PMID:17079396 (Link to Abstract)

2. Clemente C. Anatomy: A Regional Atlas of the Human Body. 3rd ed. Malvern, PA: Lea & Febiger, 1987.

3. Hoppenfeld S, deBoer P. The shoulder. In: Hoppenfeld S, deBoer P, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:1-49.

Question Authors:

Patrick O'Donnell MD/PhD, Jan Szatkowski MD, Ben Taylor MD,

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(OBQ10.103) 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? Topic

Review Topic

FIGURES: A

1. Infection
2. Osteonecrosis
3. Axillary artery injury
4. Screw cut-out
5. Axillary nerve injury

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

2. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005 Jan;(430):176-81. PMID:15662321 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ10.135) 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? Topic

Review Topic

FIGURES: A

1. Humeral prosthesis height and retroversion
2. Humeral prosthesis offset and retroversion
3. Humeral prosthesis head-neck angle and height
4. Humeral prosthesis stem width and height
5. Humeral prosthesis stem length and retroversion

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a shoulder hemiarthroplasty. 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.

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.

REFERENCES:

1. Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):675-8. PMID:17055748 (Link to Abstract)

2. Torrens C, Corrales M, Melendo E, Solano A, Rodríguez-Baeza A, Cáceres E. The pectoralis major tendon as a reference for restoring humeral length and retroversion with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2008 Nov-Dec;17(6):947-50. PMID:18774736 (Link to Abstract)

3. Greiner SH, Kääb MJ, Kröning I, Scheibel M, Perka C. Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2008 Sep-Oct;17(5):709-14. PMID:18621554 (Link to Abstract)

Question Authors:

Ben Taylor MD,

Please Rate Educational Value!

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TAG

(OBQ08.113) 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? Topic

Review Topic

FIGURES: A

1. Anterior branch of the axillary nerve
2. Posterior humeral circumflex artery
3. Long head of the biceps tendon
4. Cephalic vein
5. Musculocutaneous nerve

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect Answers
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)

Illustrations: A

REFERENCES:

1. Rowles, McGrory: Percutaneous pinning of the proximal part of the humerus: An anatomic study. JBJS 2001; 83: 1695-1699 PMID:11701793 (Link to Abstract)

2. Jaberg H, Warner JJ, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus. JBJS 1992; 74: 508-515 PMID:1583045 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Derek Moore, John Badylak MD,

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(OBQ08.157) A 68-year-old woman undergoes hemiarthroplasty for a proximal humerus fracture. What post-operative motion should be limited as it puts the most stress on the lesser tuberosity fragment fixation? Topic

Review Topic

1. pendulums
2. active-assisted internal rotation of the shoulder
3. active finger flexion
4. passive external rotation of the shoulder
5. passive internal rotation of the shoulder

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Frankle MA, Greenwald DP, Markee BA, et al: Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. JSES 2001; 10:321-326 PMID:11517361 (Link to Abstract)

2. Frankle MA, Mighell MA: Techniques and principles of tuberosity fixation for proximal humeral fractures treated with hemiarthroplasty. JSES 2004; 13:239-247 PMID:14997108 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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TAG

(OBQ07.5) A 45-year-old orthopaedic surgeon sustained a fall onto his nondominant shoulder while skiing. Radiographs of his shoulder the next day in the ER are shown. What is the best treatment option? Topic

Review Topic

FIGURES: A

1. Sling and swathe for 6 weeks then physical therapy
2. Sling and swathe until comfortable then progressive physical therapy
3. ORIF of proximal humerus
4. Closed reduction and percutaneous pinning of the greater tuberosity
5. Hemiarthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am. 2003 Sep;85-A(9):1647-55 PMID:12954821 (Link to Abstract)

2. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002 Nov;84-A(11):1919-25. PMID:12429749 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Patrick McCulloch MD,

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(OBQ06.104) A 69-year-old male sustained a proximal humerus fracture that underwent open reduction and internal fixation nine months ago. He complains of constant pain and weakness; repeat radiographs are shown in Figures A and B. What is the most appropriate surgical treatment at this time? Topic

Review Topic

FIGURES: A

1. Revision open reduction and internal fixation
2. Valgus corrective osteotomy of proximal humerus
3. Humeral hemiarthroplasty
4. Shoulder arthrodesis
5. Humeral head resection

PREFERRED RESPONSE ▶

DISCUSSION: Figures A and B show loss of fixation of a proximal humerus fracture. The most appropriate treatment for this scenario is a humeral hemiarthroplasty, as the tenuous blood supply of the proximal humerus is likely chronically disrupted, leading to osteonecrosis and poor healing potential of the proximal humerus. According to the referenced article by Norris et al, delayed shoulder hemiarthroplasty decreased shoulder pain in 95% of patients but warned of technical difficulties and limited postoperative range of motion. A total shoulder arthroplasty is needed if glenoid erosion from the screw(s) or bone occurs.

REFERENCES:

1. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg. 1995 Jul-Aug;4(4):271-80. PMID:8542370 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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(OBQ06.110) 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? Topic

Review Topic

FIGURES: A

1. Joint infection
2. Retroversion of the prosthesis
3. Glenoid arthritis
4. Axillary nerve injury
5. Greater tuberosity malunion

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Frankle MA, Mighell MA: Techniques and principles of tuberosity fixation for proximal humeral fractures treated with hemiarthoplasty. J Shoulder Elbow Surg 2004;13:239-247. PMID:14997108 (Link to Abstract)

2. Frankle MA, Ondrovic LE, Markee BA, et al: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002;11:413-420. PMID:12378158 (Link to Abstract)

3. Bosch U, Skutek M, Fremerey RW, Outcome after primary and secondary hemiarthoplasty in elderly patients with fractures of the proximal humerus. J Shoulder Elbow Surg 1998;7:479-484. PMID:9814926 (Link to Abstract)

Question Authors:

John Badylak MD, Jan Szatkowski MD, Derek Moore, Mark Miller MD,

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(OBQ06.133) A 72-year-old female presents to your office with a 24-month old painful nonunion of a 3-part fracture of the proximal humerus. She has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. Operative management should include: Topic

Review Topic

1. Closed reduction and percutaneous pinning
2. Open reduction and internal fixation
3. Rotator cuff repair with possible latissimus dorsi tendon transfer
4. Shoulder arthroplasty
5. Open bone grafting

PREFERRED RESPONSE ▶

DISCUSSION: Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with arthroplasty 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 internal fixation should be performed with caution in this patient population, due to general osteopenia and significant rates of loss of fracture reduction.

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.

REFERENCES:

1. David M. Dines, Russell F. Warren, David W. Altchek, Bruce Moeckel. Posttraumatic changes of the proximal humerus: Malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty Journal of Shoulder and Elbow Surgery January 1993 (Vol. 2, Issue 1, Pages 11-21)

2. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82 PMID:18803977 (Link to Abstract)

Question Authors:

Ben Taylor MD, Michael Hughes MD, Patrick McCulloch MD,

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(OBQ06.206) A 24-year-old female sustains a surgical neck proximal humerus fracture in an motor vehicle collision. She undergoes open reduction and internal fixation but heals in 30 degrees of varus and has significant limitation of shoulder range of motion despite 9 months of conservative treatments. What is the most appropriate treatment at this time? Topic

Review Topic

1. Manipulation under anesthesia
2. Humeral head resurfacing
3. Shoulder hemiarthroplasty
4. Revision open reduction internal fixation with osteotomy
5. Reverse total shoulder arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: Malunions of the proximal humerus typically result in significant restrictions in range of motion. This young patient has sustained a proximal humeral malunion, and treatment should include a corrective osteotomy for improved outcomes, as she has failed conservative treatment.

The cited reference by Williams et al as well as the referenced article by Siegel et al explain various techniques in management of proximal humerus malunions. They state that the two primary indications for surgical management of proximal humerus malunion include 1) pain and 2) diminished function resulting from limited range of motion. Because this patient is young, you would attempt revision ORIF/osteotomy as opposed to humeral head arthroplasty.

REFERENCES:

1. Williams GR Jr, Cople LA, Iannotti JP: The influence of intramedullary fixation on figure-of-eight wiring for surgical neck fractures of the proximal humerus: A biomechanical comparison. J Shoulder Elbow Surg 1997; 6:423-428. PMID:9356930 (Link to Abstract)

2. Siegel JA, Dines DM: Techniques in managing proximal humerus malunions. J Shoulder Elbow Surg 2003;12:69-78. PMID:10629331 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

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(OBQ04.271) 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? Topic

Review Topic

FIGURES: A

1. Shoulder dislocation
2. Pulmonary embolus
3. Loss of sensation over the lateral shoulder
4. Reduced shoulder elevation and abduction
5. Ulnar nerve palsy

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995 Mar-Apr;4(2):81-6. PMID:7600169 (Link to Abstract)

2. Bigliani LU, Bauer GS, Murthi AM. Humeral head replacement: techniques and soft-tissue preparation. Instr Course Lect. 2002;51:11-20. PMID:12064095 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Jan Szatkowski MD, Edward Perez M.D.,

Please Rate Educational Value!

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$http://upload.orthobullets.com/cases/1344/humeral fracture 2.jpg$ $http://upload.orthobullets.com/cases/1344/humeral fracture 1.jpg$	Proximal humeral fracture 4 part (C1344) Trauma - Treatment Consult - Proximal Humerus Fractures HPI - Fall from standing height 3 week ago What is the best treatment?	12/4/2012 76 responses
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Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. Includes Poll

Owsley KC, Gorczyca JT
J Bone Joint Surg Am. 2008 Feb;90(2):233-40. PMID: 18245580 (Link to Pubmed)

General - Journal Club - Proximal Humerus Fractures

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:85-95. PMID:20194347 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Bosch U, Skutek M, Fremerey RW, Outcome after primary and secondary hemiarthoplasty in elderly patients with fractures of the proximal humerus. J Shoulder Elbow Surg 1998;7:479-484. PMID:9814926 (Link to Abstract)

Level of Evidence 4 (Case Series)

Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005 Jan;(430):176-81. PMID:15662321 (Link to Abstract)
Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. 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. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007 Mar;21(3):185-91. PMID:17473755 (Link to Abstract)
Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995 Mar-Apr;4(2):81-6. PMID:7600169 (Link to Abstract)
Greiner SH, Kääb MJ, Kröning I, Scheibel M, Perka C. Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2008 Sep-Oct;17(5):709-14. PMID:18621554 (Link to Abstract)
Jaberg H, Warner JJ, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus. JBJS 1992; 74: 508-515 PMID:1583045 (Link to Abstract)
Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg. 1995 Jul-Aug;4(4):271-80. PMID:8542370 (Link to Abstract)
Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008 Feb;90(2):233-40. Erratum in: J Bone Joint Surg Am. 2008 Apr;90(4):862. PMID:18245580 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Agudelo J, Schürmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007 Nov-Dec;21(10):676-81. PMID:17986883 (Link to Abstract)
Bigliani LU, Bauer GS, Murthi AM. Humeral head replacement: techniques and soft-tissue preparation. Instr Course Lect. 2002;51:11-20. PMID:12064095 (Link to Abstract)
Frankle MA, Mighell MA: Techniques and principles of tuberosity fixation for proximal humeral fractures treated with hemiarthoplasty. J Shoulder Elbow Surg 2004;13:239-247. PMID:14997108 (Link to Abstract)
Frankle MA, Ondrovic LE, Markee BA, et al: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002;11:413-420. PMID:12378158 (Link to Abstract)
Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494. PMID:2254356 (Link to Abstract)
Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):675-8. PMID:17055748 (Link to Abstract)
Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008 Feb;90(2):233-40. Erratum in: J Bone Joint Surg Am. 2008 Apr;90(4):862. PMID:18245580 (Link to Abstract)
Rowles, McGrory: Percutaneous pinning of the proximal part of the humerus: An anatomic study. JBJS 2001; 83: 1695-1699 PMID:11701793 (Link to Abstract)
Torrens C, Corrales M, Melendo E, Solano A, Rodríguez-Baeza A, Cáceres E. The pectoralis major tendon as a reference for restoring humeral length and retroversion with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2008 Nov-Dec;17(6):947-50. PMID:18774736 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J Bone Joint Surg Am. 2006 Nov;88(11):2395-9. PMID:17079396 (Link to Abstract)
Clemente C. Anatomy: A Regional Atlas of the Human Body. 3rd ed. Malvern, PA: Lea & Febiger, 1987.

Undefined

Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82 PMID:18803977 (Link to Abstract)
David M. Dines, Russell F. Warren, David W. Altchek, Bruce Moeckel. Posttraumatic changes of the proximal humerus: Malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty Journal of Shoulder and Elbow Surgery January 1993 (Vol. 2, Issue 1, Pages 11-21)
Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991 Sep;73(8):1213-8. PMID:1890123 (Link to Abstract)
Frankle MA, Greenwald DP, Markee BA, et al: Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. JSES 2001; 10:321-326 PMID:11517361 (Link to Abstract)
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Proximal Humerus Fractures

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