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 87 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
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?
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
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
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
What structure is 7cm from the acromion and at greatest risk of injury during a deltoid splitting approach for a proximal humerus fracture?
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
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
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
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
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
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
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
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 or significant osteopenia. 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
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
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HPI - Right handed patient fell at home and was brought to emergency department complaining of left shoulder pain. No neurovascular damage.
How would you treat this patient?
HPI - fall from 10 ft ht on the shoulder.pt is manual labourer
What is your preferred method of fixation?
HPI - 32 y/o hurt his shoulder in 2010 earth quake no treatment since then