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Updated: Feb 14 2024

Proximal Humerus Fractures

Images
https://upload.orthobullets.com/topic/1015/images/3parta_moved.jpg
https://upload.orthobullets.com/topic/1015/images/3partb_moved.jpg
https://upload.orthobullets.com/topic/1015/images/fixed head split.jpg
https://upload.orthobullets.com/topic/1015/images/3-part_greater_tuberosity.jpg
https://upload.orthobullets.com/topic/1015/images/3-part_fracture-dislocation.jpg
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  • Summary
    • Proximal humerus fractures are common fractures often seen in older patients with osteoporotic bone following a ground-level fall on an outstretched arm.
    • Diagnosis is made with orthogonal radiographs of the shoulder.
    • Treatment with sling immobilization is indicated for minimally displaced fractures with surgical fixation versus arthroplasty indicated in more complex and displaced fractures.
  • Epidemiology
    • Incidence
      • common
        • 4-6% of all fractures
        • third most common non-vertebral fracture pattern seen in the elderly (>65 years old)
      • two-part surgical neck fractures are most common
    • Demographics
      • 2:1 female to male ratio
      • increasing age associated with more complex fracture types
    • Anatomic location
      • may occur at the surgical neck, anatomic neck, greater tuberosity, and lesser tuberosity
        • two-part surgical neck fractures are most common
    • Risk factors
      • osteoporosis
      • diabetes
      • epilepsy
      • female gender
  • Etiology
    • Pathophysiology
      • mechanism
        • low-energy falls
          • elderly with osteoporotic bone
        • high-energy trauma
          • young individuals
          • concomitant soft tissue and neurovascular injuries
      • pathoanatomy
        • vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
          • predictors of humeral head ischemia (Hertel criteria)
            • <8 mm of calcar length attached to articular segment
            • disrupted medial hinge
            • increasing fracture complexity 
            • displacement >10mm
            • angulation >45°
          • predictors of humeral head ischemia does not necessarily predict subsequent avascular necrosis
    • Associated conditions
      • nerve injury
        • axillary nerve injury most common
      • arterial injury
        • uncommon (incidence 5-6%), higher likelihood in older patients
        • most often occur at level of surgical neck or with subcoracoid dislocation of the head
  • Anatomy
    • Osteology
      • anatomic neck
        • represents the old epiphyseal plate
      • surgical neck
        • represents the weakened area below head
        • more often involved in fractures than anatomic neck
      • average neck-shaft angle is 135 degrees
    • Muscles
      • pectoralis major displaces shaft anteriorly and medially
      • supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity
      • subscapularis internally rotates articular segment or lesser tuberosity
    • Ligaments
      • Coracohumeral ligament
        • attaches to coracoid and greater tuberosity and strengthens the rotator interval
      • SGHL
        • restraint to inferior translation at 0° degrees of abduction (neutral rotation)
      • MGHL
        • resists AP translation in the midrange (~45°) of abduction
      • IGHL
        • restraint to AP translation at 90° degrees of abduction
    • Blood Supply
      • anterior humeral circumflex artery
        • large number of anastomosis with other vessels in the proximal humerus
        • branches
          • anterolateral ascending branch
            • arcuate artery is the terminal branch and main supply to greater tuberosity
      • posterior humeral circumflex artery
        • recent studies suggest it is the main blood supply to humeral head
  • Classification
    • 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
      • Neer Classification
      • Minimally displaced
      • Two-part
      • Three-part
      • Four-part
      • Anatomical neck
      • Surgical Neck
      • Greater Tuberosity
      • Lesser Tuberosity
      • Fracture-Dislocation
      • Head Split
  • Presentation
    • Symptoms
      • pain and swelling
      • decreased motion
    • Physical exam
      • inspection
        • extensive ecchymosis of chest, arm, and forearm
      • neurovascular exam
        • axillary nerve injury most common
          • determine function of deltoid muscle and lateral shoulder sensation
        • arterial injury may be masked by extensive collateral circulation preserving distal pulses
      • examine for concomitant chest wall injuries
  • Imaging
    • Radiographs
      • recommended views
        • complete trauma series
          • true AP (Grashey)
          • scapular Y
          • axillary
        • additional views
          • apical oblique
          • Velpeau
          • West Point axillary
        • findings
          • combined cortical thickness (medial + lateral thickness >4 mm)
            • studies suggest correlation with increased lateral plate pullout strength
          • pseudosubluxation (inferior humeral head subluxation) caused by blood in the capsule and muscular atony
    • CT scan
      • indications
        • preoperative planning
        • humeral head or greater tuberosity position uncertain
        • intra-articular comminution
        • concern for head-split fracture
    • MRI
      • indications
        • rarely indicated
        • useful to identify associated rotator cuff injury
  • Treatment
    • Nonoperative
      • sling immobilization followed by progressive rehabilitation
        • indications
          • most proximal humerus fractures can be treated nonoperatively including
            • minimally displaced surgical and anatomic neck fractures
            • greater tuberosity fracture displaced < 5mm
              • >5mm displacement will result in impingement with loss of abduction and external rotation
            • fractures in patients who are not surgical candidates
          • additional variables to consider
            • age
            • fracture type
            • fracture displacement
            • bone quality
            • dominance
            • general medical condition
            • concurrent injuries
        • outcomes
          • immediate physical therapy results in faster recover
    • Operative
      • closed reduction percutaneous pinning (CRPP)
        • indications
          • 2-part surgical neck fractures
          • 3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar
        • outcomes
          • considerably higher complication rate compared to ORIF, HA, and RSA
            • axillary nerve at risk with lateral pins
            • musculocutaneous nerve, cephalic vein, and bicep tendon at risk with anterior pins
      • ORIF
        • indications
          • displaced 2-part fractures
          • 3-, and 4-part fractures in younger patients
          • head-splitting fractures in younger patients
        • outcomes
          • medial support necessary for fractures with posteromedial comminution
            • consider use of a fibula strut if concerned about medial support or bone quality
          • calcar screw placement critical to decrease varus collapse of head
      • Intramedullary nailing
        • indications
          • surgical neck fractures or 3-part greater tuberosity fractures in younger patients
          • combined proximal humerus and humeral shaft fractures
        • outcomes
          • biomechanically inferior with torsional stress compared to plates
          • favorable rates of fracture healing and ROM compared to ORIF
        • indications
          • hemiarthroplasty
            • in younger patients (40-65 years old) with complex fracture-dislocations or head-splitting components that may fail fixation
            • recommended use of convertible stems to permit easier conversion to RSA if necessary in future
          • reverse total shoulder
            • low-demand elderly individuals with non-reconstructible tuberosities and poor bone stock
            • older patients with fracture-dislocation
            • reverse total shoulder arthroplasty following failed nonoperative management is associated with better functional outcomes than reverse total shoulder arthroplasty following failed open reduction and internal fixation
        • outcomes
          • improved results if
            • anatomic tuberosity reduction and healing
            • restoration of humeral height and version
              • humeral height is best judged from the superior border of the pectoralis major insertion
          • poor results with
            • tuberosity nonunion or malunion
            • retroversion of humeral component > 40°
  • Treatment by Fracture Type
      • Two-part fractures
      • Surgical Neck
      • Most common fx pattern
        Deforming forces: 
        1) pectoralis pulls shaft anterior and medial
        2) head and attached tuberosities stay neutral
      • Nonoperative
      • Closed reduction often possible
      • Sling
      • Operative
      • -indications controversial
      • -technique
      • --- CRPP
      • --- Plate fixation
      • --- IM nail
      • Greater tuberosity
      • Often missed
      • Deforming forces: GT pulled superior and posterior by SS, IS, and TM
      • Can only accept minimal displacement (<5mm) or else it will block ER and ABD
      • Nonoperative
      • indicated for GT displaced < 5 mm
      • Operative
      • indicated for GT displacement > 5 mm
      • - isolated screw fixation only in young with good bone stock
      • - non-absorbable suture technique for osteoporotic bone (avoid hardware due to impingement)
      • -tension band wiring
      • Lesser tuberosity
      • Assume posterior dislocation until proven otherwise
      • Nonoperative
      • Minimally or non-displaced
      • Operative
      • ORIF if large fragment
      • excision with RCR if small
      • Anatomic neck
      • Rare
      • Minimally or non-displaced
      • Operative
      • ORIF in young
      • ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly
      • Three-part fracture
      • Surgical neck and GT
      • Subscap will internally rotate articular segment
      • Often associated with longitudinal RCT
      • Nonoperative if:
      • Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees)
      • Poor surgical candidate
      • Operative:
      • Young patient
      • - percutaneous pinning (good results, protect axillary nerve)
      • - IM fixation (violates cuff)
      • - locking plate (poor results with high rate of AVN, impingement, infection, and malunion)
      • Elderly patient
      • - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty
      • Surgical neck and LT
      • Unopposed pull of posterior cuff musculature leads articular surface to point anterior
      • Often associated with longitudinal RCT
      • Trend towards nonoperative management given high complications with ORIF
      • Young patient
      • - percutaneous pinning (good results, protect axillary nerve)
      • - IM fixation (violates cuff)
      • - locking plate (poor results with high rate of AVN, impingement, infection, and malunion)
      • Elderly patient
      • - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty
      • Four-Part Fracture
      • Valgus impacted fracture
      • Radiographically will see alignment between medial shaft and head segments
      • 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 head-splitting fracture
      • Characterized by high risk of AVN (21-75%)
      • Deforming forces:
        1) shaft pulled medially by pectoralis
      • Young patient
      • - ORIF vs. hemiarthroplasty (hemiarthroplasty favored for non-reconstructible articular surface, severe head split, extruded anatomic neck fracture)
      • Elderly patient
      • - hemiarthroplasty v. reverse total shoulder arthroplasty
  • Techniques
    • Sling immobilization followed by progressive rehabilitation
      • technique
        • sling for comfort x2-3wks, immediate physical therapy for early ROM
    • CRPP (closed reduction percutaneous pinning)
      • approach
        • percutaneous
      • technique
        • use threaded pins but do not cross cartilage
        • externally rotate shoulder during pin placement
        • engage cortex 2 cm inferior to inferior border of humeral head
      • complications
        • with lateral pins
          • risk of injury to axillary nerve
        • with anterior pins
          • risk of injury to biceps tendon, musculocutaneous n., cephalic vein
        • possible pin migration
    • ORIF
      • approach
        • anterior (deltopectoral)
        • lateral (deltoid-splitting)
          • increased risk of axillary nerve injury
      • technique
        • heavy nonabsorbable sutures
          • figure-of-8 technique should be used for isolated 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 
          • screw cut-out (up to 14%) is the most common complication following ORIF with a periarticular 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(s) can prevent postoperative varus collapse, especially in osteoporotic bone
      • postoperative Rehabilitation
        • important part of management
        • best results with guided protocols (3-phase programs)
          • early passive ROM
          • active ROM and progressive resistance
          • advanced stretching and strengthening program
        • prolonged immobilization leads to stiffness
    • Intramedullary nailing
      • approach
        • superior deltoid-splitting approach
      • technique
        • lock nail with trauma or pathologic fractures
        • straight nails are placed through the superior articular cartilage (more central entry point)
        • nails with proximal bend are placed through an entry point just medial to rotator cuff insertion
      • complications
        • rod migration in older patients with osteoporotic bone is a concern
        • shoulder pain from violating rotator cuff
        • nerve injury with interlocking screw placement
          • radial nerve at risk with lateral to medial distal screw
          • musculocutaneous nerve at risk with anterior to posterior distal screw
    • Hemiarthroplasty
      • approach
        • anterior (deltopectoral)
      • technique for fractures
        • cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability
        • place greater tuberosity ~8 mm below articular surface of humeral head (HTD = head to tuberosity distance)
          • nonanatomic placement of tuberosities results in impairment in external rotation kinematics with an 8-fold increase in torque requirements
        • height of the prosthesis best determined off the superior edge of the pectoralis major tendon
          • 5.6cm between top of humeral head and superior edge of tendon
        • post-operative passive external rotation places the most stress on the lesser tuberosity fragment
    • Reverse shoulder arthroplasty
      • approach
        • anterior (deltopectoral)
        • anterolateral deltoid split
      • technique for fractures
        • ensure adequate glenoid bone stock
        • ensure functioning deltoid muscle
        • repair of the greater tuberosity is always recommended despite ability of RSA design to compensate for non-functioning tuberosities/rotator cuff
          • improves range of motion
  • Complications
    • Screw cut-out
      • incidence
        • most common complication following periarticular locking plating fixation (up to 14%)
    • Avascular necrosis
      • risk factors
        • risk factors for humeral head ischemia are not the same for developing subsequent avascular necrosis
          • better tolerated than in lower extremity
          • no relationship to type of fixation (plate or cerclage wires)
    • Nerve injury
      • incidence
        • axillary nerve injury most common (up to 58% with studies using EMG)
          • increased risk with lateral (deltoid-splitting) approach
          • axillary nerve is usually found ~5-7cm distal to the tip of the acromion
          • at risk with lateral pins in CRPP
        • suprascapular nerve (up to 48%)
        • musculocutaneous nerve
          • at risk with anterior pins in CRPP
    • Malunion
      • usually varus apex-anterior or malunion of GT
      • results inferior if converting from varus malunited fracture to TSA
        • use reverse shoulder arthroplasty instead
    • Nonunion
      • most common after two-part surgical neck fracture
      • treatment of chronic nonunion/malunion in the elderly should include arthroplasty
      • lesser tuberosity nonunion leads to weakness with lift-off testing
      • greater tuberosity nonunion after arthroplasty leads to lack of external rotation and, to a lesser degree, active shoulder elevation
      • greatest risk factors for nonunion are age and smoking
    • Rotator cuff injuries and dysfunction
    • Long head of biceps tendon injuries
      • also at risk with anterior pin in CRPP
    • Missed posterior dislocation
      • consider in all patients with lesser tuberosity fracture
    • Adhesive capsulitis and scar tissue
    • Posttraumatic arthritis
    • Infection
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