Introduction Epidemiology incidence 4-6% of all fractures third most common non-vertebral fracture pattern seen in the elderly (>65 years old) demographics 2:1 female to male ratio increasing age associated with more complex fracture types Pathophysiology mechanism low-energy falls elderly with osteoporotic bone high-energy trauma young individuals concomitant soft tissue and neurovascular injuries pathoanatomy pectoralis major displaces shaft anteriorly and medially supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity subscapularis interally rotates articular segment or lesser tuberosity vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment 3 most accurate predictors of humeral head ischemia are <8 mm of calcar length attached to articular segment disrupted medial hinge basic fracture pattern predictors of humeral head ischemia do 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 head-neck angle is 135 degrees Vascular anatomy anterior humeral circumflex artery large number of anastamoses with other vessels in the proximal humerus branches anterolateral ascending branch is a branch of the anterior humeral circumflex artery 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 MinimallyDisplaced Two Part Three Part Four Part Articular Segment Anatomical Neck Surgical Neck Greater Tuberosity Lesser Tuberosity Fracture-Dislocation Head Split Evaluation 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 (axillary n.) 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 MRI indications rarely indicated useful to identify associated rotator cuff injury Treatment Nonoperative sling immobilization followed by progressive rehab indications most proximal humerus fractures can be treated nonoperatively including minimally displaced surgical and anatomic neck fractures greater tuberosity fracture displaced < 5mm fractures in patients who are not surgical candidates additional variables to consider age fracture type fracture displacement bone quality dominance general medical condition concurrent injuries technique start early range of motion within 14 days Operative CRPP (closed reduction percutaneous pinning) indications 2-part surgical neck fractures 3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal metaphyseal comminution, and intact medial calcar outcomes considerably higher complication rate compared to ORIF, HA, and RSA ORIF indications greater tuberosity displaced > 5mm 2-,3-, and 4-part fractures in younger patients head-splitting fractures in younger patients outcomes complication rate higher compared with ORIF medial support necessary for fractures with posteromedial comminution 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 hemiarthroplasty indications controversial younger patients (40-65) with complex fractures or head-splitting components likely to have complications with ORIF recommended use of convertable stems to permit easier conversion to RSA if necessary in future outcomes improved results if accurate tuberosity reduction restoration of humeral height and version poor results with tuberosity nonunion or malunion retroversion of humeral component > 40° inconsistent results reported in literature reverse shoulder arthroplasty indications low-demand elderly individuals with nonreconstructible tuberosities and poor bone stock functioning deltoid needed outcomes early results demonstrate equivalent, and at times improved, ROM and clinical outcome scores compared to ORIF and HA incidence of scapular notching, glenoid loosening, instability, and infection have all increased with the increasing popularity of the procedure Treatment by Fracture Type Two-Part Fracture 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 device 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 - nonabsorbable 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-displacedOperative• ORIF if large fragment • excision with RCR if small Anatomic neck • Rare Nonoperative• Minimally or non-displacedOperative• 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 candidateOperative: • 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 technique1. raise articular surface and fill defects2. 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 nonreconstructible articular surface, severe head split, extruded anatomic neck fracture) • Elderly patient- hemiarthroplasty v. reverse total shoulder arthroplasty Techniques CRPP (closed reduction percutaneous pinning) approach percutaneous technique use threaded pins but do not cross cartilage externally rotate shoulder during pin placement engage cortex 2 cm inferior to inferior border of humeral head complications with lateral pins risk of injury to axillary nerve with anterior pins risk of injury to biceps tendon, musculocutaneous n., cephalic vein possible pin migration ORIF approach 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 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(s) can prevent post-operative varus collapse, especially in osteoporotic bone Intramedullary nailing 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 anterior (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 (5.6 cm 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) technique for fractures ensure adequate glenoid bone stock ensure functioning deltoid muscle repair of tuberosities recommended despite ability of RSA design to compensate for non-functioning tubersosities/rotator cuff 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 Complications Screw cut-out most common complication after locked 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 axillary nerve injury most common (up to 58% with studies using EMG) increased risk with lateral (deltoid-splitting) approach axillary nerve is usually found ~7cm distal to the tip of the acromion suprascapular nerve (up to 48%) Malunion usually varus apex-anterior or malunion of GT results inferior if converting from varus malunited fracture to TSA use reverse TSA instead Nonunion usually with surgical neck and tuberosity fx treatment of chronic nonunion/malunion in the elderly should include arthroplasty lesser tuberosity nonunion leads to weakness with lift-off testing greater tuberosity nonunion leads to lack of active shoulder elevation greatest risk factors for non-union are age and smoking Rotator cuff injuries and dysfunction Missed posterior dislocation (especially in cases with lesser tuberosity fractures) Adhesive capsulitis Posttraumatic arthritis Infection
Proximal Humerus Fracture Hemiarthroplasty Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Proximal Humerus Fracture ORIF Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team
QUESTIONS 1 of 41 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Previous Next Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase (OBQ06.133) 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? Review Topic QID: 319 1 Closed reduction and percutaneous pinning 1% (3/500) 2 Shoulder arthroplasty 25% (125/500) 3 Rotator cuff repair with possible latissimus dorsi tendon transfer 1% (3/500) 4 Open reduction and internal fixation with possible bone grafting 70% (349/500) 5 Open bone grafting 3% (14/500) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase (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? Review Topic QID: 3186 FIGURES: A 1 Humeral prosthesis height and retroversion 68% (318/468) 2 Humeral prosthesis offset and retroversion 5% (22/468) 3 Humeral prosthesis head-neck angle and height 20% (92/468) 4 Humeral prosthesis stem width and height 3% (15/468) 5 Humeral prosthesis stem length and retroversion 4% (19/468) Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase (OBQ08.157) 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? Review Topic QID: 543 1 Pendulums 2% (9/489) 2 Active-assisted internal rotation of the shoulder to the plane of the body 25% (120/489) 3 Active forearm supination 1% (4/489) 4 Passive external rotation of the shoulder past 30 degrees 69% (337/489) 5 Passive internal rotation of the shoulder to the plane of the body 3% (14/489) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.5) 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? Review Topic QID: 666 FIGURES: A 1 Sling and swathe for 6 weeks then physical therapy 3% (18/520) 2 Reverse total shoulder arthroplasty 1% (6/520) 3 ORIF of proximal humerus 85% (443/520) 4 Closed reduction and percutaneous pinning of the greater tuberosity 7% (34/520) 5 Hemiarthroplasty 3% (18/520) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 3197 FIGURES: A B 1 Infection 0% (4/1149) 2 Osteonecrosis 17% (191/1149) 3 Axillary artery injury 0% (2/1149) 4 Screw cut-out 76% (870/1149) 5 Axillary nerve injury 7% (79/1149) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3496 1 1.0 cm 5% (142/3088) 2 2.4 cm 12% (365/3088) 3 3.8 cm 11% (325/3088) 4 5.6 cm 67% (2080/3088) 5 6.5 cm 5% (163/3088) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3641 FIGURES: A 1 Insertion of both cortical and locking screws into the humeral head 10% (169/1730) 2 Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity 1% (24/1730) 3 Treatment of the fracture with closed reduction and percutaneous k-wire fixation 2% (38/1730) 4 Addition of an inferomedial locking screw within the calcar 84% (1445/1730) 5 Intramedullary nailing of the fracture 3% (48/1730) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3507 FIGURES: A B C D E 1 Axillary nerve injury 9% (287/3375) 2 Valgus migration of the fracture 3% (87/3375) 3 Nonunion 3% (118/3375) 4 Hardware failure 5% (180/3375) 5 Screw penetration 80% (2694/3375) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 296 FIGURES: A 1 Joint infection 0% (4/1908) 2 Retroversion of the prosthesis 3% (54/1908) 3 Glenoid arthritis 0% (7/1908) 4 Axillary nerve injury 8% (148/1908) 5 Greater tuberosity malunion 88% (1686/1908) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 499 FIGURES: A 1 Anterior branch of the axillary nerve 82% (491/600) 2 Posterior humeral circumflex artery 12% (69/600) 3 Long head of the biceps tendon 3% (19/600) 4 Cephalic vein 0% (2/600) 5 Musculocutaneous nerve 3% (18/600) Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 3653 1 Radial nerve 1% (23/1929) 2 Suprascapular nerve 1% (12/1929) 3 Axillary nerve 97% (1868/1929) 4 Axillary artery 1% (10/1929) 5 Axillary vein 0% (7/1929) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 3519 1 Musculocutaneous nerve 8% (254/3041) 2 Posterior humeral circumflex artery 1% (33/3041) 3 Axillary nerve 84% (2552/3041) 4 Cephalic vein 2% (47/3041) 5 Anterior humeral circumflex artery 5% (139/3041) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 1376 FIGURES: A B C 1 Shoulder dislocation 2% (22/982) 2 Pulmonary embolus 1% (5/982) 3 Loss of sensation over the lateral shoulder 5% (52/982) 4 Reduced shoulder elevation and abduction 92% (901/982) 5 Ulnar nerve palsy 0% (0/982) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3437 FIGURES: A 1 It is usually associated with a posterior shoulder dislocation 1% (23/2011) 2 The subscapularis muscle is the main deforming force 2% (33/2011) 3 Non-operative treatment of this displaced injury results in good long term shoulder function 10% (196/2011) 4 Open reduction and internal fixation is the treatment of choice 85% (1705/2011) 5 Associated rotator cuff tears are uncommon 3% (52/2011) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (SBQ07SM.16) 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? Review Topic QID: 1401 1 Anterior portion of humeral head 6% (25/410) 2 Lesser tuberosity 6% (25/410) 3 Entire humeral head except posteroinferior portion of lesser tuberosity and head 22% (90/410) 4 Entire humeral head except posteroinferior portion of greater tuberosity and head 59% (242/410) 5 Entire humeral head except entire greater tuberosity 6% (24/410) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase Sorry, this question is for Virtual Curriculum Members Only Click here to purchase
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Posterior shoulder fracture-dislocation in a 25F (C101082) Trauma - Proximal Humerus Fractures HPI - She admitted yesterday night to emergency department with sudden pain and disability of right shoulder after an epileptic seizure . Would you manage this patient surgically or attempt a course of conservative treatment? 6/3/2018 66 0 3 Proximal Humerus Fracture in 65F (C101075) Trauma - Proximal Humerus Fractures HPI - s/p fall from ladder while painting at home. No previous shoulder pain or complaints. Works part-time in a special-needs school. In addition to an AP radiograph, what additional imaging studies would you obtain to dictate treatment? 5/8/2018 10459 39 17 Humerus AVN in a 14F (C2808) Trauma - Proximal Humerus Fractures 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? 4/21/2017 99 0 3 See More See Less