• 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
• 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
• Assume posterior dislocation until proven otherwise
Nonoperative• Minimally or non-displacedOperative• ORIF if large fragment • excision with RCR if small
Nonoperative• Minimally or non-displacedOperative• ORIF in young• ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly
• 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
• 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
• 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
• 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
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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 67-year-old woman who is an avid tennis player falls onto her dominant shoulder during a tennis match. Examination reveals tenderness and swelling in the shoulder region, but no neurovascular deficits. Radiographs and CT scan are shown in Figures A through E. Combined cortical thickness is 4.2mm. What is the most appropriate treatment option?
Closed reduction and sling immobilization for 6 weeks
Closed reduction and sling immobilization for 2 weeks followed by early active range of motion exercises
Open reduction and internal fixation
Reverse total shoulder arthroplasty
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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 with motion above shoulder level. X-Rays show no shoulder arthritis, significant osteopenia, or issues with her tuberosities. The current recommended surgical 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 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 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
ORIF of proximal humerus
Closed reduction and percutaneous pinning of the greater tuberosity
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
Axillary nerve injury
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 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
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?
Valgus migration of the fracture
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 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
Posterior humeral circumflex artery
Long head of the biceps tendon
What structure is 7cm from the acromion and at greatest risk of injury during a deltoid splitting approach for a proximal humerus 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?
Anterior humeral circumflex artery
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
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
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