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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
  Minimally
Displaced
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-displaced
Operative
• ORIF if large fragment 
• excision with RCR if small

Anatomic neck • Rare

Nonoperative
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 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
 

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Technique Guides (2)
Questions (41)
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(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%

(3/503)

2

Shoulder arthroplasty

25%

(125/503)

3

Rotator cuff repair with possible latissimus dorsi tendon transfer

1%

(3/503)

4

Open reduction and internal fixation with possible bone grafting

70%

(352/503)

5

Open bone grafting

3%

(14/503)

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PREFERRED RESPONSE 4
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(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:
1

Humeral prosthesis height and retroversion

67%

(338/503)

2

Humeral prosthesis offset and retroversion

5%

(23/503)

3

Humeral prosthesis head-neck angle and height

20%

(100/503)

4

Humeral prosthesis stem width and height

3%

(17/503)

5

Humeral prosthesis stem length and retroversion

4%

(21/503)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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(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%

(9/488)

2

Active-assisted internal rotation of the shoulder to the plane of the body

25%

(120/488)

3

Active forearm supination

1%

(4/488)

4

Passive external rotation of the shoulder past 30 degrees

69%

(336/488)

5

Passive internal rotation of the shoulder to the plane of the body

3%

(14/488)

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:
1

Sling and swathe for 6 weeks then physical therapy

4%

(19/539)

2

Reverse total shoulder arthroplasty

1%

(6/539)

3

ORIF of proximal humerus

85%

(456/539)

4

Closed reduction and percutaneous pinning of the greater tuberosity

6%

(35/539)

5

Hemiarthroplasty

4%

(19/539)

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:
1

Infection

0%

(4/1168)

2

Osteonecrosis

17%

(195/1168)

3

Axillary artery injury

0%

(2/1168)

4

Screw cut-out

76%

(882/1168)

5

Axillary nerve injury

7%

(82/1168)

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%

(145/3115)

2

2.4 cm

12%

(370/3115)

3

3.8 cm

10%

(327/3115)

4

5.6 cm

67%

(2094/3115)

5

6.5 cm

5%

(164/3115)

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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:
1

Insertion of both cortical and locking screws into the humeral head

10%

(174/1760)

2

Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity

1%

(24/1760)

3

Treatment of the fracture with closed reduction and percutaneous k-wire fixation

2%

(38/1760)

4

Addition of an inferomedial locking screw within the calcar

83%

(1466/1760)

5

Intramedullary nailing of the fracture

3%

(50/1760)

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:
1

Axillary nerve injury

9%

(290/3404)

2

Valgus migration of the fracture

3%

(88/3404)

3

Nonunion

4%

(121/3404)

4

Hardware failure

5%

(181/3404)

5

Screw penetration

80%

(2713/3404)

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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:
1

Joint infection

0%

(4/1951)

2

Retroversion of the prosthesis

3%

(55/1951)

3

Glenoid arthritis

0%

(7/1951)

4

Axillary nerve injury

8%

(152/1951)

5

Greater tuberosity malunion

88%

(1722/1951)

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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:
1

Anterior branch of the axillary nerve

82%

(491/601)

2

Posterior humeral circumflex artery

12%

(70/601)

3

Long head of the biceps tendon

3%

(19/601)

4

Cephalic vein

0%

(2/601)

5

Musculocutaneous nerve

3%

(18/601)

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%

(24/1956)

2

Suprascapular nerve

1%

(12/1956)

3

Axillary nerve

97%

(1894/1956)

4

Axillary artery

1%

(10/1956)

5

Axillary vein

0%

(7/1956)

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%

(256/3066)

2

Posterior humeral circumflex artery

1%

(35/3066)

3

Axillary nerve

84%

(2570/3066)

4

Cephalic vein

2%

(48/3066)

5

Anterior humeral circumflex artery

5%

(139/3066)

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:
1

Shoulder dislocation

2%

(24/1016)

2

Pulmonary embolus

0%

(5/1016)

3

Loss of sensation over the lateral shoulder

5%

(55/1016)

4

Reduced shoulder elevation and abduction

91%

(927/1016)

5

Ulnar nerve palsy

0%

(0/1016)

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:
1

It is usually associated with a posterior shoulder dislocation

1%

(23/2016)

2

The subscapularis muscle is the main deforming force

2%

(34/2016)

3

Non-operative treatment of this displaced injury results in good long term shoulder function

10%

(198/2016)

4

Open reduction and internal fixation is the treatment of choice

85%

(1707/2016)

5

Associated rotator cuff tears are uncommon

3%

(52/2016)

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%

(25/438)

2

Lesser tuberosity

6%

(25/438)

3

Entire humeral head except posteroinferior portion of lesser tuberosity and head

23%

(100/438)

4

Entire humeral head except posteroinferior portion of greater tuberosity and head

59%

(257/438)

5

Entire humeral head except entire greater tuberosity

6%

(25/438)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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