Updated: 6/24/2018

Proximal Humerus Fracture Malunion and Nonunion

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Questions
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Evidence
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Cases
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Introduction
  • Description
    • Proximal Humerus Fracture Nonunion and Malunion are complications associated with proximal humerus fractures
      • this topic discusses these complications
      • click here to review proximal humerus fractures  
  • Malunion can lead to malposition of the humeral tuberosities; rotation, angulation, and/or offset of the head-shaft junction; or articular incongruities
  • Epidemiology
    • incidence
      • proximal humerus fractures account for 4% to 5% of all fractures 
    • risk factors for nonunion
      • fracture characteristics
        • 3 or 4 part fracture patterns
        • humeral head split
        • displaced tuberosity fractures  
      • patient factors
        • osteoporosis
        • chronic renal disease
        • chronic alcohol or steriod use
        • smoking
  • Pathophysiology of malunion
    • origin of malunion
      • initial fracture displacement 
      • secondary displacement after loss of reduction
      • failure of internal fixation
    • humeral head malunion
      • varus/valgus
      • impacted (>1cm displacement)
      • articular surface incongruity (e.g. head split)
    • greater tuberosity malunion
      • usually displaced posterior, superior and externally rotated
    • lesser tuberosity malunion
      • usually displaced medial 
  • Associated conditions
    • rotator cuff tearing
    • osteonecrosis of humeral head
    • glenohumeral joint issues
      • stiffness
      • post-traumatic arthritis
      • subluxation or dislocation
      • subacromial impingement
Anatomy
  • Humeral head
    • shape
      • spheroidal in 90% of individuals
    • size
      • average diameter is 43 mm
    • orientation  
      • retroverted 30° from transepicondylar axis of the distal humerus
      • neck-shaft agle usually 13 to 140° 
  • Greater tuberosity
    • position important for rotator cuff muscle fuction  
      • horizontal position
        • medial edge of tuberosity is 10mm lateral to humeral canal axis
      • vertical position
        • superior edge of tuberosity is 6mm inferior to upper edge of humeral head
Classification
  • Beredjiklian et al. 
 Beredjiklian
Type I                        

• Malposition of the greater or lesser tuberosity ( e.g. >1 cm from native anatomical position)

Type II       • Articular incongruity ( e.g. intra-articular fracture extension, osteoarthritis)
Type III • Articular surface malalignment ( e.g. >45° of deformity with respect to the humeral shaft in the coronal, sagittal, or axial planes
  • Boileau et al.
 Boileau
Type I  • Humeral head necrosis or impaction
Type II  • Chronic dislocations or fracture-dislocations
Type III  • Nonunion of the surgical neck
Type IV  • Severe malunion of the tuberosity
 
Presentation
  • History 
    • initial evaluation
      • date and mechanism of injury
      • current and prior function
      • handedness
      • treatment to date
      • specific goals of treatment
  • Symptoms
    • pain and weakness
    • limitations
  • Physical exam
    • inspection
      • features of systemic disease
      • muscle atrophy
      • diffuse tenderness
    • motion
      • active and passive shoulder range-of-motion
        • blocks or crepitus should be noted
      • rotator cuff
        • greater tuberosity malunion = weakness with abduction, external rotation
        • lesser tuberosity malunion = weakness with internal rotation
      • instability 
        • humeral head malunion = apprehension test 
    • neurovascular
Imaging
  • Radiographs 
    • recommended views
      • true AP, scapular Y, axillary 
    • optional views
      • apical oblique 
      • Velpeau 
      • West Point axillary 
    • findings
      • neck-shaft angle = varus or valgus
      • greater tuberosity = superiorly and posteriorly displaced, externally rotated
      • lesser tuberosity = medialized
    • measurements  
      • humeral head 
        • > 45° of deformity in any plane
        • symptomatic articular incongruity
        • neck-shaft angle <120° or >150°
      • greater or lesser tuberosity
        • >1 cm from native anatomical position
  • CT scan
    • indications
      • preoperative planning
      • assess bone stock, orientation and articular surface
    • findings
      • humeral head and greater tuberosity displacement
      • glenoid version and glenoid bone stock
      • articular injury
  • MRI
    • indications
      • preoperative planning
      • soft-tissue structures
    • findings
      • rotator cuff or labral injury
      • deltoid atrophy secondary to axillary nerve injury
      • long-head biceps injury
      • osteonecrosis
Studies
  • Labs
    • CBC, ESR, CRP, blood cultures to rule out infection
  • Electrodiagnositcs
    • concern for nerve dysfunction
Treatment
  • Nonoperative
    • NSAIDS, physical therapy, occasional corticosteriod injection
      • indications
        • low-demand patient
        • painless shoulder limitations
        • unable to comply with rehabilitation protocol
      • modalities
        • physical therapy
          • maximize ROM and strengthening program
      • outcomes
        • impacted varus and valgus fractures show good-to-excellent results 
          • return to 90% of normal fuction
  • Operative
    • ORIF +/- osteotomy, subacromial decompression, and soft tissue technique
      • indications
        • symptomatic malunion following
          • nonoperative treatment
          • failed internal fixation
        • anatomical requirements
          • adequate bone stock for fixation 
          • preserved articular surface
          • intact blood supply to humeral head
      • techniques
        • humeral head deformities
          • minor deformity techniques
            • open/arthroscopic tuberoplasty 
            • +/- acromioplasty 
            • +/- capsular release 
            • +/- bursectomy
          • severe deformity techniques
            • varus/valgus osteotomy 
            • +/- rotational osteotomy and lateral plate fixation
              • treated with corrective osteotomy/fixation if patient is young or active 
              • may be augmented with strut allograft for poor bone stock
        • greater tuberosity deformities
          • <1.5 cm displacement
            • arthroscopic subacromial decompression +/- rotator cuff repair
          • >1.5 cm displacement
            • open/arthroscopic tuberosity osteotomy +/- subacromial decompression
      • outcomes
        • complication rates associated with surgical management of malunions are higher than those associated with acute fractures
    • shoulder arthroplasty
      • indications
        • symptomatic malunion following
          • nonoperative treatment
          • failed internal fixation
        • anatomical requirements
          • inadequate bone stock for fixation techniques
          • articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split)
          • compromised blood supply 
          • chronic dislocation
      • techniques
        • hemiarthroplasty
        • total shoulder arthroplasty
        • reverse total shoulder arthroplasty 
Complications
  • Persistent pain and weakness
  • Stiffness
  • Loss of fixation
  • Infection
  • Bleeding
 

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Questions (2)

(OBQ06.104) A 69-year-old male sustained a proximal humerus fracture that underwent open reduction and internal fixation nine months ago. He complains of constant pain and weakness; repeat radiographs are shown in Figures A and B. What is the most appropriate surgical treatment at this time? Review Topic

QID: 290
FIGURES:
1

Revision open reduction and internal fixation

4%

(66/1616)

2

Valgus corrective osteotomy of proximal humerus

2%

(28/1616)

3

Shoulder arthroplasty

93%

(1506/1616)

4

Shoulder arthrodesis

0%

(2/1616)

5

Humeral head resection

0%

(5/1616)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ06.206) A 24-year-old female sustains a surgical neck proximal humerus fracture in a motor-vehicle collision. She undergoes open reduction and internal fixation but heals in 45 degrees of varus and has significant limitation of shoulder range of motion despite 9 months of conservative treatments. What is the most appropriate treatment at this time? Review Topic

QID: 217
1

Manipulation under anesthesia

4%

(21/556)

2

Humeral head resurfacing

1%

(4/556)

3

Shoulder hemiarthroplasty

3%

(15/556)

4

Revision open reduction internal fixation with osteotomy

91%

(508/556)

5

Reverse total shoulder arthroplasty

1%

(4/556)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
ARTICLES (7)
CASES (2)
Topic COMMENTS (1)
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