Updated: 9/24/2022

Proximal Humerus Fracture Nonunion and Malunion

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
3
0
0
0%
0%
Evidence
15
0
0
0%
0%
Cases
3
Topic
Images
https://upload.orthobullets.com/topic/12283/images/f2.large.jpg
https://upload.orthobullets.com/topic/12283/images/qq.jpg
  • Summary
    • Proximal Humerus Fracture Nonunion and Malunion are common complications associated with proximal humerus fractures which can lead to persistent shoulder pain, instability, and restricted motion.
    • Diagnosis is made radiographically with shoulder radiographs demonstrating malposition of the humeral tuberosities, varus/vaglus head-shaft angulation, articular incongruities, or absence of bony union.
    • Treatment ranges from nonoperative to revision ORIF to shoulder arthroplasty depending on severity of malunion, available bone stock, patient age and activity demands.
  • Epidemiology
    • Incidence
      • common
        • proximal humerus fractures account for 4% to 5% of all fractures
    • Risk factors for nonunion
      • fracture characteristics
        • 2-part (surgical neck) fracture patterns
        • humeral head split
        • displaced tuberosity fractures
      • patient factors
        • osteoporosis
        • chronic renal disease
        • chronic alcohol or steriod use
        • smoking
  • Etiology
    • Pathophysiology
      • 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 angle usually 130° 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 Classification
      • 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 Classification
      • 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
        • check axillary nerve function
  • 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 corticosteroid injection
        • indications
          • low-demand patient
          • painless shoulder limitations
          • unable to comply with the 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 function
    • 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
        • 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
            • greater improvement in functional outcome scores than hemiarthroplasty
            • lower complication rates than hemiarthroplasty 
  • techniques
    • ORIF +/- osteotomy, subacromial decompression, and soft tissue technique
      • technique
        • 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
    • Shoulder arthroplasty
      • technique
        • hemiarthroplasty
        • anatomic total shoulder arthroplasty 
        • reverse total shoulder arthroplasty 
  • Complications
    • Persistent pain and weakness
    • Stiffness
    • Loss of fixation
    • Infection
    • Bleeding
Flashcards (0)
Cards
1 of 0
Questions (3)

(OBQ06.133.1) A 72-year-old female presents to your office with a 12-month old painful nonunion of a 2-part (surgical neck) proximal humerus fracture which was managed non-operatively. Prior to her injury, she denied shoulder pain and had excellent range of motion. Since the injury, she has had persistent debilitating pain and dysfunction with motion above the shoulder level. X-Rays show good bone stock, no significant shoulder arthritis or avascular necrosis, and well-positioned tuberosities. Which of the following is the most optimal treatment for the patient?

QID: 214236

Closed reduction and percutaneous pinning

0%

(5/1619)

Shoulder hemiarthroplasty

23%

(380/1619)

Open bone grafting

2%

(25/1619)

Open reduction and internal fixation (ORIF) with or without bone grafting

65%

(1055/1619)

Reverse total shoulder arthroplasty (rTSA) with lattisimus dorsi transfer to assist with internal rotation

9%

(144/1619)

L 3 D

Select Answer to see Preferred Response

(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?

QID: 290
FIGURES:

Revision open reduction and internal fixation

4%

(127/3152)

Valgus corrective osteotomy of proximal humerus

2%

(55/3152)

Shoulder arthroplasty

93%

(2945/3152)

Shoulder arthrodesis

0%

(4/3152)

Humeral head resection

0%

(6/3152)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 217

Manipulation under anesthesia

4%

(45/1030)

Humeral head resurfacing

1%

(12/1030)

Shoulder hemiarthroplasty

3%

(27/1030)

Revision open reduction internal fixation with osteotomy

90%

(929/1030)

Reverse total shoulder arthroplasty

1%

(12/1030)

L 1 D

Select Answer to see Preferred Response

Evidence (15)
VIDEOS & PODCASTS (1)
CASES (3)
EXPERT COMMENTS (3)
Private Note