Updated: 5/23/2021

Proximal Humerus Fracture Nonunion and Malunion

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Questions
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Evidence
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Cases
2
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  • 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 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
        • 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
  • 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
Questions (3)
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(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:
1

Revision open reduction and internal fixation

4%

(122/2786)

2

Valgus corrective osteotomy of proximal humerus

2%

(49/2786)

3

Shoulder arthroplasty

93%

(2593/2786)

4

Shoulder arthrodesis

0%

(3/2786)

5

Humeral head resection

0%

(6/2786)

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
1

Manipulation under anesthesia

4%

(35/861)

2

Humeral head resurfacing

1%

(9/861)

3

Shoulder hemiarthroplasty

3%

(23/861)

4

Revision open reduction internal fixation with osteotomy

91%

(780/861)

5

Reverse total shoulder arthroplasty

1%

(9/861)

L 1 D

Select Answer to see Preferred Response

Evidence (15)
VIDEOS & PODCASTS (1)
CASES (2)
EXPERT COMMENTS (3)
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