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18

Proximal Humerus Fractures

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Topic updated on 08/09/16 11:15am
Introduction
  • Epidemiology
    • incidence
      • 4-6% of all fractures
      • third most common fracture pattern seen in elderly
    • demographics
      • 2:1 female to male ratio
      • increasing age correlates with increasing fracture risk in women
  • Pathophysiology
    • mechanism
      • low-energy falls
        • elderly with osteoporotic bone
      • high-energy trauma
        • young individuals
        • concomitant soft tissue and neurovascular injuries
    • pathoanatomy
      • vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
  • Associated conditions
    • nerve injury
      • axillary nerve palsy most common
    • fracture-dislocations
      • more commonly associated with nerve injuries
Anatomy
  • Osteology 
    • anatomic neck 
      • represents the old epiphyseal plate
    • surgical neck 
      • represents the weakened area below 
  • Vascular anatomy 
    • anterior humeral circumflex artery 
      • one of primary blood supplies to the humeral head
      • branches
        • anterolateral ascending branch
          • is a branch of the anterior humeral circumflex artery
        • arcuate artery
          • is the terminal branch 
      • course
        • runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove
        • has an interosseous anastomosis
    • posterior humeral circumflex artery 
      • recent studies suggest it is the main blood supply to humeral head  
Classification
  • Valgus impacted
    • not true 4-part fractures
    • have preserved posterior medial capsular vascularity to the articular segment
  • 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
Evaluation
  • Symptoms
    • pain and swelling
    • decreased motion
  • Physical exam
    • inspection
      • extensive ecchymosis of chest, arm, and forearm
    • neurovascular exam
      • 45% incidence of nerve injury (axillary most common)
        • distinguish from early deltoid atony and inferior subluxation of humeral head
      • arterial injury may be masked by extensive collateral circulation preserving distal pulses
Imaging
  • Radiographs
    • recommended views
      • complete trauma series
        • true AP
        • scapular Y
        • axillary
      • additional views
        • apical oblique 
        • Velpeau 
        • West Point axillary 
      • findings
        • combined cortical thickness (>4 mm)
          • studies suggest correlation with increased lateral plate pullout strength
  • 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 
        • 85% of proximal humerus fractures are minimally displaced and can be treated nonoperatively including 
          • minimally displaced surgical neck fracture (1-, 2-, and 3-part)
          • 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
    • ORIF
      • indications
        • greater tuberosity displaced > 5mm   
        • 2-,3-, and 4-part fractures in younger patients 
        • head-splitting fractures in younger patients
    • intramedullary rodding
      • indications
        • surgical neck fractures or 3-part greater tuberosity fractures in 
        • younger patients
        • combined proximal humerus and humeral shaft fractures
      • outcomes
        • 85% success rate in younger patients
    • hemiarthroplasty 
      • indications  
        • anatomic neck fractures in elderly (initial varus malalignment >20 degrees) or those that are severely comminuted
        • 4-part fractures and fracture-dislocations (3-part if stable internal fixation unachievable)
        • rotator cuff compromise
        • glenoid surface is intact and healthy
        • chronic nonunions or malunions in the elderly
        • head-splitting fractures with incongruity of humeral head
        • humeral head impression defect of > 40% of articular surface
        • detachment of articular blood supply (most 3- and 4-part fractures)
      • outcomes
        • improved results if
          • performed within 14 days
          • accurate tuberosity reduction
          • cerclage wire passed through hole in prosthesis and tuberosities
        • poor results with
          • tuberosity malunion 
          • proud prosthesis
          • retroversion of humeral component > 40°
    • total shoulder arthroplasty
      • indications
        • rotator cuff intact
        • glenoid surface is compromised (arthritis, trauma)
    • reverse shoulder arthroplasty 
      • indications
        • elderly individuals with nonreconstructible tuberosities
Treatment by Fracture Type
 
One-Part Fracture (most common)

Surgical Neck fx

• Most common type
• if stable then early ROM
• if unstable then period of immobilization followed by ROM once moves as a unit

Anatomic Neck fx

  • ORIF in young patient
• ORIF vs. hemiarthroplasty in elderly patient
• hemiarthroplasty if severely comminuted
Two-Part Fracture

Surgical Neck

• Most common fx pattern (85%)
• Deforming forces:
1) pectoralis pulls shaft anterior and medial 2) head and attached tuberosities stay neutral
• Posterior angulation tolerated better than anterior and varus angulation

Nonoperative
Closed reduction often possible
• Sling
Operative
• indicated for >45° angulation
• technique
- CRPP
- Plate fixation
- Enders rods with tension band
- IM device

Greater tuberosity

• Often missed 
• Deforming forces: GT pulled superior and posterior by SS, IS, and TM
• Can only accept minimal displacement or else it will block ER and ABD

Nonoperative
• indicated for GT displaced < 5 mm
Operative
• indicated for GT displacement > 5 mm
•AP radiograph of a left shoulder demonstrates a 2-part proximal humerus fracture at the surgical neck.
- 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

Operative
• ORIF if large fragment 
• excision with RCR if small

Anatomic neck • Rare

Operative
 ORIF in young
• ORIF vs. hemiarthroplasty in elderly patient

Three-Part Fracture
Surgical neck and GT
 

• Subscap will internally rotate articular segment
• Often associated with longitudinal RCT

 
Surgical neck and LT

• Unopposed pull of external rotators lead to articular surface to point anterior
• Often associated with longitudinal RCT

• Trend towards nonoperative management with high complications with ORIF
• Young patient
- percutaneous pinning (good results, protect axillary nerve)
- blade plate / fixed angle device
- IM fixation (violates cuff)
- T plate (poor results with high rate of AVN, impingement, infection, and malunion)
• Elderly patient
- hemiarthroplasty with RCR or tuberosity repair

Four-Part Fracture
Valgus impacted 3- and 4-part fracture
 

• Radiographically will see alignment between medial shaft and head segments

• 74% good results with ORIF
• 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 articular surface and head-splitting fracture

• Characterized by removal of soft tissue from fracture fragment leading to high risk of AVN (21-75%) 
• Deforming forces: 1) shaft pulled medially by pectoralis

• Young patient
- ORIF vs. hemiarthroplasty (nonreconstructible articular surface, severe head split, extruded anatomic neck fracture)

• Elderly patient
- hemiarthroplasty

 
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 
  • ORIF 
    • approach
      • shoulder anterior approach (deltopectoral) 
      • shoulder lateral (deltoid-splitting) approach 
        • indicated for GT and valgus-impacted 4-part fractures
        • increased risk of axillary nerve injury
    • technique
      • heavy nonabsorbable sutures
        • (figure-of-8 technique) should be used for 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
        • has improved our ability to fix these fractures
        • screw cut-out 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 can prevent post-operative varus collapse, especially in osteoporotic bone 
  • Intramedullary rodding  
    • 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
      • shoulder anterior approach (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  
      • post-operative passive external rotation places the most stress on the lesser tuberosity fragment 
  • Total shoulder arthroplasty 
  • Reverse shoulder arthroplasty 
Rehabilitation
  • Important part of management
  • Best results with guided protocols (3-phase programs)
    • early passive ROM for first 6 weeks
    • active ROM and progressive resistance
    • advanced stretching and strengthening program
  • Prolonged immobilization leads to stiffness
Complications
  • Screw penetration
    • most common complication after locked plating fixation
  • Avascular necrosis  
    • risk factors
      • 4 part fractures
      • head split
      • short calcar segments
      • disrupted medial hinge
    • no relationship to type of fixation (plate or cerclage wires)
  • Nerve injury
    • axillary nerve injury (up to 58%)
      • increased risk with anterolateral acromial approach
      • axillary nerve is found 7cm distal to the tip of the acromion 
    • suprascapular nerve (up to 48%)
  • Malunion 
    • usually varus apex-anterior or malunion of GT 
  • 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
  • Adhesive capsulitis
  • Posttraumatic arthritis
  • Infection

 

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Qbank (25 Questions)

TAG
(SBQ07.16) 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? Topic Review Topic

1. Anterior portion of humeral head
2. Lesser tuberosity
3. Entire humeral head except posteroinferior portion of lesser tuberosity and head
4. Entire humeral head except posteroinferior portion of greater tuberosity and head
5. Entire humeral head except entire greater tuberosity

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. It is usually associated with a posterior shoulder dislocation
2. The subscapularis muscle is the main deforming force
3. Non-operative treatment of this displaced injury results in good long term shoulder function
4. Open reduction and internal fixation is the treatment of choice
5. Associated rotator cuff tears are uncommon

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. 1.0 cm
2. 2.4 cm
3. 3.8 cm
4. 5.6 cm
5. 6.5 cm

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Axillary nerve injury
2. Valgus migration of the fracture
3. Nonunion
4. Hardware failure
5. Screw penetration

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Musculocutaneous nerve
2. Posterior humeral circumflex artery
3. Axillary nerve
4. Cephalic vein
5. Anterior humeral circumflex artery

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Insertion of both cortical and locking screws into the humeral head
2. Addition of a 20-gauge intraosseous tension band laterally through the greater tuberosity
3. Treatment of the fracture with closed reduction and percutaneous k-wire fixation
4. Addition of an inferomedial locking screw within the calcar
5. Intramedullary nailing of the fracture

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Radial nerve
2. Suprascapular nerve
3. Axillary nerve
4. Axillary artery
5. Axillary vein

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Infection
2. Osteonecrosis
3. Axillary artery injury
4. Screw cut-out
5. Axillary nerve injury

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Humeral prosthesis height and retroversion
2. Humeral prosthesis offset and retroversion
3. Humeral prosthesis head-neck angle and height
4. Humeral prosthesis stem width and height
5. Humeral prosthesis stem length and retroversion

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Anterior branch of the axillary nerve
2. Posterior humeral circumflex artery
3. Long head of the biceps tendon
4. Cephalic vein
5. Musculocutaneous nerve

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Pendulums
2. Active-assisted internal rotation of the shoulder to the plane of the body
3. Active forearm supination
4. Passive external rotation of the shoulder past 30 degrees
5. Passive internal rotation of the shoulder to the plane of the body

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Sling and swathe for 6 weeks then physical therapy
2. Reverse total shoulder arthroplasty
3. ORIF of proximal humerus
4. Closed reduction and percutaneous pinning of the greater tuberosity
5. Hemiarthroplasty

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Revision open reduction and internal fixation
2. Valgus corrective osteotomy of proximal humerus
3. Humeral hemiarthroplasty
4. Shoulder arthrodesis
5. Humeral head resection

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Joint infection
2. Retroversion of the prosthesis
3. Glenoid arthritis
4. Axillary nerve injury
5. Greater tuberosity malunion

PREFERRED RESPONSE ▶
TAG
(OBQ06.133) A 72-year-old female presents to your office with a 24-month old painful nonunion of a 2-part fracture of the proximal humerus. She has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. The current recommended treatment for this injury is which of the following? Topic Review Topic

1. Closed reduction and percutaneous pinning
2. Shoulder arthroplasty
3. Rotator cuff repair with possible latissimus dorsi tendon transfer
4. Open reduction and internal fixation with possible bone grafting
5. Open bone grafting

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C      

1. Shoulder dislocation
2. Pulmonary embolus
3. Loss of sensation over the lateral shoulder
4. Reduced shoulder elevation and abduction
5. Ulnar nerve palsy

PREFERRED RESPONSE ▶
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11/14/2013
538 responses
http://upload.orthobullets.com/cases/1629/screen shot 2013-09-17 at 5.26.33 pm.jpg http://upload.orthobullets.com/cases/1629/screen shot 2013-09-17 at 5.26.52 pm.jpg http://upload.orthobullets.com/cases/1629/screen shot 2013-09-17 at 5.27.12 pm.jpg
HPI - 35 yo RHD f presenting after a mechanical fall while intoxicated
poll How would you treat this patient?
9/17/2013
209 responses
http://upload.orthobullets.com/cases/1495/shlder2.jpg http://upload.orthobullets.com/cases/1495/shlder 1.jpg http://upload.orthobullets.com/cases/1495/shoulder1 ct.jpg
HPI - fall at home .pain inabilty to move the left shoulder
poll conservative or operative
4/27/2013
113 responses
http://upload.orthobullets.com/cases/1383/x-ray-1_0.jpg http://upload.orthobullets.com/cases/1383/xray-3_0.jpg http://upload.orthobullets.com/cases/1383/shoulder mri 1.jpg
HPI - 34 year old female, was incarcerated when she had a seizure 4 months ago. Her s...
poll How would you approach her care?
1/10/2013
952 responses
http://upload.orthobullets.com/cases/1348/20121203_222440.jpg http://upload.orthobullets.com/cases/1348/20121203_222521.jpg
HPI - attacked by bear while cutting woods in forest
poll what would be your plan of management
12/7/2012
24 responses
http://upload.orthobullets.com/cases/1344/humeral fracture 2.jpg http://upload.orthobullets.com/cases/1344/humeral fracture 1.jpg
HPI - Fall from standing height 3 week ago
poll What is the best treatment?
12/4/2012
80 responses
http://upload.orthobullets.com/cases/1311/1.jpg http://upload.orthobullets.com/cases/1311/2.jpg http://upload.orthobullets.com/cases/1311/3.jpg
HPI - 56 y/o male with continued left shoulder pain. Three months after injury in the...
poll What would you do now?
11/4/2012
116 responses
http://upload.orthobullets.com/cases/1304/prx1.jpg http://upload.orthobullets.com/cases/1304/prx2.jpg http://upload.orthobullets.com/cases/1304/prox preop after fall.jpg
HPI - case odf nonunion rt prox humerus, since 20yrs, able to do routine activities wi...
poll post fall treatment conservative or orif with bone graft
10/27/2012
128 responses
http://upload.orthobullets.com/cases/1302/ap humerus.jpg http://upload.orthobullets.com/cases/1302/ap 2.jpg http://upload.orthobullets.com/cases/1302/lateral humerus.jpg
HPI - 53 F with left shoulder pain after fall. Patient suffers from bipolar disorder....
poll How would you treat this injury
10/24/2012
223 responses
http://upload.orthobullets.com/cases/1217/xray1.jpg http://upload.orthobullets.com/cases/1217/xray2.jpg http://upload.orthobullets.com/cases/1217/ct1.jpg
HPI - 29 yr male. Hx of seizures but never had frank posterior shoulder dislocation. P...
poll What shoulde be done for this patient?
6/8/2012
145 responses
http://upload.orthobullets.com/cases/1199/postfxdislo.jpg http://upload.orthobullets.com/cases/1199/humeral head.jpg http://upload.orthobullets.com/cases/1199/hemi.jpg
HPI - 32 y/o hurt his shoulder in 2010 earth quake no treatment since then
poll treatment
5/5/2012
114 responses
http://upload.orthobullets.com/cases/1108/image0404.jpg http://upload.orthobullets.com/cases/1108/image0405.jpg http://upload.orthobullets.com/cases/1108/2011-12-02 16.02.13.jpg
HPI - fall from 10 ft ht on the shoulder.pt is manual labourer
poll What is your preferred method of fixation?
12/12/2011
91 responses
http://upload.orthobullets.com/cases/1095/17022011165.jpg http://upload.orthobullets.com/cases/1095/17022011166.jpg http://upload.orthobullets.com/cases/1095/17022011167.jpg
HPI - Right handed patient fell at home and was brought to emergency department compla...
poll How would you treat this patient?
12/2/2011
120 responses
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