Proximal humerus fractures

Proximal Humerus Fractures

1. Proximal Humerus Fractures Speaker- Dr. Mithilesh Ranjan

2. Proximal Humerus Fractures Defined as Fx occurring at or proximal to surgical neck 80 % of all humeral # 7% of all #.. Pt > 65 yrs – Second most common fracture of the upper extremity 65% of # occur in Pt’s > 60 yrs F:M – 3:1 Incidence increases with age.

3. Mechanism Old Pts low energy trauma. [FOOSH] Most # are nondisplaced , good prognosis – nonsurgical Risk factors: Poor quality bone ,impaired vision & balance, medical comorbidities, decreased muscle tone. Young Pts – High energy trauma Severe soft tissue disruption always require surgical intervention Seizures & electric shock – indirect causes

4. Common mechanism for low energy proximal humerus fractures in elderly patients

5. Anatomy Proximal humerus comprises of four major segments The Articular head The greater tuberosity Lesser tuberosity and The shaft Articular segment is almost spherical, with a diameter of curvature averaging 46 mm (ranging from 37 to 57 mm) Inclination of the humeral head relative to the shaft averages 130 degrees Retroversion of the head varies from 18 to 40 degrees

6. Anatomy Muscle insertions on these segments and the magnitude and direction of the forces causing injury, determine the pattern of fracture lines ,displacement and angulation . Greater tuberosity has three regions into which the supraspinatus, infraspinatus , and teres minor insert Subscapularis tendon  lesser tuberosity, which is separated from the greater tuberosity by the bicipital groove.

7. Deforming forces of PHF The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.

8. Anatomy The ascending branch of the anterior circumflex humeral artery has been considered to provide most of the blood flow to the articular segment. Several studies have shown branches from PCHA to the posteromedial head to be equally important . Arcuate artery of Liang – supplies Humeral head . If the medial calcar of the humerus is spared by the fracture, the vessel is spared.

9. Study on Twenty-four fresh-frozen cadaver shoulders (twelve matched pairs) with Gadolinium MRI Posterior humeral circumflex artery 64% of Blood Supply to Humeral Head

10. Clinical Evaluation A complete history and physical examination must be obtained about the mechanism of injury and velocity of fracture Shoulder pain and limitation of movement Ecchymosis appears 24-48 hrs. Look for rib, scapular, cervical # in high energy trauma. Concurrent brachial plexus injury 5% Axillary nerve is susceptible in anterior # dislocation . Association of arterial injury is rare The patient will hold the arm in internal rotation Radial pulse and capillary refill of fingers should be assessed

11. Imaging and other Diagnostic studies Radiographs :- consist of three views AP- Perpendicular to the plane of scapula( Grashey view) Neer View (Scapula Y view) Axillary view Grashey view- Taken in neutral arm rotation with torso rotated 30 to 45 degrees Neer view- S capula is imaged perpendicular to Grashey view Axillary view- Arm in neutral rotation and abducted as much as possible, with the pt. supine and X-ray beam projected from axilla By taking Grashey and Neer view with arm hanging gravity will provide traction which facilitates understanding of fx morphology.

12. AP Grashey view of the shoulder The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula.

13. Neer view (lateral Y) of shoulder Affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source.

14. Axillary view The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.

15. Velpeau axillary view of the shoulder The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette

16. CT Scan- Allows more detailed understanding of fracture configuration, degree of osteopenia, presence and location of bone impaction and extent of fracture comminution . MRI Is rarely indicated in trauma setting May be helpful in confirming a non-displaced Fx in a pt with shoulder trauma, normal radiographic findings and clinical symptoms Pathological Fx Angiography Vascular imaging is required when there is suspicion of vascular injury CT Angiography- Diagnostic modality of choice. It allows rapid evaluation of vascular system, while simultaneously allowing assessment of bone and soft tissues

17. USG C an be useful in diagnosis of occult proximal humeral fractures. Operator dependent Vasular doppler can be useful in early assessment of suspected vascular injury Dual energy X–ray absorptiometry (DEXA) May be useful in elderly pt. with prox. humeral fx or in those with risk factors for osteoporosis.

18. Classfication of Proximal Humeral Fractures First systems dating back to 17 th Century, classed them as Simple closed versus Open 1896 -- Kocher Focused on the location of the fracture and divided Proximal Humerus Fractures into Supra Tubercular, Peritubercular , Infratubercular , and Subtubercular In 1934 Codman described proximal humerus fractures as occurring along the lines of the epiphyseal scars and observed four possible fracture fragments: the articular surface, the humeral shaft , the greater tuberosity, and the lesser tuberosity.

19. Codman’s depiction of proximal humerus fractures.

20. Proximal Humeral Fracture Classfication AO/OTA classification Is based on fracture location and presence of impaction, angulation, translation, or comminution of the fracture, as well as whether a dislocation is present. Type A- Extra-articular unifocal fractures associated with single fracture line. Type B- Extra-articular bifocal fractures accociated with two fracture lines Type C- Articular fractures which involve the humeral head or anatomic neck. Each type is further sub classified into groups and subgroups. Each subgroup fracture is assigned a level of severity.

21. Proximal Humeral Fracture Classfication Neer Classification (1970) It is a Refinement of Codman’s System, incorporates the concept of displacement and vascular isolation of the articular segment and relates the anatomy and biomechanical forces resulting in the displacement of fragments to diagnosis and treatment Fractures are classified by evaluating the displacement of the Parts (head, shaft, greater tuberosity, lesser tuberosity) from each other Criteria to consider as a part, fragment must be rotated 45 degree or displaced 1 cm from the another fragment . Classifies as One part, Two part, Three Part and Four part Fractures

22. One-Part Fractures No fragments meet the criteria for displacement; a fracture with no fragments considered displaced is defined as a one-part fracture regardless of the actual number of fracture lines or their location. Two-Part Fractures One segment is displaced Three-Part Fractures With a three-part fracture, one tuberosity is displaced and the surgical neck fracture is displaced. The remaining tuberosity is attached, which produces a rotational deformity . Four-Part Fractures All four segments (both tuberosities , the articular surface, and the shaft) meet criteria for displacement . This is a severe injury and carries a high risk of avascular necrosis.

23. Valgus-Impacted Four-Part Fractures Neer added this pattern as a separate category in 2002 . In this situation, the head is rotated into a valgus posture and driven down between the tuberosities , which splay out to accommodate the head. Unlike in the classic four-part fracture, the articular surface maintains contact with the glenoid . Fracture Dislocations and Articular Surface Injuries Fractures combined with glenohumeral dislocation are classified as fracture dislocation. Fractures involving articular surface can be of two varieties-  head-splitting fractures and impaction fractures. They are included in group of fracture dislocations

24. Fracture Frequency In 2001 Court-Brown et al published study on distribution o f PHF types. Non-displaced or minimally displaced one-part fractures comprised half (49%) of all fractures. Two part- 37%. Surgical neck fractures comprised 3/4 th of these. Two part anatomic neck fractures were rare (0.2 %) Three part fractures- 9 % Four part- 3 %, of which one third were true fracture dislocations. Fractures involving articular surface occurred in 0.7 % cases.

25. Risk of Avascular Necrosis Four-part fractures and fracture dislocations are considered to have the highest risk for humeral head necrosis . Hertel criteria – Metaphyseal extension of the humeral head < 8 mm M edial hinge disruption of >2 mm, and Fracture through anatomical neck The combination a bove above factors had 97% positive predictive value for humeral head ischemia.

26. Metaphyseal extension of the humeral head of >9 mm Metaphyseal extension of the humeral head of <8 mm.

27. Undisplaced medial hinge Medial hinge with >2 mm of displacement

28. Non-operative Treatment of Proximal Humeral Fractures The majority of proximal humeral fractures are nondisplaced or minimally displaced and nonoperative treatment is indicated. Fracture stability can be assessed both radiographically and clinically. Radiographically , stable fractures exhibit impaction or interdigitation between bone fragments Clinically, fracture stability may be assessed by palpating the proximal humerus just distal to the acromion with one hand, while rotating the arm at the elbow with the other. If the proximal humerus is felt to move as a unit with the distal segment, the fracture is considered stable

29. Stable proximal humeral fractures through the anatomic neck

30. Non-Operative Treatment Indications Stable non-displaced or minimally displaced fractures Patients not fit for surgery Elderly patients with low functional demands Relative Contraindications Displaced fractures with loss of bony contact C lose follow-up is required to confirm acceptable alignment and fracture stability. Weekly radiographs should be performed during the first month of treatment, followed by biweekly radiographs until 6 weeks after injury or initial callus formation is visible.

31. Complications Major complications following nonoperative treatment of proximal humerus fractures include- Avascular necrosis Nonunion Malunion Stiffness Rotator cuff dysfunction Posttraumatic arthritis

32. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus involving surgical neck Studied 231 pt (114 in surgical group and 117 in nonsurgical group) aged 16 yrs or older (mean age 66 yrs ) Patients were followed up for 2 years Results There was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence.

33. T otal 518 patients (average age 70.93) met inclusion criteria. Patients were followed up for at least 1 year in all the studies . Conclusion Operative treatments did not significantly improve the functional outcome and healthy-related quality of life in elderly patients . Instead, Operative treatment for CPHFs led to higher incidence of postoperative complications.

34. Controversial What is optimal management for displaced Proximal Humerus Fractures ?

35. Operative Treatment of Proximal Humeral Fractures Many surgical techniques have been described, but no single approach is considered to be the standard of care . Appropriate treatment is individualized and selected on the basis of the fracture pattern and the underlying quality of the bone . Surgical Options- Open Reduction and Internal Fixation Tension Band Fixation Closed Reduction and Percutaneous Fixation Intramedullary Nailing Hemiarthroplasty Reverse Total Shoulder Arthroplasty

36. Open Reduction and Internal Fixation (ORIF) ORIF is the most frequently used method of surgical treatment of proximal humeral fractures. Surgical Approaches Deltopectoral Approach W orkhorse for reconstructive shoulder surgery Incision is marked out 1 cm lateral to the coracoid. This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial. Deltoid-Splitting Approach Two Major Disadvantage In anteroinferior fracture dislocations, the humeral head fragment may not be accessible Risk of damage to anterior branch of the axillary nerve thereby leading to potential deltoid dysfunction .

37. Deltopectoral Approach

38. Fixation using Conventional Plate Prior to the use of locking-plate technology, conventional plate fixation was used for the majority of patients. Several studies have reported satisfactory healing rates and functional outcomes after conventional plate and screw fixation of proximal humeral fractures, especially in younger patient populations. Many studies have however reported high rates of infection, humeral head necrosis, and subacromial impingement. Traditional plate constructs are usually reserved for Young patients with an intact medial hinge, A dequate diaphyseal cortex(> 4 mm), and N o metaphyseal comminution .

39. Fixation using Locking Plate The inability of conventional plates and screws to resist varus deforming forces in the proximal humerus , particularly if the bone is osteoporotic,has led to locking plate fixation being used for these fractures. Several clinical studies have shown high rates of healing and excellent functional recovery with proximal humerus locking plates. Plate designs vary in terms of the number of proximal screws and their arrangement, as well as the ability to place screws at different angles with regard to the plate. A plate is selected to allow at least three screws to be placed into the distal shaft segment. The plate position is also selected to avoid subacromial impingement and to allow two screws to be placed into inferomedial aspect of the humeral head .

40. A minimum of five or six screws are routinely placed into the proximal segment. Screw placement should be performed by drilling through the near cortex only. This avoids perforation of the articular surface, and reduces the possibility of secondary screw penetration. Once the plate and screws have been placed transtendinous sutures are tied onto the plate to provide additional fixation.

41. The use of IM fibular strut grafting has been described to improve stability of varus -impacted fractures in which the medial calcar may not be reliably reconstructed . G oal being to create a buttress at the inferior aspect of the anatomic neck to prevent delayed varus collapse

42. Postoperative Care Patients are followed at 2 weeks, 6 weeks, and 3 months after surgery. Patients are immobilized for 6 weeks in a sling while active range-of-motion exercises of the elbow, wrist, and hand are encouraged. Depending on the fracture pattern and stability that was achieved, passive range of motion is started between 2 and 4 weeks after surgery with forward elevation, external rotation, and pendulum exercises. If healing has adequately progressed both clinically and radiographically at 6 weeks active-assisted range of motion is started.

43. Tension Band Fixation It is most frequently used as an adjunct to plates and screw fixation, IM nailing, and arthroplasty . The main goal of tension band fixation is the neutralization of tension forces generated by the rotator cuff at the level of the tuberosities , and bending at the level of the surgical neck. The main advantage of tension band fixation is the minimal amount of hardware that is required. Thus avoiding the risks associated with hardware, which include pain , neurovascular compromise, migration, failure, and the need for removal . Contraindications P revious attempt(s ) at internal fixation or F ractures older than six weeks. H ighly comminuted four part fractures.

44. Tension-band construct with transosseous suture fixation

45. Closed Reduction and Percutaneous Fixation It has theoretical advantage of minimizing soft tissue trauma, thereby promoting healing and reducing the risk of AVN of the humeral head. It also has the advantage of decreased scarring in the scapulohumeral interface and subsequent easier rehabilitation. Indications- Fracture without significant communition in pt with good quality bone. Pt should be willing to comply with postop care plan . Contra indications Severe comminution and osteopenia are absolute contraindications Inability to reduce Fracture Fragments Fracture Dislocation Non Compliant patients

46. To avoid injury to the axillary nerve, lateral pins should enter the humeral cortex at a point at least twice the distance from the upper aspect of the head to the inferior head margin with the wire angulated approximately 45 degrees to the cortical surface . The end point for the greater tuberosity pin should be >2 cm from the inferior most margin of the humeral head .

47. Intramedullary Nailing Biomechanical advantages in osteoporotic bone It allows stabilization with minimum surgical invasion Indications- Displaced two part surgical neck fractures Pathological fractures Contraindications- V arus four-part fractures with lateral displacement of the humeral head Head-splitting fractures

48. Hemiarthroplasty A lso known as humeral head replacement Indications- F our-part fractures, T hree-part fractures in older patients with osteoporotic bone, F racture-dislocations Comminuted head-splitting fractures Head depression fractures involving more than 40% of the articular surface Contraindications- Active infection of the shoulder joint and/or the surrounding soft tissue

49. Postoperative Care Passive range-of-motion exercises are started on the first postoperative day. They are limited to neutral rotation and 90 degrees of forward elevation. Patients are followed up clinically and radiographically at 2 weeks, 6 weeks, and 3 months . Active-assisted range-of-motion exercises are started at 6 weeks and strengthening exercises at 3 months

50. Reverse Total Shoulder Arthroplasty By placing a hemisphere onto the glenoid surface and a concave tray onto the humeral stem, reverse shoulder arthroplasty allows for rotation to occur at the glenohumeral joint through activation of the deltoid, without the need for a functional rotator cuff/tuberosity unit. Indications C omplex acute proximal humeral fractures P roximal humerus malunion or nonunion where the normal anatomy of the tuberosities cannot be reliably restored G lenohumeral joint arthritis with advanced rotator cuff pathology M assive irreparable rotator cuff tears with painful pseudoparesis

51. The ideal candidate for reverse total shoulder arthroplasty in a patient with a complex proximal humerus fracture is a low demand elderly patient with pre-existing rotator cuff pathology and glenoid pathology.

52. Comparison of outcomes of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA ) in elderly pt. Sixty-two patients older than 70 years were randomized to RSA (31 patients) and HA (31 patients ) The mean functional scores and active range of motion were significantly better in the RSA group. Revision rate was lower in RSA.

53. Complications Avascular necrosis of humeral head and/or tuberosity Non-union- The normal time for clinical union of a proximal humeral fracture is typically 4 to 8 weeks. N onunion is said to be present if a fracture site is still mobile 16 weeks post injury. Malunion Post-traumatic Shoulder stiffness Post traumatic arthritis Infection Iatrogenic-such as inadequate reduction, incorrectly positioned implants, screw penetration into the joint, loss of fixation, tuberosity disruption, and nerve injury. Heterotopic bone formation

54. General Treatment Philosophy of Proximal Humerus Fractures A ll nondisplaced fractures, minimally displaced fx as well as most valgus-impacted fractures are treated non operatively especially in patients with lower functional expectations . In patients with higher baseline shoulder function and higher expectations , surgical treatment may be recommended for most displaced fractures. For patients undergoing surgical treatment fracture reduction and fixation is performed in majority of cases and effort should be made to reconstruct the proximal humerus with emphasis being placed on achieving anatomic reduction and stable fixation of the tuberosities .

55. Shoulder arthroplasty is considered in fractures in which a high suspicion of head nonviability is suspected because of severe displacement of the fracture through the anatomical neck without metaphyseal extension, disruption of the medial hinge and frank dislocation from the glenoid . In younger patients, hemiarthroplasty is the chosen treatment method, in elderly patients, reverse shoulder arthroplasty is preferred.

56. Treatment of Individual Injury Patterns of Proximal Humerus Fracture Nondisplaced or Minimally Displaced One-Part Fractures These are treated nonoperatively with initial immobilization in a sling. Weekly radiographs and clinical assessment are performed for the first 3 weeks . Elbow, wrist , and hand mobilization begins immediately . Passive range-of-motion exercises are begun at 3 weeks if no change in fracture position has been confirmed. Active-assisted range of- motion exercises are begun at 6 weeks and strengthening is started at 3 months when bony healing has been confirmed radiologically .

57. Greater Tuberosity Fractures Displacement of the greater tuberosity is poorly tolerated because of its key role in shoulder function Currently threshold of displacement for surgical treatment of greater tuberosity fractures in active patients is accepted as 5 mm (instead of 1 cm as per Neers’s criteria) Flatow et al. reported the results of 12 displaced two-part greater tuberosity fractures that were treated by heavy suture fixation and rotator cuff repair. They reported 100% excellent or good results with all fractures healing without displacement .

58. Two-Part Greater Tuberosity Fractures and Fracture Dislocations In elderly, frail patients (usually older than 80 years) with limited functional expectations, a substantial degree of displacement and these are treated non operatively. Operative treatment is advised for physiologically younger patients with fractures, which are either primarily displaced by more than 5 mm or become displaced by this amount within the first 2 weeks after injury . Fixation is obtained either with suture anchors in a double row pattern or by the use of transosseous sutures, or alternatively , a small T-plate may be fixed laterally

59. Two-Part Lesser Tuberosity Fractures and Fracture Dislocations Isolated lesser tuberosity fractures typically occur in younger or middle-aged patients and are displaced . ORIF - Preferred Single large fragment -definitive internal fixation is performed using partially threaded 3.5-mm cancellous screws, inserted through the lesser tuberosity. If communited - transosseous sutures is used for fixation.

60. Two-Part Surgical Neck Fractures All fractures in which the shaft is impacted into the surgical neck are treated nonoperatively . A substantial degree of translation of these two fragments is usually tolerated, as long as there is residual cortical contact and impaction . Displaced and comminuted surgical neck fractures in physiologically younger patients are managed with ORIF using a locking plate.

61. Three- and Four-Part Fractures I n physiologically older patients these are usually treated nonoperatively if there is residual cortical continuity of the humeral head fragment on the shaft, the tuberosities are not too widely displaced, and the humeral head appears viable. Operative treatment is offered to physiologically younger patients , where the risk of nonunion, cuff dysfunction , or osteonecrosis is high. ORIF is performed whenever possible, and preoperative CT scan provide an indication of its feasibility . The patient is always preoperatively counseled that if the fracture is deemed to be unreconstructable , an arthroplasty will be performed . Y oung patients - C emented humeral head replacement Older patients – Reverse total shoulder arthroplasty

62. Thank You