Proximal Humerus Fractures/Dislocations

1. Proximal Humerus Fractures/Dislocations D. Kevin Scheid, MDCreated March 2004; Revised March 2006

2. History/Demographics • Bimodal: young-high energy, elderly-low energy(osteoporosis) • 45% of all humerus fx. • elderly females 4:1 over males • 77% of all prox. hum. fractures female

3. Consequences/Associated Injuries • Disabilities often underestimated • Loss of motion • Loss of reduction • AVN • heterotopic bone • Associated Injuries • rotator cuff • nerve(axillary, brachial plexus) • vascular • scapula, clavicle

4. Anatomy • Appearance of Ossification Centers • epiphysis 4mo • Gr. Tub. 3yr • L. Tub. 5yr • Physeal scar closure • 20-22 yrs.

5. Proximal Humeral Retroversion • 35-40 degrees relative to epicondylar axis

6. Blood Supply • Axillary artery • ant. humeral circumflex • *ascending branch (arcuate artery) is the major blood supply to the articular surface • post. humeral circumflex Arcuate Arcua afeeffe

7. Nerves • Brachial Plexus • axillary • suprascapular • musculocutaneous

8. Rotator Cuff Muscles • Supraspinatous • Infraspinatous • Subscapularis • Teres Minor • Deltoid • Pectoralis • Long head biceps

9. Neer (4 part) 2 part AN (anatomic neck) SN (surgical neck) 3 part SN+GT, LT 4 part SN+GT+LT *head splits *articular impressions fx. dislocations AO type A 2 part extracapsular type B 3 part partially intracapsular type C vascular isolation of head 4 part intracapsular Classification

10. Classification • Neer • 2 part • SN,AN,GT,LT • 3 part • SN+GT or LT • AN+GT or LT • 4 part • neck+both tuberosities • +/- dislocation • Neer’s definition of displacement: >1cm or >45 degrees

11. Trauma Series true scapular AP axillary (head defects, displacement of tuberosities Y or transscapular Other modified axillary AP in int. and ext. rotation CT Scan articular fractures impression head split glenoid fractures assess tuberosity displacement for operative decision making Radiographic Work Up

12. Radiographic Work UpScapular AP, Axillary, Y view, CT Scan

13. Considerations for closed treatment patient age displacement surgical neck tuberosities articular surface functional demand arm dominance ability to salvage with an arthroplasty later if needed Methods of closed treatment sling sling and swath hanging cast abduction pillow Treatment

14. Fractures to Consider for Closed Treatment Minimally displaced 2 part fx’s (or positional reduction of significant displacement) GT fractures should be <5mm). Minimally displaced 3- and 4-part fractures

15. Fractures to Consider for ORIF • Displaced GT fx (> 5 mm) • LT fx with involvement of articular surface • Displaced or unstable surgical neck fx • Displaced anatomic neck fx in young pt. • Displaced, reconstructible 3- and 4-part fractures

16. Fractures to Consider Hemiarthroplasty • Young/Middle age • nonreconstructable articular surface (severe head split) or extruded anatomic neck • Elderly • many 4 parts • some severe 3 parts • most 3,4 part fracture dislocations • most head splits

17. Current Techniques of ORIF • Percutaneous Pins (Jaberg, H. 1992) • Suture, K-wire, tension band technique (Cornell,C. H. 1994, Darder, A. 1993, Hawkins, J.R. 1987, Neer, C.S. 1970) • Flexible IM nails (Lee, C. K. 1981, Robinson, C. M. 1993, Wesley, M. S. 1977) • Buttress Plates (Esser, R. D. 1994, Kristiansen, B. 1986, Paavolainen, P. 1983, Savoie, F.H. 1989) • Selected Locked Rigid IM nails • Blade Plate Fixation (Weber 1984, Sehr, Szabo 1988, Jupiter, Scheid 1999) • Proximal Humeral Locking Plates

18. Surgical Approaches Deltopectoral Deltoid Splitting Posterior Percutaneous Fracture / Fixation SN, LT,3 part, 4 part / surgeon choice GT, Some SN if using IM fixation scapula, glenoid, occasional posterior articular fracture Fx’s amenable to pinning or nailing

19. Percutaneous Pinning • Technique: beach chair position, closed manipulation, oscillating drill, terminal thread pins, at least bidirectional pins (see Jaberg H. 1992), cut pins beneath skin, sling and swath, follow closely • Associated Problems: nerve injury (axillary), pin loosening, migration, no early motion • Best Use: limited 2 or 3 part when other techniques not favorable Migration----

20. Suture or K-wire/Tension Band • Technique: beach chair position, deltoid splitting or deltopectoral approach, k wire and suture repair of tuberosities with tension band (suture or wire) to metaphysis • Associated Problems: cuff constriction, limited head fixation to shaft, wire migration • Best Use: GT, LT, GT+LT, tuberosities with undispl. SN

21. Flexible Nails • Technique: beach chair position, deltoid splitting approach, lateral tuberosity or cuff splitting insertion, may combine with tension band suture • Associated Problems: limited head fixation, migration into subachromial space, cuff violation • Best use: 2 part SN • Newer plates and nails more favorable

22. Locked Rigid Nails for Proximal Humerus • enhanced proximal fixation with twisted blades or multiple screws

23. Buttress Plating • Technique: sitting or supine, deltopectoral approach, lateral to bicepts groove to minimize vascular damage • Associated problems: poor head fixation, large dissection, iatrogenic vascular damage, impingement • Best use: low 2 part SN +/- large GT • * rarely used technique due to impingement and poor head fixation • Newer locking plates now favorable

24. Blade Plate Technique • Technique: beach chair positon, deltopectoral approach, metaphyseal slot lateral to bic. groove, minimal soft tissue stripping • Associated Problems: learning curve, penetration of humeral head in osteoporotic bone • Advantages: no impingement in high angle blade, superior head fixation to other techniques, easily combined with suture fixation of tuberosities

25. PROXIMAL HUMERAL LOCKING PLATE

26. PROXIMAL HUMERAL PLATE

27. PROXIMAL HUMERAL

28. Hemiarthroplasty • Technique: beach chair position, deltopectoral approach, retain tuberosity fragments with cuff attachments, combine suture repair of tuberosities, bone graft from head if needed • Associated Problems: unpredictable results from function standpoint, still requires bony healing (of tuberosities) • Best use: elderly 3,4 part, head splits, disvascular AN

29. SN: closed treatment has yielded 60-90% satisfactory results GT: 50-100% poor results with displaced (>.5-1cm) fractures treated closed. Good results with ORIF. 3 Part: closed treatment (min. displacement or nonoperative elderly pt.) yields unpredictable results (15-70% satisfactory) ORIF with good reduction: 60-80% good to excellent results 4 Part: poor results with closed treatment. Hemiarthroplasty gives satisfactory pain results with somewhat unpredictable functional results. ORIF in younger patient have yielded <=50% satisfactory results. Higher AVN in ORIF Head Split: If CTS shows segment attached to LT then ORIF. If severe fragmentation of articular surface then Hemi. Results

30. Complications • Misdiagnosis • degree of GT displacement • missed post. Dislocation • massive rot. cuff avulsion with high energy dislocation. Suspect when severe swelling • head split (double shadow) best seen on axillary v. or CTS

31. Complications • Nonunion • In young, treat like an acute fracture if head viable. • Consider hemiarthroplasty in elderly or osteoporotic.

32. AVN Significant incidence in 3 and 4 part fractures. Higher when treated with ORIF. Unlike hip, incidence does not correlate directly with symptoms. Can be minimized with decreased soft tissue stripping and no encroachment of circumflex/arcuate art. Adhesive Capsulitis almost universal but minimized with early motion controlled P.T. manipulation under anesthesia occasional arthroscopic release Complications

33. Classified by: Direction Etiology Involuntary vs voluntary Shoulder Dislocations

34. Most common Up to 20-40% neurologic injury (axillary, brachial plexus) Axillary x-ray or CT to assess for head impaction or Hill Sachs lesion May be associated with greater tuberosity fracture Anterior Shoulder Dislocation

35. Associated with seizures or electrical shock Commonly missed on X-ray High incidence of associated lesser tuberosity fracture Posterior Shoulder Dislocation Example of a posterior dislocation

36. Traumatic Usually unidirectional Atraumatic Often associated with multidirectional instability, psychiatric problems if voluntary Shoulder Dislocations - Etiology

37. Stretching / Tearing of capsule Usually off glenoid Occasionally off humerus (HAGL lesion) Labral damage “Bankart” lesion refers to avulsion of anterior-inferior labrum off glenoid rim. May be associated with glenoid rim fracture (“bony bankart” Humeral Head impression fracture (Hill-Sachs Lesion) Shoulder Dislocations - Pathoanatomy

38. The “posterior mechanism” of shoulder instability - coined by Dr. Ed Craig (Clin Orthop 190, 1984) Common in older patients Beware of inability to lift the arm in an older patient following a dislocation Shoulder Dislocations - Rotator Cuff Tear

39. Inspection - note fullness of anterior chest, prominence of acromion Note position of arm and restricted motion Document detailed neurovascular exam Shoulder Dislocations - Evaluation Deltoid atrophy 6 months after shoulder dislocation

40. X-rays - shoulder trauma series (CT if uncertain) Special views: Stryker notch view images Hill-Sachs lesion West Point view images anterior-inferior glenoid CT scan - best if concerned about associated fracture MRI - best for evaluating associated soft-tissue pathology Shoulder Dislocations - Imaging Torn anterior labrum

41. Immediate reduction Many techniques Adequate sedation Control scapula Immobilization Controversial re: position and duration Shoulder Dislocations - Treatment

42. 19 patients studies with MRI Effect of arm position on degree of coaptation of Bankart lesion documented for multiple positions Conclusion: Immobilization in external rotation provided the best reduction of the anterior labrum Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. Itoi E, et al, J Bone Joint Surg Am 2001, 83-A: 661-7

43. Related to Age, Direction Etiology Age < 30 Recurrence high after traumatic anterior dislocation Age > 45 Recurrence less common Shoulder Dislocations - Outcome

44. Usually reserved for patients with recurrent instability Occasionally done after first time dislocation in high-demand patient Surgical Treatment of Shoulder Dislocations

45. Arthroscopic Lavage Removal of hematoma leads to less recurrence? Bankart repair Capsulorraphy Surgical Treatment of Shoulder Dislocations Either approach allows repair of labrum and tightening of capsule. Open repair remains the “gold standard” {

46. Brachial Plexus Injury Carefully document pre- and post-reduction neuro exam in all! Recurrent dislocation Common in more active patients Treated with anterior shoulder reconstruction Shoulder Dislocations - Complication If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Upper Extremity Index