Proximal Humerus Fractures
Michael W. Leathers, M.D.
General
• Most common in active middle-aged patients (avg. age: 54 years)
• Incidence: 4-5% of all fractures• Osteoporosis major predisposing factor• Loss of trabecular bone up to epiphyseal
plate• Loss of trabeculae greatest in surgical
neck region
Anatomy & Function
• Retention glenohumeral mobility
• Muscle forces on proximal humerus, tuberosities, shaft
• Blood supply humeral head
• Neurovascular structures
Blood Supply
• Ascending branch of anterior circumflex humeral artery is primary blood supply
• Posterior circumflex artery serves much smaller portion– Primarily
posteroinferior head & posterior greater tuberosity
Schlegel TF, Hawkins RJ: JAAOS 2:54, 1994
Neer Classification
• Displacement > 1 cm• Angulation > 45o
Neer, JBJS-A, 52, 1970
4-part Displacement
• Both tuberosities detached, retracted
• Articular segment devascularized
• High incidence of AVN
• Primary prosthesis gives best results
• Surgery: Restoration humeral length and cuff fixation
• Early passive exercise, progress
Post-traumatic AVN
• Wide range of resultant osteonecrosis after 4-part fractures: (26-75%)
• Also seen in some 3-part fractures (3-14%) and with associated dislocations
• Jakob & Miniaci et al– Four part valgus impacted fracture
– 26% osteonecrosis
Jakob, Miniaci et al; JBJS, 73B:2, 1991Loebenberg, Plate, Zuckerman: AAOS ICL, 48, 1999
Rockwood & Green, Fractures in Adults, 1999
Treatment
• Options:– Non-operative
– Closed reduction
– ORIF
– Hemiarthroplasty
• Factors:– Fracture pattern
– Patient age
– Comorbidities
– Bone quality
Non-op Tx & Closed Red.
Non-operative Tx• Poor results
– 1/16 - Able raise arm > 90o
– 9/16 - Constant pain
– Satisfactory results of arthroplasty = non-operative tx of minimally displaced fx
Closed reduction• Poor results
– 3/39 - Satisfactory (3-part)
– 0/38 - Satisfactory (4-part)
Neer, JBJS-A, 52, 1970
Stableforth, JBJS-B, 66, 1984
ORIF
• Appropriate for valgus impacted 4-part fx• Ensure adequate bone stock• Beware posterior or lateral displacement• 74% satisfactory outcome; 26% AVN
Jakob, Miniaci et al; JBJS, 73B:2, 1991Resch, JSES, 4, 1995
ORIF
ORIF
Many options:• Plates & screws• IM rods (vertical
fixation)• Vertical fixation w/
tension band• Tension band alone
Results• Adequate results for 3-
part fx– 19/30 Good/excellent
• Neer, JBJS-A, 52, 1970
– 21/35 Good/excellent• Darder et al, J Orthop Trauma, 7, 1993
• Consistently poor results for 4-part fx
Paavolainen et al, Acta orthop Scand, 54, 1983Cuomo et al, JSES, 1, 1992
Koval et al, J Trauma, 2, 1993Williams, JSES, 6, 1997
Challenges• 4-part fractures
• 3-part fx & fx-disloc. in elderly with osteoporotic bone
• ORIF not possible
• Chronic ant/post disloc. with impression fractures > 40% articular surface
Zuckerman et al, 1997
Shoulder Arthroplasty
• Results of hemiarthroplasty superior to nonsurgical treatment
• Satisfactory results in 80%
• Pain outcome good
• Functional outcome less predictable
• Age most important prognostic indicator (Green, 1993)
• Determine proper height
Shoulder Arthroplasty - Technique
• Determine degree of retroversion
• Determine appropriate head size
Total Shoulder Arthroplasty
Results of HSA 4-part Fractures
• Neer: 31 of 32 excellent or satisfactory results• Kraulis: 9 of 11 unsatisfactory• Willems: 4 of 10 excellent or satisfactory• Cofield: Good pain relief
– Active forward flexion 101o
• Kay (UCLA): Excellent pain relief– Active elevation 94
o
• Cockx: Good cuff repair 109o
FF– Poor/no cuff repair 51
o
FF
Timing of Hemiarthroplasty
Acute• Same to better pain relief• Variable results of ROM,
function– Usually better
• Problems– Tuberosity healing
– RC failure
– Assoc. w/ surgical technique
Chronic• Higher rate of
complications– Surgical difficulty
– Scarring
– Distortion of anatomy
Tanner & Cofield, Clin Orthop, 179, 1983Frich et al, Orthopaedics, 14, 1991
Dines et al, JSES, 2, 1993Norris et al, JSES, 4, 1995
Greater Tuberosity Pathology
1. Abnormally painful shoulder immediately post-op
2. No progression (24%) or regression (9%) of active shoulder mobility > 3 mos post-op
3. Dissociation between active (deficient) and passive (preserved) forward elevation
- Malunion (15%); Axillary n. damage (6.5%)
* Migration & malunion (21.5%) & nonunion (11%) results in a poor functional outcome
Boileau, Rev chir orthop reparatrice appar mot, 85:2, 1999
Rotator Cuff & Deltoid
• Restoration of the rotator cuff mechanism important to functional result
• Must avoid detachment of deltoid
Tonino et al, Acta Orthop Belg, 51, 1985Green et al, JSES 2, 1993
Hawkins et al, Clin Orthop, 289, 1993Compito et al, Clin Orthop, 307, 1994
Goldman et al, JSES, 4, 1995
Cement
• Cement advocated in all cases
• Provides immediate stability
• Decreases incidence of loosening
• Also requires graft proximally to cover exposed stem
Green et al, JSES 2, 1993Hawkins et al, Clin Orthop, 289, 1993Compito et al, Clin Orthop, 307, 1994
Biceps
• Biceps often tenodesed by reattachment of tuberosities
• Currently recommended to release origin and tenodese to proximal humerus
• Otherwise, intra-articular length shortened & will restrict external rotation
Harryman et al, JSES, 7, 1998
Results
Unsatisfactory resultsUnsatisfactory results• Resorption or nonunion of tuberosities• Rotator cuff dysfunction• Cartilage space <2mm
Satisfactory resultsSatisfactory results• Radiographic union of tuberosities• Integrity of rotator cuff• Cartilage space > 2mm
Discussion
• Patients are usually asymptomatic preinjury
• Discuss results with patient before surgery
Prognosis
• More severe injuries, elderly pts less optimal results
• Avoid deltoid origin detachment
• Lingering stiffness, pain, loss AROM > 6 months
• Attention to surgical detail will improve prognosis (tuberosity reduction)
Treatment Algorithm
Naranja, JAAOS, 8:6, 2000
Complications
• #1 – Detachment of greater tuberosity
• Looseing of prosthesis• Infection• Glenoid erosion• Malpositioning of
humeral component• Dislocation
• Nerve injury (ax/mc)– 6.1% – 27%
– Also assoc. w/ closed reduction
• Heterotopic ossification– 16%, esp surgery
delayed > 10 d
Stableforth, JBJS-B, 66, 1984Neer, Rev chir orthop suppl II, 74, 1988
Bigliani, Orthop Trans, 15, 1991
Joint Stiffness
• Bursal and capsular adhesions
• Treatment: Warm applications, stretching
• Avoid manipulation
• Prevent stiffness with early exercise program
Conclusions
1. Minimal pain but limited function
2. Better results with intact rotator cuff, tuberosities and cartilage space > 2mm
3. Limited expectations
Case Presentation
• 42 yo woman fell down flight of stairs, sustaining bilateral distal radial fx, right non-displaced olecranon fx, right proximal humerus fx, & pelvis fx
• No PMH, Allergies, or Meds
Xrays & CT Scan
Post-op Xrays
Thank You