Proximal Humerus Fractures
ALAM ZEB
Learning Objectives
bullBony and Muscular anatomy of the proximal humerusbullEpidemiological factors and common mechanism of injury for proximal humeral fracturesbullDiagnostic toolsbullObjective ExaminationbullManagementbullRehabilitation program bullCommon complications
Bony Anatomy1048698 Humeral HeadShaft
1048698 Greater Tuberosity
1048698 Lesser Tuberosity
1048698 Surgical Neck
1048698 Anatomical Neck
Muscular Anatomy
bull Subscapularis attaches to lesser tuberositybullSupraspinatusInfraspinatusTeres Minor attaches to greater tuberositybullDeltoid attaches to deltoid tuberositybullPectorolis Major attaches to lateral lip of bicipital groove
Epidemiologybull 4-5 of all fracturesbull 75 of humeral fractures in patients over 40bull Women incidence gt Men ndash osteoporotic factor
Mechanism of InjuryOver 50 ndash Minimal to moderate trauma ndash More typically indirect mechanism such as fall on an outstretched hand Under 50 ndash High-energy trauma ndash More typically direct impact or fall on the shoulder ndash May be concurrent with dislocation due to higher forces
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Learning Objectives
bullBony and Muscular anatomy of the proximal humerusbullEpidemiological factors and common mechanism of injury for proximal humeral fracturesbullDiagnostic toolsbullObjective ExaminationbullManagementbullRehabilitation program bullCommon complications
Bony Anatomy1048698 Humeral HeadShaft
1048698 Greater Tuberosity
1048698 Lesser Tuberosity
1048698 Surgical Neck
1048698 Anatomical Neck
Muscular Anatomy
bull Subscapularis attaches to lesser tuberositybullSupraspinatusInfraspinatusTeres Minor attaches to greater tuberositybullDeltoid attaches to deltoid tuberositybullPectorolis Major attaches to lateral lip of bicipital groove
Epidemiologybull 4-5 of all fracturesbull 75 of humeral fractures in patients over 40bull Women incidence gt Men ndash osteoporotic factor
Mechanism of InjuryOver 50 ndash Minimal to moderate trauma ndash More typically indirect mechanism such as fall on an outstretched hand Under 50 ndash High-energy trauma ndash More typically direct impact or fall on the shoulder ndash May be concurrent with dislocation due to higher forces
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Bony Anatomy1048698 Humeral HeadShaft
1048698 Greater Tuberosity
1048698 Lesser Tuberosity
1048698 Surgical Neck
1048698 Anatomical Neck
Muscular Anatomy
bull Subscapularis attaches to lesser tuberositybullSupraspinatusInfraspinatusTeres Minor attaches to greater tuberositybullDeltoid attaches to deltoid tuberositybullPectorolis Major attaches to lateral lip of bicipital groove
Epidemiologybull 4-5 of all fracturesbull 75 of humeral fractures in patients over 40bull Women incidence gt Men ndash osteoporotic factor
Mechanism of InjuryOver 50 ndash Minimal to moderate trauma ndash More typically indirect mechanism such as fall on an outstretched hand Under 50 ndash High-energy trauma ndash More typically direct impact or fall on the shoulder ndash May be concurrent with dislocation due to higher forces
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Muscular Anatomy
bull Subscapularis attaches to lesser tuberositybullSupraspinatusInfraspinatusTeres Minor attaches to greater tuberositybullDeltoid attaches to deltoid tuberositybullPectorolis Major attaches to lateral lip of bicipital groove
Epidemiologybull 4-5 of all fracturesbull 75 of humeral fractures in patients over 40bull Women incidence gt Men ndash osteoporotic factor
Mechanism of InjuryOver 50 ndash Minimal to moderate trauma ndash More typically indirect mechanism such as fall on an outstretched hand Under 50 ndash High-energy trauma ndash More typically direct impact or fall on the shoulder ndash May be concurrent with dislocation due to higher forces
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Epidemiologybull 4-5 of all fracturesbull 75 of humeral fractures in patients over 40bull Women incidence gt Men ndash osteoporotic factor
Mechanism of InjuryOver 50 ndash Minimal to moderate trauma ndash More typically indirect mechanism such as fall on an outstretched hand Under 50 ndash High-energy trauma ndash More typically direct impact or fall on the shoulder ndash May be concurrent with dislocation due to higher forces
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Diagnostic Studies
X-ray (Trauma Series)ndash A-Pndash Lateral (Y-view)ndash Axillary View CT Scanndash To determine fracturealignment anddisplacement
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Objective Examination
bull Varies related to type of fracture and amount of displacementbull Painful motionbull Swelling and delayed ecchymosisbull Tenderness to palpationbull Crepitus indicative of fracture instabilitybull IRER to assess proximal and distal humerus move simultaneously as a unit
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
General Treatment OptionsNon-Operative
bull80 of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY
Operativebull20 of PHF are Displaced which can be treated operatively and non-operativelyit depends upon the fracture paterrnOperative Techniques used are - Percutaneous pinningndash Plates and screwsndash Intramedullary rodsndash Humeral head prosthesis
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Operative Techniques
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Rehabilitation Early and aggressive rehabilitation program designed to bullPrevent stiffness and restore nomal ROMbullMaintain normal relationship between head of Humerus and gleniod cavitybullProvide stability at Fracture sitebullRegain strength of shoulder musles
bull Rehabilitation exercise needs to begin within14 days of injury to increase likelihood ofacceptable outcome and reduce chance formotion complications
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Typical ProgressionIst weekbullAll shoulder movements are avoidedbullStrengthening exercises are avoidedbullWeight bearing is strictly prohibitedbullProvide assistance in daily life activities Weeks 2-4 bullPendulum exercises with sling are startedbullIsometric shoulder exercisesbullWeight bearing is prohibitedWeeks 4-8 bullPerform active active assisted and passive ROM to shoulder and elbowbullIsometric and Isotonic exercise
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Typical Progression
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans
Common Complicationsbull Stiffnessbull Non-Union or Malunionbull Avascular Necrosisbull Neurovascular Injurybull Myositis Ossificans