proximal humerus fracture

Question 1

Epidemiology

Answer 1

• incidence
  
  • 4-6% of all fractures
  • third most common non-vertebral fracture pattern seen in the elderly (>65 years old)
• demographics
  
  • 2:1 female to male ratio
  • increasing age associated with more complex fracture types

Question 2

mechanism

Answer 2

mechanism

• low-energy falls
  
  • elderly with osteoporotic bone
• high-energy trauma
  
  • young individuals
  • concomitant soft tissue and neurovascular injuries

Question 3

pathoanatomy

Answer 3

• pectoralis major displaces shaft anteriorly and medially
• supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity
• subscapularis interally rotates articular segment or lesser tuberosity
• vascularity of articular segment is more likely to be preserved if ≥ 8mm of calcar is attached to articular segment
  
  • 3 most accurate predictors of humeral head ischemia are
    
    • <8 mm of calcar length attached to articular segment
    • disrupted medial hinge
    • basic fracture pattern
  • predictors of humeral head ischemia do not necessarily predict subsequent avascular necrosis

Question 4

Vascular anatomy

Answer 4

• anterior humeral circumflex artery
  
  • large number of anastamoses with other vessels in the proximal humerus
  • branches
    
    • anterolateral ascending branch
      
      • is a branch of the anterior humeral circumflex artery
    • arcuate artery
      
      • is the terminal branch and main supply to greater tuberosity
• posterior humeral circumflex artery
  
  • recent studies suggest it is the main blood supply to humeral head

Question 5

Classification

Answer 5

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

Question 6

Imaging

Answer 6

• Radiographs
  
  • recommended views
    
    • complete trauma series
      
      • true AP (Grashey)
      • scapular Y
      • axillary
    • additional views
      
      • apical oblique
      • Velpeau
      • West Point axillary
    • findings
      
      • combined cortical thickness (medial + lateral thickness >4 mm)
        
        • studies suggest correlation with increased lateral plate pullout strength
      • pseudosubluxation (inferior humeral head subluxation) caused by blood in the capsule and muscular atony
• CT scan
  
  • indications
    
    • preoperative planning
    • humeral head or greater tuberosity position uncertain
    • intra-articular comminution

Question 7

Nonoperative

Answer 7

• sling immobilization followed by progressive rehab
  
  • technique

start early range of motion within 14 days

Question 8

indications of Nonop treatement

Answer 8

• most proximal humerus fractures can be treated nonoperatively including
• minimally displaced surgical and anatomic neck fractures
• greater tuberosity fracture displaced < 5mm
• fractures in patients who are not surgical candidates

Question 9

additional variables to consider for Nonop Rx

Answer 9

1. age
2. fracture type
3. fracture displacement
4. bone quality
5. dominance
6. general medical condition
7. concurrent injuries

Question 10

Operative

Answer 10

1. CRPP (closed reduction percutaneous pinning)
2. ORIF
3. intramedullary nailing
4. arthroplasty

Question 11

CRPP (closed reduction percutaneous pinning)

indications and outcomes

Answer 11

• 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
• outcomes
  
  • considerably higher complication rate compared to ORIF, HA, and RSA

Question 12

ORIF

Answer 12

• indications
  
  • greater tuberosity displaced > 5mm
  • 2-,3-, and 4-part fractures in younger patients
  • head-splitting fractures in younger patients
• outcomes
  
  • medial support necessary for fractures with posteromedial comminution
  • calcar screw placement critical to decrease varus collapse of head

Question 13

intramedullary nailing

Answer 13

• indications
  
  • surgical neck fractures or 3-part greater tuberosity fractures
  • in younger patients
  • combined proximal humerus and humeral shaft fractures
• outcomes
  
  • biomechanically inferior with torsional stress compared to plates
  • favorable rates of fracture healing and ROM compared to ORIF

Question 14

arthroplasty

Answer 14

indications

• hemiarthroplasty
  
  • controversial when considering hemiarthroplasty versus RSA
  • younger patients (40-65) with complex fractures or head-splitting components likely to have complications with ORIF
  • recommended use of convertible stems to permit easier conversion to RSA if necessary in future
• reverse total shoulder
  
  • low-demand elderly individuals with non-reconstructible tuberosities and poor bone stock
  • low-demand patients with fracture dislocation

outcomes

• improved results if
  
  • anatomic tuberosity reduction and healing
  • restoration of humeral height and version
• poor results with
  
  • tuberosity nonunion or malunion
  • retroversion of humeral component > 40°

Question 15

Treatment by Fracture Type

Answer 15

• Two-Part Fracture
• Three-Part Fracture
• Four-Part Fracture

Question 16

Two-Part Fracture

Surgical Neck

Answer 16

• Most common fx pattern
  
  • Nonoperative • Closed reduction often possible • Sling
  • Operative
    
    • controversial
      
      • technique
        
        • CRPP
        • Plate fixation
        • IM device

Question 17

Functional outcomes after nonoperative management of fractures of the proximal humerus.

Hanson B

Answer 17

difficult to demonstrate a significant advantage of surgical over nonoperative treatment in patients with proximal humeral fractures.

Question 18

Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

Lefevre-Colau MM

Answer 18

Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy

Question 19

Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment

Answer 19

Surgical treatment of displaced greater tuberosity fractures revealed good functional and radiographic results. Reduction and fixation of those fractures is recommended because patients with nonoperative treatment showed significantly worse results. Similar results can be achieved for open reduction and internal fixation, or closed reduction and percutaneous fixation.

Question 20

Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up

Answer 20

Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

Question 21

Innovations in the management of displaced proximal humerus fractures

Answer 21

Proximal humerus fractures must be evaluated on an individual basis, with treatment tailored according to patient and fracture characteristics.

Question 22

The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients.

Answer 22

This fracture was relatively common in the elderly population and non-operative treatment sometimes resulted in increased varus angulation. Decreased shoulder function was associated with increasing age but not with increasing varus angulation. After nonoperative management the outcome was good, regardless of the degree of varus, 1 year after fracture. Age was the main predictor of outcome. Physiotherapy did not improve outcome.

Question 23

Functional outcome after minimally displaced fractures of the proximal part of the humerus.

Koval KJ

Answer 23

The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.

Question 24

Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures.

Goldman RT

Answer 24

This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable

Question 25

Two-Part Fracture Greater tuberosity

Answer 25

**Nonoperative** • indicated for GT displaced \< 5 mm **Operative** • indicated for GT displacement \> 5 mm - isolated screw fixation only in young with good bone stock - nonabsorbable suture technique for osteoporotic bone (avoid hardware due to impingement) - tension band wiring

Question 26

Two-Part Fracture Lesser tuberosity

Answer 26

*Nonoperative* • Minimally or non-displaced ***Operative*** * ORIF if large fragment * excision with RCR if small * * COPY

Question 27

two part Anatomic neck

Answer 27

Rare **Nonoperative** • Minimally or non-displaced **Operative** • ORIF in young • ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly​

Question 28

Three-Part Fracture Surgical neck and GT

Answer 28

**Nonoperative if:** • Minimally displaced (GT\<5 mm; articular segment \<1 cm and \<45 degrees) • Poor surgical candidate **Operative:** • **_Young patient_** - percutaneous pinning (good results, protect axillary nerve) - IM fixation (violates cuff) - locking plate (poor results with high rate of AVN, impingement, infection, and malunion) **_• Elderly patient_** - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty

Question 29

Three-Part Fracture Surgical neck and LT

Answer 29

•Trend towards nonoperative management given high complications with ORIF * *_• Young patient_** - percutaneous pinning (good results, protect axillary nerve) - IM fixation (violates cuff) - locking plate (poor results with high rate of AVN, impingement, infection, and malunion) * *_• Elderly patient_** - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty

Question 30

Four-Part Fracture Valgus impactedfracture

Answer 30

• 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

Question 31

Four-Part Fracture 4-part with head-splitting fracture

Answer 31

* *Young patient** - ORIF vs. hemiarthroplasty (hemiarthroplasty favored for nonreconstructible articular surface, severe head split, extruded anatomic neck fracture) * *• Elderly patient** - hemiarthroplasty v. reverse total shoulder arthroplasty * COP

Question 32

Rehabilitation

Answer 32

* Important part of management * Best results with guided protocols (3-phase programs) * early passive ROM * active ROM and progressive resistance * advanced stretching and strengthening program * Prolonged immobilization leads to stiffness

Question 33

Complications

Answer 33

* Screw cut-out * Avascular necrosis * Nerve injury * Malunion * Nonunion * Rotator cuff injuries and dysfunction * Long head of biceps tendon injuries [![]()](https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures?expandLeftMenu=true#213037) * Missed posterior dislocation (especially in cases with lesser tuberosity fractures) * Adhesive capsulitis * Posttraumatic arthritis * Infection

Question 34

Malunion

Answer 34

* usually varus apex-anterior or malunion of GT * results inferior if converting from varus malunited fracture to TSA * use reverse TSA instead

Question 35

Nonunion

Answer 35

* usually with surgical neck and tuberosity fx * treatment of chronic nonunion/malunion in the elderly should include arthroplasty [![]()](https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures?expandLeftMenu=true#319) [![]()](https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures?expandLeftMenu=true#290) * lesser tuberosity nonunion leads to weakness with lift-off testing [![]()](https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures?expandLeftMenu=true#365) * greater tuberosity nonunion leads to lack of active shoulder elevation * greatest risk factors for non-union are age and smoking

Question 36

General points need to be taken into consideration:

Answer 36

* 80% of proximal humeral fractures are undisplaced, and can be treated conservatively * Three and four-part fractures are notoriously difficult to manage and yield poor results – but one in fact uncommon injuries, with very small series reported in the literature * The commonest fracture pattern seen is the two-part fractures of the surgical neck.

Question 37

DECISION MAKING

Answer 37

1. Fracture configuration 1. Neer 2. Hertel 3. Lateral shift 2. Capsular attachments 3. Head vascularity 4. Osteoporosis augmented fixation 5. Age of patient 1. Hemiarthroplasty 2. RSA

Question 38

Treatment Plan

Answer 38

1. Decide on fixation or replacement 2. Fixation then assess medial cortex if intact and cortical thickness \>4mm, no augmentation 3. Medial cortex intact \<4mm then fixation plus calcium phosphate or cancellous bone 4. Medial cortex not intact, then fibular strut graft.

Question 39

ARTHROPLASTY FOR FRACTURE

Answer 39

—Hemiarthroplasty for fractures has been shown to demonstrate good pain relief, but poorer functional outcomes compared to replacement arthroplasty for osteoarthritis. —Important to restore humeral height, humeral version and tuberosity reconstruction.

Question 40

Pascal Boileau(2002) described the “unhappy triad”

Answer 40

—Excessive height of prosthesis —Excessive retroversion of prosthesis —Greater tuberosity positioned too low Poor functional results and persistent pain and stiffness

Question 41

RSA Advantages

Answer 41

—More favourable and predictable results than HA —Much better ROM particularly AFE and Abduction —Lower postoperative pain —Earlier initiation of rehabilitation

Question 42

RSA Disadvantages

Answer 42

—Scapular notching —Decreased Active external rotation —Acromial fractures —Instability But with lateralization of glenosphere with RSA there is less notching, greater AER and AIR and much less instability

Question 43

Florian Grubhofer

Answer 43

Many studies in recent years support the use of RSA for displaced proximal humeral fractures in the elderly.

Question 44

must know

Answer 44

* Proximal humeral fractures are common and can have a significant effect on quality of life in the elderly if not appropriately treated. * Each fracture must be assessed on its own merit. There is no single correct treatment option. * All current treatment options have limitations and there is still an unacceptably high failure rate with both fixation and arthroplasty. * We must provide one operation for patients.