Proximal Humerus Fractures - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University

Orthopedics

Description: Proximal Humerus Fractures, Heterotopic Bone, Brachial Plexus, Ossification Centers, Physeal Scar Closure, Proximal Humeral Retroversion, Epicondylar Axis, Rotator Cuff Muscles are some points from this lecture. This lecture is for Orthopaedics Trauma course. This lecture is part of a complete lectures series on the course you can find in my uploaded files.
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Proximal Humerus Fractures/Dislocations

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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

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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

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Anatomy

• Appearance of Ossification Centers – epiphysis 4mo – Gr. Tub. 3yr – L. Tub. 5yr

• Physeal scar closure – 20-22 yrs.

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Proximal Humeral Retroversion

• 35-40 degrees relative to epicondylar axis

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Blood Supply

• Axillary artery – ant. humeral circumflex

• *ascending branch (arcuate artery) is the major blood supply to the articular surface

– post. humeral circumflex

Arcua Arcuate afeeffe

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Nerves

• Brachial Plexus – axillary – suprascapular – musculocutaneous

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Rotator Cuff Muscles

• Supraspinatous • Infraspinatous • Subscapularis • Teres Minor

• Deltoid • Pectoralis • Long head biceps

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Classification

• 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

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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

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Radiographic Work Up

• 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

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Treatment

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

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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

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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

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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

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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

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• 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

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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----

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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

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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

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Locked Rigid Nails for Proximal Humerus

• enhanced proximal fixation with twisted blades or multiple screws

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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

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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

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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

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Results • 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.

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Complications

• Nonunion – In young, treat like an

acute fracture if head viable.

– Consider hemiarthroplasty in elderly or osteoporotic.

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Complications

• 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

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Shoulder Dislocations

• Classified by: – Direction – Etiology – Involuntary vs

voluntary

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Anterior Shoulder Dislocation

• 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

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Posterior Shoulder Dislocation

• Associated with seizures or electrical shock

• Commonly missed on X-ray

• High incidence of associated lesser tuberosity fracture Example of a posterior

dislocation

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Shoulder Dislocations - Etiology

• Traumatic – Usually unidirectional

• Atraumatic – Often associated with

multidirectional instability, psychiatric problems if voluntary

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Shoulder Dislocations - Pathoanatomy

• 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)

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Shoulder Dislocations - Rotator Cuff Tear

• 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

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Shoulder Dislocations - Evaluation

• Inspection - note fullness of anterior chest, prominence of acromion

• Note position of arm and restricted motion

• Document detailed neurovascular exam

Deltoid atrophy 6 months after shoulder dislocation

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Shoulder Dislocations - Imaging

• 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

Torn anterior labrum

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Shoulder Dislocations - Treatment

• Immediate reduction – Many techniques – Adequate sedation – Control scapula

• Immobilization – Controversial re:

position and duration

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Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic

resonance imaging.

• 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

Itoi E, et al, J Bone Joint Surg Am 2001, 83-A: 661-7

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Shoulder Dislocations - Outcome

• Related to Age, Direction Etiology

• Age < 30 – Recurrence high after

traumatic anterior dislocation • Age > 45

– Recurrence less common

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Surgical Treatment of Shoulder Dislocations

• Usually reserved for patients with recurrent instability

• Occasionally done after first time dislocation in high- demand patient

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Surgical Treatment of Shoulder Dislocations

• Arthroscopic Lavage – Removal of hematoma

leads to less recurrence?

• Bankart repair • Capsulorraphy

{ Either approach allows repair of labrum and tightening of capsule. Open repair remains the “gold standard”

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