Proximal Humerus Fractures - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University
devaki21 December 2012

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

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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 lec...
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Proximal Humerus Fractures/Dislocations


• 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

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


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

• Physeal scar closure – 20-22 yrs.

Proximal Humeral Retroversion

• 35-40 degrees relative to epicondylar axis

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


• Brachial Plexus – axillary – suprascapular – musculocutaneous

Rotator Cuff Muscles

• Supraspinatous • Infraspinatous • Subscapularis • Teres Minor

• Deltoid • Pectoralis • Long head biceps


• 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 • 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

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.


• CT Scan– articular fractures

• impression • head split

– glenoid fractures – assess tuberosity

displacement for operative decision making


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

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

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

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

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

• Surgical Approaches – Deltopectoral

– Deltoid Splitting

– Posterior


• 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

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


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

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

Locked Rigid Nails for Proximal Humerus

• enhanced proximal fixation with twisted blades or multiple screws

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

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


• 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

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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