Proximal humerus fracture

Mabelle Makary
• Epidemiology 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
• Pathophysiology
mechanism
– low-energy falls
• elderly with osteoporotic bone
– high-energy trauma
• young individuals
• concomitant soft tissue and neurovascular injuries
• pathoanatomy
– pectoralis major displaces shaft anteriorly and medially
– supraspinatus, infraspinatus, and teres minor externally rotate greater
tuberosity

– subscapularis internally 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
• Associated conditions
• nerve injury
– axillary nerve injury most common

• arterial injury
– uncommon (incidence 5-6%), higher likelihood in
older patients

– most often occur at level of surgical neck or with

subcoracoid dislocation of the head
 Anatomy
• Osteology
– anatomic neck
• represents the old
epiphyseal plate
– surgical neck
• represents the
weakened area below
head
• more often involved in
fractures than anatomic
neck

– average neck-shaft
angle is 135 degrees
• Vascular anatomy
– 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
 Classification
• AO/OTA organiz
es fractures into
3 main groups
and additional
subgroups
based on
– fracture
location
– status of the
surgical neck
– presence/abse
nce of
dislocation
• Neer
classification based on
anatomic relationship
of 4 segments
– greater tuberosity1
– lesser tuberosity3
– articular surface2
– shaft4
• considered a separate
part if
– displacement of > 1
cm
– 45° angulation
 Neer Classification

Minimally Articular
Two Part Three Part Four Part
Displaced Segment
Anatomical
Neck

Surgical Neck

Greater
Tuberosity

Lesser
Tuberosity

Fracture-
Dislocation

Head Split
 Evaluation
• Symptoms
– pain and swelling
– decreased motion
• Physical exam
– inspection
• extensive ecchymosis of chest, arm, and forearm
– neurovascular exam
• axillary nerve injury most common
– determine function of deltoid muscle (axillary n.)
• arterial injury may be masked by extensive collateral
circulation preserving distal pulses
– examine for concomitant chest wall injuries
 Imaging
• 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
• MRI
– indications
• rarely indicated
• useful to identify associated rotator cuff injury
 Treatment
• Non-operative
– sling immobilization followed by progressive rehab
• indications
– most proximal humerus fractures can be treated non-operatively including
» minimally displaced surgical and anatomic neck fractures
» greater tuberosity fracture displaced < 5mm
» fractures in patients who are not surgical candidates
– additional variables to consider

» age
» fracture type
» fracture displacement
» bone quality
» dominance
» general medical condition
» concurrent injuries
• technique
– start early range of motion within 14 days
• Operative
– CRPP (closed reduction percutaneous pinning)
• 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
– ORIF
• 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
• intramedullary nailing
– 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

• arthroplasty
– 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°
 Treatment by fracture type
Two-Part Fracture
Surgical Neck • Most common fx pattern Nonoperative
• Deforming forces: • Closed reduction often possible
1) pectoralis pulls shaft anterior and • Sling
medial 2) head and attached tuberosities Operative
stay neutral • indications controversial
• technique
- CRPP
- Plate fixation
- IM device
Greater tuberosity • Often missed Nonoperative
• Deforming forces: GT pulled superior and • indicated for GT displaced < 5 mm
posterior by SS, IS, and TM Operative
• Can only accept minimal displacement • indicated for GT displacement > 5 mm
(<5mm) or else it will block ER and ABD - isolated screw fixation only in young with
good bone stock
- nonabsorbable suture technique for
osteoporotic bone (avoid hardware due to
impingement)
- tension band wiring

Lesser tuberosity • Assume posterior dislocation until proven Nonoperative

otherwise • Minimally or non-displaced
Operative
• ORIF if large fragment
• excision with RCR if small

Anatomic neck • Rare Nonoperative

• Minimally or non-displaced
Operative
• ORIF in young
• ORIF v. hemiarthroplasty v. reverse total
shoulder arthroplasty in elderly
 Three-Part Fracture
Surgical neck and GT • Subscap will internally rotate articular Nonoperative if:
segment • Minimally displaced (GT<5 mm; articular
• Often associated with longitudinal RCT 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

Surgical neck and LT • Unopposed pull of posterior cuff •Trend towards nonoperative
musculature leads articular surface to point management given high complications with
anterior ORIF
• Often associated with longitudinal RCT • 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
a

b c
 Four-Part Fracture
Valgus impacted fracture • Radiographically will see alignment • Low rate of AVN if posteromedial
between medial shaft and head component intact thus preserving
segments intraosseous blood supply
• Surgical technique
1. raise articular surface and fill
defects
2. repair tuberosities

4-part with head-splitting fracture • Characterized by high risk of AVN • Young patient
(21-75%) - ORIF vs. hemiarthroplasty
• Deforming forces: (hemiarthroplasty favored for
1) shaft pulled medially by pectoralis nonreconstructible articular surface,
severe head split, extruded anatomic
neck fracture)
• Elderly patient
- hemiarthroplasty v. reverse total
shoulder arthroplasty
 Techniques
• CRPP (closed reduction percutaneous pinning)
– approach
• percutaneous
– technique
• use threaded pins but do not cross cartilage
• externally rotate shoulder during pin placement
• engage cortex 2 cm inferior to inferior border of humeral head
– complications
• with lateral pins
– risk of injury to axillary nerve
• with anterior pins
– risk of injury to biceps tendon, musculocutaneous n., cephalic vein
• possible pin migration
 2 part proximal
humerus fracture

Axillary
ap
• ORIF approach
– anterior (deltopectoral)
– lateral (deltoid-splitting)
• increased risk of axillary nerve injury
• technique
– heavy nonabsorbable sutures
• (figure-of-8 technique) should be used for isolated greater tuberosity fx
reduction and fixation (avoid hardware due to impingement)
– isolated screw
• may be used for greater tuberosity fx reduction and fixation in young patients
with good bone stock
– locking plate
• screw cut-out (up to 14%) is the most common complication following
fixation of 3- and 4- part proximal humeral fractures and fractures treated
with locking plates
• more elastic than blade plate making it a better option in osteoporotic bone
• place plate lateral to the bicipital groove and pectoralis major tendon to
avoid injury to the ascending branch of anterior humeral circumflex artery
• placement of an inferomedial calcar screw(s) can prevent post-operative
varus collapse, especially in osteoporotic bone
Head splitting fracture of the proximal humerus

AP radiograph of the right shoulder

showing an ORIF of the proximal
humerus showing a proximal
humeral locking plaque and screws
• intramedullary nailing
– approach
• superior deltoid-splitting approach
– technique
• lock nail with trauma or pathologic fractures
– complications
• rod migration in older patients with osteoporotic bone
is a concern
• shoulder pain from violating rotator cuff
• nerve injury with interlocking screw placement
Segmental fracture of
the left humerus
• Hemiarthroplasty
– approach
• anterior (deltopectoral)
– technique for fractures
• cerclage wire or suture passed through hole in prosthesis and
tuberosities improves fracture stability
• place greater tuberosity 10 mm below articular surface of
humeral head (HTD = head to tuberosity distance)
– impairment in ER kinematics and 8-fold increase in torque with
nonanatomic placement of tuberosities
• height of the prosthesis best determined off the superior edge
of the pectoralis major tendon (5.6 cm between top of
humeral head and superior edge of tendon)
• post-operative passive external rotation places the most stress
on the lesser tuberosity fragment
Displaced, 4 part proximal
humerus fracture in an elderly
patient
• Reverse shoulder
arthroplasty approach
– anterior (deltopectoral)

– anterolateral deltoid split

• technique for fractures

– ensure adequate glenoid

bone stock
– ensure functioning deltoid
muscle
– repair of tuberosities
recommended despite ability
of RSA design to compensate
for non-functioning
tubersosities/rotator cuff
 Rehabilitation
• 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
 Complications
• Screw cut-out
– most common complication after locked plating fixation (up to
14%)
• Avascular necrosis
– risk factors
• risk factors for humeral head ischemia are not the same for developing
subsequent avascular necrosis
– better tolerated than in lower extremity
– no relationship to type of fixation (plate or cerclage wires)
• Nerve injury
– axillary nerve injury most common (up to 58% with studies using
EMG)
• increased risk with lateral (deltoid-splitting) approach
• axillary nerve is usually found ~7cm distal to the tip of the acromion
– suprascapular nerve (up to 48%)
• Malunion
– usually varus apex-anterior or malunion of GT
– results inferior if converting from varus malunited fracture to TSA
• use reverse TSA instead
• Nonunion
– usually with surgical neck and tuberosity fx
– treatment of chronic nonunion/malunion in the elderly should include
arthroplasty
– lesser tuberosity nonunion leads to weakness with lift-off testing
– greater tuberosity nonunion leads to lack of active shoulder elevation
– greatest risk factors for non-union are age and smoking
• Rotator cuff injuries and dysfunction
• Long head of biceps tendon injuries
• Missed posterior dislocation (especially in cases with lesser
tuberosity fractures)

• Adhesive capsulitis
• Posttraumatic arthritis
• Infection
Thank you