Proximal HumerusFractures/Dislocations

www.fisiokinesiterapia.biz

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

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

Anatomy

• 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

ArcuaArcuateafeeffe

Nerves

• Brachial Plexus– axillary– suprascapular– musculocutaneous

Rotator Cuff Muscles

• Supraspinatous• Infraspinatous• Subscapularis• Teres Minor

• Deltoid• Pectoralis• Long head biceps

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

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.

rotation

• CT Scan– articular fractures

• impression• head split

– glenoid fractures– assess tuberosity

displacement for operative decision making

Radiographic Work UpScapular AP, Axillary, Y view, CT Scan

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

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, reconstructible3- 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

– 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

Percutaneous Pinning

• Technique: beach chair position, closed manipulation, oscillating drill, terminal thread pins, at least bidirectional pins (see JabergH. 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----

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

PROXIMAL HUMERAL LOCKING PLATE

PROXIMAL HUMERAL PLATE

PROXIMALHUMERAL

Hemiarthroplasty

• Technique: beach chair position, deltopectoralapproach, retain tuberosityfragments 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 nonoperativeelderly 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.

Complications

• Misdiagnosis– degree of GT displacement– missed post. Dislocation– massive rot. cuff avulsion

with high energy dislocation. Suspect when severe swelling

– head split (double shadow)best seen on axillary v. or CTS

Complications

• Nonunion– In young, treat like an

acute fracture if head viable.

– Consider hemiarthroplasty in elderly or osteoporotic.

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

Shoulder Dislocations

• Classified by:– Direction– Etiology– Involuntary vs

voluntary

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 tuberosityfracture

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

Shoulder Dislocations - Etiology

• Traumatic– Usually unidirectional

• Atraumatic– Often associated with

multidirectional instability, psychiatric problems if voluntary

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)

Shoulder Dislocations -Rotator Cuff Tear

• The “posterior mechanism” of shoulder instability - coined by Dr. Ed Craig (ClinOrthop 190, 1984)

• Common in older patients• Beware of inability to lift the arm in an older

patient following a dislocation

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

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

Shoulder Dislocations -Treatment

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

• Immobilization– Controversial re:

position and duration

• 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

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

magnetic resonance imaging.

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

Shoulder Dislocations - Outcome

• Related to Age, Direction Etiology

• Age < 30– Recurrence high after traumatic

anterior dislocation• Age > 45

– Recurrence less common

Surgical Treatment of Shoulder Dislocations

• Usually reserved for patients with recurrent instability

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

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”

Shoulder Dislocations -Complication

• Brachial Plexus Injury– Carefully document pre-

and post-reduction neuroexam in all!

• Recurrent dislocation– Common in more active

patients– Treated with anterior

shoulder reconstruction