Proximal Humerus Fractures

Michael W. Leathers, M.D.

General

• Most common in active middle-aged patients (avg. age: 54 years)

• Incidence: 4-5% of all fractures• Osteoporosis major predisposing factor• Loss of trabecular bone up to epiphyseal

plate• Loss of trabeculae greatest in surgical

neck region

Anatomy & Function

• Retention glenohumeral mobility

• Muscle forces on proximal humerus, tuberosities, shaft

• Blood supply humeral head

• Neurovascular structures

Blood Supply

• Ascending branch of anterior circumflex humeral artery is primary blood supply

• Posterior circumflex artery serves much smaller portion– Primarily

posteroinferior head & posterior greater tuberosity

Schlegel TF, Hawkins RJ: JAAOS 2:54, 1994

Neer Classification

• Displacement > 1 cm• Angulation > 45o

Neer, JBJS-A, 52, 1970

4-part Displacement

• Both tuberosities detached, retracted

• Articular segment devascularized

• High incidence of AVN

• Primary prosthesis gives best results

• Surgery: Restoration humeral length and cuff fixation

• Early passive exercise, progress

Post-traumatic AVN

• Wide range of resultant osteonecrosis after 4-part fractures: (26-75%)

• Also seen in some 3-part fractures (3-14%) and with associated dislocations

• Jakob & Miniaci et al– Four part valgus impacted fracture

– 26% osteonecrosis

Jakob, Miniaci et al; JBJS, 73B:2, 1991Loebenberg, Plate, Zuckerman: AAOS ICL, 48, 1999

Rockwood & Green, Fractures in Adults, 1999

Treatment

• Options:– Non-operative

– Closed reduction

– ORIF

– Hemiarthroplasty

• Factors:– Fracture pattern

– Patient age

– Comorbidities

– Bone quality

Non-op Tx & Closed Red.

Non-operative Tx• Poor results

– 1/16 - Able raise arm > 90o

– 9/16 - Constant pain

– Satisfactory results of arthroplasty = non-operative tx of minimally displaced fx

Closed reduction• Poor results

– 3/39 - Satisfactory (3-part)

– 0/38 - Satisfactory (4-part)

Neer, JBJS-A, 52, 1970

Stableforth, JBJS-B, 66, 1984

ORIF

• Appropriate for valgus impacted 4-part fx• Ensure adequate bone stock• Beware posterior or lateral displacement• 74% satisfactory outcome; 26% AVN

Jakob, Miniaci et al; JBJS, 73B:2, 1991Resch, JSES, 4, 1995

ORIF

ORIF

Many options:• Plates & screws• IM rods (vertical

fixation)• Vertical fixation w/

tension band• Tension band alone

Results• Adequate results for 3-

part fx– 19/30 Good/excellent

• Neer, JBJS-A, 52, 1970

– 21/35 Good/excellent• Darder et al, J Orthop Trauma, 7, 1993

• Consistently poor results for 4-part fx

Paavolainen et al, Acta orthop Scand, 54, 1983Cuomo et al, JSES, 1, 1992

Koval et al, J Trauma, 2, 1993Williams, JSES, 6, 1997

Challenges• 4-part fractures

• 3-part fx & fx-disloc. in elderly with osteoporotic bone

• ORIF not possible

• Chronic ant/post disloc. with impression fractures > 40% articular surface

Zuckerman et al, 1997

Shoulder Arthroplasty

• Results of hemiarthroplasty superior to nonsurgical treatment

• Satisfactory results in 80%

• Pain outcome good

• Functional outcome less predictable

• Age most important prognostic indicator (Green, 1993)

• Determine proper height

Shoulder Arthroplasty - Technique

• Determine degree of retroversion

• Determine appropriate head size

Total Shoulder Arthroplasty

Results of HSA 4-part Fractures

• Neer: 31 of 32 excellent or satisfactory results• Kraulis: 9 of 11 unsatisfactory• Willems: 4 of 10 excellent or satisfactory• Cofield: Good pain relief

– Active forward flexion 101o

• Kay (UCLA): Excellent pain relief– Active elevation 94

o

• Cockx: Good cuff repair 109o

FF– Poor/no cuff repair 51

o

FF

Timing of Hemiarthroplasty

Acute• Same to better pain relief• Variable results of ROM,

function– Usually better

• Problems– Tuberosity healing

– RC failure

– Assoc. w/ surgical technique

Chronic• Higher rate of

complications– Surgical difficulty

– Scarring

– Distortion of anatomy

Tanner & Cofield, Clin Orthop, 179, 1983Frich et al, Orthopaedics, 14, 1991

Dines et al, JSES, 2, 1993Norris et al, JSES, 4, 1995

Greater Tuberosity Pathology

1. Abnormally painful shoulder immediately post-op

2. No progression (24%) or regression (9%) of active shoulder mobility > 3 mos post-op

3. Dissociation between active (deficient) and passive (preserved) forward elevation

- Malunion (15%); Axillary n. damage (6.5%)

* Migration & malunion (21.5%) & nonunion (11%) results in a poor functional outcome

Boileau, Rev chir orthop reparatrice appar mot, 85:2, 1999

Rotator Cuff & Deltoid

• Restoration of the rotator cuff mechanism important to functional result

• Must avoid detachment of deltoid

Tonino et al, Acta Orthop Belg, 51, 1985Green et al, JSES 2, 1993

Hawkins et al, Clin Orthop, 289, 1993Compito et al, Clin Orthop, 307, 1994

Goldman et al, JSES, 4, 1995

Cement

• Cement advocated in all cases

• Provides immediate stability

• Decreases incidence of loosening

• Also requires graft proximally to cover exposed stem

Green et al, JSES 2, 1993Hawkins et al, Clin Orthop, 289, 1993Compito et al, Clin Orthop, 307, 1994

Biceps

• Biceps often tenodesed by reattachment of tuberosities

• Currently recommended to release origin and tenodese to proximal humerus

• Otherwise, intra-articular length shortened & will restrict external rotation

Harryman et al, JSES, 7, 1998

Results

Unsatisfactory resultsUnsatisfactory results• Resorption or nonunion of tuberosities• Rotator cuff dysfunction• Cartilage space <2mm

Satisfactory resultsSatisfactory results• Radiographic union of tuberosities• Integrity of rotator cuff• Cartilage space > 2mm

Discussion

• Patients are usually asymptomatic preinjury

• Discuss results with patient before surgery

Prognosis

• More severe injuries, elderly pts less optimal results

• Avoid deltoid origin detachment

• Lingering stiffness, pain, loss AROM > 6 months

• Attention to surgical detail will improve prognosis (tuberosity reduction)

Treatment Algorithm

Naranja, JAAOS, 8:6, 2000

Complications

• #1 – Detachment of greater tuberosity

• Looseing of prosthesis• Infection• Glenoid erosion• Malpositioning of

humeral component• Dislocation

• Nerve injury (ax/mc)– 6.1% – 27%

– Also assoc. w/ closed reduction

• Heterotopic ossification– 16%, esp surgery

delayed > 10 d

Stableforth, JBJS-B, 66, 1984Neer, Rev chir orthop suppl II, 74, 1988

Bigliani, Orthop Trans, 15, 1991

Joint Stiffness

• Bursal and capsular adhesions

• Treatment: Warm applications, stretching

• Avoid manipulation

• Prevent stiffness with early exercise program

Conclusions

1. Minimal pain but limited function

2. Better results with intact rotator cuff, tuberosities and cartilage space > 2mm

3. Limited expectations

Case Presentation

• 42 yo woman fell down flight of stairs, sustaining bilateral distal radial fx, right non-displaced olecranon fx, right proximal humerus fx, & pelvis fx

• No PMH, Allergies, or Meds

Xrays & CT Scan

Post-op Xrays

Thank You