Proximal Humerus
Fractures
Principles of Diagnosis,
Decision Making and Treatment
Christopher G. Finkemeier, MD, MBA
Revised: May 2011
Acknowledgement: AO faculty lecture archive
Objectives
1. Learn the principles of diagnosis
2. Learn the principles of decision making
3. Learn the various treatment options
Epidemiology
All upper extremity fractures
1. forearm fxs
2. proximal humerus fxs
All fractures in patients > 65 yrs
1. hip fxs
2. “colles” fxs
3. proximal humerus fxs
4 Anatomic Parts
Deforming forces determine fx displacement
GREATER TUBEROSITY:
supra/infraspinatus
insertion
HUMERAL HEAD:
precarious blood supply
AVN
SURGICAL NECK/SHAFT:
deltoid/pectoralis major
largely dictates fx behavior
compression: stable
shear: unstable
LESSER TUBEROSITY:
subscapularis insertion
Vascular Supply
Lateral ascending branch
of anterior humeral
circumflex artery
Damage may lead to AVN
Humeral Head Vascularity
Gerber et al.,
JBJS, 1990
Non shaded area is supplied
by the lateral ascending branch
of the anterior humeral circumflex
artery.
Humeral Head Vascularity
In the fractured humerus, the arcuate artery is
generally interupted.
Recent anatomic and clinical findings confirm
that perfusion from the posterior circumflex vessels
alone may be adequate for head survival.
Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001
Radiography
True AP
Transcapular “Y”
Lesser Tuberosity
Axillary View
CT Scan
Articular surface
–Head splitting injury
Tuberosity displacement,
especially lesser tuberosity
Treatment
80% of PHF are NONDISPLACED and can be
successfully treated NONOPERATIVELY
20% Displaced
Operative
?
Nonoperative
Fx pattern
Head viability
Bone quality
Implant limitations
Patient age & comorbidities
Neer
Classification
> 1 cm
45º
Codman’s
4 parts
AO Classification
A-type: 2-part
B-type: 3-part
C-type: 4-part +
anatomic neck
Predictors of ischemia:
– Metaphyseal head extension (calcar) < 8 mm.
Loss of integrity of medial hinge
 Fracture Pattern (anatomic neck)

Hertel et al, J Shoulder Elbow Surg 2004;13:427
97%
PPV
BEWARE of lateral
displacement of head
Metaphyseal
head extension < 8mm
Blood Supply
Potentially Torn if
medial hinged
displaced
 This head is likely NOT viable.
Medial Hinge not
displaced
This head is
likely viable
Metaphyseal head
Extension > 8mm
Bone Quality
Tingert et al, JBJS(B), 2003
Mean cortical thickness
A+B+C+D
2 cm
A B
C D
4
“A mean cortical thickness
< 4 mm
is highly indicative of low BMD”
Predictable loss of fixation ?
Implant limitations
Recognizing what implants are
appropriate for certain fracture
types is a key decision making factor.
Conventional implants
Poorly control varus
collapse, screw loosening
and screw back out.
Locking plates are less prone
to failure due to the fixedangled screws.
Operative
?
Nonoperative
Fx pattern
Head viability
Bone quality
Implant limitations
Patient age & comorbidities
Putting it all together
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospitalfor
forSpecial
SpecialSurgery
Surgery
Hospital
protocol
protocol
Nonoperative Tx
sling + ROM
Nonop tx = surgery
Court-Brown et al., JBJS(B), 2001
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Elderly
Non-displaced
or mod displaced
Nonoperative Tx
sling + ROM
Nonop tx = surgery
Court-Brown et al., JBJS(B), 2001
Treatment: Non-operative
Koval et al., JBJS, 1997
– 77% good or excellent; 13% fair, 10% poor
results
– Functional recovery averaged 94%
– Sling with ROM exercises by 2 weeks
Treatment: Non-operative
Court-Brown et al., JBJS(B), 2001
– Mean age 72 yrs
– Outcome determined by age and degree of
translation
– Surgery did not improve outcomes regardless
of translation
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
“significant displacement”
>5mm GT
>66% SN
Poor bone quality
Operative Tx
heavy suture
through rotator
cuff insertion
or
Locking plate
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Satisfactory bone quality
Operative Tx
Closed reduction
percutaneous pins
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Satisfactory bone quality
Operative Tx
ORIF
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Nonoperative Tx
B1.1
Poor bone quality
Court-Brown, JBJS(B), 2002
Zyto et al, JBJS(B), 1997
Non-op = surgery
maybe better
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
ORIF
High failure rates with
standard plates
Especially in patients
with poor bone
Locking plates have
dramatically improved
fixation
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Hemiarthroplasty
Highly displaced fxs
“3 or 4-part”
Poor bone quality
Not reconstructable
Hemiarthroplasty
Hemiarthroplasy
Pain relief generally good
Good function depends on anatomic
tuberosity placement
Despite all the advances, shoulder
flexion above 90º is difficult to acheive
Journal of the American Academy of Orthopedic Surgeons
Jan 07
Hospital for Special Surgery
protocol
Anatomic neck fxs
have high rate of
AVN (+/- 50%).
Unless able to fix
anatomically, better to
replace (hemi)
Gerber et al. JSES, 1998
Poor bone
Good bone
Hemi
Fix
Summary of
Decision Making Process
“Young” Patients
<30yrs? <40yrs? <50 yrs?
“good bone quality”
Preservation of function is primary objective
“Full court press”
Anatomic reduction/soft tissue sparing
Stable fixation
Hemiarthroplasty for non-reconstructable fxs
only
Elderly Patients
“poor bone quality”
Pain relief primary objective
Non op RX if fracture stable and early motion possible
If unstable:
ORIF if head viable and fracture reducible
Hemiarthroplasty if head not viable or fracture not
repairable
Caveat
“A proximal humeral fracture that is at risk
for AVN has to be reduced anatomically
if joint preserving treatment is selected. If
anatomic reduction cannot be obtained,
other treatment options such as arthroplasty
should be considered.”
Gerber et al.
The clinical relevance of posttraumatic avascular
Necrosis of the humeral head.
JSES, 1998
GT fx +
Surgical neck fx
with extension
Medial
hinge intact
Metaphyseal spike
> 8mm
93 y/o male
RHD
Healthy
Fell
6 weeks
+ callus
FE 90
References
Neer, CS. Displaced Proximal Humeral Fractures.
JBJS 52-A: 1077-1089, 1970.
Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:
1090-1103, 1970.
Gerber, C. et al. The Arterial Vascularization of the Humeral Head.
JBJS 72-A: 1486-1494, 1990.
Brooks, CH et al. Vascularity of the Humeral Head After Proximal Humeral
Fractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.
Hertel, R et al. Predictors of Humeral Head Ischemia After Intracapsular
Fracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004
References
Nho, SJ. et al. Innovations in the Management of Displaced Proximal Humerus
Fractures . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007.
Koval, KJ. et al. Functional Outcome after Minimally Displaced Fractures
of the Proximal Part of the Humerus
JBJS 79-A: 79: 203 – 7, 1997.
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