Proximal Humerus Fractures
ORIF & Arthroplasty
Reza Omid, M.D.
Assistant Professor
Department of Orthopaedic Surgery
Keck School of Medicine of USC
Introduction
• 5-7% of all fractures
• 80% treated nonoperatively (Neer)
• Bimodal incidence
• Bone quality- important factor in obtaining secure
fixation
Etiology
Elderly
– fall onto outstretched hand
– direct blow- fall
– bone fragility- a/w distal radius fractures
Young
– high energy
– seizures, electrical injury
OITE Facts
• How many with neurologic
injury?
– 21-36%
– recent study- 45%- fx or dislocation on EMG
• Which nerves?
– Axillary, suprascapular, radial, musculocut.
• How many with persistent motor
loss?
– 8%
Codman’s Description
Neer’s Classification
AO Classification
Classification
Neer’s classification
Sidor, Zuckerman, JBJS 1993
Gerber, JBJS, 1993
– poor inter and intra observer reliability
– best results among trained shoulder surgeons
– suggested CT scans would increase reliability
Proximal Humeral Anatomy
Understanding Fracture Patterns
–4 bony fragments
»Lesser Tub
»Greater Tub
»Head
»Shaft
Neer, JBJS ‘70
Proximal Humerus Assesment
Neer Classification
–1 cm displaced
–45 deg angulated
–Excessive rotation
Proximal Humerus Fractures
Fracture Patterns
–Stable
»Fx not controlled by muscle
–Unstable
»Fx controlled by attached muscle
Proximal Humerus Fracture
Fracture Anatomy
–Greater Tub – posterior,
–Lesser Tub – medial,
–Head – remaining tub
energy
–Shaft – medial, superior
proximal
inferior
or fx
X-Rays
AP view scapular plane (Grashey)
AP view of shoulder
X-Rays
Axillary Lateral
Scapular Y
Proximal Humerus Fracture
Radiographic Analysis
–Normal Appearance
»Axillary: lesser tub, greater tub not seen
Proximal Humerus Fracture
Radiographic Analysis
– Normal Appearance
» AP: external rotation shows
greater tub
» AP: internal rotation,
greater tub not seen
Proximal Humerus Fracture
Fracture Anatomy
Consideration for Surgery
Bone Quality
Comorbidities
Functional demand
Vascularity???
Gerber JBJSAm 1990: 1486-94
Vascularity
– anterior humeral circumflex
» Anterolateral branch
Of AHC (arcuate artery)
Along lateral aspect of
groove
Brooks JBJSBr 1993: 132-136
• Vascularized through
interosseous anastomoses
• Between metaphyseal vessels (via
posterior humeral circumflex)
and the arcuate artery after
ligation of the anterior circumflex
humeral.
Coudane JSES 2000: 548
• Arteriography done on 20 patients
after proximal humerus fractures.
• 80% had disruption of AHC artery
• 15% had disruption of PHC artery
• Since AVN is rare (bw 1-34%) after fx
it suggests the PHC artery may be
dominant supply
Hettrich JBJSAm 2010:
943-8
– MRI cadavers
– posterior humeral
circumflex
– supplied 64% of
head (superior,
lateral and inferior).
Hertel Criteria
Hertel et al JSES 2004:13:427
– Medial calcar segment <8mm
– Medial hinge is disrupted (>2mm
displacement of the diaphysis)
– Comminution of the medial metaphysis
– Anatomic neck fracture
Bastian JSES 2008: 2-8
• Follow-up study by Hertel showed that
initial predictors of humeral head ischemia
doesn’t predict development of AVN.
• 80% of patients with “ischemic
heads” did NOT collapse
• Fixation is worth considering even if signs
of ischemia are present
Nonoperative Treatment
Immobilize initially
Passive ROM 2-3 weeks
– supine FE
– supine ER
– pendulums
AROM at 6 weeks or when consolidated
77% good to excellent results-Zuckerman 1995
Optimal Treatment
• UNKOWN????
• JSES 2011: 1118-1124 (RCT ORIF vs
Non-op)
• JSES 2011: 747-55 (RCT ORIF vs Non-op
• JSES 2011: 1025-1033 (RCT Hemi vs
Non-op)
• JOT 2011 (RCT ORIF vs Non-op)
Percutaneous Pinning
Surgical Technique
– Retrograde Pins
» Start Anterior
» Diverge Pins
– Antegrade Pins
» Supplemental
» GT to Medial Shaft
Percutaneous Pinning
Reduction Maneuver
• Surgical neck
– flexion, adduction, traction
– anterior pressure
• Greater tuberosity
– engage and move anteriorly/inferiorly
Percutaneous Pinning
Pin Placement
– Slight medial placement of head to shaft
» Allows placement of one pin centrally
– Wide spread of pins for stability
– *Remember normal humeral head retroversion
for pin placement
– Pin entry is just above the deltoid insertion
Pins
– Three 2.5mm terminally threaded pins
» 2 lateral pins
» 1 anterior pin
» 1-2 pins from GT to medial shaft
Jaberg H. JBJS. 74A. 1992. 508-15.
Structures At Risk
Cadaveric Study
– Lateral pins
» 3mm from Ant branch Ax
» Penetration of head articular
cartilage
– Anterior pins
» 2mm from biceps tendon
» 11mm from cephalic v.
– Proximal tuberosity pins
» 6-7mm from ax n. & posterior
circumflex artery
Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.
Recommendations
Starting point of proximal
lateral pin
– At or distal to a point 2x the
distance from the superior
aspect of the humeral head to
the inferior margin of the head
Greater tuberosity pins
– Engage medial cortex >2cm
from the inferior most aspect
of the humeral head
Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.
Greater Tuberosity Fractures
Displacement
– Superior
» Impingement
– Posterior
» Block to ER
Greater Tuberosity Fractures
Displacement?
– 5mm maybe problematic (McLaughlin et al.)
– 3mm maybe problematic in the athlete or heavy laborer
(Park et al.)
– Concern for RTC tears in minimally displaced fxs
Positioning critical
– *Exposure
» Approach: Superior, Posterior, Anterior
Reduction
– Head height 6-8mm superior to GT
» Posterior displacement more tolerated than superior displacement
Greater Tuberosity Fractures
– Surgical Approach
» Superior
» Deltopectoral
– Fixation Options
» Sutures
» Screws
» Plate
– Interval Closure
Three-Part Fractures
Surgical Neck
+
Greater Tuberosity
Lesser Tuberosity
Three-Part Fractures
Fixation Options
– Percutaneous Pins
– Interfragmentary Suture/Wire
–Plate/Screws
– IM Nail
– Blade Plate
–Hemiarthroplasty
Three-Part Fractures
–Approach
» Deltopectoral
» Closed Reduction/Pinning
–Goals
» Tuberosity Fixation
» Longitudinal Stability
Hemiarthroplasty
• Rarely Indicated
• Older Patients
• Osteopenic Bone
• Fracture-Dislocations
– > 40% Impression Defect
Three-Part Fractures
Complications
– Nonunion
– Malunion
– Hardware Problems
(screw cutout)
– AVN
Indications for ORIF of
Four-part Fractures
Valgus impacted four part with an intact medial soft
tissue hinge
Four part in a young patient (less than 40)
Indications for Pinning
Valgus impacted 4 part proximal humerus
fracture
– Vascularity preserved by feeding vessels in attached capsule
Valgus Impacted Four Part
Reduction Maneuver
Small incision (2 cm)
anterior shoulder
Line of fracture
usually lies 5 mm
lateral to
intertubercular
groove
Percutaneous Pinning
Reduction Maneuver
Valgus Impacted 4 Part
Valgus Impacted Four Part
Pinning Technique
Pin fragments
Valgus Impacted Four Part
47 y.o. female, trip and fall
When to plate?
Factors
–High energy/low energy
–Displacement
»2 part vs 3 or 4 part
»Integrity of soft tissue sleeve
Proximal Humerus Fractures
3 part
Proximal Humerus Fractures
3 part- locking plate
46 yo male
Rollover dirt bike
8 wks post op
46 yo male
high speed auto accident
Post op
Fracture-Dislocation
Fracture-Dislocation
Clinical Example
ORIF Technique
Reduction & Grafting
• Impaction grafting of head
• Iliac crest cube
• Fibular strut
Tag Tuberosities
Reduction & Grafting
Close Book
Plate
Indications for Hemiarthoplasty
Anatomic neck and four part
fractures: Isolate anatomic
humeral head from its blood
supply
Some three part fractures with
severe osteoporosis in the elderly
Split humeral head fractures
Hemiarthroplasty Technique
Patient Position
Surgical Technique
Extended deltopectoral exposure:
deltoid origin and insertion intact
Surgical Technique
Identify the LHB and Tuberosities
Evaluate the rotator cuff injury
Surgical Technique
Remove the humeral head
Evaluate the glenoid
Muscular Anatomy
Supraspinatus
–Usually starts just post
bicipital groove
–Pt. > 60 yo - strong
RCT
Sher, et al JBJS ‘95
to
possibility of
Tuberosity Suture Technique
Place suture at the tendon bone interface
Doug Robertson, MD
Louis U Bigliani, MD
Evan L Flatow, MD
Ken Yamaguchi, MD
JBJS ‘00
Results
Anatomy
–Retroversion: avg 19°, range: 9-31°
–Posterior offset: avg 2mm, range:-1-8mm
–Head thickness: avg 19mm, range:15-24mm
–Inclination:avg 41°, range: 34-47°
–Thickness linked to Radius (avg 23mm)
Head Size
Solutions
–removed head is guide
»thickness > radius
–error towards undersize
–check gross appearance
Position of Greater
Tuberosity
Height Relative to Humeral Head
Surgical Technique
Assess the humeral height and version
Trial tuberosity reduction
Mark the stem position
5-8 mm
Height of
the Greater
Tuberosity
Lesser
Tuberosity
Tuberosity Height = Prosthetic
Height
5-8 mm
Height of
the Greater
Tuberosity
Lesser
Tuberosity
Determining Height
–Superior border of Pectoralis tendon
(5.6cm±0.5cm)
–Side to Side comparison (x-ray)
–View calcar contour (gothic arch)
Determining Height
Proximal Humerus Fracture
Humeral Version
Version
Effect of Incorrect Version
Too Anteverted
Too Retroverted
Bicipital Groove Anatomy
–Anterior to head center
–Anterior to keel location
–Location dependant on shaft depth
»Variable retroversion
distal
Biceps Groove Version
Groove shifts medially from
proximal to distal, changing
retroversion values 15.9° from
the upper to lower part of the
bicipital groove (Itamura)
Bicipital Groove Anatomy
Surgical Technique
Prepare the fixation sutures for ORIF of the tuberosities.
– 2-3 vertical and 2 horizontals, one medial one lateral
Surgical Technique
Surgical Technique
Tuberosity fixation and bone
graft
Biceps tenodesis
Wound drains and closure
Results of Hemiarthroplasty for
Acute Fractures
Goldman et. al. J. Shoulder and
Elbow 1995
26 patients with acute fractures
73% had slight or no pain
Average forward flexion 107 degrees: stiff
73% had difficulty with at least 3 of the 10
ASES question of ADL
Results of Hemiarthoplasty for
Late Reconstruction
Dines et. al. J. Shoulder and Elbow
1993
Demanding procedure with wide variation in
results: average 80 points (HSS Scale)
Stiffness, scar, hardware problems
Tuberosity malposition
Results of Hemi. Early vs Late
Frick et. Al. Orthopaedics 1991
Pain scores better in acute
Function no different
More complications in the late reconstruction
group
Results of Hemi. Early vs Late
Norris et al J. Shoulder and Elbow
1995
Good pain relief in both but better
results in the acute group.
Only 53% had ability to use arm above
shoulder level post op in late
reconstruction, 15% pre-op
Results of Hemi. Early vs Late
Tanner and Cofield CORR 1983
16 acute hemi, 27 late reconstruction
Both had good pain relief
Both had had average active shoulder
elevation to 105-110 degrees
Acute surgeries was easier and with less
complications
Factors Affecting Outcome
•
•
•
•
Bone density
Rotator cuff tissue quality
Tuberosity healing
Restoration of anatomic humeral head
height
• Restoration of anatomic humeral
version
• Rehabilitation
Sequelae of Proximal Humerus
Fractures
Boileau proposed a classification
scheme for proximal humerus
fracture sequelae and treatment
recommendations (CORR
2006:442:121-130)
Reverse for Fracture
• Age >70-75 (I will consider for age >65)
• Tuberosities heal more predictably and
function is not as dependent on tuberosity
healing
• More predictable outcome than with hemi
• Best outcome of a hemi is better than best
outcome of a reverse
Conclusions
• Best to perform repair for acute fracture
• Anatomic restoration of humeral height and
version
• Secure tuberosity fixation
• Repair the cuff
• Tenodesis of the LHB
• Early protected PROM, close supervision of the
rehabilitation program
Conclusions
Pain relief is expected in >90% of
cases
Active shoulder level elevation in
>75% of cases