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Proximal Humerus Fractures ORIF &
ArthroplastyReza Omid, M.D.
Assistant ProfessorDepartment of Orthopaedic
SurgeryKeck School of Medicine of USC
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Introduction
• 5-7% of all fractures
• 80% treated nonoperatively (Neer)
•Bimodal incidence
•Bone quality- important factor in obtaining secure fixation
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Etiology
Elderly– fall onto outstretched hand– direct blow- fall– bone fragility- a/w distal radius fractures
Young– high energy– seizures, electrical injury
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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%
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Codman’s Description Neer’s Classification
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AO Classification
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ClassificationNeer’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
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Proximal Humeral Anatomy
Understanding Fracture PatternsUnderstanding Fracture Patterns–4 bony fragments4 bony fragments»Lesser TubLesser Tub»Greater TubGreater Tub»HeadHead»ShaftShaft
Neer, JBJS ‘70
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Proximal Humerus Assesment
Neer ClassificationNeer Classification–1 cm displaced1 cm displaced–45 deg angulated45 deg angulated–Excessive rotationExcessive rotation
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Proximal Humerus Fractures
Fracture PatternsFracture Patterns–StableStable»Fx not controlled by muscleFx not controlled by muscle
–UnstableUnstable»Fx controlled by attached muscleFx controlled by attached muscle
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Proximal Humerus FractureFracture AnatomyFracture Anatomy
–Greater Tub – posterior, proximalGreater Tub – posterior, proximal–Lesser Tub – medial, inferiorLesser Tub – medial, inferior–Head – remaining tub or Head – remaining tub or fx energyfx energy
–Shaft – medial, superiorShaft – medial, superior
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X-Rays
AP view scapular plane (Grashey)
AP view of shoulder
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X-RaysAxillary Lateral
Scapular Y
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Proximal Humerus FractureRadiographic AnalysisRadiographic Analysis
–Normal AppearanceNormal Appearance»Axillary: lesser tub, greater tub Axillary: lesser tub, greater tub not seennot seen
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Proximal Humerus Fracture
Radiographic AnalysisRadiographic Analysis– Normal AppearanceNormal Appearance
» AP: external rotation shows AP: external rotation shows
greater tubgreater tub» AP: internal rotation, AP: internal rotation,
greater tub not seengreater tub not seen
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Proximal Humerus FractureFracture AnatomyFracture Anatomy
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Consideration for Surgery
Bone Quality
Comorbidities
Functional demand
Vascularity???
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Gerber JBJSAm 1990: 1486-94
Vascularity– anterior humeral circumflex
» Anterolateral branchOf AHC (arcuate artery)Along lateral aspect of groove
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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.
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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
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Hettrich JBJSAm 2010: 943-8
–MRI cadavers–posterior humeral circumflex
–supplied 64% of head (superior, lateral and inferior).
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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
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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
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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
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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)
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Percutaneous PinningSurgical Technique
– Retrograde Pins» Start Anterior» Diverge Pins
– Antegrade Pins» Supplemental» GT to Medial Shaft
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Percutaneous PinningReduction Maneuver
•Surgical neck– flexion, adduction, traction– anterior pressure
•Greater tuberosity– engage and move
anteriorly/inferiorly
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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.
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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.
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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.
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Greater Tuberosity Fractures
Displacement
– Superior» Impingement
– Posterior» Block to ER
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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
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Greater Tuberosity Fractures
– Surgical Approach» Superior» Deltopectoral
– Fixation Options» Sutures» Screws» Plate
– Interval Closure
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Three-Part Fractures
Surgical Neck
Greater Tuberosity Lesser Tuberosity
+
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Three-Part Fractures
Fixation Options– Percutaneous Pins– Interfragmentary Suture/Wire
–Plate/Screws– IM Nail– Blade Plate
–Hemiarthroplasty
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Three-Part Fractures
–Approach»Deltopectoral»Closed Reduction/Pinning
–Goals»Tuberosity Fixation»Longitudinal Stability
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Hemiarthroplasty
•Rarely Indicated•Older Patients•Osteopenic Bone•Fracture-Dislocations
– > 40% Impression Defect
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Three-Part Fractures
Complications–Nonunion–Malunion–Hardware Problems (screw cutout)
–AVN
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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)
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Indications for PinningValgus impacted 4 part proximal
humerus fracture– Vascularity preserved by feeding vessels in attached
capsule
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Valgus Impacted Four PartReduction Maneuver
Small incision (2 cm) anterior
shoulder
Line of fracture usually lies 5 mm
lateral to intertubercular
groove
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Percutaneous PinningReduction ManeuverValgus Impacted 4 Part
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Valgus Impacted Four Part
Pinning Technique
Pin fragments
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Valgus Impacted Four Part47 y.o. female, trip and fall
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When to plate?Factors
–High energy/low energy–Displacement»2 part vs 3 or 4 part»Integrity of soft tissue sleeve
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Proximal Humerus Fractures
3 part
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Proximal Humerus Fractures
3 part- locking plate
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46 yo male
Rollover dirt bike
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8 wks post op
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46 yo malehigh speed auto accident
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Post op
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Fracture-Dislocation
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Fracture-Dislocation
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Clinical Example
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ORIF Technique
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Reduction & Grafting
•Impaction grafting of head
•Iliac crest cube•Fibular strut
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Tag Tuberosities
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Reduction & Grafting
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Close Book
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Plate
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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
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Hemiarthroplasty Technique
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Patient Position
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Surgical Technique
Extended deltopectoral exposure: deltoid origin
and insertion intact
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Surgical TechniqueIdentify the LHB and Tuberosities
Evaluate the rotator cuff injury
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Surgical TechniqueRemove the humeral head
Evaluate the glenoid
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Muscular AnatomySupraspinatus
–Usually starts just post to bicipital groove–Pt. > 60 yo - strong possibility of RCT
Sher, et al JBJS ‘95
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Tuberosity Suture TechniquePlace suture at the tendon bone
interface
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Doug Robertson, MDDoug Robertson, MDLouis U Bigliani, MDLouis U Bigliani, MDEvan L Flatow, MDEvan L Flatow, MD
Ken Yamaguchi, MDKen Yamaguchi, MDJBJS ‘00
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ResultsAnatomy
–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)
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Head Size
Solutions–removed head is guide»thickness > radius
–error towards undersize–check gross appearance
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Position of Greater Tuberosity
Height Relative to Humeral Head
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Surgical TechniqueAssess the humeral height and version
Trial tuberosity reduction
Mark the stem position
Lesser
Tuberosity
Height ofthe GreaterTuberosity
5-8 mm
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Tuberosity Height = Prosthetic Height
Height ofthe GreaterTuberosity
Lesser Tuberosity
5-8 mm
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Determining Height
–Superior border of Pectoralis tendon (5.6cm±0.5cm)–Side to Side comparison (x-ray)–View calcar contour (gothic arch)
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Determining Height
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Proximal Humerus Fracture
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Humeral Version
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VersionEffect of Incorrect Version
Too Anteverted Too Retroverted
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Bicipital Groove Anatomy
–Anterior to head center–Anterior to keel location–Location dependant on shaft depth»Variable retroversion distal
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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)
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Bicipital Groove Anatomy
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Surgical TechniquePrepare the fixation sutures for ORIF of the
tuberosities.– 2-3 vertical and 2 horizontals, one medial one lateral
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Surgical Technique
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Surgical TechniqueTuberosity fixation and
bone graftBiceps tenodesis
Wound drains and closure
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Results of Hemiarthroplasty for
Acute FracturesGoldman et. al. J. Shoulder
and Elbow 199526 patients with acute fractures
73% had slight or no painAverage forward flexion 107
degrees: stiff73% had difficulty with at least 3
of the 10 ASES question of ADL
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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
problemsTuberosity malposition
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Results of Hemi. Early vs Late
Frick et. Al. Orthopaedics 1991
Pain scores better in acuteFunction no different
More complications in the late reconstruction group
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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
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Results of Hemi. Early vs Late
Tanner and Cofield CORR 1983
16 acute hemi, 27 late reconstructionBoth had good pain relief
Both had had average active shoulder elevation to 105-110 degrees
Acute surgeries was easier and with less complications
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Factors Affecting Outcome
•Bone density•Rotator cuff tissue quality•Tuberosity healing•Restoration of anatomic
humeral head height•Restoration of anatomic
humeral version•Rehabilitation
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Sequelae of Proximal Humerus Fractures
Boileau proposed a classification scheme for
proximal humerus fracture sequelae and
treatment recommendations (CORR
2006:442:121-130)
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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
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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
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Conclusions
Pain relief is expected in >90% of cases
Active shoulder level elevation in >75% of
cases