fractures of the proximal humerus
DESCRIPTION
FRACTURES OF THE PROXIMAL HUMERUS. Presented by Mahsa Mehdizade Dr. Mardani Porsina Hospital Spring 1392. Incidence. Proximal humerus fxs comprise 4-5% of all fxs. Minimal displacement 80% Two-part fxs 10% Three-part fxs 3% Four-part fxs 4% Articular surface fxs 3%. Anatomy. - PowerPoint PPT PresentationTRANSCRIPT
FRACTURES OF THE PROXIMAL HUMERUS
Presented by Mahsa Mehdizade
Dr. MardaniPorsina Hospital
Spring 1392
IncidenceProximal humerus fxs comprise 4-5% of all fxs.
Minimal displacement 80%Two-part fxs 10%Three-part fxs 3%Four-part fxs 4%Articular surface fxs 3%
AnatomyComprised of four segments:
Humeral headGreater tuberosityLesser tuberosityHumeral shaft
Neurovascular SupplyAnterior and posterior humeral circumflex arteriesArcuate artery-continuation of the ant humeral circumflex and supplies most of the humeral head.Axillary nerve-most commonly injured
Forces on SegmentsGreater tuberosity is displaced superiorly and posteriorly by the supraspinatus and external rotators.Lesser tuberosity is displaced medially by the subscapularis.The shaft is displaced medially by the pectoralis major.
Mechanism of InjuryElderly, osteoporotic, usually female: fall on outstretched arm.Young adults: high-energy trauma; usually more severe fxs and dislocations
Radiographic EvaluationA/P viewScapular Y viewAxillary view
Best view for glenoid articular fxs and dislocations
CT scan: helpful in evaluating articular involvement and degree of displacement
ClassificationsNeer-four parts: greater and lesser tuberosities; shaft; humeral head.
A part is displaced only if >1cm of displacement or 45 degrees of angulation is present.At least 2 views must be obtained
AO-emphasizes the vascular supply to the articular segment
Three types:• Type A: Extraarticular unifocal fxs• Type B: Extraarticular bifocal fxs• Type C: Articular fxs
Not commonly used
Neer Classification
Treatment OptionsClosed reduction
ImmobilizationEarly ROM if stable
External stabilizationPercutaneous pinsExternal fixatorIlizarov frame
Open reduction and internal fixation
Screw fixationTension bandingButtress platingFix-Clip system
Intramedullary fixation
Rush rodsEnder’s nailsNails with interlocking screws
Excisional arthroplastyHemiarthroplasty
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 ORIFDisplaced GT fx (> 5 mm)LT fx with involvement of articular surfaceDisplaced or unstable surgical neck fxDisplaced anatomic neck fx in young pt.Displaced, reconstructible 3- and 4-part fractures
Fractures to Consider Hemiarthroplasty
Young/Middle agenonreconstructable articular surface (severe head split) or extruded anatomic neck
Elderlymany 4 partssome severe 3 partsmost 3,4 part fracture dislocationsmost head splits
Potential ComplicationsNeurologic injury
Brachial plexus-Stableforth reported an incidence of 6.1%Axillary-common
Vascular injuryStableforth also reported a 4.9% incidence of arterial injury with displaced fxs; most commonly the axillary arteryAn intact radial pulse doe not exclude an arterial injury so keep it in mind.
Complications cont.Avascular necrosis
Hagg and Lungberg reported an incidence of 3 – 14% with 3- part fxs and 13 – 34% with 4-part fxs, using closed reduction.
Nonunion (uncommon)Malunion – often associated with AVNAdhesive capsulitisMyositis ossificansInfection