proximal humerus fractures: evaluation and management · 2019-01-22 · anatomy. pathophysiology...
TRANSCRIPT
![Page 1: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/1.jpg)
Proximal Humerus Fractures:Evaluation and Management
![Page 2: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/2.jpg)
I have no disclosures to report
![Page 3: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/3.jpg)
Anatomy
![Page 4: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/4.jpg)
Pathophysiology
• Low energy falls - elderly• High energy trauma - young
![Page 5: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/5.jpg)
• 6% of all fractures in Western world
• 85% occur in individuals 50 or older
• Peaks in 60-90 year olds• Female : Male ratio 70:30
![Page 6: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/6.jpg)
Tendons produce reliable deforming forces• Supraspinatus and teres minor-
posteriosuperior deformity• Subscapularis – medial deformity• Pectoralis major – medial
deformity • Deltoid – lateral deformity
![Page 7: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/7.jpg)
![Page 8: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/8.jpg)
Blood Supply• Anterior and posterior humeral
circumflex (branches of axillary artery)
• Arcuate artery enters humeral head
![Page 9: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/9.jpg)
![Page 10: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/10.jpg)
Nerve Injury• Rare• Most commonly injured: axillary,
suprascapular, radial, musculocutaneous, median, ulnar
• Most commonly traction injuries that fully recover
![Page 11: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/11.jpg)
Neer Classification• Based on 4 fracture parts:
• Greater tuberosity• Lesser tuberosity• Humeral head• Humeral shaft
![Page 12: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/12.jpg)
Neer Classification System for proximal humeral fractures
![Page 13: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/13.jpg)
Historical elements• Level of independence• Functional demands• Pre-existing rotator cuff
conditions
![Page 14: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/14.jpg)
Evaluation• Skin and soft tissue• Neurologic
• Fingers, Wrist, Elbow
X-rays• AP, lateral, axillary views
![Page 15: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/15.jpg)
CT scan• Complex fractures• Fracture lines not clear
MRI• Assessing RTC when considering non-
operative treatment
Bone density• Predictor of surgical reduction and screw
cut out
![Page 16: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/16.jpg)
Non-operative Management• Minimally displaced• Poor surgical candidates• Low demand patients
Treatment• Sling 4-6 weeks, Codman exercises
early, PT at 4-6 weeks depending on bone healing
![Page 17: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/17.jpg)
Operative Treatment• Patient age• Fracture type and displacement• Bone quality• Hand dominance• General medical condition• Other injuries
![Page 18: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/18.jpg)
Types of fixation1. Percutaneous pinning
• 2-part surgical neck• 2- part and valgus impacted 4-part
fractures2. Intramedullary rodding
• Surgical neck• 3-part greater tuberosity fractures• Combined proximal humerus and
shaft fractures
![Page 19: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/19.jpg)
3. ORIF with locking plates• Greater tuberosity displaced > 5mm• 2-,3- and 4-part fractures in younger
patients• Head splitting fractures in younger
patients4. Hemiarthroplasty or RTSA
• Complex fractures• Humeral head ischemia• Poor bone quality
![Page 20: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/20.jpg)
![Page 21: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/21.jpg)
![Page 22: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/22.jpg)
![Page 23: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/23.jpg)
![Page 24: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/24.jpg)
![Page 25: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/25.jpg)
Conclusions• Common in the elderly• Majority can be treated non-op• Early movement and PT• Multiple factors play into op
treatment• Multiple ways to treat operatively
depending on fracture type.
![Page 26: Proximal Humerus Fractures: Evaluation and Management · 2019-01-22 · Anatomy. Pathophysiology • Low energy falls - elderly • High energy trauma ... Neer Classification System](https://reader033.vdocuments.us/reader033/viewer/2022052923/5f03e0727e708231d40b3492/html5/thumbnails/26.jpg)
ReferencesProximal humerus fractures: Evaluation and Management in Elderly Patients, Adam Schumaier, MD and Brian Grawe, MD