Proximal Humerus Proximal Humerus Fractures Fractures Principles of Diagnosis, Principles of Diagnosis, Decision Making and Treatment Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Christopher G. Finkemeier, MD, MBA Revised: May 2011 Revised: May 2011 Acknowledgement: AO faculty lecture archive
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Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement:
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Proximal HumerusProximal Humerus
FracturesFracturesPrinciples of Diagnosis,Principles of Diagnosis,
Decision Making and TreatmentDecision Making and TreatmentChristopher G. Finkemeier, MD, MBAChristopher G. Finkemeier, MD, MBA
Revised: May 2011Revised: May 2011
Acknowledgement: AO faculty lecture archive
Objectives
1. Learn the principles of 1. Learn the principles of diagnosisdiagnosis
2. Learn the principles of 2. Learn the principles of decision makingdecision making
3. Learn the 3. Learn the various treatment optionsvarious treatment options
All fractures in patients > 65 yrsAll fractures in patients > 65 yrs
1. hip fxs1. hip fxs2. “colles” fxs2. “colles” fxs3. proximal humerus fxs3. proximal humerus fxs
HUMERAL HEAD:precarious blood supplyAVN
LESSER TUBEROSITY:subscapularis insertion
GREATER TUBEROSITY:supra/infraspinatus
insertion
SURGICAL NECK/SHAFT:deltoid/pectoralis major
largely dictates fx behaviorcompression: stable
shear: unstable
4 Anatomic PartsDeforming forces determine fx displacementDeforming forces determine fx displacement
Vascular Supply
Lateral ascending branch of anterior
humeral circumflex artery
Damage may lead to AVN
Humeral Head VascularityHumeral Head Vascularity
Gerber et al., JBJS, 1990
Non shaded area is suppliedNon shaded area is suppliedby the lateral ascending branchby the lateral ascending branch of the anterior humeral circumflexof the anterior humeral circumflexartery.artery.
Humeral Head VascularityHumeral Head Vascularity
In the fractured humerus, the arcuate artery isIn the fractured humerus, the arcuate artery isgenerally interupted.generally interupted.
Recent anatomic and clinical findings confirmRecent anatomic and clinical findings confirmthat perfusion from the posterior circumflex vesselsthat perfusion from the posterior circumflex vesselsalonealone may be adequate for head survival. may be adequate for head survival.
Loss of integrity of medial hinge Fracture Pattern (anatomic neck)
BEWARE of lateral displacement of head
Blood Supply Potentially Torn if medial hinged displaced
This head is likely NOT viable.
Metaphyseal head extension < 8mm
Medial Hinge notMedial Hinge not displaceddisplaced
Metaphyseal headMetaphyseal headExtension > 8mmExtension > 8mmThis head isThis head is
likely viablelikely viable
Bone QualityTingert et al, JBJS(B), 2003Tingert et al, JBJS(B), 2003
2 cm2 cmAA
DDCCBB
Mean cortical thicknessMean cortical thickness
A + B + C + DA + B + C + D
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““A mean cortical thickness A mean cortical thickness < 4 mm< 4 mm is highly indicative of low is highly indicative of low BMD”BMD”
Predictable loss of fixation ?Predictable loss of fixation ?
Implant limitationsImplant limitations
Locking plates are less proneto failure due to the fixed-angled screws.
Conventional implantsPoorly control varus
collapse, screw looseningand screw back out.
Recognizing what implants areRecognizing what implants areappropriate for certain fractureappropriate for certain fracturetypes is a key decision making factor.types is a key decision making factor.
Operative Nonoperative?Fx pattern
Head viabilityBone quality
Implant limitationsPatient age & comorbidities
Putting it all togetherPutting it all together
Hospital for Special Surgeryprotocol
Nonoperative TxNonoperative Tx
Nonop tx = surgeryNonop tx = surgery
sling + ROMsling + ROM
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons
Court-Brown et al., JBJS(B), 2001
Jan 07Jan 07
Hospital for Special Surgeryprotocol
Hospital for Special Surgeryprotocol
Nonoperative TxNonoperative Tx
ElderlyElderlyNon-displacedNon-displacedor mod displacedor mod displaced
Nonop tx = surgeryNonop tx = surgery
sling + ROMsling + ROM
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons
Court-Brown et al., JBJS(B), 2001
Jan 07Jan 07
Treatment: Non-operativeKoval 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-operativeCourt-Brown et al., JBJS(B), 2001
– Mean age 72 yrs
– Outcome determined by age and degree oftranslation
– Surgery did not improve outcomes regardlessof translation
Hospital for Special Surgeryprotocol
Poor bone qualityPoor bone qualityOperative TxOperative Tx
heavy sutureheavy suturethrough rotatorthrough rotatorcuff insertioncuff insertion
““significant displacement”significant displacement”>5mm GT >66% SN>5mm GT >66% SN
Locking plate
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
oror
Hospital for Special Surgeryprotocol
Operative TxOperative Tx
Satisfactory bone qualitySatisfactory bone quality
Non op RX if fracture stable and early motion possible
Lock
ing plate
““poor bone quality”poor bone quality”
If unstable:
ORIF if head viable and fracture reducible
Hemiarthroplasty if head not viable or fracture not repairable
CaveatCaveat
““A proximal humeral fracture that is at riskA proximal humeral fracture that is at riskfor AVN has to be reduced anatomicallyfor AVN has to be reduced anatomicallyif joint preserving treatment is selected. Ifif joint preserving treatment is selected. Ifanatomic reduction cannot be obtained,anatomic reduction cannot be obtained,other treatment options such as arthroplastyother treatment options such as arthroplastyshould be considered.”should be considered.”
Gerber et al.Gerber et al.The clinical relevance of posttraumatic avascularThe clinical relevance of posttraumatic avascularNecrosis of the humeral head. JSES, 1998 Necrosis of the humeral head. JSES, 1998
93 y/o male93 y/o maleRHDRHD
HealthyHealthyFellFell
Medial hinge intact
Metaphyseal spike> 8mm
GT fx +GT fx +Surgical neck fxSurgical neck fxwith extensionwith extension
Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A:1090-1103, 1970.1090-1103, 1970.
Gerber, C. et al. The Arterial Vascularization of the Humeral Head. Gerber, C. et al. The Arterial Vascularization of the Humeral Head. JBJS 72-A: 1486-1494, 1990.JBJS 72-A: 1486-1494, 1990.
Brooks, CH et al. Vascularity of the Humeral Head After Proximal HumeralBrooks, CH et al. Vascularity of the Humeral Head After Proximal HumeralFractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.Fractures: An Anatomical Study. JBJS 75-B: 132-136, 1993.
Hertel, R et al. Predictors of Humeral Head Ischemia After IntracapsularHertel, R et al. Predictors of Humeral Head Ischemia After IntracapsularFracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004Fracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004
ReferencesReferences
Nho, SJ. et al. Nho, SJ. et al. Innovations in the Management of Displaced Proximal Humerus Innovations in the Management of Displaced Proximal Humerus FracturesFractures . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007. . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007.
Koval, KJ. et al. Koval, KJ. et al. Functional Outcome after Minimally Displaced Fractures Functional Outcome after Minimally Displaced Fractures of the Proximal Part of the Humerusof the Proximal Part of the HumerusJBJS 79-A: 79: 203 – 7, JBJS 79-A: 79: 203 – 7, 1997.1997.
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