Decision Making in Tibia Diaphyseal Fractures

Proximal HumerusFracturesByWoro Nugroho

Supervisordr. M. PanduNugraha, Sp. OT

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EpidemiologyAll upper extremity fractures1. forearm fxs2. proximal humerus fxsAll fractures in patients > 65 yrs1. hip fxs2. colles fxs3. proximal humerus fxs

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HUMERAL HEAD:precarious blood supplyAVN

LESSER TUBEROSITY:subscapularis insertion

GREATER TUBEROSITY:supra/infraspinatusinsertion

SURGICAL NECK/SHAFT:deltoid/pectoralis majorlargely dictates fx behaviorcompression: stable shear: unstable

4 Anatomic PartsDeforming forces determine fx displacement

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Vascular SupplyLateral ascending branch of anterior humeral circumflex artery

Damage may lead to AVN

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Humeral Head VascularityIn the fractured humerus, the arcuate artery isgenerally interuptedRecent anatomic and clinical findings confirmthat perfusion from the posterior circumflex vesselsalone may be adequate for head survival.

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Nerve INJURIES

Radial nerve1. Low Lesions -- Elbow2. High Lesions -- Humerus3. Very High Lesions -- Axillamedian Nerveulnar Nerve1. Low Lesions 2. High Lesions1. Low Lesions 2. High Lesions

Treatment80% of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY20% Displaced

OperativeNon Operative?Fx patternHead viabilityBone qualityImplant limitationsPatient age & comorbidities

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Codmans 4 parts

> 1 cm45Neer Classification

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A-type: 2-partB-type: 3-partC-type: 4-part + anatomic neck

AO Classification

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Predictors of ischemia:

Metaphyseal head extension (calcar) < 8 mm.

Loss of integrity of medial hinge Fracture Pattern (anatomic neck)

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Bone QualityTingert et al, JBJS(B), 2003

2 cmADCBMean cortical thicknessA + B + C + D

4A mean cortical thickness < 4 mm is highly indicative of low BMDPredictable loss of fixation ?

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OperativeNonoperative?Fx patternHead viabilityBone qualityImplant limitationsPatient age & comorbidities

Putting it all together

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Hospital for Special SurgeryprotocolNonoperative TxNonop tx = surgery

sling + ROMJournal of the American Academy of Orthopedic Surgeons

Court-Brown et al., JBJS(B), 2001Jan 07Hospital for Special Surgeryprotocol

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ReferencesChristopher G. Finkemeier, MD, MBARevised: May 2011

Louis, S. et al. Aples System of Orthopaedics: Ninth Editionhttps://www.youtube.com/watch?v=_Cu6ttAhe8Yhttps://www.youtube.com/watch?v=NPDQkH1kyekhttps://www.youtube.com/watch?v=PTpUzXdBvpohttps://www.youtube.com/results?search_query=proximal+humerus+fractures

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Thank You