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Proximal Humerus. Fractures. Principles of Diagnosis, Decision Making and Treatment. Christopher G. Finkemeier, MD, MBA Revised: May 2011. Acknowledgement: AO faculty lecture archive. Objectives. 1. Learn the principles of diagnosis. 2. Learn the principles of decision making. - PowerPoint PPT Presentation
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Proximal HumerusProximal HumerusFracturesFractures
Principles of Diagnosis,Principles of Diagnosis,Decision Making and TreatmentDecision Making and Treatment
Christopher G. Finkemeier, MD, MBAChristopher G. Finkemeier, MD, MBARevised: 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
EpidemiologyAll upper extremity fracturesAll upper extremity fractures
1. forearm fxs1. forearm fxs2. proximal humerus fxs2. proximal humerus fxs
All fractures in patients > 65 yrsAll fractures in patients > 65 yrs1. 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 VascularityGerber 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.
Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001
True AP Transcapular “Y”
RadiographyRadiography
Axillary View
Lesser Tuberosity
CT ScanArticular surface
– Head splitting injury
Tuberosity displacement, especially lesser
tuberosity
Treatment80% of PHF are NONDISPLACED and can be
successfully treated NONOPERATIVELY20% Displaced
Operative Nonoperative?Fx pattern
Head viabilityBone quality
Implant limitationsPatient age & comorbidities
Neer Classification
Codman’s 4 parts
> 1 cm> 1 cm45º45º
A-type: 2-partA-type: 2-part
B-type: 3-partB-type: 3-part
C-type: 4-part +C-type: 4-part + anatomic neckanatomic neck
AO Classification
Predictors of ischemia:
– Metaphyseal head extension (calcar) < 8 mm.
Hertel et al, J Shoulder Elbow Surg 2004;13:427
97%PPV
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 cm AADDCCBB
Mean cortical thicknessMean cortical thickness
A + B + C + DA + B + C + D44
““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 07Hospital for Special Surgery
protocol
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 TxSatisfactory bone qualitySatisfactory bone quality
Closed reductionClosed reductionpercutaneous pinspercutaneous pins
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
Hospital for Special Surgeryprotocol
Operative TxOperative TxSatisfactory bone qualitySatisfactory bone quality
ORIFORIF
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
Hospital for Special Surgeryprotocol
Nonoperative TxNonoperative Tx
B1.1B1.1Poor bone qualityPoor bone quality
Court-Brown, JBJS(B), 2002Court-Brown, JBJS(B), 2002Zyto et al, JBJS(B), 1997Zyto et al, JBJS(B), 1997
Non-op = surgeryNon-op = surgerymaybe bettermaybe better
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
Hospital for Special Surgeryprotocol
ORIFORIFHigh failure rates withHigh failure rates withstandard platesstandard plates
Especially in patients Especially in patients with poor bonewith poor bone
Locking plates have Locking plates have dramatically improved dramatically improved fixationfixation
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
Hospital for Special Surgeryprotocol
HemiarthroplastyHemiarthroplastyHighly displaced fxsHighly displaced fxs““3 or 4-part”3 or 4-part”
Poor bone qualityPoor bone quality
Not reconstructableNot reconstructable
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
HemiarthroplastyHemiarthroplasty
HemiarthroplasyHemiarthroplasyPain relief generally goodGood function depends on anatomic tuberosity placement
Despite all the advances, shoulder flexion above 90º is difficult to acheive
Hospital for Special Surgeryprotocol
Anatomic neck fxsAnatomic neck fxshave high rate ofhave high rate ofAVN (+/- 50%).AVN (+/- 50%).
Poor bonePoor bone HemiHemiGood boneGood bone FixFix
Journal of the American Academy of Orthopedic SurgeonsJournal of the American Academy of Orthopedic Surgeons Jan 07Jan 07
Unless able to fixUnless able to fixanatomically, better to anatomically, better to replace (hemi)replace (hemi)
Gerber et al.Gerber et al.JSES, 1998 JSES, 1998
Summary ofSummary ofDecision Making ProcessDecision Making Process
““Young” PatientsYoung” Patients<30yrs? <40yrs? <50 yrs?<30yrs? <40yrs? <50 yrs?
““Full court press”Full court press”
Hemiarthroplasty for non-reconstructable fxs Hemiarthroplasty for non-reconstructable fxs onlyonly
Preservation of function is primary objectivePreservation of function is primary objective
Anatomic reduction/soft tissue sparingAnatomic reduction/soft tissue sparingStable fixation Stable fixation
““good bone quality”good bone quality”
Elderly PatientsElderly Patients
Pain relief primary objectivePain relief primary objectiveNon op RX if fracture stable and early motion possible
Locking 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
6 weeks6 weeks+ callus+ callus
FE 90FE 90
ReferencesReferencesNeer, CS. Displaced Proximal Humeral Fractures. Neer, CS. Displaced Proximal Humeral Fractures. JBJS 52-A: 1077-1089, 1970.JBJS 52-A: 1077-1089, 1970.
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
ReferencesReferencesNho, 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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