PROXIMAL HUMERUS FRACTURES

Dr.D.SUDHEER KUMARP.G, M.S(ORTHO),GANDHI HOSPITAL

INTRODUCTION

• Common in old age group• 4-5% of all fractures• 80-85% un displaced or minimally displaced-treted

conservatively.• 15% displaced require surgical intervention.• 2:1, F:M.• Shoulder has greatest ROM than other joints, due to shallow

glenoid cavity. 25% of head contact, enveloped by cuff.

HISTORY

• In 460 bc Hippocrates documented proximal humerus fractures and treated with wt traction.

• 1896 Kocher developed anatomic classification to improve diagnosis and treatment.

• 1907 Keen performed orif of greater tuberosity.• 1970 Neer published a article on classification &

treatment.

ANATOMY• One primary ossification centre for head appears at 4-6 months.• 2 secondary- 1 gt-3yrs. 1 lt-5yrs.• These coalesce between 4-7yrs.• Fuse b/w 15-17 yrs.

• Physeal plate-concave inf., spherical at apex post.and medial to its centre.

• This asymmetric shape and strong thick periostium along posterior surface explain ant. Displacement of metaphysis rathar than post.

• 80% growth occurs at upper end, so this region has greater potential for remodelling.

VASCULAR ANATOMY

• Highly vascular.• Supplied by ant.circumflex humeral –ant.lat. Br.• Post.circumflex.• Anastomosis-ant.circumflex. -post.circuflex. -thoraco acromial. -sub scapularis. -profunda brachi.• Fracture of anatomical neck is poor prognosis due to

precarious blood suply. # is un common.

MECHANISM OF INJURY

• Fall on to an out stretched UL. Common in older& osteoporotic.

• High energy trauma in youngers.• Excessive abduction• Direct trauma to GT.• Electric shock.• Pathological.

MUSCULAR ATTACHMENTS

• Sub scapularis inserted at LT.• Supra spinatus, infra spinatus, t.minor at GT.• Long head of biceps tendon passes through bicipital

groove. Pectoralis.major-medial lip. T.major –Lat.lip.• Deltoid muscle lies superficial& inserted into the

deltoid groove lat surface of u/3rd humerus.• Muscle attachment& direction of forces are imp. In

deformity and displacement.

Muscle forces• In one part or minimally displaced #s- the periostium, rotator cuff, joint capsule

attachments hold the fragments together.• Two part #; in displaced surgical neck:shaft displaced forward& medially-P.major Gt& head in neutral bcoz cuff is intact& balanced. In# GT-sup.post displaced. In # LT-medial.• Three part #; When displaced SN is component along with GT:, the unopposed pull of sub

scapularis internally rotates the articular, face post. This pattern may be accompanied with longitudinal tear of cuff.

SN along with LT:unopposed pull of cuff causes articular surface face ant.• Four part#: GT-sup.post LT-ant.medial shaft-medially deltoid insertion causes-abduction of proximal fragment.Articular segment may impact on shaft or displaced

Clinical presentation

• Upper extremity held closed to the chest by contra lat.hand.

• Pain,swelling,crepitus, painfull rom.• Ecchymosis.• pulse.• Loss of sensation lat.aspect of proximal arm&

deltoid.

RADIOLOGY

• X-ray true ap. true lat. axillary views.

• MRI

• CT Scan– articular fractures• impression• head split

– glenoid fractures– assess tuberosity

displacement for operative decision making

CLASSIFICATION

• KOCHERS;-based on different anatomic levels. Anatomic neck Epiphyseal region Surgical neck.Did not included #s at multiple level, degree of displacement,

dislocations, mechanism.• Watson Jones-contusion crack #s. Impacted #s. Impacted abducted#s.• Codmann”s based on epiphyseal region-identifies four

possible #s GT ,LT ,anatomic head, shaft

NEER’S CLASSIFICATION• Based on the # fragment displacement not on the # lines. anatomic relations of

segments of GT, LT, articular surface, shaft.• displacement considered >1cm/angulation>45*-indication for surgery.• One part-minimally displaced/un displaced.• Two part-displacement of one segment, remaining 3 segments either not

fractured or not displaced.• Three part –displacement of 2 segments GT& shaft or LT& shaft• Four part-displacement of all segments• Fracture dislocation; Ant. post.• Articular surface #: Impression # Head split#

VALGUS IMPACTED

• Specific type of four part# characterized by valgus impaction of head and variable displacement of tuberosities.

• AO classification: it gives more emphysis on vascular supply to articular segment of proximal humerus.

• Type A: extra articular uni focal: involve on of the tuberosities with or without concomitant metaphyseal #

• Type B: extra articular bi focal: one of the tuberosities with concomitant metaphyseal # or glenohumeral dislocation.

• Type C:articular: vascular isolation of articular segment

TREATMENT

• CONSERVATIVE:85% un displaced /minimally displaced #’s treated conservatively.

• Arm sling/u slab/cast for 4-6 wks.• Frequent radiological follow-up.early shoulder motion .• Pendulum exersices.• Passive rom.• After 6 wks AROM.• Resistive exersices after 12 wks.• Anatomic neck #’s difficult to treat by CR, requires

ORIF/prosthesis –due to osteonecrosis.

SURGICAL TREATMENT

• Indications: >1cm dispalcement/angulation >45* Three part fracture/fracture dislocation Four part fracture/ fracture dislocation Two part displaced # / # dislocation Valgus impacted fracture Split of head

APPROACHES

• Antero medial approach/ delto pectoral/ Thomson or Henry approach

• Deltoid splitting approach• Transacromial approach• Posterior inverted U approach• Percutaneus

DELTO-PECTORAL APPROACH• Most widely used approach• Incision begin at anterior aspect of acromio clavicular joint• Extend it medially along anterior margin of lat. 1/3rd of clavicle• Then distal along ant. Border of deltoid upto mid point of its origin and

insertion• Dissect soft tissue• Then delto-pectoral groove is identified i.e. cephalic veins and deltoid

branches of thoraco-acromial vessels lie in the groove.• Cephalic vein is either retracted medially or ligated• Clavicular origin of deltoid muscle is detached by dividing it near by its

origin retracted laterally• P. major retracted medially• This exposes ant. Part of joint capsule and corocoid process• For better exposure corocoid process cand osteotomized and short head

of biceps coracobrachialis and p.minor are reflected medially and distally• For wider exposure subscapularis is divided at musculotendinous junction

TREATMENT OF TWO PART FRACTURES

• LESSER TUBEROSITY FRACTURES: Displaced fragment blocks the internal rotation. LT # ass. With SN #/ post. Dislocation Fragment displaced medially due to sub scapularis

pull, this results in some seperation of anter. Portion of cuff

If the fragment is large ORIF with TBW/ heavy suture material oblique screw fixation can be done

If the fragment is small or communited then sub scapularis tendon is repaired at fracture site

TREATMENT OF TWO PART FRACTURES

• GREATER TUBEROSITY FRACTURES: Fragment displaced sup. Into sub acromial space if

supra spinatus is involved or posteriorly if the infra spinatus/T.minor involved.

It is ass with longitudinal tear of rotator cuff. Displaced fragments may block abduction or ext.

rotation. May develop non union/sub acromial impingment Isolated GT fracture can be approached by deltoid

split

TREATMENT OF TWO PART FRACTURES

• DELTOID SPLIT APPROACH: Incision: The deltoid is split no more than 5cm from the lat.

Aspect of acromion. -Fracture bed exposed -Fracture reduced and secured into place. Using number 5 non absorbable sutures in figure of 8

fashion through drill holes in the shaft and bone tendon junction

-rotator cuff tear closed -ORIF with screw fixation/ TBW plus suturing/ wire fixation

TREATMENT OF TWO PART FRACTURES

• SURGICAL NECK FRACTURES: In these fractures shaft may be displaced and pulled medially by p.major

If the fracture is reducible with closed reduction p/c fixation with k wires can be done followed by immobilization in sling for 3 to 4 wks

If not reducible ORIF can be done: -Combination of flexible IM nailing plus TBW -IM nailing with proximal locking screw -Hand bent semi tubular plate can be used as blade plate -BUTTERS plate with screws -PHILOS plate Multiple p/c pinning may cause nerve injury/ pin loosening/ migration/ inability to

move arm.

TREATMENT OF THREE PART FRACTURE

• Two types: 1) Dispalcement of GT and shaft with LT attached to articular segment 2) Displacement of LT and shaft with GT attached to articular surfaceClosed reductuion is difficult due to muscular forces• Surgical techniques: -Plate and screw fixation -P/c pinning -P/c canulated screw fixation -TBW -IM nailing plus TBW -prosthetic replacement of head -ex. Fix. -locking plate(Philos)• Idea behind combined approach is to convert three part # into two and two part #

into one

Locked Rigid Nails for Proximal Humerus

• enhanced proximal fixation with twisted blades or multiple screws

TREATMENT OF FOUR PART FRACTURE

• Incidence of osteonecrosis is high • Fixation is best achieved with locking plate • Hemiarthroplasty is second option for elderly• Comibination of locking plate/ wire fixation/

screw fixation/ heavy suturing can be done

HEMIARTHOPLASTY

• INDIACTIONS: -Four part fractures and fracture dislocation -Three part # and # dislocation in elderly/

osteoporotic/ communuted -Head splitting fracture -Anatomic neck fracture that can not be

reduced -Chronic dislocation with impression fracture

greater than 40%

HEMIARTHOPLASTY

• BASIC PRINCIPLES: - Tuberosity reconstruction should be done -Delto pectoral approach that preserves the

origin and insertion of deltoid muscle -Insertion of prosthesis must restore humoral

length and proper retro version -Fixation of the tuberosities to the prosthesis

and each other that they secure enough to optimize post-op functional recovery

HEMIARTHOPLASTY• IMPLANTS: - Neer’s I original umbrella shaped prosthesis - Neer’s type 2- It has longer neck and therefore increase

levarage and improves function -Co-field process- Used in total shoulder arthroplasties• COMPLICATIONS: -Prosthetic loosening -Malposition -Dislocation -Deep infection -Tuberosity detachment -Intra operative nerve injury -Intra operative fractures at tip

PHILOS PLATE (Proximal humerus interlocking system)

• INDICATIONS: -Dislocated 2, 3, or 4 fragment fractures of osteopenic bone -Pseudoarthrosis -Osteotomies in proximal humerus -Long Philos plate can be used fracture extending into shaft

or with out medial support• CONTRA-INDICATIONS: -Acute infections -Children during growth plates -Isolated shaft fractures

PROXIMAL HUMERAL LOCKING PLATE

PROXIMAL HUMERAL PLATE

PHILOS PLATE (Proximal humerus interlocking system)

• Short plate: length is 90mm with 3 shaft holes -9 proximal screw holes for LCP locking screws -10 proximal suture holes -3 or 5 distal LCP combi holes in the shaft • Long plate: Proximal part identical to short plate -length is 140 to 270 mm - 5,6,8,10 and 12 elongated holes in the shaft

PROXIMAL HUMERAL

PHILOS PLATE• PLATE POSITION: -8mm distal to the upper end of GT determine the position of

plate using k-wire -center the plate laterally against the GT ensuring that a

sufficient gap is maintained between the plate and long head of biceps

• INSTRUMENTS: -Centring sleeve for PHILOS aiming device -Drill sleeve for PHILOS aiming device -Centring sleeve for K-wire (1.6mm)• Reduce the fragments and check• Stability of structures will be improved with insertion of sutures• The insertion of sutures are recommended in weak bone where

only short screws can be used because of risk of penetration

TREATMENT OF VALGUS IMPACTED FRACTURE

• In this fracture pattern type articular segment is impacted and angulated rather than displaced and thus may retain vascularity

• It is a specific type four part fracture• Open reduction by disimpacting the fracture

fragments and internal fixation with K-wires/ canulated screws

• Humeral head replacement/ shoulder hemi arthroplasty

TREATMENT OF FRACTURE DISLOCATIONS

• All fracture dislocation should be reduced open or closed immediately

• Depending upon fracture pattern managed either conservatively or surgically

POST-OP CARE

• PHYSIOTHERAPY- It should be initiated at proper time• Aim - To gain full active and passive range of motion -To strengthen the ligaments and muscles• When managed conservatively -First three weeks self resistive isometric contractions

of deltoid, triceps and biceps -After 3wks elbow and shoulder mobilization exercises-

flexion extension abduction pendular exercise -After 12wks resistive device exercise

COMPLICATIONS• FREQUENT COMPLICATIONS: -Stiffness -Malunion -Non-union -Subacromial impingement -Rotatory cuff tear -Traumatic arthritis• LESS COMMON COMPLICATIONS: -Instability -Osteonecrosis -Infection -Heterotropic ossification• More devastating complications nerve and vascular injury

COMPLICATIONS

• Stiffness: It may be extracapsular or intra capsular• Causes of intracapsular stiffness -Tightness at rotator interval -Loss of inferior pouch -Articular incongruity -Tissue contractions• Causes of extracapsular stiffness -Shortening of coracohumeral ligament -Adhesions in sub acromial and sub deltoid bursae -Bony incongruence with mal united fracture

PROXIMAL HUMERUS FRACTURES IN CHILDREN

• Etiology - Birth related injury due to hyper extension or rotation of arm during

passage -Direct blow to shoulder -Fall on outstretched hand• SALTER HARIS CLASSIFICATION: -Type 1: Fracture through physis- less than 5yrs -Type 2: Fracture line exiting through mataphysis usually after 11yrs -Type 3: Fracture line exiting through epiphysis -Type 4: Involving both metaphysis and epiphysis• Treatment: Because of tremendous potential for healing and remodelling

fractures of proximal humerus in children rarely require surgery - Sling and Swathe immobilization is sufficient - If fracture is unstable closed reduction and p/c k-wire fixation can be done