Fracture of the upper

Humerus
Dr. Anthony Olasinde FWACS, MPH
Senior Lecturer/ Orthopaedic Surgeon
Dept of surgery
Kampala International University
Western Campus Ishaka- Bushenyi
Learning objectives
• Epidemiology of proximal humeral fractures
• Incidence
• Demographics
• anatomic location
• Risk factors
• Etiology
• Pathophysiology
• Pathoanatomy
• Anatomy
• Classification
• Clinical spectrum
• Treatment
introduction
• Common fractures in Osteoporotic elderly patient
• Represents 4-6% of all fractures
• Third most common non- vertebral fracture pattern seen in
elderly>65 years old
• Two parts fractures are most common
• 2:1 female to male ratio
• Increasing age associated with more complex fracture types.
Anatomic location
• May occur at surgical neck, anatomic neck, GT, and Lesser tuberosity
• Risk factors
• Osteoporosis
• Diabetes
• Epilepsy
• Female gender
Etiology
• Pathophysiology
• Low energy falls
• Elderly with osteoporotic bones
• High energy trauma
• Young individuals
• Concomitant soft tissue and Neurovascular injuries
• Patho-anatomy
• Vascularity of articular segment is more likely to be preserved if > or equal to 8mm of
calcar is attached segment
Predictors of proximal humeral head
ischemia
• Hertel criteria
• <8mm of the calcar length attached to the articular segment
• Disrupted medial hinge
• Increasing fractures complexity
• Displacement of more than 10mm
• Angulation of more than 45 degrees
• Fractures of the anatomical neck
• Associated conditions
• Nerve injury – axillary nerve most commonly affected
• Arterial injury uncommon ( 5-6%) > in elderly patients
• Occurs at surgical neck or sub-coracoid dislocation of the head
Relevant anatomy
• Osteology
• Anatomic
• represent old epiphyseal plate
• Surgical neck
• represent weakened area below head more often in fractures than anatomic neck
• Neck shaft angle 135 degrees approximately
• Muscles
• PM displaces shaft anteriorly and medially
• SIT-minor externally rotate GT
• Subscapularis internally rotates articular segment or lesser tuberosity
Ligaments
• CHL
• Coracoid and GT – strengths rotator interval
• SGHL
• Restraint to inferior translation at 0 deg. of abduction
• MGHL
• Resist AP translation in midrange ( ~45 deg. of abduction
• IGHL
• Restraint to AP translation at 90 deg. Of abduction
• Blood supply
• ACHArtery- anastomosis with large vessel in proximal humerus
• Branches- anterolateral ascending branch
• Arcuate artery – terminal and main branch supply to GT
• PCHArtery – main bld. supply to humeral head
Neer’s Classification
AO/OTA classification
Symptoms and Signs
• Pain
• Swelling
• Pseudo-paralysis ( inability to use the affected limb)
• Check for neurovascular status of the limb
• Document your finding pictorially
• Axillary nerve palsy
• Examine for concomitant chest injuries
Investigations
• Plain Radiographs
• True AP view
• Scapular Y view
• Axillary view
• CT scan
• Indication. Confirmation of head split
• Preop plan
• Intra-articular comminution
• Head and GT position unknown
• MRI rarely needed identification of rotator cuff injury
Non- operative
• Indications
• 2, 3, or impacted 4 part fracture in presence of good bone stock
• Minimally displaced surgical or anatomical neck fractures
• GT displacement less than 5mm
• Unfit for surgical intervention
• Others variables to consider are age, bone quality, fracture displacement, general Medical
condition, concurrent injuries
• Early mobilization bring relatively good outcomes
• Good analgesic
• Supervised ROM
• Rehabilitation.
Operative
• CRPP ( closed reduction and percutaneous pinning)
• Indications
• 2, 3 , or impacted 4 parts valgus impacted in young patient minimal metaphyseal comminution and
intact medial calcar.
• Outcomes
• Higher cx compared to ORIF, HA, or RSA
• Increase of axillary nerve injuries
• MCN ( musculocutaneous nerve), cephalic vein and Biceps tendons – anterior pin
• ORIF
• Indications
• GT displacement >5mm
• 2 part displaced fractures
• 3 and 4part displaced fracture in younger patients
Operative Treatment contd
• IMN
• Indication
• Surgical neck and shaft fractures
• 3part GT #s in young patients
• Adv. Favorable rates of healing and ROM compare to ORIF
• HA- hemiarthroplasty
• Indications
• 40-60 years with complex fracture dislocation
• Head splitting fractures that nail many not fix
• RSA
• Indication- low demand elderly with re-constructible GT + poor bone stock
• Older patients with fracture dislocations
Complication
• Early or Late
• Early
• Nerve injuries
• Infection
• Joint stiffness
• Malunion
• Humeral head Ischemia
• Late
• AVN of the head of humerus
• Complication related to techniques of fixation
• Non union
• Rotator cuff injuries
• Post traumatic OA
• Adhesive capsulitis
Clinical forum
ORIF with plate and Screw
CRPP
HA