Transcript Proximal Humerus Fractures
Proximal Humerus Fractures ORIF & Arthroplasty
Reza Omid, M.D.
Assistant Professor Department of Orthopaedic Surgery Keck School of Medicine of USC
Introduction
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5-7% of all fractures
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80% treated nonoperatively (Neer)
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Bimodal incidence
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Bone quality- important factor in obtaining secure fixation
Etiology Elderly
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fall onto outstretched hand direct blow- fall bone fragility- a/w distal radius fractures Young
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high energy seizures, electrical injury
OITE Facts
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How many with neurologic injury?
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21-36% recent study- 45%- fx or dislocation on EMG
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Which nerves?
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Axillary, suprascapular, radial, musculocut.
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How many with persistent motor loss?
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8%
Codman
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s Description Neer
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s Classification
AO Classification
Classification Neer
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s classification Sidor, Zuckerman, JBJS 1993 Gerber, JBJS, 1993
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poor inter and intra observer reliability
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best results among trained shoulder surgeons
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suggested CT scans would increase reliability
Proximal Humeral Anatomy
Understanding Fracture Patterns
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4 bony fragments
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Lesser Tub
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Greater Tub
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Head
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Shaft Neer, JBJS
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70
Proximal Humerus Assesment
Neer Classification
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1 cm displaced
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45 deg angulated
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Excessive rotation
Proximal Humerus Fractures
Fracture Patterns
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Stable
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Fx not controlled by muscle
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Unstable
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Fx controlled by attached muscle
Proximal Humerus Fracture
Fracture Anatomy
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Greater Tub – posterior, proximal
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Lesser Tub – medial, inferior
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Head – remaining tub or fx energy
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Shaft – medial, superior
X-Rays AP view scapular plane (Grashey) AP view of shoulder
X-Rays Axillary Lateral Scapular Y
Proximal Humerus Fracture Radiographic Analysis
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Normal Appearance
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Axillary: lesser tub, greater tub not seen
Proximal Humerus Fracture Radiographic Analysis
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Normal Appearance
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AP: external rotation shows greater tub
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AP: internal rotation, greater tub not seen
Proximal Humerus Fracture Fracture Anatomy
Consideration for Surgery Bone Quality Comorbidities Functional demand Vascularity???
Gerber JBJSAm 1990: 1486-94 Vascularity
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anterior humeral circumflex
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Anterolateral branch Of AHC (arcuate artery) Along lateral aspect of groove
Brooks JBJSBr 1993: 132-136
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Vascularized through interosseous anastomoses
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Between metaphyseal vessels (via posterior humeral circumflex) and the arcuate artery after ligation of the anterior circumflex humeral.
Coudane JSES 2000: 548
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Arteriography done on 20 patients after proximal humerus fractures.
80% had disruption of AHC artery 15% had disruption of PHC artery Since AVN is rare (bw 1-34%) after fx it suggests the PHC artery may be dominant supply
Hettrich JBJSAm 2010: 943-8
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MRI cadavers
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posterior humeral circumflex
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supplied 64% of head (superior, lateral and inferior).
Hertel Criteria Hertel et al JSES 2004:13:427
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Medial calcar segment <8mm
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Medial hinge is disrupted (>2mm displacement of the diaphysis)
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Comminution of the medial metaphysis
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Anatomic neck fracture
Bastian JSES 2008: 2-8
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Follow-up study by Hertel showed that initial predictors of humeral head ischemia doesn’t predict development of AVN.
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80% of patients with “ischemic heads” did NOT collapse Fixation is worth considering even if signs of ischemia are present
Nonoperative Treatment Immobilize initially
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supine FE Passive ROM 2-3 weeks
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supine ER
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pendulums AROM at 6 weeks or when consolidated 77% good to excellent results-Zuckerman 1995
Optimal Treatment
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UNKOWN????
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JSES 2011: 1118-1124 (RCT ORIF vs Non-op)
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JSES 2011: 747-55 (RCT ORIF vs Non-op
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JSES 2011: 1025-1033 (RCT Hemi vs Non-op)
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JOT 2011 (RCT ORIF vs Non-op)
Percutaneous Pinning
Surgical Technique
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Retrograde Pins
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Start Anterior
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Diverge Pins
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Antegrade Pins
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Supplemental GT to Medial Shaft
Percutaneous Pinning
Reduction Maneuver
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Surgical neck
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flexion, adduction, traction anterior pressure
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Greater tuberosity
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engage and move anteriorly/inferiorly
Percutaneous Pinning Pin Placement
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Slight medial placement of head to shaft
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Allows placement of one pin centrally
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Wide spread of pins for stability *Remember normal humeral head retroversion for pin placement
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Pin entry is just above the deltoid insertion Pins
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Three 2.5mm terminally threaded pins
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2 lateral pins 1 anterior pin 1-2 pins from GT to medial shaft Jaberg H. JBJS. 74A. 1992. 508-15.
Structures At Risk Cadaveric Study
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Lateral pins
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3mm from Ant branch Ax Penetration of head articular cartilage
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Anterior pins
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2mm from biceps tendon 11mm from cephalic v.
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Proximal tuberosity pins
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6-7mm from ax n. & posterior circumflex artery Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.
Recommendations Starting point of proximal lateral pin
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At or distal to a point 2x the distance from the superior aspect of the humeral head to the inferior margin of the head
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Greater tuberosity pins Engage medial cortex >2cm from the inferior most aspect of the humeral head Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.
Greater Tuberosity Fractures
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Displacement Superior
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Impingement Posterior
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Block to ER
Greater Tuberosity Fractures Displacement?
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5mm maybe problematic (McLaughlin et al.)
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3mm maybe problematic in the athlete or heavy laborer (Park et al.)
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Concern for RTC tears in minimally displaced fxs Positioning critical
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*Exposure
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Approach: Superior, Posterior, Anterior Reduction
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Head height 6-8mm superior to GT
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Posterior displacement more tolerated than superior displacement
Greater Tuberosity Fractures
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Surgical Approach
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Superior
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Deltopectoral
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Fixation Options
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Sutures Screws Plate
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Interval Closure
Three-Part Fractures Surgical Neck + Greater Tuberosity Lesser Tuberosity
Three-Part Fractures Fixation Options
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Percutaneous Pins Interfragmentary Suture/Wire
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Plate/Screws
IM Nail Blade Plate
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Hemiarthroplasty
Three-Part Fractures
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Approach
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Deltopectoral
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Closed Reduction/Pinning
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Goals
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Tuberosity Fixation
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Longitudinal Stability
Hemiarthroplasty
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Rarely Indicated
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Older Patients
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Osteopenic Bone
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Fracture-Dislocations
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> 40% Impression Defect
Three-Part Fractures Complications
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Nonunion
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Malunion
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Hardware Problems (screw cutout)
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AVN
Indications for ORIF of Four-part Fractures Valgus impacted four part with an intact medial soft tissue hinge Four part in a young patient (less than 40)
Indications for Pinning Valgus impacted 4 part proximal humerus fracture
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Vascularity preserved by feeding vessels in attached capsule
Valgus Impacted Four Part
Reduction Maneuver
Small incision (2 cm) anterior shoulder Line of fracture usually lies 5 mm lateral to intertubercular groove
Percutaneous Pinning
Reduction Maneuver
Valgus Impacted 4 Part
Valgus Impacted Four Part
Pinning Technique
Pin fragments
Valgus Impacted Four Part 47 y.o. female, trip and fall
When to plate?
Factors
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High energy/low energy
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Displacement
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2 part vs 3 or 4 part
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Integrity of soft tissue sleeve
Proximal Humerus Fractures
3 part
Proximal Humerus Fractures
3 part- locking plate
46 yo male Rollover dirt bike
8 wks post op
46 yo male high speed auto accident
Post op
Fracture-Dislocation
Fracture-Dislocation
Clinical Example
ORIF Technique
Reduction & Grafting
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Impaction grafting of head
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Iliac crest cube
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Fibular strut
Tag Tuberosities
Reduction & Grafting
Close Book
Plate
Indications for Hemiarthoplasty Anatomic neck and four part fractures: Isolate anatomic humeral head from its blood supply Some three part fractures with severe osteoporosis in the elderly Split humeral head fractures
Hemiarthroplasty Technique
Patient Position
Surgical Technique Extended deltopectoral exposure: deltoid origin and insertion intact
Surgical Technique Identify the LHB and Tuberosities Evaluate the rotator cuff injury
Surgical Technique Remove the humeral head Evaluate the glenoid
Muscular Anatomy Supraspinatus
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Usually starts just post to bicipital groove
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Pt. > 60 yo - strong possibility of RCT Sher, et al JBJS
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95
Tuberosity Suture Technique Place suture at the tendon bone interface
Doug Robertson, MD Louis U Bigliani, MD Evan L Flatow, MD Ken Yamaguchi, MD JBJS
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00
Results Anatomy
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Retroversion: avg 19
°
, range: 9-31
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Posterior offset: avg 2mm, range:-1-8mm
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Head thickness: avg 19mm, range:15-24mm
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Inclination:avg 41
°
, range: 34-47
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Thickness linked to Radius (avg 23mm)
Head Size Solutions
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removed head is guide
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thickness > radius
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error towards undersize
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check gross appearance
Position of Greater Tuberosity
Height Relative to Humeral Head
Surgical Technique Assess the humeral height and version Trial tuberosity reduction Mark the stem position 5-8 mm Height of the Greater Tuberosity Lesser Tuberosity
Tuberosity Height = Prosthetic Height 5-8 mm Height of the Greater Tuberosity Lesser Tuberosity
Determining Height
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Superior border of Pectoralis tendon (5.6cm
±
0.5cm)
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Side to Side comparison (x-ray)
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View calcar contour (gothic arch)
Determining Height
Proximal Humerus Fracture
Humeral Version
Version Effect of Incorrect Version Too Anteverted Too Retroverted
Bicipital Groove Anatomy
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Anterior to head center
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Anterior to keel location
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Location dependant on shaft depth
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Variable retroversion distal
Biceps Groove Version Groove shifts medially from proximal to distal, changing retroversion values 15.9
°
from the upper to lower part of the bicipital groove (Itamura)
Bicipital Groove Anatomy
Surgical Technique Prepare the fixation sutures for ORIF of the tuberosities.
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2-3 vertical and 2 horizontals, one medial one lateral
Surgical Technique
Surgical Technique Tuberosity fixation and bone graft Biceps tenodesis Wound drains and closure
Results of Hemiarthroplasty for Acute Fractures Goldman et. al. J. Shoulder and Elbow 1995 26 patients with acute fractures 73% had slight or no pain Average forward flexion 107 degrees: stiff 73% had difficulty with at least 3 of the 10 ASES question of ADL
Results of Hemiarthoplasty for Late Reconstruction Dines et. al. J. Shoulder and Elbow 1993 Demanding procedure with wide variation in results: average 80 points (HSS Scale) Stiffness, scar, hardware problems Tuberosity malposition
Results of Hemi. Early vs Late Frick et. Al. Orthopaedics 1991 Pain scores better in acute Function no different More complications in the late reconstruction group
Results of Hemi. Early vs Late Norris et al J. Shoulder and Elbow 1995 Good pain relief in both but better results in the acute group.
Only 53% had ability to use arm above shoulder level post op in late reconstruction, 15% pre-op
Results of Hemi. Early vs Late Tanner and Cofield CORR 1983 16 acute hemi, 27 late reconstruction Both had good pain relief Both had had average active shoulder elevation to 105-110 degrees Acute surgeries was easier and with less complications
Factors Affecting Outcome
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Bone density Rotator cuff tissue quality Tuberosity healing
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Restoration of anatomic humeral head height
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Restoration of anatomic humeral version
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Rehabilitation
Sequelae of Proximal Humerus Fractures Boileau proposed a classification scheme for proximal humerus fracture sequelae and treatment recommendations (CORR 2006:442:121-130)
Reverse for Fracture
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Age >70-75 (I will consider for age >65) Tuberosities heal more predictably and function is not as dependent on tuberosity healing More predictable outcome than with hemi Best outcome of a hemi is better than best outcome of a reverse
Conclusions
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Best to perform repair for acute fracture Anatomic restoration of humeral height and version Secure tuberosity fixation Repair the cuff
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Tenodesis of the LHB Early protected PROM, close supervision of the rehabilitation program
Conclusions Pain relief is expected in >90% of cases Active shoulder level elevation in >75% of cases