1. Proximal Humerus Fractures
Gregory L. DeSilva, MD

2. History/Demographics
Bimodal: young-high energy, elderly-low energy (osteoporosis)
45% of all humerus fx.
elderly females 4:1 over males
77% of all prox. hum. fractures female

3. Consequences/Associated Injuries
Disabilities often underestimated
Loss of motion
Loss of reduction
AVN
heterotopic bone
Associated Injuries
rotator cuff
nerve (axillary, brachial plexus)
vascular
scapula, clavicle

4. Anatomy

5. Proximal Humeral Retroversion
35-40 degrees relative to epicondylar axis

6. Blood Supply Axillary artery ant. humeral circumflex
*ascending branch (arcuate artery) is the major blood supply to the articular surface
post. humeral circumflex
Arcuate
Arcua
afeeffe

7. Nerves
Brachial Plexus
axillary
suprascapular
musculocutaneous

8. Classification Neer 2 part SN,AN,GT,LT 3 part SN+GT or LT AN+GT or LT
neck + both tuberosities
+/- dislocation
Neer’s definition of displacement: >1cm or >45 degrees

9. Classification AO/OTA type A-Unifocal type B-Bifocal type C-Articular
2 part extracapsular
type B-Bifocal
3 part partially intracapsular
type C-Articular
vascular isolation of head
4 part intracapsular

10. Classification AO/OTA type A-Unifocal type B-Bifocal type C-Articular
2 part extracapsular
type B-Bifocal
3 part partially intracapsular
type C-Articular
vascular isolation of head
4 part intracapsular

11. Radiographic Work Up Trauma Series Other CT Scan true scapular AP
axillary (head defects, displacement of tuberosities
Y or transscapular
Other
modified axillary
AP in int. and ext. rotation
CT Scan
articular fractures
impression
head split
glenoid fractures
assess tuberosity displacement for operative decision making

12. Radiographic Work Up Scapular AP, Axillary, Y view, CT Scan

13. Shoulder Trauma -X-Rays

15. Avoid Missed Shoulder Dislocation
Clinical Suspicion
Proper x-rays
Axillary view is a must!
Axillary view is mandatory!
Don’t accept lack of axillary view!

16. Nothing is Dislocated until it is proven that it is dislocated!!!!!!!
Nothing is Reduced until it is proven that it is reduced!!!!!!!

17. Fractures to Consider for Closed Treatment
Minimally displaced 2 part fx’s (or positional reduction of significant displacement)
GT fractures should be <5mm).
Minimally displaced 3- and 4-part fractures

18. Fractures to Consider for ORIF
Displaced GT fx (> 5 mm)
LT fx with involvement of articular surface
Displaced or unstable surgical neck fx
Displaced anatomic neck fx in young pt.
Displaced, reconstructible 3- and 4-part fractures
Polytrauma

19. Fractures to Consider Hemiarthroplasty
Young/Middle age
nonreconstructable articular surface (severe head split) or extruded anatomic neck
Elderly
many 4 parts
some severe 3 parts
most 3,4 part fracture dislocations
most head splits

20. Current Techniques of ORIF
Percutaneous Pins (Jaberg, H. 1992)
Suture, K-wire, tension band technique (Cornell,C. H. 1994, Darder, A. 1993, Hawkins, J.R. 1987, Neer, C.S. 1970)
Flexible IM nails (Lee, C. K. 1981, Robinson, C. M. 1993, Wesley, M. S. 1977)
Buttress Plates (Esser, R. D. 1994, Kristiansen, B. 1986, Paavolainen, P. 1983, Savoie, F.H. 1989)
Selected Locked Rigid IM nails
Blade Plate Fixation (Weber 1984, Sehr, Szabo 1988, Jupiter, Scheid 1999)
Proximal Humeral Locking Plates

21. Percutaneous Pinning
Associated Problems: nerve injury (axillary), pin loosening, migration, no early motion
Best Use: limited 2 or 3 part when other techniques not favorable
Migration----

22. Suture or K-wire/Tension Band
Best Use: GT, LT, GT+LT, tuberosities with undispl. SN

23. Flexible Nails Best use: 2 part SN
Newer plates and nails more favorable

24. Locked Rigid Nails for Proximal Humerus
enhanced proximal fixation with twisted blades or multiple screws

25. PROXIMAL HUMERAL LOCKING PLATE

26. PROXIMAL HUMERAL PLATE

27. PROXIMAL HUMERAL

28. Hemiarthroplasty
Associated Problems: unpredictable results from function standpoint, still requires bony healing (of tuberosities)
Best use: elderly 3,4 part, head splits, dysvascular AN

29. Complications Misdiagnosis degree of GT displacement
missed post. Dislocation
massive rot. cuff avulsion with high energy dislocation. Suspect when severe swelling
head split (double shadow) best seen on axillary v. or CTS

30. Complications Nonunion
In young, treat like an acute fracture if head viable.
Consider hemiarthroplasty in elderly or osteoporotic.

31. Complications Adhesive Capsulitis AVN
Significant incidence in 3 and 4 part fractures. Higher when treated with ORIF.
Unlike hip, incidence does not correlate directly with symptoms.
Can be minimized with decreased soft tissue stripping and no encroachment of circumflex/arcuate art.
Adhesive Capsulitis
almost universal but minimized with early motion
controlled P.T.
manipulation under anesthesia
occasional arthroscopic release

32. Summary Challenging fractures Get proper x-rays
Axillary view is a must
Don’t miss a fracture-dislocation!
Neer vs. AO/OTA classification
AVN
Osteoporosis/insufficiency fx
Poor ROM