FRACTURES OF THE PROXIMAL HUMERUS Presented by Mahsa Mehdizade Dr. Mardani Porsina Hospital Spring 1392

Incidence Proximal humerus fxs comprise 4-5% of all fxs. Minimal displacement 80% Two-part fxs 10% Three-part fxs 3% Four-part fxs 4% Articular surface fxs 3%

Anatomy Comprised of four segments: Humeral head Greater tuberosity Lesser tuberosity Humeral shaft

Neurovascular Supply Anterior and posterior humeral circumflex arteries Arcuate artery- continuation of the ant humeral circumflex and supplies most of the humeral head. Axillary nerve-most commonly injured

Forces on Segments Greater tuberosity is displaced superiorly and posteriorly by the supraspinatus and external rotators. Lesser tuberosity is displaced medially by the subscapularis. The shaft is displaced medially by the pectoralis major.

Mechanism of Injury Elderly, osteoporotic, usually female: fall on outstretched arm. Young adults: high-energy trauma; usually more severe fxs and dislocations

Radiographic Evaluation A/P view Scapular Y view Axillary view Best view for glenoid articular fxs and dislocations CT scan: helpful in evaluating articular involvement and degree of displacement

Classifications Neer-four parts: greater and lesser tuberosities; shaft; humeral head. A part is displaced only if >1cm of displacement or 45 degrees of angulation is present. At least 2 views must be obtained AO-emphasizes the vascular supply to the articular segment Three types: Type A: Extraarticular unifocal fxs Type B: Extraarticular bifocal fxs Type C: Articular fxs Not commonly used

Neer Classification

Treatment Options Closed reduction Immobilization Early ROM if stable External stabilization Percutaneous pins External fixator Ilizarov frame Open reduction and internal fixation Screw fixation Tension banding Buttress plating Fix-Clip system Intramedullary fixation Rush rods Ender’s nails Nails with interlocking screws Excisional arthroplasty Hemiarthroplasty

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

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

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

Potential Complications Neurologic injury Brachial plexus-Stableforth reported an incidence of 6.1% Axillary-common Vascular injury Stableforth also reported a 4.9% incidence of arterial injury with displaced fxs; most commonly the axillary artery An intact radial pulse doe not exclude an arterial injury so keep it in mind.

Complications cont. Avascular necrosis Hagg and Lungberg reported an incidence of 3 – 14% with 3- part fxs and 13 – 34% with 4-part fxs, using closed reduction. Nonunion (uncommon) Malunion – often associated with AVN Adhesive capsulitis Myositis ossificans Infection