2. Glenohumeral joint  High motion at the expense of low stability  Most commonly dislocated large joint in the body  98% anterior Static RestraintsDynamic Restraints Articular anatomyRotator cuff muscles = 1° role Negative pressureLH biceps tendon CapsuleScapulothoracic motion Glenoid Labrum CH ligament SGH ligament MGH ligament IGH ligament

3. Proximal Humerus Fractures  Third most common fracture pattern seen in elderly  2:1 female to male ratio

4. Proximal humerus anatomy  Humeral head inclined in coronal plane with respect to humeral shaft 130-150 degrees  Most cephalad point of articular surface is 8mm proximal to tip of greater tuberosity  Humeral head is retroverted 0-55 degrees

5. Humeral head vasculature  Anterolateral branch of humeral circumflex artery  Supplies humeral head  Runs parallel and lateral to tendon of the long head of the biceps – terminates as arcuate artery  Posterior humeral circumflex artery  Now considered primary blood supply to humeral head In a cadaver study, Hettrich quantitatively assessed the vascularity of the proximal humerus and found that the posterior circumflex humeral artery contributes 64% of the blood supplied to the proximal humerus, whereas the anterior circumflex humeral artery contributes just 36%.  Predictors of humeral head ischemia with fracture  Disruption of integrity of medial hinge between humeral head and shaft leads to higher risk of ischemia  Anatomic neck fx = higher ischemia risk  Vascularity of articular segment is more likely to be preserved if >8mm of calcar is attached to articular segment

6. Clinical evaluation  Neurologic exam  45% chance of nerve injury  Integrity of nervous structures  Axillary nerve  Motor supply of axillary nerve comes from ant branch- close proximity to prox humerus fx  Suprascapular n  Musculocutaneous n  Nerve injury more common in elderly pts due to hematoma formation  Most nerve damage resolves within 4 months  Must check distal pulses  Axillary artery passes medial to humeral head and surgical neck  can be injured in low or high energy trauma

7. Radiographic evaluation  AP  Relationship of humeral head with respect to glenoid  Humeral neck-shaft angle  Offset of center of rotation of head with respect to shaft  Relationship of GT to head  Better view with arm externally rotated  Axillary  Is humeral head located?  Glenoid rim pathology  Evaluation of tuberosity displacement  Scapular-y  Saggital plane translation of humeral head  Greater tuberosity displacement  Ct scans  Can help to delineate fracture pattern  Comminution  Fracture relationships

8. Fracture Classification  Neer  4 parts  Head  Shaft  Greater tuberosity  Lesser tuberosity  What makes a part  > 1 cm displacement  >45 degrees angulation  >5mm displacement in GT fxs

9. Muscle forces on fx fragments  Deforming muscle forces  GT  Superiorly and posteriorly by supraspinatus and ext rotators  LT  Medially by subscapularis  Humeral shaft  medially by pec major

10. Non-operative Treatment  Sling immobilization with progressive rehab  85% of prox humerus fxs  Elderly patients  Minimally displaced surgical neck fxs  GT <5 mm displacement  Begin early ROM within 14 days  Recent literature has shifted towards operative tx in younger patients and more functional older patients

11. Trends and Variation in Incidence, Surgical Treatment, and Repeat Surgery of Proximal Humeral Fractures in the Elderly  JBJS Jan. 2011  Compared rates of operatively treated fx’s from 1999-2000 and 2004-2005  Used Medicare Part B data  Percent treated operatively increased from 12.5% to 15.7%  Increases in both ORIF and hemiarthroplasty

12. Treatment options ORIF  Nonlocked plating  Locked plating  Wiring Arthroplasty  Hemiarthroplasty  Total Shoulder  Reverse Total Shoudler

13.  155 pts- Avg age 62.9  Prospective  Followed at 3, 6, and 12 months Outcomes For ORIF in Proximal Humerus Fractures

15. Complications  62 complications in 52 (34%) of 155 pts  29 pts (19%) had re- operation by 12 months  4 infection  15 early implant removal  3 screw exchanges  3 conversion to hemi  4 repeat ORIF for failure

16. Summary  34% complication rate  19% re-operation rate  40% of complications were present at the end of the procedure and directly related to surgical technique  Patients continue to improve up to one year post-op

17. Results after Internal Fixation of Proximal Humerus Fractures  JOT May 2011- 4 year follow up  57 pts- mainly 3 and 4 part fractures  65 years  29% re-operation rate all within 18 months  75% good to excellent results at 4 years  Most improvement in first year but continued to improve over entire follow-up period

18. Analysis of Efficacy and Failure in Proximal Humerus Fractures Treated With Locking Plate  JOT Dec 2007  153 pts- Avg age 62.3  Failure rates associated with malreduction  Head-shaft angle  <120 o - 30.4% failure rate  >120 o - 11% failure rate

19. Locked Plating of 3- and 4-Part Proximal Humerus Fractures in Older Patients: The Effect of Initial Fracture Pattern on Outcome  JOT Feb 2009  70pts  18 month f/u  Compared pre-operative fx configuration with results  All fractures fixed with Locked plating

20. Pre-operative Configuration ValgusVarus Complication Rate* 19%79% Constant Score71.263.3 AVN15%21% Secondary Surgery 15%63%  *Included varus malreduction >5 o in complications

21. Predicting Outcomes  Worse outcomes with varus fracture patterns  Patients with valgus impacted fractures with a metaphyseal segment length >2 mm experienced better clinical outcomes than did patients with fracture patterns with initial varus malalignment.  Humeral head angulation had the greatest effect on final clinical outcomes.  Varus fracture patterns may be better treated with options other than ORIF  Metaphyseal extension of humeral head fragment  <8mm- higher rates of AVN  Medial hinge disruption  >2mm- higher rates of AVN  Smoking history  Higher rates of AVN and non-union

22. Post-operative Predictors of Outcomes  Restoration of the tuberosities and rotator cuff function  Screw placement  Subchondral bone  Medial calcar support  Maintaining reduction out of varus

23. Primary Hemiarthroplasty for Treatment of Proximal Humeral Fractures  JBJS 2003  138 pts- age 68.5  Avg 6.3 year f/u  Prosthetic Survival  1 year- 96.9%  5 years- 95.3%  10 years- 93.9%

24. Complications  Re-operation  8(5.7%)  3 for periprosthetic fracture  3 for dislocation  1 for deep infection  1 for loosening  Tuberosity migration  10pts >2cm

25. Function  Good pain relief  Function varied considerably based on age  Avg constant score- 68  CS decrease by 8 for every 10 year increase in age  Can explain difference in CS in ORIF vs Hemi  Displacement of tuberosities leads to worse outcomes

26. Predictive Factors for function at 1 year  Pre-op  Neurological deficit, hx of Etoh or tobacco  6 week  Age  Re-operation  Persistent neurological deficit  Displacement of tuberosities

27.  Loebenberg 2005 demonstrated that active ROM following hemiarthroplasty for four part humerus fracture is affected by the placement of the greater tuberosity fragment relative to the superior margin of the prosthetic head.  Tuberosity placement 10 to 16 mm distal to the superior margin of the prosthetic head resulted in significantly improved active forward elevation and external and internal rotation compared with tuberosities positioned too proximal (3 to 9 mm) or too distal (17 to 28 mm).

28. Proximal Humeral Fractures in Younger Patients: fixation techniques and arthroplasty  JSES 2011  Review article  Discusses common pitfalls in the management of proximal humerus fractures including:  Risk of osteonecrosis  Greater tuberosity fixation  Internal rotation of the humeral shaft

29. Internal rotation of the humeral shaft  In non-op treated fractures in a shoulder sling  Rotatory malunion  Lose tension of external rotators/disturbs path of the biceps tendon  In operatively treated fractures placed in sling post-op  Places undue tension on your GT repair while protecting your subscap/LT repair

31.  Recommended immobilization in neutral rotation  Hemi indicated in young patients with:  Compromised humeral head(dislocation, devitalization)  Poor bone quality  ORIF still recommended in patients with adequate bone

32. Unhappy Triad of Arthroplasty  Boileau et al 2000  Excessive prosthesis height  humeral lengthening >10 mm caused by a proud prosthesis significantly correlated with tuberosity detachment and proximal migration of the prosthesis under the acromial arch, resulting in limited function  Increased retroversion  Excessive retroversion can force malpositioning of the greater tuberosity in the horizontal plane, thereby creating excessive tension on the tuberosity repair with the arm in internal rotation.  Improper version may result in instability  Malpositioning of tuberosities

33. Humeral Prosthesis Height  Murachovsky et al- 2006 JSES  5.6 +/- 0.3 cm from the superior border of the pec major insertion to the superior aspect of the humeral head

35. Transosseous Suture Fixation of Proximal Humeral Fractures  JBJS 2007  Avg age- 54*  64- 3 part fractures  45- 4 part fractures  94% of surgeries done within 5 days of injury

37.  Avg f/u 5.4 years  Hemi- Avg constant score- 68  ORIF relative constant score- 71

38. Summary  87% patient satisfaction  94% excellent/very good radiographic outcomes  Low rates of AVN  Little stripping of soft tissues  Great functional results  Age?  Avg age 54  Age in ORIF and Hemi studies averaged 62 or +  Hemi study showed Constant Score decrease of 8 points for every 10 years of age

39. Treatment of Comminuted Fractures of the Proximal Humerus in Elderly Patients With the Delta III Reverse Shoulder Prosthesis  JOT- Dec 2009  20 patients  Avg age- 75  Avg Constant Score- 67.85  Complications  1 dislocation  2 infections- treated with I&D

41.  Negative predictive factors in Hemiarthroplasty  Massive RTC tears  Position and healing potential of the tuberosities  Reverse TSA may lack internal/external  Maintains Forward flexion and Abduction

42.  Greater tuberosity repair restores infraspinatus and teres minor function and improves external rotation  Repair of the lesser tuberosity is controversial:  Effectively weakens external rotators by increasing internal rotation strength  May decrease anterior instability  Avoid scapular notching  Predictors of notching include superior positioning of the glenosphere, medialization of the center of rotation, and a high body mass index.

44. Reverse TSA  Absolute contraindications for RSA include:  permanent axillary nerve dysfunction  global deltoid muscle dysfunction  global brachial plexopathy  Implant longevity remains a concern, and few successful salvage options are available if the arthroplasty fails; long- term outcomes beyond 10 years are not well defined.

45.  JSES 2015  Retrospective review of medicare patient database - proximal humerus fractures from 2009 - 2012  The utilization rate decreased significantly for HA from 52% to 39%, increased significantly for RSA from 11% to 28%, and did not change significantly for ORIF  JSES 2016  Retrospective review of medicare database – proximal humerus fractures 2005 – 2012  259,506 proximal humerus fxs, 79% occurring in female patients.  In all age groups, nonoperative treatment of PHF was the most common method (67%).  Within the surgical group, ORIF was most frequently used  There has been an increase in treatment with arthroplasty including RTSA, with a low rate of early revisions.

46. Conclusions  Primary ORIF has better function than hemi Results of ORIF are strongly dependant on bone quality and proper surgical technique – Many complications are present at the end of surgery but not recognized until later  Primary hemi-arthroplasty has better functional results than revision for failed ORIF  Must identify cases at high risk for failure  Arthroplasty results depends greatly on tuberosity fixation  Order of results  Hemiarthroplasty with intact tuberosities  Reverse TSA with intact tuberosities  Reverse TSA without intact tuberosities  Hemiarthroplasty without intact tuberosities