1. Proximal humeral fractures
Author: Pierre Guy
AO Trauma Advanced Principles Course

2. Learning objectives
Evaluate relative indications for internal fixation and arthroplasty
Describe anatomical landmarks and surgical approaches
Outline techniques for reducing 2, 3, and 4-part fractures
Explain the key issues in the treatment of proximal humeral fractures
Discuss expected outcomes and rehabilitation
List key outcome publications
Teaching points:
Relate this lecture to the PHILOS practical exercise.

3. Unique problems Anatomy Fracture classification—difficult
Bone + soft tissue = complex
Rotator cuff critical for function
Fracture classification—difficult
Vascular supply—avascular necrosis a potential problem
Demographics
Elderly with poor bone and low functional demand
Young patients with good bone stock and high functional demand
Proximal humeral fractures are a challenging problem. The anatomy, especially the interplay of bone and soft tissue anatomy, is complex. The injuries can be at risk for long-term problems, such as AVN. Treatment needs to be focused on minimizing the risk of long-term disability. The treatment algorithms will change depending on issues related to both the fracture itself and the patient overall health, and the functional outcome that is expected.

4. Other facts about this fracture
Systematic reviews demonstrate:
Assessment of fracture type is difficult
Wide range of treatments exist
Evidence does not support any specific operative treatment choice
Most surgeons are convinced “they” know the “correct” treatment
References:
Lanting B, MacDermid J, Drosdowech D et al. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg Jan-Feb;17(1): doi: /j.jse Review.
Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced three- and four-part proximal humerus fractures. J Orthop Trauma Apr;24(4): doi: /BOT.0b013e3181bdc46a.

5. Neer Classification Four potential parts (+/- dislocation)
1 part = fracture line + displacement > 1cm or angulation > 45°
Fracture line alone ≠ 1 part
Assists OR planning
Some link to prognosis
Based on Codman’s original description
Although there may not be universal agreement on the classification of any one fracture, the use of this scheme helps one understand the important aspects of a fracture.
References:
Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation.
J Bone Joint Surg Am Sep;52(6):
Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement.
J Bone Joint Surg Am Sep;52(6): No abstract available.

6. AO/OTA Classification
Proximal humerus = 11
A = Extraarticular, unifocal
B = Extraarticular, bifocal
C = Articular A1

7. AO/OTA Classification
Proximal humerus = 11
A = Extraarticular, unifocal
B = Extraarticular, bifocal
C = Articular A2

8. AO/OTA Classification
Proximal humerus = 11
A = Extraarticular, unifocal
B = Extraarticular, bifocal
C = Articular B1

9. AO/OTA Classification
Proximal humerus = 11
A = Extraarticular, unifocal
B = Extraarticular, bifocal
C = Articular C1

10. Additional information: Type B and C (3–4 part)
Coronal deformity
Location of comminution/compression failure
Varus
Valgus
Besides knowing how many fracture fragments there are, it is important to look at:
Varus versus valgus displacement
Degree of comminution
Displacement

11. Imaging Traditional imaging: x-ray and trauma series References:
From PFxM2, Chapter 6
It is essential to get all three views. The axillary view is the only view that shows the lesser tuberosity and the retroversion of the neck. It can be painful if done as shown.

12. Imaging: consider alternative
Traditional
axillary view
“Bumped-up” view (trauma axillary view)
Velpeau view
References:
From PFxM2, Chapter 6
Orthopedic Trauma Operative Techniques, 1st edition
Rockwood & Green
Axillary lateral can be painful. There are other ways to get it other than the classical position shown. It is very important to get an axillary view, and should always be obtained.

13. Additional imaging
CT scan and reconstruction can assist treatment planning
When the fracture is poorly understood, a CT may be helpful. This is especially true when:
Trying to decide if a fracture is reconstructible versus doing an arthoplasty
Deciding between surgical approaches
Ruling out glenoid injury with dislocation
A head split is suspected

14. Treatment considerations
Patient factors:
Functional needs
Comorbidities
Surgeon factors
Fracture “personality”
Displacement
Deforming forces
Fragment stability: impaction-comminution
Bone quality
There are both patient and fracture considerations when choosing the treatment.

15. Treatment goals Pain control Restore function
Restore and maintain bony/soft tissue anatomy
Initiate early rehabilitation
The goal of treatment for proximal humeral fractures are to control pain and restore function.
In general, the younger the patient, the more important it becomes to restore function.

16. Deforming forces GT–LT: tension AN: compression SN: bending/torsion
The forces in the proximal humerus are quite complex. Constructs should take this into account.
References:
Poppen NK, Walker PS. Forces at the glenohumeral joint in abduction. Clin Orthop Relat Res Sep;(135):
Kwon BK, Goertzen DJ, O'Brien PJ et al. Biomechanical evaluation of proximal humeral fracture fixation supplemented with calcium phosphate cement. J Bone Joint Surg Am Jun;84-A(6): (?)

17. Restore bony/soft tissue anatomy
Reduction:
Gleno-humeral dislocation (if present)
Humeral and tuberosity alignment relate to clinical result
Achieved closed or open
Fixation:
Maintain alignment until union with a stable construct
Achieved operatively or nonoperatively
Restoration of anatomy is important for function. The head acts as a cam, and the tuberosities are obviously important for muscle control of the shoulder.

18. Nonoperative treatment
Indications
Undisplaced fractures (1–4 part)
Displaced fractures (2–4 part)
High comorbidity
Low demand
Low compliance
Poor bone quality
Displaced fractures have unfavorable results when above mentioned criteria are met.
Results differ significantly depending on individual factors.
Minimally displaced fractures in valgus do not pose a great problem.
Nondisplaced 4-part fractures (as an example) do well without surgery.
Three-part with major tuberosity included, the picture shows immobilization with Gilchrist bandage.

19. Nonoperative protocol
Initial sling support
Pain control
Early rehabilitation
The same protocol can be used postoperatively as well.

20. Rehabilitation Neer Protocol Commonly used 3-phase approach Used for:
Nonoperative care
Postsurgery

21. Nonoperative outcome Simple A2, A3 Multifragmentary but undisplaced
Standardized therapy regimen
About 75% are good to excellent results
Best when therapy starts less than 14 days postinjury
References:
Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br Aug;83(6):
Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br May;84(4):504-8.
Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand Oct;74(5):580-5.
Koval KJ, Gallagher MA, Marsicano JG et al. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am Feb;79(2):203-7.

22. Operative treatment Patient factors: Surgeon factors
Needs
Comorbidities
Surgeon factors
Fracture “personality”
Displacement
Deforming forces
Fragment stability: impaction/comminution
Bone quality
Many operative options
None superior

23. Operative indications
Open fracture
Associated dislocation
Displaced tuberosity fractures
Displaced/unstable 2-part fractures
3/4-part fractures (young/active patients)
4-part valgus-impacted fractures
In the elderly, the indications for surgery are relative

24. Fixation options: nail
Proximal humeral nail
Less invasive
Proximal stability
 w/ fixed angle screws
Used for
Surgical neck:
+/- proximal comminution
Shaft extension
Ipsilateral shaft
Possibly 3-4 part

25. Fixation options: plates
Proximal humerus
Standard 3.5 mm
clover leaf plate
3.5 mm proximal humeral locking plate
Standard plates may work well in a 4-part valgus impacted fracture.
Most other fractures are likely to get better fixation with a locked implant.

26. Surgical approaches Deltopectoral (caveat: devascularization)
Position can be beach chair or supine.
Approach can be deltopectoral or deltoid split.
Deltoid split requires identification and protection of the axillary nerve. It is unlikely to work for arthroplasty. It is also unlikely to allow you to deal with any glenoid pathology due to dislocation.
Deltopectoral
(caveat: devascularization)
Deltoid split
(caveat: axillary nerve)

27. ORIF strategy Reduce shoulder dislocation (if present)
5-7mm
~20 mm
~130
ORIF strategy
Reduce shoulder dislocation (if present)
Reduce fragments well
Neck/shaft relationship
“Calcar” contact if possible
Reduce/secure tuberosities (sutures)
Oppose deforming forces
Support failed/comminuted section
Fix to good bone
Control of head fragment can be improved by using 2.5 mm Schanz screw “joysticks”.

28. ORIF strategy Reduce shoulder dislocation (if present)
Reduce fragments well
Neck/shaft relationship
“Calcar” contact if possible
Reduce/secure tuberosities (sutures)
Oppose deforming forces
Support failed/comminuted section
Fix to good bone
Sutures from the tendon-bone insertions can augment the fixation and neutralize the cuff muscles.
The implant can support areas of comminution.

29. Support failed/comminuted section
Location of comminution/compression failure related to deformity
Varus
Valgus
The area of comminution is different, depending on the fracture type and severity.

30. Support failed/comminuted section
Valgus
For a valgus fracture, the implant helps support the lateral cortex.

31. Support failed/comminuted section
Valgus
For a valgus fracture, the implant helps support the lateral cortex.

32. Support failed/comminuted section
Valgus
LT+GT
screws
Unlocked
plate
For a valgus fracture, the implant helps support the lateral cortex.

33. Support failed/comminuted section
Varus
Locked screws
Inferomedial screws vs
For a varus fracture, the area requiring support is in the medial neck area, which is often comminuted. In order to do this, it is important to have screws in the inferior head/neck area.
Note that the reduction is also important. Although both of these cases are malreduced, the one on the left does not fail further because the implant supports the medial neck. On the other hand, the case on the right shows comminution and lack of medial support.
References:
Gardner MJ, Weil Y, Barker JU et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma Mar;21(3):

34. Specific fractures Tuberosities in Type A (Reduce dislocation)
ORIF displacement indication
Young: 5 mm
Older: 10 mm
Fixation:
Oppose tension forces
Sutures: bone-bone, rotator interval
Screw
Fractures of the greater tuberosity can occur with or without dislocation. The goal of treatment is to ensure healing in a position that is compatible with good function. In younger patients with higher demands, this may mean a lower threshold for surgical treatment.
The treatment construct chosen should take into account the forces of displacement, which are largely tensile.

35. Specific fractures Tuberosities in Type B and C Oppose tension forces
Suture fixation through plate
+/- lag screw
Suture “rotator interval”

36. Specific fractures: Type B and C
36-year-old man
3-part fracture dislocation

37. Locked plate/screw and suture fixation
GT: sutures and screws oppose tension
The greater tuberosity has been reduced to the head and the lateral cortex has been restored to assist length assessment.
Note the residual varus deformity

38. Locked plate/screw and suture fixation
GT: sutures and screws oppose tension
AN: buttress locked screws oppose compression
The plate is used to support the lateral cortex. The sutures around the tendon insertions and the plate help to neutralize the pull of the rotator cuff muscles. The tendency to varus is neutralized by the fixed-angle screws locked into the plate.

39. Locked plate/screw and suture fixation
GT: sutures and screws oppose tension
AN: buttress locked screws oppose compression
SN: plate for varus/torsion control
Even though this fracture was left in some varus, the stability of the construct allowed for eventual healing.

40. Relative indications for arthroplasty
Thin head fragment in osteopenic bone
The ability to fix the proximal humerus is in large part dependent on the ability of screws to hold in the head fragment. This is dependent on the size of the fragment, as well as the quality of the bone.
Of course, this only applies to elderly patients who are candidates for arthroplasty. Younger patients do poorly with arthroplasty in terms of function.

41. Prognostic outcome factors
Poor prognosis
Preoperative delay > 13 days
Tuberosity problems: loss of fixation, resorption, malunion
Malpositioned prosthesis
Height: humeral head to greater tuberosity distance:
Lengthening (overstuffing): > 10–14 mm
Shortening: GT < 10 mm below
GT 5 mm above prosthesis
Offset: humeral head lateral cortex at GT
Lateralization < 23 mm
Version: < 10° or > 40° retroversion
Outcomes after arthroplasty are dependant on component position and tuberosity reduction and healing.
References:
Demirhan M, Kilicoglu O, Altinel L, et al. Prognostic factors in prosthetic replacement for acute proximal humerus fractures.
J Orthop Trauma Mar;17(3):181-8; discussion

42. High complication rate 12 studies (791 patients)
ORIF is not simple
High complication rate
12 studies (791 patients)
12.2% loss of reduction
11.6% screw cut-out
AVN 7.9%
13.7% reoperation rate
In spite of technological improvements in plate design, with the introduction of locking plate systems, there are still a high number of complications.

43. Reviews + RCTs: no clear winner, small samples
Author,year
Study type
Fracture type n
Non-op
ORIF HA
Conclusions
Dai, 2013
Meta
no RCT
complex
567 X
Constant O > H Complic H > O
Den Hartog, 2010
3,4
1096
Constant N > H (limitations)
Cai, 2012
RCT >
67 yrs
32 -> 27 (5 yrs)
DASH HA > O (<mcd)
Complic same (24 m)
Boons, 2012
65 yrs 4
105-> 50-47
(5 yrs)
Constant ns
N > ABD strength (12 m)
Fjalestad, 2012
60 yrs
X-ray O > N (12 m)
Olerud, 2011
58 yrs
-55
EQ, (0.16) sig; <mcd
DASH, pain ns
Constant ns (24 m)
From the literature, it is not clear what the next treatment for elderly patients is in terms of outcomes.

44. Take-home messages—treatment for young patients
Reduction is key to stability and outcome
Different surgical options to achieve stable fixation
Restoration of soft tissues
Strategy to allow early motion
Hemiarthroplasty only if unreconstructible and poor function
Young patients should get stable fixation because they do poorly with a hemiarthroplasty. The key is proper reduction and stabilization of both the soft tissues and the fracture.

45. Take-home messages—treatment for elderly patients
Stable 2-part fracture: nonoperative treatment
Unstable 2-part fracture: consider ORIF
Stable 3-4 part fracture with comorbidities: nonoperative treatment
Displaced 3-4 part fracture
+ good bone
+ poor bone +…
+ comorbidities
Consider
ORIF
(hemiarthroplasty)
Hemiarthroplasty
Nonoperative