Acknowledgement: AO faculty lecture archive Proximal Humerus Fractures Principles of Diagnosis, Decision Making and Treatment Christopher G. Finkemeier, MD, MBA Revised: May 2011 Acknowledgement: AO faculty lecture archive

3. Learn the various treatment options Objectives 1. Learn the principles of diagnosis 2. Learn the principles of decision making 3. Learn the various treatment options

Epidemiology All upper extremity fractures 1. forearm fxs 2. proximal humerus fxs All fractures in patients > 65 yrs 1. hip fxs 2. “colles” fxs 3. proximal humerus fxs

4 Anatomic Parts Deforming forces determine fx displacement HUMERAL HEAD: precarious blood supply AVN GREATER TUBEROSITY: supra/infraspinatus insertion SURGICAL NECK/SHAFT: deltoid/pectoralis major largely dictates fx behavior compression: stable shear: unstable LESSER TUBEROSITY: subscapularis insertion

Vascular Supply Lateral ascending branch of anterior humeral circumflex artery Damage may lead to AVN

Humeral Head Vascularity Gerber et al., JBJS, 1990 Non shaded area is supplied by the lateral ascending branch of the anterior humeral circumflex artery.

Humeral Head Vascularity In the fractured humerus, the arcuate artery is generally interupted. Recent anatomic and clinical findings confirm that perfusion from the posterior circumflex vessels alone may be adequate for head survival. Brooks, JBJS 1993; Coudane, JSES, 2000; Duparc, Surg RadAnat, 2001

Radiography True AP Transcapular “Y”

Lesser Tuberosity Axillary View

Tuberosity displacement, especially lesser tuberosity CT Scan Articular surface Head splitting injury Tuberosity displacement, especially lesser tuberosity

Patient age & comorbidities Treatment 80% of PHF are NONDISPLACED and can be successfully treated NONOPERATIVELY 20% Displaced Operative Nonoperative ? Fx pattern Head viability Bone quality Implant limitations Patient age & comorbidities

Neer Classification > 1 cm 45º Codman’s 4 parts

AO Classification A-type: 2-part B-type: 3-part C-type: 4-part + anatomic neck

Loss of integrity of medial hinge Predictors of ischemia: Metaphyseal head extension (calcar) < 8 mm. 97% PPV Loss of integrity of medial hinge Fracture Pattern (anatomic neck) Hertel et al, J Shoulder Elbow Surg 2004;13:427

Metaphyseal head extension < 8mm BEWARE of lateral displacement of head Metaphyseal head extension < 8mm Blood Supply Potentially Torn if medial hinged displaced  This head is likely NOT viable.

Medial Hinge not displaced Metaphyseal head Extension > 8mm This head is likely viable

Bone Quality A B 2 cm C D 4 Predictable loss of fixation ? Tingert et al, JBJS(B), 2003 Mean cortical thickness A B 2 cm A + B + C + D C D 4 “A mean cortical thickness < 4 mm is highly indicative of low BMD” Predictable loss of fixation ?

Implant limitations Recognizing what implants are appropriate for certain fracture types is a key decision making factor. Locking plates are less prone to failure due to the fixed- angled screws. Conventional implants Poorly control varus collapse, screw loosening and screw back out.

Patient age & comorbidities Operative Nonoperative ? Fx pattern Head viability Bone quality Implant limitations Patient age & comorbidities Putting it all together

Court-Brown et al., JBJS(B), 2001 Jan 07 Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Hospital for Special Surgery protocol Nonoperative Tx sling + ROM Nonop tx = surgery Court-Brown et al., JBJS(B), 2001

Court-Brown et al., JBJS(B), 2001 Jan 07 Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Elderly Non-displaced or mod displaced Nonoperative Tx sling + ROM Nonop tx = surgery Court-Brown et al., JBJS(B), 2001

Treatment: Non-operative Koval et al., JBJS, 1997 77% good or excellent; 13% fair, 10% poor results Functional recovery averaged 94% Sling with ROM exercises by 2 weeks

Treatment: Non-operative Court-Brown et al., JBJS(B), 2001 Mean age 72 yrs Outcome determined by age and degree of translation Surgery did not improve outcomes regardless of translation

Poor bone quality Operative Tx or “significant displacement” Jan 07 Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol “significant displacement” >5mm GT >66% SN Poor bone quality Operative Tx heavy suture through rotator cuff insertion or Locking plate

Satisfactory bone quality Jan 07 Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Satisfactory bone quality Operative Tx Closed reduction percutaneous pins

Satisfactory bone quality Jan 07 Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Satisfactory bone quality Operative Tx ORIF

B1.1 Nonoperative Tx Non-op = surgery Jan 07 Poor bone quality Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Nonoperative Tx B1.1 Poor bone quality Court-Brown, JBJS(B), 2002 Zyto et al, JBJS(B), 1997 Non-op = surgery maybe better

ORIF Jan 07 High failure rates with standard plates Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol ORIF High failure rates with standard plates Especially in patients with poor bone Locking plates have dramatically improved fixation

Hemiarthroplasty Jan 07 Highly displaced fxs “3 or 4-part” Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Hemiarthroplasty Highly displaced fxs “3 or 4-part” Poor bone quality Not reconstructable

Hemiarthroplasty

Hemiarthroplasy Pain relief generally good Good function depends on anatomic tuberosity placement Despite all the advances, shoulder flexion above 90º is difficult to acheive

Hemi Fix Poor bone Good bone Jan 07 Anatomic neck fxs Journal of the American Academy of Orthopedic Surgeons Hospital for Special Surgery protocol Anatomic neck fxs have high rate of AVN (+/- 50%). Unless able to fix anatomically, better to replace (hemi) Gerber et al. JSES, 1998 Poor bone Hemi Good bone Fix

Decision Making Process Summary of Decision Making Process

“Young” Patients “good bone quality” <30yrs? <40yrs? <50 yrs? Preservation of function is primary objective “Full court press” Anatomic reduction/soft tissue sparing Stable fixation Hemiarthroplasty for non-reconstructable fxs only

Elderly Patients “poor bone quality” Pain relief primary objective Non op RX if fracture stable and early motion possible If unstable: ORIF if head viable and fracture reducible Hemiarthroplasty if head not viable or fracture not repairable Locking plate

“A proximal humeral fracture that is at risk Caveat “A proximal humeral fracture that is at risk for AVN has to be reduced anatomically if joint preserving treatment is selected. If anatomic reduction cannot be obtained, other treatment options such as arthroplasty should be considered.” Gerber et al. The clinical relevance of posttraumatic avascular Necrosis of the humeral head. JSES, 1998

GT fx + 93 y/o male RHD Healthy Fell Surgical neck fx with extension Medial hinge intact Metaphyseal spike > 8mm 93 y/o male RHD Healthy Fell

6 weeks + callus FE 90

References Neer, CS. Displaced Proximal Humeral Fractures. JBJS 52-A: 1077-1089, 1970. Neer, CS. Displaced Proximal Humeral Fractures, Part II. JBJS 52-A: 1090-1103, 1970. Gerber, C. et al. The Arterial Vascularization of the Humeral Head. JBJS 72-A: 1486-1494, 1990. Brooks, CH et al. Vascularity of the Humeral Head After Proximal Humeral Fractures: An Anatomical Study. JBJS 75-B: 132-136, 1993. Hertel, R et al. Predictors of Humeral Head Ischemia After Intracapsular Fracture of the Proximal Humerus. J Shoulder Elbow Surg: 427-433, 2004

References Nho, SJ. et al. Innovations in the Management of Displaced Proximal Humerus Fractures . J. Am. Acad. Ortho. Surg. 15: 12 – 26, 2007. Koval, KJ. et al. Functional Outcome after Minimally Displaced Fractures of the Proximal Part of the Humerus JBJS 79-A: 79: 203 – 7, 1997.

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