1. 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

2. 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

3. 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. 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

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

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

7. 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

8. Radiography
True AP
Transcapular “Y”

9. Lesser Tuberosity
Axillary View

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

11. 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

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

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

14. 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

15. 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.

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

17. 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 ?

18. 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.

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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

30. 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

31. Hemiarthroplasty

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

33. 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

34. Decision Making Process
Summary of
Decision Making Process

35. “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

36. 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

37. “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

38. 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

41. 6 weeks
+ callus
FE 90

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

43. 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.

44. Thank you!
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