Proximal Humerus Fractures ORIF &

ArthroplastyReza Omid, M.D.

Assistant ProfessorDepartment of Orthopaedic

SurgeryKeck School of Medicine of USC

Introduction

• 5-7% of all fractures

• 80% treated nonoperatively (Neer)

•Bimodal incidence

•Bone quality- important factor in obtaining secure fixation

Etiology

Elderly– fall onto outstretched hand– direct blow- fall– bone fragility- a/w distal radius fractures

Young– high energy– seizures, electrical injury

OITE Facts

•How many with neurologic injury?– 21-36%– recent study- 45%- fx or dislocation on EMG

•Which nerves?– Axillary, suprascapular, radial, musculocut.

•How many with persistent motor loss?– 8%

Codman’s Description Neer’s Classification

AO Classification

ClassificationNeer’s classification

Sidor, Zuckerman, JBJS 1993

Gerber, JBJS, 1993

– poor inter and intra observer reliability

– best results among trained shoulder surgeons

– suggested CT scans would increase reliability

Proximal Humeral Anatomy

Understanding Fracture PatternsUnderstanding Fracture Patterns–4 bony fragments4 bony fragments»Lesser TubLesser Tub»Greater TubGreater Tub»HeadHead»ShaftShaft

Neer, JBJS ‘70

Proximal Humerus Assesment

Neer ClassificationNeer Classification–1 cm displaced1 cm displaced–45 deg angulated45 deg angulated–Excessive rotationExcessive rotation

Proximal Humerus Fractures

Fracture PatternsFracture Patterns–StableStable»Fx not controlled by muscleFx not controlled by muscle

–UnstableUnstable»Fx controlled by attached muscleFx controlled by attached muscle

Proximal Humerus FractureFracture AnatomyFracture Anatomy

–Greater Tub – posterior, proximalGreater Tub – posterior, proximal–Lesser Tub – medial, inferiorLesser Tub – medial, inferior–Head – remaining tub or Head – remaining tub or fx energyfx energy

–Shaft – medial, superiorShaft – medial, superior

X-Rays

AP view scapular plane (Grashey)

AP view of shoulder

X-RaysAxillary Lateral

Scapular Y

Proximal Humerus FractureRadiographic AnalysisRadiographic Analysis

–Normal AppearanceNormal Appearance»Axillary: lesser tub, greater tub Axillary: lesser tub, greater tub not seennot seen

Proximal Humerus Fracture

Radiographic AnalysisRadiographic Analysis– Normal AppearanceNormal Appearance

» AP: external rotation shows AP: external rotation shows

greater tubgreater tub» AP: internal rotation, AP: internal rotation,

greater tub not seengreater tub not seen

Proximal Humerus FractureFracture AnatomyFracture Anatomy

Consideration for Surgery

Bone Quality

Comorbidities

Functional demand

Vascularity???

Gerber JBJSAm 1990: 1486-94

Vascularity– anterior humeral circumflex

» Anterolateral branchOf AHC (arcuate artery)Along lateral aspect of groove

Brooks JBJSBr 1993: 132-136

•Vascularized through interosseous anastomoses

•Between metaphyseal vessels (via posterior humeral circumflex) and the arcuate artery after ligation of the anterior circumflex humeral.

Coudane JSES 2000: 548

•Arteriography done on 20 patients after proximal humerus fractures.

•80% had disruption of AHC artery

•15% had disruption of PHC artery•Since AVN is rare (bw 1-34%)

after fx it suggests the PHC artery may be dominant supply

Hettrich JBJSAm 2010: 943-8

–MRI cadavers–posterior humeral circumflex

–supplied 64% of head (superior, lateral and inferior).

Hertel Criteria

Hertel et al JSES 2004:13:427

–Medial calcar segment <8mm–Medial hinge is disrupted (>2mm displacement of the diaphysis)

–Comminution of the medial metaphysis

–Anatomic neck fracture

Bastian JSES 2008: 2-8

• Follow-up study by Hertel showed that initial predictors of humeral head ischemia doesn’t predict development of AVN.

•80% of patients with “ischemic heads” did NOT collapse

• Fixation is worth considering even if signs of ischemia are present

Nonoperative Treatment

Immobilize initially

Passive ROM 2-3 weeks– supine FE– supine ER– pendulums

AROM at 6 weeks or when consolidated

77% good to excellent results-Zuckerman 1995

Optimal Treatment

•UNKOWN????•JSES 2011: 1118-1124 (RCT ORIF vs Non-op)

•JSES 2011: 747-55 (RCT ORIF vs Non-op

•JSES 2011: 1025-1033 (RCT Hemi vs Non-op)

•JOT 2011 (RCT ORIF vs Non-op)

Percutaneous PinningSurgical Technique

– Retrograde Pins» Start Anterior» Diverge Pins

– Antegrade Pins» Supplemental» GT to Medial Shaft

Percutaneous PinningReduction Maneuver

•Surgical neck– flexion, adduction, traction– anterior pressure

•Greater tuberosity– engage and move

anteriorly/inferiorly

Percutaneous Pinning

Pin Placement– Slight medial placement of head to

shaft» Allows placement of one pin centrally

– Wide spread of pins for stability– *Remember normal humeral head

retroversion for pin placement– Pin entry is just above the deltoid

insertion

Pins– Three 2.5mm terminally threaded pins

» 2 lateral pins» 1 anterior pin» 1-2 pins from GT to medial shaft

Jaberg H. JBJS. 74A. 1992. 508-15.

Structures At Risk

Cadaveric Study– Lateral pins

» 3mm from Ant branch Ax» Penetration of head

articular cartilage

– Anterior pins» 2mm from biceps tendon» 11mm from cephalic v.

– Proximal tuberosity pins» 6-7mm from ax n. &

posterior circumflex artery

Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.

Recommendations

Starting point of proximal lateral pin– At or distal to a point

2x the distance from the superior aspect of the humeral head to the inferior margin of the head

Greater tuberosity pins– Engage medial cortex

>2cm from the inferior most aspect of the humeral head

Rowles DJ, McGrory JE. “Percutaneous Pinning of the Proximal Part of the Humerus. JBJS. 83A(11)2001.1695-99.

Greater Tuberosity Fractures

Displacement

– Superior» Impingement

– Posterior» Block to ER

Greater Tuberosity Fractures

Displacement?– 5mm maybe problematic (McLaughlin et al.) – 3mm maybe problematic in the athlete or heavy

laborer (Park et al.)– Concern for RTC tears in minimally displaced fxs

Positioning critical – *Exposure

» Approach: Superior, Posterior, Anterior

Reduction– Head height 6-8mm superior to GT

» Posterior displacement more tolerated than superior displacement

Greater Tuberosity Fractures

– Surgical Approach» Superior» Deltopectoral

– Fixation Options» Sutures» Screws» Plate

– Interval Closure

Three-Part Fractures

Surgical Neck

Greater Tuberosity Lesser Tuberosity

+

Three-Part Fractures

Fixation Options– Percutaneous Pins– Interfragmentary Suture/Wire

–Plate/Screws– IM Nail– Blade Plate

–Hemiarthroplasty

Three-Part Fractures

–Approach»Deltopectoral»Closed Reduction/Pinning

–Goals»Tuberosity Fixation»Longitudinal Stability

Hemiarthroplasty

•Rarely Indicated•Older Patients•Osteopenic Bone•Fracture-Dislocations

– > 40% Impression Defect

Three-Part Fractures

Complications–Nonunion–Malunion–Hardware Problems (screw cutout)

–AVN

Indications for ORIF of Four-part Fractures

Valgus impacted four part with an intact medial soft tissue hinge

Four part in a young patient (less than 40)

Indications for PinningValgus impacted 4 part proximal

humerus fracture– Vascularity preserved by feeding vessels in attached

capsule

Valgus Impacted Four PartReduction Maneuver

Small incision (2 cm) anterior

shoulder

Line of fracture usually lies 5 mm

lateral to intertubercular

groove

Percutaneous PinningReduction ManeuverValgus Impacted 4 Part

Valgus Impacted Four Part

Pinning Technique

Pin fragments

Valgus Impacted Four Part47 y.o. female, trip and fall

When to plate?Factors

–High energy/low energy–Displacement»2 part vs 3 or 4 part»Integrity of soft tissue sleeve

Proximal Humerus Fractures

3 part

Proximal Humerus Fractures

3 part- locking plate

46 yo male

Rollover dirt bike

8 wks post op

46 yo malehigh speed auto accident

Post op

Fracture-Dislocation

Fracture-Dislocation

Clinical Example

ORIF Technique

Reduction & Grafting

•Impaction grafting of head

•Iliac crest cube•Fibular strut

Tag Tuberosities

Reduction & Grafting

Close Book

Plate

Indications for Hemiarthoplasty

Anatomic neck and four part fractures: Isolate

anatomic humeral head from its blood supply

Some three part fractures with severe

osteoporosis in the elderly

Split humeral head fractures

Hemiarthroplasty Technique

Patient Position

Surgical Technique

Extended deltopectoral exposure: deltoid origin

and insertion intact

Surgical TechniqueIdentify the LHB and Tuberosities

Evaluate the rotator cuff injury

Surgical TechniqueRemove the humeral head

Evaluate the glenoid

Muscular AnatomySupraspinatus

–Usually starts just post to bicipital groove–Pt. > 60 yo - strong possibility of RCT

Sher, et al JBJS ‘95

Tuberosity Suture TechniquePlace suture at the tendon bone

interface

Doug Robertson, MDDoug Robertson, MDLouis U Bigliani, MDLouis U Bigliani, MDEvan L Flatow, MDEvan L Flatow, MD

Ken Yamaguchi, MDKen Yamaguchi, MDJBJS ‘00

ResultsAnatomy

–Retroversion: avg 19°, range: 9-31°–Posterior offset: avg 2mm, range:-1-8mm–Head thickness: avg 19mm, range:15-24mm–Inclination:avg 41°, range: 34-47°–Thickness linked to Radius (avg 23mm)

Head Size

Solutions–removed head is guide»thickness > radius

–error towards undersize–check gross appearance

Position of Greater Tuberosity

Height Relative to Humeral Head

Surgical TechniqueAssess the humeral height and version

Trial tuberosity reduction

Mark the stem position

Lesser

Tuberosity

Height ofthe GreaterTuberosity

5-8 mm

Tuberosity Height = Prosthetic Height

Height ofthe GreaterTuberosity

Lesser Tuberosity

5-8 mm

Determining Height

–Superior border of Pectoralis tendon (5.6cm±0.5cm)–Side to Side comparison (x-ray)–View calcar contour (gothic arch)

Determining Height

Proximal Humerus Fracture

Humeral Version

VersionEffect of Incorrect Version

Too Anteverted Too Retroverted

Bicipital Groove Anatomy

–Anterior to head center–Anterior to keel location–Location dependant on shaft depth»Variable retroversion distal

Biceps Groove Version

Groove shifts medially from proximal to distal, changing

retroversion values 15.9° from the upper to lower part of the bicipital

groove (Itamura)

Bicipital Groove Anatomy

Surgical TechniquePrepare the fixation sutures for ORIF of the

tuberosities.– 2-3 vertical and 2 horizontals, one medial one lateral

Surgical Technique

Surgical TechniqueTuberosity fixation and

bone graftBiceps tenodesis

Wound drains and closure

Results of Hemiarthroplasty for

Acute FracturesGoldman et. al. J. Shoulder

and Elbow 199526 patients with acute fractures

73% had slight or no painAverage forward flexion 107

degrees: stiff73% had difficulty with at least 3

of the 10 ASES question of ADL

Results of Hemiarthoplasty for Late Reconstruction

Dines et. al. J. Shoulder and Elbow 1993

Demanding procedure with wide variation in results: average 80

points (HSS Scale)Stiffness, scar, hardware

problemsTuberosity malposition

Results of Hemi. Early vs Late

Frick et. Al. Orthopaedics 1991

Pain scores better in acuteFunction no different

More complications in the late reconstruction group

Results of Hemi. Early vs Late

Norris et al J. Shoulder and Elbow 1995

Good pain relief in both but better results in the acute

group.

Only 53% had ability to use arm above shoulder level post op in late reconstruction, 15%

pre-op

Results of Hemi. Early vs Late

Tanner and Cofield CORR 1983

16 acute hemi, 27 late reconstructionBoth had good pain relief

Both had had average active shoulder elevation to 105-110 degrees

Acute surgeries was easier and with less complications

Factors Affecting Outcome

•Bone density•Rotator cuff tissue quality•Tuberosity healing•Restoration of anatomic

humeral head height•Restoration of anatomic

humeral version•Rehabilitation

Sequelae of Proximal Humerus Fractures

Boileau proposed a classification scheme for

proximal humerus fracture sequelae and

treatment recommendations (CORR

2006:442:121-130)

Reverse for Fracture

•Age >70-75 (I will consider for age >65)

• Tuberosities heal more predictably and function is not as dependent on tuberosity healing

•More predictable outcome than with hemi

•Best outcome of a hemi is better than best outcome of a reverse

Conclusions•Best to perform repair for acute fracture•Anatomic restoration of humeral height

and version•Secure tuberosity fixation•Repair the cuff•Tenodesis of the LHB•Early protected PROM, close supervision

of the rehabilitation program

Conclusions

Pain relief is expected in >90% of cases

Active shoulder level elevation in >75% of

cases