Proximal Humerus Fractures

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Proximal humerus fracture

• 70 % occur in female

NEER Classification

Based on 4 fracture segments
1) Head/ articular surface
2) Greater tuberosity
3) Lesser tuberosity
4) Humeral shaft

-To assess the position of humerus head: xray Ap- Scapular Y view / axillary view

Treatment depends on Age

• No. Of fracture parts
• Fracture displacement

Greater tuberosity fracture

• Rotator cuff retract the fragment superiorly and posteriorly.
• If displacement is >5mm Or > 3mm( in young ) fixation should be done
• Need of surgery is to avoid malunion, impingement, mechanical block, altered shoulder mechanics.

 2 part surgical neck fracture

• Shaft moves forward and medially by pectoralis major muscle

Treatment

Conservative treatment-
1) Brief immobilization
2) Pendulum exercise
3) Elbow ROM

• Good outcome will occur after initiation of physiotherapy and passive motion within 2 weeks of injury.
• Immobilization > 3 weeks lead to stiffness of shoulder

If unstable and displaced fracture

In young individual – ORIF

Old individual- Fixation/Prosthesis/conservative

If > 65 year old, no difference between functional outcome of operative and non operative treatment.

• In the operative group, high risk for reoperation and low risk of non union
• majority of non union occur at surgical neck

Head shaft angle – line over diaphyseal axis and line perpendicular to anatomic neck segment plane.
– If angle > 90° & Head shaft translation< 50% — good prognosis
– If angle 50%– bad prognosis, surgical treatment needed

SURGERY

1) Locked plate technique – In younger individual with displaced humerus fracture

• Plating restore the medial cortical support
• Advantage is reduced fixation failure
• complications: Screw cutout, penetration of articular surface
• Deltopectoral approach ( put the plate lateral to bicipital groove) – To preserve axillary nerve

Blood supply of the proximal humerus -anterior humeral circumflex artery and it’s ascending branch with it’s terminal branch

– blood supply depends on the metaphyseal extension to humeral head
– If the extension >8-9mm, medial hinge is not displaced, or valgus impacted fracture – indicates blood supply is present

2) Arthroplasty
Indications

– In older age
– In head splitting fracture
– In displaced 4- part fracture
– Poor bone quality
– Varus malalignment

• Arthroplasty has better outcome if prosthesis done acutely.
• Hemi arthroplasty produces a reliable pain relief and unreliable function, which has to do with the difficulty in reconstruction of the Tuberosities to restore the rotator cuff function .
• To restore the retroversion (~25°) keep the forearm in flexed elbow position.
• Restore the head height by measuring from top of the head to the superior border of pectoralis major(approx~ 5.6 CM)
• Repair of the tuberosity is mandatory otherwise there will be non union and restriction of overhead motion and rotation.
• Reverse total shoulder arthroplasty is indicated in fractures, cuff,or the Tuberosities are unreconstructable in elderly.
• Healing of greater tuberosity in reverse arthroplasty lead to increase in external rotation.