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FOOSH-Fall on Outstretched Hand High energy- fall from ht, sports, RTA, assaults
The region of transition between the articular cartilage and surrounding bone is defined as the anatomic neck, whereas the region immediately inferior to the tuberosities is termed the surgical neck.
Several studies have shown branches from PCHA to the posteromedial head to be equally important.
Axillary nerve- hypoesthesia over lateral aspect of prox. Arm suggest axillary n. injury
True AP View -- Identifies major Fracture lines ,Tuberosity ,and humeral head displacement.
This view is perpendicular to Grashey view
Axillary view reveals the articular surface , in relation to glenoid , evaluates the degree of Tuberosity displacement, surface defects, and dislocations
Usually pain does not allow sufficient abduction to obtain a useful axillary view. A modified Velpeau axillary view is then performed.This can be done with the upper extremity in a sling.
3D CT images providing enhanced detail of a complex proximal humerus fracture seen from (a) anterior and (b) posterior views
Fractures were described as occurring between the greater tuberosity (a), humeral head (c), lesser tuberosity (b) or shaft (d)
AO/OTA classification for proximal humerus fractures
In a meta analysis of RCT comparing operative vs non-operative treatment in complex prox. humeral fx
Despite many studies the answer for------ remains controversial.
Incision is marked out 1 cm lateral to the coracoid. This point is connected to a point at the level of the axillary crease dividing the arm in 60% lateral and 40% medial.
Plate position should avoid impingement onto the bicipital groove .Note transtendinous sutures threaded through the plate to reinforce the construct.
Two-part surgical neck fracture of the proximal humerus with posteromedial communition Fixation using a combination of and intramedullary cortical strut and plate
Image of young pt. showing Proximal humerus fracture with comminution at the surgical neck and extension into the humeral shaft. Fixation is obtained with a intramedullary nail.
Four-part fracture dislocation
Proximal humerus fractures
Proximal Humerus Fractures
Speaker- Dr. Mithilesh Ranjan
Proximal Humerus Fractures
• Defined as Fx occurring at or
proximal to surgical neck
• 80 % of all humeral #
• 7% of all #..
• Pt > 65 yrs – Second most common
fracture of the upper extremity
• 65% of # occur in Pt’s > 60 yrs
• F:M – 3:1
• Incidence increases with age.
• Old Pts low energy trauma. [FOOSH]
• Most # are nondisplaced, good prognosis – nonsurgical
• Risk factors: Poor quality bone ,impaired vision &
balance, medical comorbidities, decreased muscle tone.
• Young Pts – High energy trauma
• Severe soft tissue disruption always require surgical
• Seizures & electric shock – indirect causes
Common mechanism for low energy proximal humerus fractures in
• Proximal humerus comprises of
four major segments
• The Articular head
• The greater tuberosity
• Lesser tuberosity and
• The shaft
• Articular segment is almost
spherical, with a diameter of
curvature averaging 46 mm
(ranging from 37 to 57 mm)
• Inclination of the humeral head
relative to the shaft averages 130
• Retroversion of the head varies
from 18 to 40 degrees
• Muscle insertions on these
segments and the magnitude and
direction of the forces causing
injury, determine the pattern of
fracture lines ,displacement and
• Greater tuberosity has three regions
into which the supraspinatus,
infraspinatus, and teres minor insert
• Subscapularis tendon lesser
tuberosity, which is separated from
the greater tuberosity by the bicipital
Deforming forces of PHF
• The greater tuberosity is
pulled posteromedially by
the effect of the supra- and
• The lesser tuberosity is
pulled anteriorly by the
• The shaft segment is pulled
anteromedially by the
pectoralis major tendon.
• The ascending branch of the
anterior circumflex humeral
artery has been considered to
provide most of the blood flow
to the articular segment.
• Several studies have shown
branches from PCHA to the
posteromedial head to be
• Arcuate artery of Liang –
supplies Humeral head.
• If the medial calcar of the
humerus is spared by the
fracture, the vessel is spared.
Study on Twenty-four fresh-frozen cadaver shoulders (twelve matched
pairs) with Gadolinium MRI
64% of Blood Supply
to Humeral Head
• A complete history and physical examination must be
obtained about the mechanism of injury and velocity of
• Shoulder pain and limitation of movement
• Ecchymosis appears 24-48 hrs.
• Look for rib, scapular, cervical # in high energy trauma.
• Concurrent brachial plexus injury 5%
• Axillary nerve is susceptible in anterior # dislocation.
• Association of arterial injury is rare
• The patient will hold the arm in internal rotation
• Radial pulse and capillary refill of fingers should be
Imaging and other Diagnostic studies
• Radiographs :- consist of three views
• AP- Perpendicular to the plane of scapula(Grashey view)
• Neer View (Scapula Y view)
• Axillary view
• Grashey view- Taken in neutral arm rotation with torso rotated
30 to 45 degrees
• Neer view- Scapula is imaged perpendicular to Grashey view
• Axillary view- Arm in neutral rotation and abducted as much
as possible, with the pt. supine and X-ray beam projected
• By taking Grashey and Neer view with arm hanging gravity
will provide traction which facilitates understanding of fx
AP Grashey view of the shoulder
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the
injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the
plane of the scapula.
Neer view (lateral Y) of shoulder
Affected shoulder located against the cassette the patient’s torso is rotated
60 degrees bringing the side opposite to the injured shoulder toward the source.
The arm is abducted as much as possible, with the patient supine and the x-ray
beam projected from the axilla onto the cassette located on top of the
Velpeau axillary view of the shoulder
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked
to lean back, to place the shoulder between the x-ray source and the cassette
• CT Scan- Allows more detailed understanding of fracture
configuration, degree of osteopenia, presence and
location of bone impaction and extent of fracture
• Is rarely indicated in trauma setting
• May be helpful in confirming a non-displaced Fx in a
pt with shoulder trauma, normal radiographic findings
and clinical symptoms
• Pathological Fx
• Vascular imaging is required when there is suspicion
of vascular injury
• CT Angiography- Diagnostic modality of choice. It
allows rapid evaluation of vascular system, while
simultaneously allowing assessment of bone and soft
• Can be useful in diagnosis of occult proximal humeral
• Operator dependent
• Vasular doppler can be useful in early assessment of
suspected vascular injury
• Dual energy X–ray absorptiometry (DEXA)
• May be useful in elderly pt. with prox. humeral fx or in
those with risk factors for osteoporosis.
Classfication of Proximal Humeral
• First systems dating back to 17th Century, classed them
as Simple closed versus Open
• 1896 -- Kocher Focused on the location of the fracture
and divided Proximal Humerus Fractures into Supra
Tubercular, Peritubercular, Infratubercular, and
• In 1934 Codman described proximal humerus
fractures as occurring along the lines of the
epiphyseal scars and observed four possible fracture
fragments: the articular surface, the humeral
shaft, the greater tuberosity, and the lesser tuberosity.
Codman’s depiction of proximal humerus fractures.
Proximal Humeral Fracture Classfication
• Is based on fracture location and presence of impaction,
angulation, translation, or comminution of the fracture, as
well as whether a dislocation is present.
• Type A- Extra-articular unifocal fractures associated with
single fracture line.
• Type B- Extra-articular bifocal fractures accociated with
two fracture lines
• Type C- Articular fractures which involve the humeral
head or anatomic neck.
• Each type is further sub classified into groups and
subgroups. Each subgroup fracture is assigned a level of
Proximal Humeral Fracture Classfication
Neer Classification (1970)
• It is a Refinement of Codman’s System, incorporates
the concept of displacement and vascular isolation of the
articular segment and relates the anatomy and
biomechanical forces resulting in the displacement of
fragments to diagnosis and treatment
• Fractures are classified by evaluating the displacement
of the Parts (head, shaft, greater tuberosity, lesser
tuberosity) from each other
• Criteria to consider as a part, fragment must be rotated
45 degree or displaced 1 cm from the another fragment.
• Classifies as One part, Two part, Three Part and Four
• No fragments meet the criteria for displacement; a fracture
with no fragments considered displaced is defined as a one-
part fracture regardless of the actual number of fracture
lines or their location.
• One segment is displaced
• With a three-part fracture, one tuberosity is displaced and
the surgical neck fracture is displaced. The remaining
tuberosity is attached, which produces a rotational
• All four segments (both tuberosities, the articular surface,
and the shaft) meet criteria for displacement. This is a
severe injury and carries a high risk of avascular necrosis.
Valgus-Impacted Four-Part Fractures
• Neer added this pattern as a separate category in 2002 .
In this situation, the head is rotated into a valgus posture
and driven down between the tuberosities, which splay out
to accommodate the head. Unlike in the classic four-part
fracture, the articular surface maintains contact with the
Fracture Dislocations and Articular Surface Injuries
• Fractures combined with glenohumeral dislocation are
classified as fracture dislocation.
• Fractures involving articular surface can be of two
varieties- head-splitting fractures and impaction fractures.
They are included in group of fracture dislocations
• In 2001 Court-Brown et al published study on distribution
of PHF types.
• Non-displaced or minimally displaced one-part fractures
comprised half (49%) of all fractures.
• Two part- 37%. Surgical neck fractures comprised 3/4th
of these. Two part anatomic neck fractures were rare
• Three part fractures- 9 %
• Four part- 3 %, of which one third were true fracture
dislocations. Fractures involving articular surface
occurred in 0.7 % cases.
Risk of Avascular Necrosis
• Four-part fractures and fracture dislocations are
considered to have the highest risk for humeral head
• Hertel criteria –
• Metaphyseal extension of the humeral head < 8 mm
• Medial hinge disruption of >2 mm, and
• Fracture through anatomical neck
• The combination above above factors had 97% positive
predictive value for humeral head ischemia.
Metaphyseal extension of the humeral
head of >9 mm
Metaphyseal extension of the humeral
head of <8 mm.
Undisplaced medial hinge Medial hinge with >2 mm of
Non-operative Treatment of Proximal
• The majority of proximal humeral fractures are
nondisplaced or minimally displaced and nonoperative
treatment is indicated.
• Fracture stability can be assessed both radiographically
• Radiographically, stable fractures exhibit impaction or
interdigitation between bone fragments
• Clinically, fracture stability may be assessed by palpating
the proximal humerus just distal to the acromion with one
hand, while rotating the arm at the elbow with the other.
If the proximal humerus is felt to move as a unit with the
distal segment, the fracture is considered stable
Stable proximal humeral fractures through
the anatomic neck
• Stable non-displaced or minimally displaced fractures
• Patients not fit for surgery
• Elderly patients with low functional demands
• Relative Contraindications
• Displaced fractures with loss of bony contact
• Close follow-up is required to confirm acceptable
alignment and fracture stability. Weekly radiographs
should be performed during the first month of treatment,
followed by biweekly radiographs until 6 weeks after
injury or initial callus formation is visible.
• Major complications following nonoperative treatment of
proximal humerus fractures include-
• Avascular necrosis
• Rotator cuff dysfunction
• Posttraumatic arthritis
Surgical vs nonsurgical treatment of adults with displaced fractures of
the proximal humerus involving surgical neck
Studied 231 pt(114 in surgical group and 117 in nonsurgical group) aged 16
yrs or older (mean age 66 yrs)
Patients were followed up for 2 years
• There was no significant difference between surgical treatment
compared with nonsurgical treatment in patient-reported clinical
outcomes over 2 years following fracture occurrence.
• Total 518 patients (average age 70.93) met inclusion
• Patients were followed up for at least 1 year in all the
• Operative treatments did not significantly improve the
functional outcome and healthy-related quality of life in
elderly patients. Instead, Operative treatment for CPHFs
led to higher incidence of postoperative complications.
What is optimal management for
displaced Proximal Humerus
Operative Treatment of Proximal
• Many surgical techniques have been described, but no single
approach is considered to be the standard of care.
• Appropriate treatment is individualized and selected on the
basis of the fracture pattern and the underlying quality of the
• Surgical Options-
• Open Reduction and Internal Fixation
• Tension Band Fixation
• Closed Reduction and Percutaneous Fixation
• Intramedullary Nailing
• Reverse Total Shoulder Arthroplasty
Open Reduction and Internal Fixation (ORIF)
• ORIF is the most frequently used method of surgical
treatment of proximal humeral fractures.
• Surgical Approaches
• Deltopectoral Approach
• Workhorse for reconstructive shoulder surgery
• Incision is marked out 1 cm lateral to the coracoid. This
point is connected to a point at the level of the axillary
crease dividing the arm in 60% lateral and 40% medial.
• Deltoid-Splitting Approach
• Two Major Disadvantage
• In anteroinferior fracture dislocations, the humeral head
fragment may not be accessible
• Risk of damage to anterior branch of the axillary nerve
thereby leading to potential deltoid dysfunction.
Fixation using Conventional Plate
• Prior to the use of locking-plate technology, conventional
plate fixation was used for the majority of patients.
• Several studies have reported satisfactory healing rates
and functional outcomes after conventional plate and
screw fixation of proximal humeral fractures, especially
in younger patient populations.
• Many studies have however reported high rates of
infection, humeral head necrosis, and subacromial
• Traditional plate constructs are usually reserved for
• Young patients with an intact medial hinge,
• Adequate diaphyseal cortex(>4 mm), and
• No metaphyseal comminution.
Fixation using Locking Plate
• The inability of conventional plates and screws to resist varus
deforming forces in the proximal humerus, particularly if the
bone is osteoporotic,has led to locking plate fixation being
used for these fractures.
• Several clinical studies have shown high rates of healing and
excellent functional recovery with proximal humerus locking
• Plate designs vary in terms of the number of proximal screws
and their arrangement, as well as the ability to place screws
at different angles with regard to the plate.
• A plate is selected to allow at least three screws to be placed
into the distal shaft segment. The plate position is also
selected to avoid subacromial impingement and to allow two
screws to be placed into inferomedial aspect of the humeral
• A minimum of five or six screws are routinely placed into the
proximal segment. Screw placement should be performed by
drilling through the near cortex only. This avoids perforation of
the articular surface, and reduces the possibility of secondary
• Once the plate and screws have been placed transtendinous
sutures are tied onto the plate to provide additional fixation.
• The use of IM fibular strut grafting has been described to
improve stability of varus-impacted fractures in which the
medial calcar may not be reliably reconstructed.
• Goal being to create a buttress at the inferior aspect of
the anatomic neck to prevent delayed varus collapse
• Patients are followed at 2 weeks, 6 weeks, and 3 months
• Patients are immobilized for 6 weeks in a sling while
active range-of-motion exercises of the elbow, wrist, and
hand are encouraged.
• Depending on the fracture pattern and stability that was
achieved, passive range of motion is started between 2
and 4 weeks after surgery with forward elevation,
external rotation, and pendulum exercises.
• If healing has adequately progressed both clinically and
radiographically at 6 weeks active-assisted range of
motion is started.
Tension Band Fixation
• It is most frequently used as an adjunct to plates and screw
fixation, IM nailing, and arthroplasty.
• The main goal of tension band fixation is the neutralization of
tension forces generated by the rotator cuff at the level of the
tuberosities, and bending at the level of the surgical neck.
• The main advantage of tension band fixation is the minimal
amount of hardware that is required. Thus avoiding the risks
associated with hardware, which include pain, neurovascular
compromise, migration, failure, and the need for removal.
• Previous attempt(s) at internal fixation or
• Fractures older than six weeks.
• Highly comminuted four part fractures.
Tension-band construct with transosseous
Closed Reduction and Percutaneous Fixation
• It has theoretical advantage of minimizing soft tissue trauma,
thereby promoting healing and reducing the risk of AVN of the
• It also has the advantage of decreased scarring in the
scapulohumeral interface and subsequent easier rehabilitation.
• Fracture without significant communition in pt with good
• Pt should be willing to comply with postop care plan.
• Contra indications
• Severe comminution and osteopenia are absolute
• Inability to reduce Fracture Fragments
• Fracture Dislocation
• Non Compliant patients
To avoid injury to the axillary nerve, lateral pins
should enter the humeral cortex at a point at least
twice the distance from the upper aspect of the
head to the inferior head margin with the wire
angulated approximately 45 degrees to the cortical
surface. The end point for the greater tuberosity pin
should be >2 cm from the inferior most margin of
the humeral head.
• Biomechanical advantages in osteoporotic bone
• It allows stabilization with minimum surgical invasion
• Displaced two part surgical neck fractures
• Pathological fractures
• Varus four-part fractures with lateral displacement of
the humeral head
• Head-splitting fractures
• Also known as humeral head replacement
• Four-part fractures,
• Three-part fractures in older patients with
• Comminuted head-splitting fractures
• Head depression fractures involving more than 40%
of the articular surface
• Active infection of the shoulder joint and/or the
surrounding soft tissue
• Passive range-of-motion exercises are started on the
first postoperative day. They are limited to neutral
rotation and 90 degrees of forward elevation.
• Patients are followed up clinically and radiographically at
2 weeks, 6 weeks, and 3 months.
• Active-assisted range-of-motion exercises are started at
6 weeks and strengthening exercises at 3 months
Reverse Total Shoulder Arthroplasty
• By placing a hemisphere onto the glenoid surface and a
concave tray onto the humeral stem, reverse shoulder
arthroplasty allows for rotation to occur at the
glenohumeral joint through activation of the deltoid,
without the need for a functional rotator cuff/tuberosity
• Complex acute proximal humeral fractures
• Proximal humerus malunion or nonunion where the normal
anatomy of the tuberosities cannot be reliably restored
• Glenohumeral joint arthritis with advanced rotator cuff
• Massive irreparable rotator cuff tears with painful
The ideal candidate for reverse total shoulder arthroplasty in a patient with a
complex proximal humerus fracture is a low demand elderly patient with pre-
existing rotator cuff pathology and glenoid pathology.
Comparison of outcomes of reverse shoulder arthroplasty (RSA) and
hemiarthroplasty (HA) in elderly pt.
Sixty-two patients older than 70 years were randomized to RSA (31 patients) and HA
The mean functional scores and active range of motion were significantly better in the
RSA group. Revision rate was lower in RSA.
• Avascular necrosis of humeral head and/or tuberosity
• Non-union- The normal time for clinical union of a proximal
humeral fracture is typically 4 to 8 weeks. Nonunion is said to
be present if a fracture site is still mobile 16 weeks post injury.
• Post-traumatic Shoulder stiffness
• Post traumatic arthritis
• Iatrogenic-such as inadequate reduction, incorrectly
positioned implants, screw penetration into the joint, loss
of fixation, tuberosity disruption, and nerve injury.
• Heterotopic bone formation
General Treatment Philosophy of
Proximal Humerus Fractures
• All nondisplaced fractures, minimally displaced fx as well
as most valgus-impacted fractures are treated non
operatively especially in patients with lower functional
• In patients with higher baseline shoulder function and
higher expectations, surgical treatment may be
recommended for most displaced fractures.
• For patients undergoing surgical treatment fracture
reduction and fixation is performed in majority of cases
and effort should be made to reconstruct the proximal
humerus with emphasis being placed on achieving
anatomic reduction and stable fixation of the tuberosities.
• Shoulder arthroplasty is considered in fractures in which
a high suspicion of head nonviability is suspected
because of severe displacement of the fracture through
the anatomical neck without metaphyseal extension,
disruption of the medial hinge and frank dislocation from
• In younger patients, hemiarthroplasty is the chosen
treatment method, in elderly patients, reverse shoulder
arthroplasty is preferred.
Treatment of Individual Injury Patterns
of Proximal Humerus Fracture
• Nondisplaced or Minimally Displaced One-Part
• These are treated nonoperatively with initial
immobilization in a sling.
• Weekly radiographs and clinical assessment are
performed for the first 3 weeks. Elbow, wrist, and hand
mobilization begins immediately.
• Passive range-of-motion exercises are begun at 3
weeks if no change in fracture position has been
confirmed. Active-assisted range of- motion exercises
are begun at 6 weeks and strengthening is started at 3
months when bony healing has been confirmed
• Greater Tuberosity Fractures
• Displacement of the greater tuberosity is poorly tolerated
because of its key role in shoulder function
• Currently threshold of displacement for surgical
treatment of greater tuberosity fractures in active
patients is accepted as 5 mm (instead of 1 cm as per
• Flatow et al. reported the results of 12 displaced two-part
greater tuberosity fractures that were treated by heavy
suture fixation and rotator cuff repair. They reported
100% excellent or good results with all fractures healing
without displacement .
• Two-Part Greater Tuberosity Fractures and Fracture
• In elderly, frail patients (usually older than 80 years) with
limited functional expectations, a substantial degree of
displacement and these are treated non operatively.
• Operative treatment is advised for physiologically
younger patients with fractures, which are either
primarily displaced by more than 5 mm or become
displaced by this amount within the first 2 weeks after
• Fixation is obtained either with suture anchors in a
double row pattern or by the use of transosseous
sutures, or alternatively, a small T-plate may be fixed
• Two-Part Lesser Tuberosity Fractures and Fracture
• Isolated lesser tuberosity fractures typically occur in
younger or middle-aged patients and are displaced.
• ORIF- Preferred
• Single large fragment -definitive internal fixation is
performed using partially threaded 3.5-mm cancellous
screws, inserted through the lesser tuberosity.
• If communited- transosseous sutures is used for
• Two-Part Surgical Neck Fractures
• All fractures in which the shaft is impacted into the
surgical neck are treated nonoperatively. A substantial
degree of translation of these two fragments is usually
tolerated, as long as there is residual cortical contact and
• Displaced and comminuted surgical neck fractures in
physiologically younger patients are managed with ORIF
using a locking plate.
• Three- and Four-Part Fractures
• In physiologically older patients these are usually treated
nonoperatively if there is residual cortical continuity of
the humeral head fragment on the shaft, the tuberosities
are not too widely displaced, and the humeral head
• Operative treatment is offered to physiologically younger
patients, where the risk of nonunion, cuff dysfunction, or
osteonecrosis is high.
• ORIF is performed whenever possible, and preoperative
CT scan provide an indication of its feasibility. The
patient is always preoperatively counseled that if the
fracture is deemed to be unreconstructable, an
arthroplasty will be performed.
• Young patients - Cemented humeral head replacement
• Older patients – Reverse total shoulder arthroplasty