FRACTURES OF THE PROXIMAL HUMERUS
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Transcript of FRACTURES OF THE PROXIMAL HUMERUS
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FRACTURES OF THE PROXIMAL HUMERUS
Presented by Mahsa Mehdizade
Dr. MardaniPorsina Hospital
Spring 1392
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IncidenceProximal humerus fxs comprise 4-5% of all fxs.
Minimal displacement 80%Two-part fxs 10%Three-part fxs 3%Four-part fxs 4%Articular surface fxs 3%
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AnatomyComprised of four segments:
Humeral headGreater tuberosityLesser tuberosityHumeral shaft
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Neurovascular SupplyAnterior and posterior humeral circumflex arteriesArcuate artery-continuation of the ant humeral circumflex and supplies most of the humeral head.Axillary nerve-most commonly injured
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Forces on SegmentsGreater tuberosity is displaced superiorly and posteriorly by the supraspinatus and external rotators.Lesser tuberosity is displaced medially by the subscapularis.The shaft is displaced medially by the pectoralis major.
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Mechanism of InjuryElderly, osteoporotic, usually female: fall on outstretched arm.Young adults: high-energy trauma; usually more severe fxs and dislocations
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Radiographic EvaluationA/P viewScapular Y viewAxillary view
Best view for glenoid articular fxs and dislocations
CT scan: helpful in evaluating articular involvement and degree of displacement
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ClassificationsNeer-four parts: greater and lesser tuberosities; shaft; humeral head.
A part is displaced only if >1cm of displacement or 45 degrees of angulation is present.At least 2 views must be obtained
AO-emphasizes the vascular supply to the articular segment
Three types:• Type A: Extraarticular unifocal fxs• Type B: Extraarticular bifocal fxs• Type C: Articular fxs
Not commonly used
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Neer Classification
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Treatment OptionsClosed reduction
ImmobilizationEarly ROM if stable
External stabilizationPercutaneous pinsExternal fixatorIlizarov frame
Open reduction and internal fixation
Screw fixationTension bandingButtress platingFix-Clip system
Intramedullary fixation
Rush rodsEnder’s nailsNails with interlocking screws
Excisional arthroplastyHemiarthroplasty
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Fractures to Consider for Closed Treatment
Minimally displaced 2 part fx’s (or positional reduction of significant displacement)GT fractures should be <5mm). Minimally displaced 3- and 4-part fractures
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Fractures to Consider for ORIFDisplaced GT fx (> 5 mm)LT fx with involvement of articular surfaceDisplaced or unstable surgical neck fxDisplaced anatomic neck fx in young pt.Displaced, reconstructible 3- and 4-part fractures
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Fractures to Consider Hemiarthroplasty
Young/Middle agenonreconstructable articular surface (severe head split) or extruded anatomic neck
Elderlymany 4 partssome severe 3 partsmost 3,4 part fracture dislocationsmost head splits
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Potential ComplicationsNeurologic injury
Brachial plexus-Stableforth reported an incidence of 6.1%Axillary-common
Vascular injuryStableforth also reported a 4.9% incidence of arterial injury with displaced fxs; most commonly the axillary arteryAn intact radial pulse doe not exclude an arterial injury so keep it in mind.
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Complications cont.Avascular necrosis
Hagg and Lungberg reported an incidence of 3 – 14% with 3- part fxs and 13 – 34% with 4-part fxs, using closed reduction.
Nonunion (uncommon)Malunion – often associated with AVNAdhesive capsulitisMyositis ossificansInfection
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