Proximal Humerus Fractures
Proximal Humerus Fractures
Shoulder anatomy
Description:
- The shoulder joint is a multi-axial joint with muscles crossing it to allow shoulder range of motion (ROM)
- The rotator cuff muscles are important in allowing shoulder ROM
- The rotator cuff muscles consists of Subscapularis, Supraspinatus, Infraspinatus and Teres Minor
- Other important shoulder muscles that allow shoulder ROM include long head of Biceps and the Deltoid muscle
Proximal Humerus Fracture
- The mechanism usually a fall to the arm or motor vehicle accident
- More common in females
Risk factors:
- Osteoporosis
Presentation:
- Pain
- Swelling
- Deformity
- Decreased ROM
Clinically:
- Swelling and bruising of chest, arm, forearm
- Bone tenderness
- Assess axillary nerve and arterial function and exclude associated injury
Investigations:
- X-ray: AP, axillary and lateral
- CT: for fracture evaluation and surgical planning
Axillary Nerve Function
The Axillary nerve supplies the Deltoid muscle & the muscle is responsible for shoulder abduction movement. In clinical practice to test nerve motor function: test resisted shoulder abduction with arm at 90° abducted position.
Extra-Articular Shoulder Fractures
Neers Classification for Proximal Humerus Fractures
AO Classification of Proximal Humerus Fractures
A: Unifocal, extra-articular, 2-part, intact blood supply
B: Bifocal, extra-articular, possible injury to blood supply
C: Articular, involving anatomic neck, high risk of necrosis
Hertel Criteria for Predicting Avascular Necrosis of Humeral Head Fracture
Proximal humerus fracture risk factors for AVN include:
- Medial calcar segment < 8mm
- Medial hinge disruption (>2 mm displacement of the diaphysis)
- Medial metaphysis comminution
- Anatomic neck fracture
Hertel criteria predicting increased risk of humeral head AVN. An intact hinge with a longer intact metaphyseal component, the less likelihood of AVN.
Tuberosity Fracture Management
Nondisplaced greater tuberosity fracture can be managed nonoperatively with immobilization.
Arm sling and wrath/collar and cuff/shoulder immobilizer for 2-3 weeks
- Active forearm and Hand grip exercises
- Pendulum shoulder exercise as pain permits
- Scapular stabilizer exercises
Shoulder immobilizer
Shoulder abduction cushion takes off tension on Supraspinatus tendon & greater tuberosity
Displaced Greater Tuberosity Fractures
Surgery indications:
- > 1cm displacement
Greater tuberosity fracture
Greater tuberosity surgical screw fixation
Proximal Humerus Head/Neck Fractures
Surgery indications:
- Displaced
Options:
- ORIF plate & screw fixation
- Shoulder joint replacement
Proximal Humerus Fracture Plate and Screw Fixation
Shoulder Joint Replacement Principles
Surgery Technique
Surgery Greater Tuberosity Screw Fixation
Approach: Deltoid
Fixation: screw fixation
Proximal Humerus Fracture Plate and Screw Fixation
Deltopectoral approach
Plate and screw fixation
Shoulder Joint Replacement
Principles of shoulder joint replacement:
Approach: Deltopectoral
Arthroplasty:
- Bone template cuts
- Prepare humerus shaft
- Size humerus head for implant size selection
- Suture tuberosities for fixation to implant
- Implant insertion
Rehabilitation
Phases of rehabilitation:
- Immobilization
- Passive/ assisted ROM/isometric exercise of shoulder girdle
- Progressive strengthening exercises with resistance exercises after 6-8 weeks
Pendulum shoulder range of motion
Hand grip exercise
Download ASSIC performance fingerprint app or ASSIC strength & conditioning app for shoulder rehab guideline routine under professional supervision
References
- Fractures of the proximal humerus in osteoporotic bone. Ralph Hertel. Osteoporosis Int (2005) 16: S65-S72.
- Complex proximal humerus fractures: Hertel’s criteria reliability to predict head necrosis. G Campochiaro, M Rebuzzi, P Baudi, F Catani. Musculoskelet Surg. 2015 Sep;99 Supl 1: S9-15.
