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Proximal Humerus Fractures

Categories
  • Joint/Tendon
Tags
  • Shoulder injury
Shoulder

Proximal Humerus Fractures

Shoulder anatomy

Anatomy:

Shoulder anatomy
Rotator Cuff Muscles

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
Normal Upper Limb Anatomy
Triceps Brachii Muscle
Humerus Bone
Left Brachial plexus

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

Axillary nerve
Axillary nerve

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.

Axillary nerve: Sensory distribution

Extra-Articular Shoulder Fractures

Extra-articular shoulder fractures

Neers Classification for Proximal Humerus Fractures

Neers classification for proximal humerus fractures

AO Classification of 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 for predicting avascular necrosis

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 immobilizer

Shoulder abduction cushion

Shoulder abduction cushion takes off tension on Supraspinatus tendon & greater tuberosity

Displaced Greater Tuberosity Fractures

Surgery indications:

  • > 1cm displacement
Greater tuberosity fracture

Greater tuberosity fracture

Greater tuberosity surgical screw fixation

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

Osteosynthesis

Shoulder Joint Replacement Principles

Shoulder joint replacement principles

Surgery Technique

Surgery

Surgery Greater Tuberosity Screw Fixation

Surgery Greater tuberosity screw fixation

Approach: Deltoid

Fixation: screw fixation

Proximal Humerus Fracture Plate and Screw Fixation

Proximal humerus fracture plate and screw fixation

Deltopectoral approach

Plate and screw fixation

Shoulder Joint Replacement

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
Shoulder pendulums

Pendulum shoulder range of motion

Hand grip exercises with arm in splint

Hand grip exercise

Download ASSIC performance fingerprint app or ASSIC strength & conditioning app for shoulder rehab guideline routine under professional supervision

apple app store  google play store

References

  1. Fractures of the proximal humerus in osteoporotic bone. Ralph Hertel. Osteoporosis Int (2005) 16: S65-S72.
  2. 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.

Contributor:

Dr N J Kauta

Learn More

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