Proximal Humerus
Fractures
February 10, 2016
Ryan Perlus
Epidemiology
•5 % of all appendicular fractures
• 3rd most common osteoporotic facture
• 2-3:1 W:M
• Age-specific
incidence of osteoporotic PHF increasing in
men and women > 60y
Etiology
1) Low-energy (87%)
• Elderly, osteoporotic fragility fractures
2) High-energy
• Young
• Associated soft-tissue/neurovascular injury
Anatomy
• Bony Anatomy
• Anatomic Neck
• Surgical Neck
• Greater Tuberosity
• 6mm from articular surface
• 10mm lateral to humeral canal
axis
• Lesser Tuberosity
• Neck-shaft angle 130o
• Head retroverted 30o relative to shaft
• Medial posterior hinge
Anatomy
Muscular attachments
• GT-supraspinatus, infraspinatus,
teres minor
• LT-subscapularis
• Proximal humeral shaft-pec
major, latissimus dorsi, teres
major, deltoid
Anatomy
Vascular Anatomy
• Anterior humeral circumflex artery
•Anterolateral ascending branch
•Arcuate Artery
• Posterior humeral circumflex
artery
• Angiography study suggests
PHCA dominant blood supply to
head (Coudane, 2003)
Classification
Neer Classification
• 4 parts
*part = displaced >1cm, or > 45 degrees of
angulation
• 6 types
Classification
AO Classification
a) Extra-capsular, unifocal
b) Extra-capsular, bifocal
c) Intra-capsular
Treatment
Non-operative
• Cuff & Collar, early ROM
Operative
•CRPP
•ORIF
•TSA
•Hemiarthroplasty
Treatment
Majority of fractures are treated non-operatively:
• Minimally displaced, stable fractures
• Greater tuberosity fracture, displaced < 5mm
Indications for operative treatment (<1% of injuries):
• 3-, or 4-part fracture-dislocations
• Head-split fractures
• Pathologic fractures
• Open fractures
• Neurovascular injury
Treatment
Predictors of Ischemia
• Metaphyseal head extension (calcar) <
8 mm
• Loss of integrity of medial hinge
• Fracture Pattern (anatomic neck)
• 97% positive predictive value of all 3
combined (Hertel et al., 2004)
Treatment
Factors affecting treatment decision
• Fracture pattern/characteristic
involvement of anatomic neck
degree of comminution
medial hinge/risk of AVN
• Patient Factors
-age, comorbidities, activity/demand level
• Surgeon preference/ technical expertise
Surgical vs. Non-surgical management
2012 Cochrane Review (Handoll HH, Ollivere BJ, Rollins KE, 2012 )
• Review evidence (RCTs) supporting various treatment and rehabilitation interventions for proximal humeral
fractures
Insufficient evidence to:
a) Inform management of these fractures (operative vs non-op of PHF)
b) Establish best method of surgical treatment
• N=250, >16, Mean Age 66 (77% F)
• Multi-centre, RCT
• F/U for 2 years (215)
• Main outcomes: Oxford Shoulder Score, SF-12 (6, 12, and 24 months)
• Exclusion criteria: fracture-dislocation, open injury, multiple injuries, path fracture, cognitive impairment,
comorbidities precluding surgery/anesthesia
• Surgical Group (109) - 90 ORIF, 10 Hemiarthroplasty, 4 IMN, 5 Other
• Non-Surgical Group (123) – 85 Shoulder Sling, 35 Cuff and Collar, 3 Hanging Arm Cast
Results:
Patient-reported outcomes following surgical, and non-surgical treatment of displaced surgical neck fracture
were not statistically significantly different over 2 years.
Take Home
• Non-surgical treatment of displaced fractures may be as effective as surgical
management for displaced PHF
• Majority of evidence based around low-energy factors, always important to consider
factors other than fracture pattern
Case
• 64F, isolated mechanical fall onto L arm
• No head trauma, No LOC, No Secondary Symptoms
• Isolated Injury
• Healthy Lady
• Lives independently, Able to perform ADLs
