Simplifying fracture of the proximal humerus. All information taken from authentic sources.

1. Fracture Proximal Humerus
Dr. Ashiqur Rahman
Resident Orthopedics
Dhaka Medical college Hospital

2. Introduction
 Fracture of the proximal humerus usually occur after middle age &
most of the patients are osteoporotic, post-menopausal women.
 However, in 20% cases there is considerable displacement of one or
more fragments and a significant risk of complications due to bone
fragility.
 Deciding between operative & non-operative treatment can be very
difficult.

3. Mechanism of injury
 Fall on outstretched arm – the type of injury which, in younger
people, might cause dislocation of the shoulder.
 Sometimes, indeed there is both fracture & a dislocation.

4. Classification of proximal humeral fracture
Neer classification:
Limitations: Limited reliability, reproductivity among observers,
consistency by the same observer at different times based on four
part anatomy:
(i) Humeral Head
(ii) Lesser tuberosity
(iii) Greater tuberosity
(iv) Proximal humeral shaft

6. Neer’s classification distinguishes between the number of displaced
fragments, with displacement defined as greater than 45 degrees of
angulation or 1 cm of separation.
a. One part fracture: Many fracture lines and the fragments are
un- displaced.
b. Two part fracture: ( when fracture fragment is two in number)
Impacted, unimpacted and comminuted.
- It has also greater tuberosity fracture, lesser tuberosity
fracture and fracture dislocation variety

7. c. Three part fracture: Where two fragments are displaced, that
is a three-part fracture. Displaced tuberosity identifies types of
three part fracture.
d. In four part pattern: All three part are displaced.

8. Clinical features
 Because the # is often firmly impacted, pain may not be severe.
 Appearance of large bruise on the upper part of the arm is
suspicious.
 Signs of axillary nerve & brachial plexus injury should be sought.

9. Imaging
1. X-ray :
- AP view
- Axillary
- & Scapular lateral views should always be obtained, to exclude
dislocation of the shoulder.
2. CT scan with 3D reconstruction has helped to reduce the degree of
inter & intraobserver error.
 As the # heals, the humeral head is sometimes seen to be subluxated
downwards; this is due to muscle atony & it usually recovers once
exercises are begun.

10. Treatment
1. Minimally displaced fracture:
- They need no Rx, apart from period of a week or two of rest
with the arm in a sling until pain subsides & then gentle passive
movements of the shoulder.
- Once the # has united (usually 06 weeks), active exercises are
encouraged; the elbow & hand are, of course, actively exercised
from the start.

11. Two-part fracture
1. Surgical neck fracture:
- The fragment are gently manipulated into alignment & the arm
is immobilized in a sling for about 04 weeks, until # feels stable
& the x-ray shows some sign of healing.
- Elbow & hand exercise encouraged throughout this period;
shoulder exercise are commenced @ about 04 weeks.
- The result of conservative Rx are generally satisfactory,
considering that most of this pt. are over 65 & don’t demand
perfect reduction.

12. - If the # can not be reduced closed or if the # are unstable after
close reduction, then fixation is required.
- Option include percutaneous pins, bone sutures, Intramedullary
pins with tension band wiring or a locked intramedullary nail.
- Plate fixation requires a wider exposure & newer locking plates
offer a stable fixation without the need for extensive periosteal
stripping.

13. 2. Greater tuberosity fracture :
- #GT is often associated with anterior dislocation & it reduces to
a good position when the shoulder is relocated.
- if it does not reduce, the fragment can be reattached through a
small incision with interosseous sutures or, in young hard bone,
cancellous screw.

14. 3. Anatomical neck fracture:
- These are very rare, in young it should be fixed.
- In older pt. prosthetic replacement (hemi-arthroplasty) is
preferable because of the high risk of avascular necrosis of the
humeral head.

15. Three part fracture
- These usually involve displacement of the surgical neck & GT;
they are extremely difficult to reduce closed.
- In active individual this injury is best managed by open
reduction & internal fixation.
- Locked plating & nailing are biomechanically superior in
osteoporotic bone.

16. Four part fracture
 The surgical neck & both tuberosities are displaced.
 These are severe injuries with high risk of complications such as
vascular injuries, brachial plexus damage, injuries of the chest wall &
AVN of humeral head.
 In younger pt. attempt should be made at reconstruction.
 In older pt. if the # pattern is such that blood supply is likely to be
compromised, or that reconstruction & IF is extremely difficult, then
Rx of choice is prosthetic replacement of the proximal humerus.

17. Blood supply of the humeral head

20. Fracture-dislocations
 Two-part # dislocations (GT with anterior dislocation & lesser
Tuberosity with posterior) can usually be reduced by closed means.
 Three-part # dislocations, when surgical neck is also broken, usually
require open reduction & fixation; brachial plexus is at particular risk
of this operation.
 Four-part # dislocations have a poor prognosis; prosthetic
replacement is recommended in all but young and very active
patients.

21. Indication of operative treatment
1. Displaced two part fracture
2. Displaced (>5mm) greater tuberosity fracture
3. Displaced three part fracture
4. Displaced four part fracture in young patients

22. Types of fixation
1. Trans-osseous suture
2. Per-cutaneous pinning
3. Intra-medullary nailing
4. Plate fixation

26. Plate fixation:
Advantages:
- Provide more stable fixation of three fixation method.
- Locking plate add stability specially in osteoporotic bone.
- ORIF allow rigid fixation with accurate reduction & stabilization
of the tuberosities.
 Disadvantages:
- Extensive soft tissue dissection, increased osteonecrosis of the
humeral head.
- Risk of damage of neurovascular structure. Particularly
asending branch of the lateral circumflex artery.

30. Correct plate position:
1. About 5 - 8mm distal to the top of the greater tuberosity.
2. Aligned properly along the axis of the humeral shaft.
3. Slightly posterior to the bicipital groove(2 – 4mm).

33. Anteromedial approach to shoulder(Thombson;Henry)/Deltopectoral
approach

34. (THOMPSON; HENRY):
- Begin the incision over the anterior aspect of the
acromioclavicular joint, passing it medially along the anterior
margin of the lateral one third of the clavicle.
- And distally along the anterior margin of the deltoid muscle to a
point two thirds the distance between its origin and insertion.
- Expose the anterior margin of the deltoid.
- The cephalic vein and the deltoid branches of the
- Thoraco-acromial artery lie in the interval between the deltoid
and pectoralis major muscles (the deltopectoral groove), and

35. - Although the cephalic vein may be retracted medially along
with the fibre of the deltoid muscle or ligating the vein
proximally & distally as soon as it is reached.
- Define the origin of the deltoid muscle on the clavicle; detach it
by dividing it near the bone or at the bone together with the
adjacent periosteum.
- We prefer the first method, leaving enough soft tissue attached
to the clavicle to allow suturing the deltoid to its origin later.
- Laterally reflect the anterior part of the deltoid muscle to
expose the structures around the coracoid process and the
anterior part of the joint capsule.

36. - To expose the deep aspects of the shoulder joint more easily,
including the anterior margin of the glenoid, osteotomize the
tip of the coracoid process.
- First, incise the periosteum of the superior aspect of the
coracoid; next, cut through the bone and reflect medially and
distally the tip of the bone along with the attached origins of
the coracobrachialis, the pectoralis minor, and the short head of
the biceps. Predrill the coracoid process.
- For wider exposure, divide the subscapularis at its
musculo-tendinous junction about 2.5 cm medial to its insertion
into the lesser humeral tuberosity; separate the tendon
medially from the underlying capsule and expose the glenoid
labrum.

37. - When closing the wound, replace the tip of the coracoid and
secure with a screw.
- Suture the deltoid in place and close the wound in the usual
way.

38. Complications
1. Vascular & Nerve injury:
- Axillary nerve is at particular risk.
2. Avascular necrosis:
- Reported incidence of AVN of humeral head is in the range of
10 – 30% in 03 part # & 10 – 50% in 04 part #.
- Blood supply of the humeral head is provided by the anterior
circumflex artery & its ascending branch (arcuate artery).
- Additional supply arises from the postero-medial aspect of the
proximal humerus, metaphyseal vessels & vessels of the GT & LT
which anastomose with the intra-osseous arcuate artery.

39. - Thus in 03 & 04 part fractures with only supply coming from the
posteromedial vessels.
- There may still be sufficient perfusion of the humeral head if
the head fragment includes a sizeable part of the calcar on the
medial side of the anatomical neck.
- Fracture of the anatomical neck with a medial metaphyseal
(Calcar) spike shorter than 8mm carry a high risk of developing
humeral head avascular necrosis.
- Disruption of medial periosteal hinge is another predictor of
avascular necrosis.

40. 3. Stiffness of the shoulder
4. Malunion