American Academy of Orthopaedic Surgeons
1999 Annual Meeting
Proximal Humerus Fractures: An Unsolved Fracture?
D Kevin Scheid, MD, Indianapolis, IN
Monday, February 8, 1999
08:00 AM - 10:00 AM
Stephen K Benirschke, MD, Seattle, WA
Louis U Bigliani, MD, New York, NY
Christian Gerber, MD, Zurich, SWITZERLAND
Clayton R Perry, MD, Saint Louis, MO
Timothy G Weber, MD, Carmel, IN
Surgical treatment of proximal humerus fractures is still considered
"unsolved" by many
accomplished shoulder reconstruction and trauma surgeons.
No consensus exists on preferred reconstructive technique or outcome measures.
This symposium attempts to bring together, in a unique format, both reconstructive
and upper extremity trauma experts in hopes of solidifying the decision
making process when surgically treating these fractures. Speakers have been
chosen with special interest in each of the various surgical techniques.
Well known surgical techniques as well as newer fixation methods will be
reviewed. Talks will focus on Anatomy, Classification, Precutaneous Fixation,
Tension Band Techniques, Locked IM Nails, Place Fixation (Blade Plate Technique),
Hemiarthroplasty and Outcomes.
- Anatomy Review
Louis U. Bigliani, MD, New York, NY
- Classification, Consensus?
Christian Gerber, MD, Zurich, SWITZERLAND
- Percutaneous Fixation
Stephen K. Benirschke, MD, Seattle, WA
- Tension Band Techniques (suture, wire, flexible nails)
Louis U. Bigliani, MD, New York, NY
- Locked IM Nails
Timothy G. Weber, MD, Carmel, IN
- Plate Fixation, Blade Plate Technique
D. Kevin Scheid, MD, Indianapolis, IN
Louis U. Bigliani, MD, New York, NY
Louis U. Bigliani, MD
Chairman, Dept. of Orthopaedic Surgery
Chief, The Shoulder Service
New York Orthopaedic Hospital
Columbia-Presbyterian Medical Center
New York, New York
- Proximal Humeral Anatomy
- Osseous anatomy
- Codman described four anatomic segments (1934) based on epiphyses
- humeral shaft
- articular segment
- greater tuberosity
- lesser tuberosity
- basis for the Neer classification system (1970)
- criteria for displacement: > lcm displacement or > 45 degrees angulation
- current trend: only 5mm displacement acceptable, especially greater tuberosity fractures
- Neck-shaft inclination angle averages 145 degrees
- Humeral head retroversion relative to epicondylar axis averages 30 degrees
- Deltoid, rotator cuff muscles, biceps, pectoralis major, teres major, and latissimus dorsi can all exert deforming forces on proximal humerus fracture fragments
- Musculotendinous anatomy
- Subscapularis: internal rotator, pulls lesser tuberosity medially
- Supraspinatus: abductor, humeral head depressor, pulls greater tuberosity fragment
- Infraspinatus, teres minor: external rotators, pull greater tuberosity fragment posteriorly
- Pectoralis major: internal rotator, pulls shaft anteromedially
- Deltoid: flexor, abductor, extensor, pulls shaft superiorly
- Long head of biceps tendon: useful anatomic landmark, identifies rotator interval, may be interposed between fracture fragments in surgical neck fractures
- Vascular anatomy
- Arcuate artery (of Laing) is main blood supply to articular segment
- arises from anterior humeral circumflex artery and ascends in lateral aspect of bicipital groove
to enter articular segment
- less significant contributions from the posterior humeral circumflex and small arteries entering through rotator cuff insertions
- Reported rates of osteonecrosis following displaced four-part fracture-dislocations range
from 20 to 100%
- Brachial plexus and its branches
- may be injured by medially displaced spike of shaft fragment or by humeral head dislocation (especially anterior fracture- dislocations)
- 45% of 101 proximal humeral fractures or dislocations in recent study showed electrodiagnostic evidence of nerve injury
- axillary (most commonly injured), suprascapular, radial, and musculocutaneous nerves at risk
- OPERATIVE TREATMENT OF PROXIMAL HUMERUS FRACTURES:
ORIF vs. ARTHROPLASTY
Two-part surgical neck fractures in which a satisfactory closed reduction cannot be achieved or maintained, are suitable for open reduction and internal fixation (ORIF). Displaced two-part greater tuberosity, two-part lesser tuberosity, three-part fractures and two- and three-part fracture dislocations are likewise treated with ORIF. Hemiarthroplasty is indicated for four part fractures, head splitting fractures, most anatomic neck fractures, head impression fractures > 50% of the articular surface and some 3-part fractures in osteoporotic bone.
- Importance of accurate radiographs: Trauma series AP and lateral views in the scapular plane Velpeau axillary view
- CT scan: assists in assessing tuberosity displacement and articular surface
- Management of Specific Fractures
- Surgical indications
- Two-part greater or lesser tuberosity fractures
- Two-part surgical neck fractures
- Three-part fractures
- Fracture-dislocations (two- and three-part)
- interscalene block, beach chair position
- superior deltoid approach: isolated displaced greater tuberosity fractures or insertion of intramedullary rods
- long deltopectoral approach: remaining fractures (limited approach for isolated lesser tuberosity)
- heavy no. 2 or 5 nonabsorbable suture through bone, pass through rotator cuff if bone osteoporotic (18 ga. wire alternative)
- expose fracture edges and inspect biceps tendon and rotator cuff
- drill holes in fracture fragments and place 4 - 5 no. 2 non-absorbable sutures ant., lat., and post.
- drill holes at fracture edge in proximal humerus
- repair rotator interval/tears
- reduce and secure sutures
- if fx is a comminuted 2-part surg. neck or 3-part fx. use figure of eight technique through cuff.
Secure tuberosity to head and other tuberosity first, then secure both to the humeral shaft.
- may use Enders rods for additional longitudinal stability, particularly when neck is comminuted (fig. of eight tech.)
- range the joint.
- Cuomo et al, 1992
22 pts (2 & 3-part fx.) O.R.I.F.
82% good-excellent results
- Flatow et al, 1991
12 pts (2-part greater tuberosity fx) O.R.I.F.
12 (100%) good/excellent results
170 ( avg. forward elev.)
- Surgical indications
- four-part fractures and fracture dislocations, head splitting fractures, humeral head
impression fractures >50% of articular surface, most anatomic neck fractures, and
some 3-part fractures in the elderly
- Interscalene block regional anaesthesia
- Delto-pectoral interval (preserve deltoid)
- Avoid axillary/musculocutaneous nerves
- Biceps: "guide" to rotator interval
- Mobilize tuberosities
- Proper length
- Proper version: 30-400 retroversion (may differ for post dislocation)
- Cement all fractures
- Secure Tuberosity Fixation
- multiple heavy, nonabsorbable sutures
- secure to drill holes in shaft
- avoid cement between shaft and tuberosities
- incorporate rotator cuff tendon (often stronger than soft, osteoporotic bone)
- Repair rotator interval (not always torn)
- early passive motion
- active motion when tuberosities and cuff healed
- strengthening later
- Neer 1970 "satisfactory but imperfect"
- Neer & Mcllveen 1988
- 61 cases
- avg. F/U 7 yrs (1.5-12)
- 85% active elevation > 145(
- no loosening
- no glenoid wear
- Goldman RT, et al. 1995
- 26 hemiarthroplasties for 3 & 4-part fxs
- 73% slight/no pain
- function & ROM less predictable
- Our current experience
Levine, Bigliani et al. , 1998
70 pts - hemi (4-part fx)
avg. 4.5 yr f/u
82% satisfactory (Neer's criteria)
95% pain-free with ADL's
Displaced two- and three-part fractures of the proximal humerus are usually
amendable to O.R.I.F. using heavy, non-absorbable sutures. Three-part fractures with a
comminuted surg. neck may require additional stabilization using Enders rods and figure
of eight tension band technique. Good to excellent results can be expected in 80% to 100% of
the patients. Those patients with osteoporotic bone or severe articular involvement
of the humeral head may be candidates for primary hemiarthroplasty. Relief of pain
can be expected in these patients, although return of normal function and motion are less predictable.
- Bigliani, L.U.: Treatment of two- and three- part fractures of the proximal humerus.
Instructional Course Lectures 38:231-244. Park Ridge, Illinois, AAOS, 1989.
- Bigliani, L.U.: Fractures of the proximal humerus. In Rockwood, C.A., and Matsen, F.A.,
III (eds.): The Shoulder. Phila. WB Saunders Co., 1990.
- Bigliani, LU, Flatow, EL, McCluskey, GM and Fischer, RA: Failed
Prosthetic Replacement for Displaced Proximal Humerus Fractures Orthop Trans. 15:747-748,1991.
- Cuomo, F.; Flatow, E.L.; Maday, M.; Miller, S.R.; Mcllveen, S.J.; and Bigliani, L.U.:
Open reduction and internal fixation of two- and three-part displaced surgical neck
fractures of the proximal humerus. J. Shoulder Elbow Surg., 1:287-295, 1992.
- Esser, R.D.: Treatment of three- and four-part fractures of the proximal humerus with
a modified cloverleaf plate. J. Orthop. Trauma. 8(l):15-22, 1994.
- Fischer, RA, Nicholson, GP, Mcllveen SJ, McCann, PD, Flatow, EL, Bigliani, LU:
Primary Humeral Head Replacement for Severely Displaced Proximal Humerus Fractures.
Presented at American Academy of Orthopaedic Surgeons, Washington, DC, February, 1992.
- Flatow, E.L.; Cuomo, F.; Maday, M.G.; Miller, S.R.; Mcllveen, S.J.; and Bigliani, L.U.:
Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity
of the proximal part of the humerus. J. Bone Joint Surg., 73(8):1213-8, 1991.
- Goldman, RT, Koval KJ, Cuomo, F; Gallagher, MA; Zuckerman, JD; Functional outcome after
humeral for acute three- and four-part proximal humeral fractures. J. Shoulder Elbow S. 4;81-86, 1995
- Gerber, C.; Schneeberger, A.; and Vinh, T.: The arterial vascularization of the humeral head.
J. Bone Joint Surg., 72A: 1486-1494, 1990.
- Hawkins, R.J.; Bell, R.H.; and Gurr, K.: The three-part fracture of the proximal part
of the humerus. Operative treatment. J. Bone Joint Surg., 68A: 1410-1414, 1986.
- Jakob, RP, Miniaci, A, Anson, PS, Jaberg, H, Osterwalder, A, Ganz,R: Four-Part Valgus
Impacted Fractures of the Proximal Humerus. J Bone Joint Surg 73B:295-298, 1991.
- Ko, JY; Yamamoto, R; Surgical treatment of complex fracture of the proximal humerus.
Clin Orthop., 327;225-37, 1996
- Laing,PG: The Arterial Supply of the Adult Humerus. J Bone Joint Surg 38A:1105-1116, 1956.
- Levine, AN; Connor, PM; Yamaguchi K; Self, EB; Arroyo, JS; Pollock, RG; Flatow,EL; Bigliani,
LU: Humeral head replacement for proximal humeral fractures. Orthopedics 21(l):68-73, 1998
- Muller, M.E., Allgower, M, Willenegger, H: The technique of internal fixation of fractures.
New York, Springer-Veriag, 1965.
- Muller ME, Nazarian S, Koch P, Schatzker J: The Comprehensive Classification of Fractures
of Long Bones. Springer-Verlag, Berlin, 1990, pp. 54-63.
- Neer, C.S.: Displaced proximal humeral, fractures. Part 1. Classification and evaluation.
J. Bone Joint Surg., 52A: 1077-1089, 1970.
- Neer, C. S.: Displaced proximal humeral fractures. Part 11. Treatment of
three-part and four-part displacement. J. Bone Joint Surg., 52A: 1090-1103, 1970.
- Stableforth PG: Four-Part Fractures of the Neck of the Humerus. J Bone Joint Surg
- Sturzenegger, M.; Fomaro, E.; and Jakob, R.P.: Results of surgical treatment of multifragmented
fractures of the humeral head. Arch. Orthop. Trauma Surg., 100:249-259, 1982.
- Svend-Hansen H: Displaced Proximal Humerus Fractures. Acta Ortho Scand 45:359-364, 1974.
- Tanner, MW, Cofield, RH: Prosthetic Arthroplasty for Fractures and Fracture-Dislocations
of the Proximal Humerus. Clin Orthop 179:116-128, 1983.
Stephen K. Benirschke, M.D.
Harborview Medical Center
University of Washington
- Basic Anatomy
- Originates from the labrum and its surrounding bone and attaches to the periosteum of the anatomical neck of the humeral shaft.
- Capsule is reinforced by broad tendons about an inch in length.
- Capsule is large enough to contain two humeral heads
- Muscular Attachments
- Supraspinatus-most superior and inserts into the greater tuberosity.
- Infraspinatus and teres minor also insert into the greater tuberosity.
- subscapularis tendon attaches to the lesser tuberosity.
- Pectoralis major attraches to the lateral border of the intertubercular groove of the humerous.
- Blood Supply Often Damaged by Proximal Humeral Fracture
- Damage can cause AVN.
- Anterior humeral circumflex aftery
- Anteriod lateral ascending branches and arcuate artery.
- Posterios humeral circumflex and the posterior medica branches.
- Nerves easily damaged by proximal humeral fractures
- Radial nerve
- Axillary n.
- FRACTURE CLASSIFICATION OF PROXIMAL HUMERUS
- Neer classification
- Developed in 1970.
- Based on the displacement of at least one of four segments of the proximal humerus including
the articulating head, the lesser tuberosity, the greater tuberosity and the shaft.
- Segments displaced if they are shifted by more than 1.0 centimeter or are angulated more than
- TREATMENTS USED FOR PROMIMAL HUMERUS FRACTURES
- Conservative management is often successful if fractures are undisplaced.
- Displaced fractures or fracture-dislocations often require special treatment
including hemiarthroplasty, open reduction internal fixation or percutaneous pinning.
- Disadvantages: wider exposure, high association with head necrosis, poor functional results due to subacromial impingement, nerve lesions and plate and screw loosening.
- Advantages: according to Jaberg: Useful for severely displaced irreducible 3 and 4 part fractures.
ORIF produces less pain with earlier functional active therapy.
- Disadvantages: decreased joint integrity
- Advantages: useful for very old patients with limited functional demands,
patients with severe osteoporasis, failed internal fixation and in patients
with a high anesthesia risk.
- Percutaneous pinning
- Advantages: least jeopardy to vascular supply, no extensive dissection of soft
tissues necessary; maintains stability of the reduction.
- Disadvantages: DePalma describes percutaneous pinning as technically difficult.
Limited amount of ROM post surgery until pins are DC'd.
- PERCUTANEOUS PINNING
- Candidates for percutaneous pinning:
- Demonstrate good compliance, good bone integrity, minimal devalscularization, patients who require a strong and functional shoulder.
- Percutaneous pinning can be sued with unstable fracture patterns that can be reduced by
manipulation with the patient under anesthesia and that fit in the following specifications
by Neer: less than one centimeter of displacement or less than 45° of angulation or both.
- Reduction technique:
- Using bi-plane image intensification with patient supine and arm abducted between 60 - 90�.
- Longitudinal traction is exerted on the arm and the humeral shaft reduced to articular segment.
- Direct pressure to the anterior aspect of the humerus shaft will help correct residual
apex anterior angulation evident with most fracture patterns between shaft and articular segment.
- Operative technique:
- Pt. Prepared, draped, and given IV antibiotics.
- Arm is reduced and held stable
- C-arm image intensifier is used to visualize the fracture.
- Place Schanz pins going from humeral shaft to the head of the humerus.
- Check alignment and advance Schanz pins into humeral head.
- Place pins from greater tuberosity through medial cortex of humeral shaft.
- Place pins from distal to proximal through the anterior shaft of the humerus into the head of the humerus if needed.
- Place pin securing reduced lesser tuberosity through posterior cortex of humeral shaft.
- Assess stability.
- Pins are cut short beneath the deltoid fascia
- Pins are removed when there is adequate/healing.
3 weeks: lesser tuberosity Schanz pin
6 weeks: greater tuberosity Schanz pins
8 weeks: shaft Schanz pins
- Repeat reduction and pinning, mal-union, superficial pin tract infections,
deep pin tract infections, non-union, complete AVN and transient AVN.
- GENERAL PT TREATMENT FOR PERCUTANEOUS PINNING OF PROXIMAL HUMERUS FRACTURES
NWB - 2 1/2 to 3 months.
Abduction pillow usually for 6 weeks
ROM allowed is variable for each patient
PROM only initially.
Post Operative day 1 to until pin through lesser tuberosity is
removed (3 weeks)
- Gentle shoulder passive ROM with abduction pillow in place
- Forward flexion (flexion of GH joint following plane of abduction pillow)
- External rotation (beginning from plane of abduction pillow position)
- Occasionally internal rotation is allowed from point of abduction pillow
- Gentle passive small are pendulum within plane of pillow.
- Passive abduction past the abduction splint can cause impingement with pin
and/or fulcrum the pin on acromion
- Elbow, wrist and hand AROM.
- Posture and body mechanics instruction to maintain normal spine alignment.
- Aerobic program with arm in abduction pillow (walking).
After removal of anterior pin placed into lesser tuberosity (usually 3 weeks)
- Begin active shoulder motion within a pain-free range and within the range
allowed with the abduction pillow on.
- Continue elbow, wrist and hand AROM.
- Continue posture and body mechanics instruction.
- Continue aerobic activity.
After removal of pins into the greater tuberosity (usually 6 weeks)
- Increase shoulder ROM especially abduction and adduction.
- Begin weaning from abduction pillow.
After shaft pin removal (8 weeks).
- Progress ROM and strength to tolerance.
- Encourage normal daily activities.
- Bigliani LU: Fractures of the Proximal Humerus, The Shoulder, Vol 1, WB Saunders Co, 1990.
- DePalsm AF: Surgery of the Shoulder, 2nd Edition, 296-310, JB Lippencott, 1973.
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and Chronic Proximal Humeral Fractures, Shoulder Arthroplasty, 14:9, 949-954, 1991
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J. Bone Joint Surgery, 72-A:10, 1486-1494, 1990
- Hawkins RJ, Bell RH, Gurr K: The Three-Part Fracture of the Proximal part of the Humerus,
J. Bone Joint Surgery, 68-A:9, 1410-1414, 1986.
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Clin. Orthop. Rela. Research, 112:250-253, 1995.
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the Humerus, J. Bone Joint Surgery, 74-A:4, 508-515,1992.
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of Treatment of Fractures of the Proximal Humerus, Surgery of the Shoulder, 1994.
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of the Prximal part of the Humerus, J. Bone Joint Surgery, 74-A:6,884-889, 1992.
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J. Bone Joint Surgery, 52-A:6, 1077-1089, 1970
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Distal Radius Fractures, Orthop. Clin. North Amer., 24:2, 287-300, 1993.
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Classification System for Proximal Humeral Fractures, J. Bone Joint Surgery, 75-A:12, 1745-1750, 1993.
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and Expected Results, Clin Orthop. Rel. Res, 292, 13-25, 1993.
Locked IM Nails Handout
T.G. Weber, MD
What is a locked IM nail?
- IM nails had greater stiffness and less angular displacement of fragments
during cyclic loading. When loading the constructs to failure, the intramedullary
device proved to have greater failure torques, stiffness, energy absorbed, and angular
displacement before failure.
Who is a candidate
- Fracture type
- Associated shaft extension
- Patient Profile
- Young high energy
- Old low energy
- Room set-up
- Patient is positioned supine on a radiolucent table with a small bump beneath the scapula.
Anesthesia can be general, intrascalene block or a combination of both.
The unaffected upper extremity is tucked at the patients side. The entire affected
upper extremity (including the hand) is prepped free. The C-arm is positioned
perpendicular to the patient and brought in from the opposite side of the patients injured shoulder.
AP glenoid and Scapular Y are the two views utilized for verifying reduction and placement of the
- Intramedullary nailing can be done eitherthrough an open deltoid splitting approach
which allows visualization of the cuff, incising it in line with the fibers and
ultimately allowing repair of the cuff. Alternatively good results have been reported
with a percutaneous technique. We prefer the open approach.
- Effected by longitudinal traction. Tuberosities can be reduced through the
open wound because of the
direct access to the cuff. The relationship of the head to the shaft will
also be significantly effected by placement of the nail.
- Entry for the nail is the sulcus just lateral to the articular surface and in the middle
of the tuberosity on the scapular Y view. Proximal and distal locking screws allow stabilization
of the head fragment to the shaft fragment.
- Critical to repair the rent in the rotator cuff that was made for placement of the nail.
- Positional aids
- In general no abduction pillows or slings are necessary.
- Physical therapy
- 2-part - initiate active and passive ROM immediately
- 3 and 4-part - full passive ROM immediately and begin active ROM at approximately 4 weeks.
- can be initiated at 6-8 weeks post-op.
- small dissection
- usually good alignment
- Fixation is stable enough to not need additional braces or supports and to allow early ROM.
- Requires violation of the rotator cuff for placement of the nail.
- Riemer BL, D'Ambrosia R: The Risk of Injury to the Axillary
- Nerve, Artery, and Vein from Proximal Locking Screws of Humeral Intramedullary Nails.
Orthop 1992; 6:697-9.
- Riemer BL, D'Ambrosia R, Kellam JF, Butterfield SL, Burke CJ: The Anterior Acromial
Approach for Antegrade Intramedullary Nailing of the Humeral Diaphysis. Orthop 1993; 11:1219-23.
- Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ: Proximal Humeral Fracures: Management Techniques
and Expected Results. Clin Orthop 1993; 292:13-25.
- Wheeler DL, Colville MR: Biomechanical Comparison of Intramedullary and Percutaneous
Pin Fixation for Proximal Humeral Fracture Fixation. J Orthop Trauma 1997; 11: 363-367.
Small Fragment Blade Plate Fixation of
Proximal Humerus Fractures
D. Kevin Scheid, M.D.
Director Orthopedic Education Methodist Hosp.
|Suture Fixation/K-wire tension band
||Cuff constriction, limited head fixation, Wire migration
||Delayed motion, early loosening
||Impingement, limited head fixation, Possible cuff violation, varus deformity
||Impingement, no "fixed" stabilization of head, Vascular impingement?
||Unpredictable results, tuberosity healing
Consequences/ Associated Injuries
Loss of motion
Loss of reduction
AVN (14-25%) 3-part
Rotator cuff injury
Axillary N., brachial plexus
Blade Plate Concept (Advantages)
Fixed angle head fixation
Low profile, no impingement
No rotator cuff constriction or violation
Resists varus deformity
May allow early motion
Minimal hardware in comminuted fractures
Blade Plate Concept (Disadvantages)
Age 28-78 yrs
- 42 acute fractures, 7 nonunions
- 17 2-part
- 22 3-part
- 3 4-part (2 head splits, 1 dislocation)
- 7 nonunions
- 7 hole
- 3.5 DC or LCDC plate
- 1/3 tubular plate-(I or 2 stack) prebent 110-140 degrees
|Position: ||beech chair|
|c-arm at head of bed|
|expose lateral to bicepts groove|
|usually no stripping of fracture site needed|
|Insertion: ||no chisel needed for 1/3 tubular|
|osteotome for chisel if 3.5|
Post Op Care
neutral rotation sling (Don Joy Uhra sling)
occasionally abduction pillow
gentle passive abduction only for 4 weeks
then active assist
f/u: 11-40 months (ave. 27)
41/42 acute fractures
Neer 100 pt functional assessment
3 loss of reduction (varus) due to low angle blades (<110 degrees)
2 adhesive capsulitis requiring manipulation
5 rotation of blade in osteoporotic head before use of neutral rotation sling
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