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FRACTURES OF THE PROXIMAL HUMERUS

FRACTURES OF THE PROXIMAL HUMERUS. Presented by Mahsa Mehdizade Dr. Mardani Porsina Hospital Spring 1392. Incidence. Proximal humerus fxs comprise 4-5% of all fxs. Minimal displacement 80% Two-part fxs 10% Three-part fxs 3% Four-part fxs 4% Articular surface fxs 3%. Anatomy.

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FRACTURES OF THE PROXIMAL HUMERUS

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  1. FRACTURES OF THE PROXIMAL HUMERUS Presented by Mahsa Mehdizade Dr. Mardani Porsina Hospital Spring 1392

  2. Incidence • Proximal humerus fxs comprise 4-5% of all fxs. • Minimal displacement 80% • Two-part fxs 10% • Three-part fxs 3% • Four-part fxs 4% • Articular surface fxs 3%

  3. Anatomy • Comprised of four segments: • Humeral head • Greater tuberosity • Lesser tuberosity • Humeral shaft

  4. Neurovascular Supply • Anterior and posterior humeral circumflex arteries • Arcuate artery-continuation of the ant humeral circumflex and supplies most of the humeral head. • Axillary nerve-most commonly injured

  5. Forces on Segments • Greater tuberosity is displaced superiorly and posteriorly by the supraspinatus and external rotators. • Lesser tuberosity is displaced medially by the subscapularis. • The shaft is displaced medially by the pectoralis major.

  6. Mechanism of Injury • Elderly, osteoporotic, usually female: fall on outstretched arm. • Young adults: high-energy trauma; usually more severe fxs and dislocations

  7. Radiographic Evaluation • A/P view • Scapular Y view • Axillary view • Best view for glenoid articular fxs and dislocations • CT scan: helpful in evaluating articular involvement and degree of displacement

  8. Classifications • Neer-four parts: greater and lesser tuberosities; shaft; humeral head. • A part is displaced only if >1cm of displacement or 45 degrees of angulation is present. • At least 2 views must be obtained • AO-emphasizes the vascular supply to the articular segment • Three types: • Type A: Extraarticular unifocal fxs • Type B: Extraarticular bifocal fxs • Type C: Articular fxs • Not commonly used

  9. Neer Classification

  10. Closed reduction Immobilization Early ROM if stable External stabilization Percutaneous pins External fixator Ilizarov frame Open reduction and internal fixation Screw fixation Tension banding Buttress plating Fix-Clip system Intramedullary fixation Rush rods Ender’s nails Nails with interlocking screws Excisional arthroplasty Hemiarthroplasty Treatment Options

  11. Fractures to Consider for Closed Treatment Minimally displaced 2 part fx’s (or positional reduction of significant displacement) GT fractures should be <5mm). Minimally displaced 3- and 4-part fractures

  12. Fractures to Consider for ORIF • Displaced GT fx (> 5 mm) • LT fx with involvement of articular surface • Displaced or unstable surgical neck fx • Displaced anatomic neck fx in young pt. • Displaced, reconstructible 3- and 4-part fractures

  13. Fractures to Consider Hemiarthroplasty • Young/Middle age • nonreconstructable articular surface (severe head split) or extruded anatomic neck • Elderly • many 4 parts • some severe 3 parts • most 3,4 part fracture dislocations • most head splits

  14. Potential Complications • Neurologic injury • Brachial plexus-Stableforth reported an incidence of 6.1% • Axillary-common • Vascular injury • Stableforth also reported a 4.9% incidence of arterial injury with displaced fxs; most commonly the axillary artery • An intact radial pulse doe not exclude an arterial injury so keep it in mind.

  15. Complications cont. • Avascular necrosis • Hagg and Lungberg reported an incidence of 3 – 14% with 3- part fxs and 13 – 34% with 4-part fxs, using closed reduction. • Nonunion (uncommon) • Malunion – often associated with AVN • Adhesive capsulitis • Myositis ossificans • Infection

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