Neal test large - Slideshare

1. Proximal Humerus Fractures
Michael W. Leathers, M.D.

2. General
• Most common in active middle-aged
patients (avg. age: 54 years)
• Incidence: 4-5% of all fractures
• Osteoporosis major predisposing factor
• Loss of trabecular bone up to epiphyseal
plate
• Loss of trabeculae greatest in surgical
neck region

3. Anatomy & Function
• Retention glenohumeral
mobility
• Muscle forces on
proximal humerus,
tuberosities, shaft
• Blood supply humeral
head
• Neurovascular
structures

4. Blood Supply
• Ascending branch of
anterior circumflex
humeral artery is
primary blood supply
• Posterior circumflex
artery serves much
smaller portion
– Primarily
posteroinferior head
& posterior greater
tuberosity
Schlegel TF, Hawkins RJ: JAAOS 2:54, 1994

5. Blood Supply
1) Anterior
Circumflex
Artery (ACA)
2) Anterolateral
branch of ACA
3) Entry of AL ACA
4) Lesser tuberosity
5) Greater tuberosity
Hatched – No ACA
supply
Gerber et al, JBJS-A, 72, 1990

6. Neer Classification
• Displacement > 1 cm
• Angulation > 45o
Neer, JBJS-A, 52, 1970

7. 4-part Displacement
• Both tuberosities detached,
retracted
• Articular segment devascularized
• High incidence of AVN
• Primary prosthesis gives best
results
• Surgery: Restoration humeral
length and cuff fixation
• Early passive exercise, progress

8. Post-traumatic AVN
• Wide range of resultant
osteonecrosis after 4-part
fractures: (26-75%)
• Also seen in some 3-part
fractures (3-14%) and with
associated dislocations
• Jakob & Miniaci et al
– Four part valgus impacted fracture
– 26% osteonecrosis
Jakob, Miniaci et al; JBJS, 73B:2, 1991
Loebenberg, Plate, Zuckerman: AAOS ICL, 48, 1999
Rockwood & Green, Fractures in Adults, 1999

9. Treatment
• Options: • Factors:
– Non-operative – Fracture pattern
– Closed reduction – Patient age
– ORIF – Comorbidities
– Hemiarthroplasty – Bone quality

10. Non-op Tx & Closed Red.
Non-operative Tx Closed reduction
• Poor results • Poor results
– 1/16 - Able raise arm > 90o – 3/39 - Satisfactory (3-part)
– 9/16 - Constant pain – 0/38 - Satisfactory (4-part)
– Satisfactory results of Neer, JBJS-A, 52, 1970
arthroplasty = non-
operative tx of minimally
displaced fx
Stableforth, JBJS-B, 66, 1984

11. ORIF
• Appropriate for valgus impacted 4-part fx
• Ensure adequate bone stock
• Beware posterior or lateral displacement
• 74% satisfactory outcome; 26% AVN
Jakob, Miniaci et al; JBJS, 73B:2, 1991
Resch, JSES, 4, 1995

12. ORIF

13. ORIF
Many options: Results
• Plates & screws • Adequate results for 3-
• IM rods (vertical part fx
fixation) – 19/30 Good/excellent
• Neer, JBJS-A, 52, 1970
• Vertical fixation w/ – 21/35 Good/excellent
tension band • Darder et al, J Orthop Trauma, 7, 1993
• Consistently poor
• Tension band alone
results for 4-part fx
Paavolainen et al, Acta orthop Scand, 54, 1983
Cuomo et al, JSES, 1, 1992
Koval et al, J Trauma, 2, 1993
Williams, JSES, 6, 1997

14. Challenges
• 4-part fractures
• 3-part fx & fx-disloc. in elderly with osteoporotic
bone
• ORIF not possible
• Chronic ant/post disloc. with
impression fractures > 40%
articular surface
Zuckerman et al, 1997

15. Shoulder Arthroplasty
• Results of hemiarthroplasty superior to
nonsurgical treatment
• Satisfactory results in 80%
• Pain outcome good
• Functional outcome less predictable
• Age most important prognostic indicator
(Green, 1993)

16. Shoulder Arthroplasty -
Technique
• Determine degree of
• retroversion
Determine proper height
• Determine appropriate head size

17. Total Shoulder Arthroplasty

18. Results of HSA 4-part Fractures
• Neer: 31 of 32 excellent or satisfactory results
• Kraulis: 9 of 11 unsatisfactory
• Willems: 4 of 10 excellent or satisfactory
• Cofield: Good pain relief
– Active forward flexion 101
o
• Kay (UCLA): Excellent pain relief
– Active elevation 94
o
o
• Cockx: Good cuff repair 109 FF
– Poor/no cuff repair 51 FF
o

19. Timing of Hemiarthroplasty
Acute Chronic
• Same to better pain relief • Higher rate of
• Variable results of ROM, complications
function – Surgical difficulty
– Usually better – Scarring
• Problems – Distortion of anatomy
– Tuberosity healing
– RC failure
– Assoc. w/ surgical
Tanner & Cofield, Clin Orthop, 179, 1983
technique Frich et al, Orthopaedics, 14, 1991
Dines et al, JSES, 2, 1993
Norris et al, JSES, 4, 1995

20. Greater Tuberosity Pathology
1. Abnormally painful shoulder immediately post-
op
2. No progression (24%) or regression (9%) of
active shoulder mobility > 3 mos post-op
3. Dissociation between active (deficient) and
passive (preserved) forward elevation
- Malunion (15%); Axillary n. damage (6.5%)
* Migration & malunion (21.5%) & nonunion (11%)
results in a poor functional outcome
Boileau, Rev chir orthop reparatrice appar mot, 85:2, 1999

21. Rotator Cuff & Deltoid
• Restoration of the rotator cuff mechanism
important to functional result
• Must avoid detachment of deltoid
Tonino et al, Acta Orthop Belg, 51, 1985
Green et al, JSES 2, 1993
Hawkins et al, Clin Orthop, 289, 1993
Compito et al, Clin Orthop, 307, 1994
Goldman et al, JSES, 4, 1995

22. Cement
• Cement advocated in all cases
• Provides immediate stability
• Decreases incidence of loosening
• Also requires graft proximally to cover exposed
stem
Green et al, JSES 2, 1993
Hawkins et al, Clin Orthop, 289, 1993
Compito et al, Clin Orthop, 307, 1994

23. Biceps
• Biceps often tenodesed by reattachment of
tuberosities
• Currently recommended to release origin
and tenodese to proximal humerus
• Otherwise, intra-articular length shortened
& will restrict external rotation
Harryman et al, JSES, 7, 1998

24. Results
Unsatisfactory results
• Resorption or nonunion of tuberosities
• Rotator cuff dysfunction
• Cartilage space <2mm
Satisfactory results
• Radiographic union of tuberosities
• Integrity of rotator cuff
• Cartilage space > 2mm

25. Discussion
• Patients are usually asymptomatic preinjury
• Discuss results with patient before surgery

26. Prognosis
• More severe injuries, elderly pts less
optimal results
• Avoid deltoid origin detachment
• Lingering stiffness, pain, loss AROM > 6
months
• Attention to surgical detail will improve
prognosis (tuberosity reduction)

27. Treatment Algorithm
Naranja, JAAOS, 8:6, 2000

28. Complications
• #1 – Detachment of • Nerve injury (ax/mc)
greater tuberosity – 6.1% – 27%
• Looseing of prosthesis – Also assoc. w/ closed
reduction
• Infection
• Heterotopic
• Glenoid erosion
ossification
• Malpositioning of – 16%, esp surgery
humeral component delayed > 10 d
• Dislocation
Stableforth, JBJS-B, 66, 1984
Neer, Rev chir orthop suppl II, 74, 1988
Bigliani, Orthop Trans, 15, 1991

29. Joint Stiffness
• Bursal and capsular adhesions
• Treatment: Warm applications, stretching
• Avoid manipulation
• Prevent stiffness with early exercise
program

30. Conclusions
1. Minimal pain but limited function
2. Better results with intact rotator cuff,
tuberosities and cartilage space > 2mm
3. Limited expectations

31. Case Presentation
• 42 yo woman fell down flight of stairs,
sustaining bilateral distal radial fx, right
non-displaced olecranon fx, right proximal
humerus fx, & pelvis fx
• No PMH, Allergies, or Meds

32. Xrays & CT Scan

33. Post-op Xrays

34. Thank You