An in-depth review of Proximal Humerus Fractures. Ortho Reviews - Flashcard

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Previously the main blood supply was thought to be from the anterior humeral circumflex artery, but a 2010 study by Hettrich et al. published in @jbjs showed that 64% of the blood supply comes from the posterior humeral circumflex artery making it the main blood supply.

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A 2004 study by Hertel et al. described predictors of humeral head ischemia.

The two most critical factors were:
1) < 8 mm of calcar length
2) Medial Hinge Disruption

Increasing fracture complexity may also be associated with an increased risk of AVN.

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The proximal humerus has four bony segments:
✯ Humeral Head
✯ Greater Tuberosity (GT)
✯ Lesser Tuberosity (LT)
✯ Humeral Shaft

Fractures at the anatomic neck will produce a humeral head fragment and fractures at the surgical neck will produce a humeral shaft fragment.

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Deforming forces on proximal humerus fragments:
✯ GT: Supraspinatus/Infraspinatus/Teres Minor
-Superior and ER
✯ LT: Subscapularis

Surgical Neck Fractures:
✯ Proximal Fragment: Deltoid
✯ Humeral Shaft: Pec. Major

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The Neer Classification System for proximal humerus fx is based on the four bony segments.

A fragment is defined as having either:
✯ >10 mm displacement or
✯ >45° angulation

1-part fractures are ones without significant displacement, they may also be 2-part, 3-part, or 4-part

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Proximal humerus are forgiving and many can be treated non-operatively.

A 2015 study by Handoll et al. "The ProFHER Study" showed no difference in outcomes between non-operative and surgical management of surgical neck fx.

Of note: the mean age was 66 y.o. and 77% were female.

Most minimally displaced fractures can be treated with immobilization in a sling and swathe.

An axillary roll may be used to counteract the deforming force of pec. major in surgical neck fractures.

Greater tuberosity fractures with > 5 mm displacement may require surgical repair with ORIF due to their tendency to displace superiorly and cause impingement.

Options include cannulated screw fixation, tension band constructs, and suture anchoring.

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Displaced anatomic neck and head-splitting fractures are treated based on age.

Young patients:
Elderly patients:
✯ Anatomic vs. reverse shoulder replacement

RTS may be indicated if:
✯ low-demand patient
✯ deficient rotator cuff
✯ non-repairable tuberosities

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Surgical management of 3-part fractures:

Young patients:
✯ ORIF with IM nailing or plate/screws.

Older patients:
✯ ORIF vs. shoulder replacement

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✯ Humeral Head AVN following anatomic neck or head-splitting fractures treated with ORIF
✯ Non-union: most commonly varus deformity in surgical neck fx
✯ Hardware failure (combined cortical thickness > 4 mm has been suggested to be associated with reduced risk)

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Ortho Reviews - Proximal Humerus Fractures