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Innovations in the Management of Displaced Proximal Humerus Fractures

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Innovations in the Management of Displaced Proximal Humerus Fractures Innovations in the Management of Displaced Proximal Humerus Fractures Shane J. Nho, MD Abstract Robert H. Brophy, MD The management of displaced proximal humerus fractures has Joseph U. Barker, MD evolved toward humeral head preservation, with treatment Charles N. Cornell, MD decisions based on careful assessment of vascular status, bone quality, fracture pattern, degree of displacement, and patient age John D. MacGillivray, MD and activity level. The AO/ASIF fracture classification is helpful in guiding treatment and in stratifying the risk for associated disruption of the humeral head blood supply. Nonsurgical treatment consists of sling immobilization. For patients requiring Dr. Nho is Resident, Department of surgery, options include closed reduction and percutaneous Orthopaedic Surgery, Hospital for fixation; transosseous suture fixation; open reduction and internal Special Surgery, New York, NY. Dr. Brophy is Resident, Department of fixation, with either conventional or locking plate fixation; bone Orthopaedic Surgery, Hospital for graft; and hemiarthroplasty. Proximal humerus fractures must be Special Surgery. Dr. Barker is Resident, evaluated on an individual basis, with treatment tailored according Department of Orthopaedic Surgery, to patient and fracture characteristics. Hospital for Special Surgery. Dr. Cornell is Attending Orthopaedic Surgeon, Department of Orthopaedic Surgery, Hospital for Special Surgery. Dr. roximal humerus fractures are ticular fractures5-11 and in locking MacGillivray is Assistant Attending Pincreasingly common in socie- plate technology,8,12 which are par- Orthopaedic Surgeon, Department of ties with maturing populations.1 ticularly relevant to the care of these Orthopaedic Surgery, Hospital for These fractures are not simple to fractures.7,13-15 Locking plate tech- Special Surgery. treat. A variety of options exists; nology and the use of osteobiologics None of the following authors or the however, outcomes are less than ide- may become increasingly important departments with which they are al in many patients.2,3 Most proxi- in the management of displaced affiliated has received anything of value mal humerus fractures are either proximal humerus fractures, facili- from or owns stock in a commercial nondisplaced or minimally displaced tating humeral head preservation in company or institution related directly or and can be treated nonsurgically.4 appropriately selected patients. indirectly to the subject of this article: Nonsurgical options focus on early Dr. Nho, Dr. Brophy, Dr. Barker, Dr. functional exercises with the goal of Epidemiology Cornell, and Dr. MacGillivray. achieving a functionally acceptable Reprint requests: Dr. MacGillivray, range of motion (ROM). For the 15% Proximal humerus fracture is the Department of Orthopaedic Surgery, to 20% of displaced proximal hu- second most common fracture of the Hospital for Special Surgery, 535 East merus fractures that may benefit upper extremity, following distal 1 70th Street, New York, NY 10021. from surgery, no single approach is forearm fracture. In people older considered to be the standard of care. than age 65 years, fracture of the J Am Acad Orthop Surg 2007;15:12-26 Surgeons should be familiar with the proximal humerus is the third most Copyright 2007 by the American different treatment options avail- common fracture, after hip fracture Academy of Orthopaedic Surgeons. able, including recent advances in and Colles’ fracture.1 Proximal hu- the management of complex periar- merus fracture is associated with 12 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, et al significant morbidity, leading to Figure 1 functional impairment lasting at least 3 months.16 Displaced proxi- mal humerus fractures generally re- sult in long-term functional disabil- ity. This type of injury usually is sustained after a moderate-energy fall in an individual with low bone density.16 Anatomy The proximal humerus is divided into the shaft, surgical neck, ana- tomic neck, lesser tuberosity, and greater tuberosity. Classification of proximal humerus fractures based on these anatomic divisions predi- cates treatment and predicts out- come. The humeral head has a spherically shaped articular surface; the anatomic neck demarcates the junction of the head and metaphy- sis. The neck-shaft angle is 130°, and the head is retroverted 19° to 22° rel- ative to the shaft.17 The greater and lesser tuberosities are located adja- cent to the articular margin of the head; they are separated by the bicip- ital groove. The surgical neck serves as the junction between the metaph- ysis and the humeral diaphysis. Hertel radiographic criteria. A and B, Metaphyseal head extension is a radiographic Tendinous insertions contribute measurement of the articular fragment from the head-neck junction to the inferior to the pattern of fracture displace- extent of the medial cortex. A, Metaphyseal head extension >8 mm. B, Metaphyseal head extension <8 mm. C and D, Medial hinge integrity is determined by the ment around the proximal humerus continuity of the medial calcar. C, Undisplaced medial hinge. D, Medial hinge by transmitting deforming muscular displaced >2 mm. (Adapted with permission from Hertel R, Hempfing A, Stiehler forces to the bony fragments. The in- M, Leunig M: Predictors of the humeral head ischemia after intracapsular fracture of sertions of the supraspinatus, in- the proximal humerus. J Shoulder Elbow Surg 2004;13:427-433.) fraspinatus, and teres minor tendons onto the greater tuberosity contrib- ute to the typical posterior and supe- tends to be very dense and strong, disrupted, implying, in the fractured rior retraction of this fragment. The thus providing a potential site for proximal humerus that perfusion rotator interval functions as a check- fracture fixation, it is important from the posterior circumflex hu- rein on the humeral head fragment when using suture fixation to re- meral artery alone may be sufficient and limits displacement of two-part member that the tendons are even for humeral head survival. Hertel et fractures and most three-part frac- stronger than the bone.18 al22 conducted perfusion studies in tures. Functionally significant tears The anterior circumflex humeral proximal humerus fractures to deter- of the rotator interval are uncom- artery and the arcuate artery are con- mine factors predictive of humeral mon. The pull of the subscapularis sidered to be the major sources of head ischemia. They demonstrated muscle tends to retract lesser tuber- humeral head perfusion,19 but stud- the significance of metaphyseal head osity fragments medially. When the ies characterizing the vascular anat- extension (ie, the amount of me- lesser tuberosity remains attached to omy were performed in the intact taphysis, typically posteromedial) the head fragment, the head frag- proximal humerus.20,21 Even in sim- that remains attached to the humer- ment is rotated internally. Although ple fracture patterns, the anterior al head determines the amount of the bone at the tendinous insertion circumflex humeral artery is often head extension22 (Figure 1, A). Meta- Volume 15, Number 1, January 2007 13 Innovations in the Management of Displaced Proximal Humerus Fractures Figure 2 angulation >45°), direction of dislo- cation, and involvement of the artic- ular surface.4 The AO/ASIF classifi- cation system for proximal humerus fractures broadly groups fractures based on the degree of articular in- volvement and likelihood of vascu- lar injury23 (Figure 2). Observer reli- ability and reproducibility for both the Neer and the AO/ASIF classifica- tion is fair to poor; it is unlikely that one orthopaedic surgeon will assign the same classification to a proximal humerus fracture at two separate times, just as it is unlikely that two orthopaedic surgeons will agree on a classification. Given these limita- tions, the AO/ASIF classification for the three basic types of humerus fracture is more user-friendly than the Neer classification,24 although still complex. Treatment Algorithm Although the management of dis- placed proximal humerus fractures has evolved toward humeral head preservation, treatment should be guided by careful assessment of vas- cular status, bone quality, fracture pattern, and degree of comminution, as well as patient factors, such as age and activity level. Patients who are either medically unstable or inactive AO/ASIF classification for proximal humerus fractures. Top, A, Unifocal, extra- are poor candidates for surgery and articular two-part fracture with intact vascular supply. Middle, B, Bifocal extra- instead may be treated with sling articular fracture with possible injury to the vascular supply. Bottom, C, Articular immobilization until the fracture fracture involving the anatomic neck, with high likelihood of necrosis. (Adapted with permission from Müller ME: Appendix A: The comprehensive classification of heals. The ultimate goal is maxi- fractures of long bones, in Müller ME, Allgöwer M, Schneider R, Willenegger H mum shoulder function and mini- [eds]: Manual of Internal Fixation: Techniques Recommended by the AO-ASIF mal shoulder pain. A proposed treat- Group. Berlin, Germany: Springer-Verlag, 1991, pp 118-125.) ment algorithm (Figure 3) provides a working guideline for the manage- ment of proximal humerus fractures, physeal head extension <8 mm was humeral head ischemia.22 but treatment, whether nonsurgical found to be a good predictor of is- or surgical, must be individualized chemia (accuracy, 0.84).22 Another according
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