Proximal Humerus Injuries

Educational Objectives

The goal of this program is to improve the treatment of proximal humerus fractures. After hearing and assimilating this program, the clinician will be better able to:

1. Visualize the vascular supply to the humeral head and predict the risk for avascular necrosis in proximal humerus fractures.

2. Cite critical factors that affect the surgical outcome of proximal humerus fractures.

Summary

Open reduction internal fixation: doubles risk for avascular necrosis (AVN) compared to closed treatment; >3-fold increased incidence of AVN after open buttress plating; Neer recommended minimal osteosynthesis in 3-part humerus fractures and prosthesis in 4-part humerus fractures; prosthetic replacement — Zyto et al (1998) reported ≈33% of patients experienced moderate to severe pain and moderate disability; Goldman et al (1995) reported 73% of patients experienced disability; prosthesis represents salvage treatment for proximal humerus fractures; hemiarthroplasty (typical results) — range of motion (ROM) shoulder level; forward flexion 100°; internal rotation to lower back; external rotation 20° to 40°; poor functional outcome scores

Blood supply to humeral head: Gerber et al (1990) — reported arterial blood supply to humeral head relied on terminal branch of anterior humeral circumflex (AHC) artery; Coudane et al (2000) — looked at arteriography for 20 patients with complex proximal humerus fractures; AHC artery disrupted in 80% of patients; posterior humeral circumflex (PHC) artery intact in 85% of patients; overall percentage of cases with AVN <80%; PHC artery critical for vascularization to humeral head; Hettrich et al (2010) — reported 3-fold caliber for PHC artery; more significant uptake of gadolinium into humeral head from PHC artery compared to AHC artery; PHC artery comprises two-thirds of blood supply to proximal humerus and remained intact in fractures; decision making — perfusion of head critical but not only component in choosing treatment; consider bone quality, ability to achieve stable fixation, and ability to repair and anatomically replace tuberosities for future reconstruction

Surgical approaches: deltopectoral — uses anterior incision to treat tuberosity fractures that displace posteriorly; minimize medial dissection to preserve PHC artery; requires more retraction of deltoid to access area for plating; not appropriate for treatment of proximal humerus fractures; between anterior and lateral heads of deltoid — more direct approach for reduction and fixation; avoid splitting deltoid 5 cm distal to acromion to prevent injury to axillary nerve; relies on axillary nerve consisting of one branch; anterior branch of axillary nerve crosses interval between anterior and lateral head of deltoid, then arborizes anteriorly and posteriorly; locate nerve 3.5 cm from tip of greater tuberosity

Surgical technique: locked plates — use multiple mini blade plates with locked screws; difficult with elderly patients with poor bone quality in humeral head; most techniques place screws that fail to reach subchondral bone; failure rates ≤40% with screw cutout; bone fails to hold implant

Gardner et al (2007): reported on 35 proximal humerus fractures treated with locked plate; 100% healed; significant increase in catastrophic failure when calcar not reduced and fixation not placed low into humeral head; significant loss in head height; calcar reduction and support most significant factors; augment calcar when reduction not possible

Hettrich et al (2012): reported on 32 patients with endosteal support from allograft fibula; 100% healed; average loss of reduction <1 mm; no hardware-related complications; one radiographic failure

Conclusion: function follows form; stable reconstruction and fixation mandatory; begin aggressive active and passive ROM and continuous passive motion on postoperative day one; reduction of calcar critical; augment calcar when reduction not possible; aggressively treat osteoporosis locally and systemically

Readings

Suggested Reading

Davis JT et al: The effect of pitching biomechanics on the upper extremity in youth and adolescent baseball pitchers. Am J Sports Med, 2009 Aug;37(8):1484-91; Fleisig GS et al: Prevention of elbow injuries in young baseball pitchers. Curr Sports Med Rep, 2009 Sep-Oct;8(5):250-4; Freehill MT, Safran MR: Diagnosis and management of ulnar collateral ligament injuries in throwers. Curr Sports Med Rep, 2011 Sep-Oct;10(5):271-8; Gardner MJ et al: The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma, 2007 Mar;21(3):185-91; Gerber C et al: The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am, 1990 Dec;72(10):1486-94; Hettrich CM et al: Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma, 2012 Apr;26(4):212-5; Hettrich CM et al: Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am, 2010 Apr;92(4):943-8; Letts M et al: Osteochondritis dissecans of the talus in children. J Pediatr Orthop, 2003 Sep-Oct;23(5):617-25; O’Loughlin PF et al: Current concepts in the diagnosis and treatment of ostechondral lesions of the ankle. Am J Sports Med, 2010 Feb;38(2):392-404; Perumal V et al: Juvenile osteochondritis dissecans of the talus. J Pediatr Orthop, 2007 Oct-Nov;27(7):821-5; Zyto K et al: Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg, 1998 Mar-Apr;7(2):85-9.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Lorich and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Lorich was recorded at the 14th Annual Chicago Trauma Symposium, sponsored by Advocate Health Care, held August 2-5, 2012, in Chicago, IL. D To learn about the next Chicago Trauma Symposium, please go to chicagotraumasymposium.com.  The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR361301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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