Issues in the

Treatment of
Proximal Humerus
Fractures
Robert P Dunbar, MD
Associate Professor
Harborview Medical Center
University of Washington
Seattle, WA, USA

Greetings from Seattle

Proximal Humerus Issues

Stability
Head Viability
Treatment Choices
Avoiding Problems

Goals
Locate joint
Relieve pain
Protect soft
tissues
Restore
function
Motion

Proximal Humerus
Fractures
Extremely common
Low energy Osteoporotic
fracture
High energy

Complicating factors
Poor bone quality
Require early motion

Difficult to:
Obtain & maintain a good
reduction
Get a good functional outcome

The Good News

Majority of
fractures are
stable
Can be
successfully
treated
nonoperatively

Stability
Understand
fragments &
their
displacement
Greater tuberosity
Lesser tuberosity
Epi/metaphysis
Anatomic vs surgical
neck

Humeral Head Blood

Supply

Predictors of AVN
Metaphyseal extension (calcar) < 8 mm.
Loss of integrity of medial hinge
97%
Fracture Pattern (anatomic neck)

PPV

Hertel et al, J Shoulder Elbow Surg 2004;13:427

BEWARE of lateral
displacement of
head

Metaphyseal
head extension < 8mm
Blood Supply
Potentially Torn
if medial hinged
displaced

This head is likely NOT

This head is
likely viable

Medial Hinge no
displaced

Metaphyseal head
Extension > 8mm

Options for Treatment

Non-Operative
Percutaneous
Fixation
ORIF
IMN
Replacement

Considerations
Age
Bone Quality
Fracture Characteristics
Head Viability
Level of Activity
Hand Dominance
Occupations/Hobbies
Surgeon/Hospital Factors

Percutaneous Pinning

Technical
Pin number
Types of pins

2.5 mm Terminally threaded Shanz pins

 Complications?
Pin removal?
Benefits?

ORIF

Positioning
Beach Chair

Supine

Surgical Approach
Deltopectoral

Deltopectoral
Disadvantages
Difficult getting
to greater
tuberosity
Commonly
displaces
proximally &
posteriorly due
to cuff
attachments

Anterolateral Acromial
Approach

Supine or beach chair

Ensure adequate fluoro prior to prep and
drape

APProximal
Humerus

Transcapular
Lateral

Anterolateral Acromial
Approach

Incision from
anterolateral corner
of acromion distally

Anterolateral Acromial
Approach

Identify avascular raphe

between anterior and
middle heads of deltoid.

Anterolateral Acromial
Approach

Identify and incise

bursa in proximal

Anterolateral Acromial
Approach

Identify axillary nerve (~65 mm from

acromion) and humeral shaft distally

Anterolateral Acromial
Approach

Incise bursa to
expose fracture and

Reduction - tuberosities

Reduction - tuberosities

Hertel 2005

Anterolateral Acromial
Approach
After fracture
reduction, insert
plate deep to
axillary nerve
along shaft

Reduction head/neck
Anatomic/surgical neck component
Rule #1: Do not leave head/neck in
varus

Reduction

head/neck
Restore medial contour!

THIS WILL NOT DO

WELL

BETTER!

Reduction

Restore proper retroversi

Reduction - varus
Get Head out of
Varus

1. K-wire
joysticks
2. Cuff
sutures
3. Elevator
3. Arm
abduction

Technique

Plate applied to the

reduced fracture (typical)

K-wire provisional fixation

Plate Fixed to Head then Reduced

to Shaft

Technique
What the plate does NOT neutralize

Smaller/comminuted
greater tuberosity
The lesser tuberosity
Consider:
Independent screw
fixation
Suture repair to plate

Technical Aspects
8 mm distal to rotator
cuff attachment
If too proximal
impingement
If too distal difficulty
with screw placement
in head

ORIF
Stable fixation
can be difficult
to achieve
Systematic review:
Screw cut-out 11.6%
Reoperation 13.7%
AVN 7.9%
Thanasas et al., JSES

mplant Limitations
Recognizing what implants are appropriate for
certain fracture types is KEY!

Conventional
implants
Poorly control varus
collapse, screw
loosening
and screw back out.

Locking plates are less prone

to failure due to the fixedangled screws.

Locked Plating Results:

Sudkamp et al, JBJS, 2009
Multicenter 155 patients: ORIF
locked plates (2 part fxs)
34% complications!
Many preventable (1/2 related to
the surgical technique)
21 intraoperative screw penetration
4 patients with cranial plate
position (impingement)

ORIF Whats the Problem?

Strong muscle deforming forces
Short segments

ORIF Whats the

Problem?
Osteopenic bone

Implant (screw)
purchase
compromised
Meyer DC, et al., JSES
2004

What Can We Do?

Osteobiologic Augmentation

Osteobiologic
Augmentation

Fibular Strut Allograft

Lorich et al. CORR 2011

Rotator Cuff Sutures

Intramedullary Fixation

76yo

Hemiarthroplasty

Indications (relative) for Hemiarthroplasty

Elderly patients

Severe osteopenia

Some 4-part fractures

Fractures with predictable lack of viability

Loss of medial hinge

Lack of distal extension medially

Head displacement laterally

Head-splitting fractures

PROSTHESIS
The key is the position & healing of the tuberosities

Keys to success:
Summary
1.Accurate imaging & diagnosis
Assess displacement, stability &
viability

2.Careful patient & treatment selection

3.Biologically friendly dissection
4.Reduction, reduction, reduction

Tuberosities; no neck varus; restore medial

support

5.Consider augmentation in complex

cases

Terima kasih banyak!

Puget Sound & Olympic Mountains

as seen from Seattle