Majority of the proximal humeral fractures occur in older patients. This is so because older patients have osteopenic or osteoporotic bones which get damaged easily by trivial trauma. High energy trauma can produce these fractures in any person of any age.
Most of these fractures occur due to a simple fall on the arm. Strong muscular contraction might be responsible in the setting of electric shock or seizure.
Most fractures are believed to result from indirect violence.
Muscle forces contribute to their displacement. Pectoralis major draws the shaft anteriorly and medially. The greater tuberosity may be pulled posteriorly by the infraspinatus and superiorly by the supraspinatus. The subscapularis tends to rotates internally a head segment where lesser tuberosity remains attached.
Most patients with acute fractures of the proximal humerus present with a painful, swollen arm. There could be bruises over the injured area or they might develop over a period.
Apart from the injured area that patient has presented with, the patient should be assessed for neck and chest injury. It goes without saying that distal limb should be examined for any neurovascular involvement.
The most commonly injured nerve is the axillary.
If the patient has amnesia, bilateral injuries, or a posterior fracture-dislocation, a seizure disorder or electric shock must be ruled out.
The ordered radiographs for these fractures must include anteroposterior (AP) view of the scapula, a lateral “Y-view” of the scapula, and an axillary view.
If a good radiograph fails to detect anything CT scans are most helpful in checking for dislocations, in ruling out a glenoid fracture, and in assessing posterior retraction of the greater tuberosity.
Most commonly used classification method is that of Neer’s. Fractures are classified by evaluating displacement of any of the four principal fragments (head, shaft, greater tuberosity, and lesser tuberosity).
All fractures in which no segment is displaced more than 1 cm or is rotated more than 45 degrees are considered minimally displaced and are considered together as one-part fractures, regardless of the number or location of fracture lines.
A single segment is displaced in a two-part fracture. This occurs most commonly with surgical neck displacement, in which the shaft is separated from the head and both attached tuberosities. It is also seen seen with greater tuberosity displacement.
A fracture with three-part displacement has the shaft and either the greater (most often) or lesser (rarely) tuberosity separated from the head, to which one of the tuberosities remains attached.
A four-part fracture is present when the head is separated from all other segments, even if the tuberosities are together (thus, there can be three pieces, one of which comprises both tuberosities). The head is completely dislocated out of the glenoid and is devoid of any soft tissue attachment. In the “valgus-impacted” four-part fracture, the head is rotated to face upward Although the head is completely out of contact with the glenoid.
If the head is split or has suffered an impression fracture, it is considered to have articular loss.
Surgical Neck Fractures
Displaced fractures in an older patient with lower demands can be treated with conservative methods. In such cases the patient would even accept higher angulation and if the shoulder is well rehabilitated, the motion of shoulder joint would compensate most of the movements hampered by angulation.
However in young, active patients with higher demands, a surgical procedure would be necessary.
The arm is adducted and is flexed 90 degrees. This maneuver relaxes Pectoralis muscle.. A translation force (usually posteriorly and laterally) is applied to reduce the deformity while longitudinal traction is applied. After it is felt that reduction has been achieved a gentle reimpaction is tried.
After the fracture has been reduced immobilization is continued for 4 weeks.
If the fracture is reducible but unstable, percutaneous pins after closed reduction might be used. If a reduction cannot be achieved, open reduction and internal fixation are considered.
Rehabilitation After Surgery
If fixation is good and fracture is stable, early passive range of motion is instituted, including pulley elevation in the scapula plane, external rotation with a stick, pendulum, and hand and elbow range of motion. Progression to full stretches is rapid. Strengthening is added at 6 weeks.
Three Part Fractures
Three part fractures involves a fracture of surgical neck of humerus along with fracture of either greater tuberosity or lesser tuberosity. While surgical neck is quite displaced to miss out, small degree of tuberosity displacement may be easily missed and may require additional radiographic views.
Open reduction and internal fixation is the preferred treatment. Failure of the treatment may lead to hemiarthroplasy i.e. replacement of head component with prosthesis.
In this injury, there is fracture of the head which results in its separation from rest of the structures and there are fractures of lesser and greater tuberosities. Very often, the head is dislocated anteriorly, laterally, or posteriorly. The greater and lesser tuberosities are not always separated, and they may be held together by muscle attachments.
This injury is best shown by anteroposterior views. A computed tomogram clearly delineates the fracture.
Four-part fractures have not done well with nonoperative treatment and repaired fractures do better than nonoperative cases.
Historically, results of surgery of four part fractures have not been found good but improved techniques of fixation and better patient selection have brought better results.
Avascular necrosisof the head is a significant problem in these fractures. A subtype of the fracture, namely the valgus-impacted fracture is less likely to develop avascular necrosis. Recent works of various surgeons have concluded that
Hemiarthroplasty should not be avoided at all costs in young patients.
However hemiarthroplasty has a role to play in classic four-part fracture with an enucleated head.
In active, young patients with a valgus-impacted fracture, internal fixation with minimal soft tissue dissection should be done. This should be followed byonly pendulum and hand and elbow exercises dependong on the quality of the fixation followed by gradual strengthening exercises.
Displaced Fractures of Tuberosity
‘Greater and lesser tuberosity fractures are well known fractures of upper end of humerus. Out of these two greater tuberosity is commoner than lesser one.
These fractures are quite often missed in the emergency. This may occur due to following reasons
- Small piece of fractured bone may be overlooked. But it is important to understand that fractured bone may be attached to rotator cuff.
- Small fragments may be missed to be calcific deposits.
- Pieces may be superimposed on the humeral head and may be difficult to appreciate.
- When an anterior glenohumeral dislocation is present in association with a greater tuberosity fracture, attention may be focused on the dislocation, and the tuberosity fracture may be missed.
The greater tuberosity is displaced superiorly by the supraspinatus or posteromedially by the infraspinatus and teres minor. In lesser tuberosity fractures on the other hand, displacement tends to be medial because of the pull of the subscapularis.
7% to 15% of glenohumeral dislocations have an associated greater tuberosity fracture. A gentle attempt to reduce the dislocation might be given but much force should not be applied so as not to cause further fracture in the humerus. Rarely surgery for open reduction of the dislocation may be required. Once the glenohumeral dislocation has been reduced, the greater tuberosity usually reduces into its bed
If it remains displaced after reduction of dislocation, open reduction and internal fixation be considered.
Lesser tuberosity fractures tend to occur in conjunction with posterior glenohumeral dislocations but are less common. The line of treatment is similar as discussed previously. The dislocation is addressed first and further evaluation is done to assess the fracture for suitable treatment.
Nonoperative treatment is rarely used for displaced greater tuberosity fractures, unless age or infirmity argues against surgical management.The treatment protocol ids similar to that of undisplaced fractures
Traditionally displaced fractures of the lesser tuberosity were treated non-operatively but now there is data to suggest that patients are benefited by internal fixation of the fragment.
When to operate?
- More than 10 mm of posterior retraction
- 5 mm of superior displacement
In both these cases the patient might be considered for surgical repair. However he treatment should be individualized depending on patient’s activity level and demands.
Patients with greater tuberosity fractures
- Passive elevation, external rotation with help of a stick, and pendulum exercises are immediately begun.
- Active motion is not allowed until radiographs show early bone healing.
- Stretches and light active to resistive exercises are begun at 6 weeks.
- Strengthening and stretching are begun at 3 months.
Patients with lesser tuberosity fractures
- Forward flexion to about 90 degrees in full internal rotation is immediately begun .
- Gentle passive external rotation is also performed but the limb should not go beyond neutral position.
- External rotation to 45 degrees and full elevation are allowed depending upon the bone healing as demonstrated on radiographs after 6 weeks
- Full stretching and strengthening exercises are initiated after 3 months or as guided by fracture healing.
Fractures of Proximal Humerus – When To Treat Non operatively?
A large number of patients with fractures of proximal humerus can be managed with non operative methods. The principle of treatment by conservative methods is early protection combined with gradual mobilization.
Elderly people accept non operative treatment quite well. Even deformities like displacement and angulation are taken very well by these patients. Angulation is well compensated for by shoulder motion.
Method of Treatment
Most patients are placed in a sling for the first week to 10 days. Hand, wrist, and elbow motion begins immediately. After this, the patient is examined by holding the elbow and flexed forearm in one hand and moved while palpating the the tuberosities and biceps groove with the other hand. If the entire limb moves as one unit it means fracture is becoming glued nad the patient is started on gentle pendulum range of motion.
If crepitus is felt or there is a slip or giveaway sensation, the patient is left immobilized for another week and then is reassessed.
Radiographs are done after 3 or 4 weeks. If the fracture configuration has not worsened and the feel is solid, gentle assistive exercises like pulley elevation, external rotation with a stick, extension with a stick are begun along with formal physical therapy.
Gradula stretching exercises are also begunn and continued till maximum range of motion is achieved.
When to put patient on non operative treatment*
- <5mm of superior or 10 mm of posterior greater tuberosity displacement in active people
- <10 mm of superior displacement in non dominant arm of sedentary paients
Surgical neck fractures
- Any kind of bony contact in elderly patients
- Young patients : Less than half shaft diameter displacements and less than 45 degree angulation in dominant arm
- If the patient is willing to accept stiff shoulder
- If the patient is unable to tolerate surgery and anesthesia
Poor rehabilitation candidate
- The patient is too weak to pursue rehabilitation
- Patient is unable to understand or remember postoperative instructions.
Complications of Fractures of Proximal Humerus
Complications in fractures of proximal humerus are more likely after surgical than after nonoperative fracture care. Therefore a careful postoperative follow-up is necessary to note the complication at the earliest and intervene at the right time
Most common complications associated with fractures of proximal humerus are-
True glenohumeral instability is unusual after fractures. This usually results from muscle atony, blood in the joint, capsular tears, or any combination of these conditions. Treatment consists of sling support, deltoid isometrics, and observation. Instability should not be ignored.
Incorrect diagnosis, poor reduction, inadequate fixation are frequent causes of malunion. Treatment depends on severity of the malunion. For less severity, the malunion can be left as such. Sevre malunions can be treated by release of adhesions with or without osteotomy. Trimming of prominences can also be considered.
Non union is rare in proximal humeral fractures. Early motion and poor bone stockare the fequent causes. It should be treated by surgical methods including humeral head replacement when necessary.
it is more common in three part and four part fractures. Most patients are followed and watched. Gentle stretching exercises and mild analgesics are the usual tratment inmost patients. If collapse occurs or pain becomes unbearable, humeral head replacement is considered. In case of development of glenoid arthritis, a total shoulder replacement considered.
Due to large envelope of soft issues infection in shoulder has a low rate. ANtibiotics, debridement and regular wound care are the basic management techniques.
As many as 45% of patients with surgical neck fractures or glenohumeral dislocations have been found to have some degree of nerve injury. The risk is more in elderly patients or when a hematoma develops.
When associated with closed fracture, the prognosis for recovery is good, and observation is indicated. Splints may be used to support weak joints, and therapy is used to maintain passive motion.
In case of injury occurs after a surgical procedure or after a manipulation, exploration may have to be considered.
Arterial injury from displaced fractures is common especially in four-part fractures with the head in the axilla and medially displaced shaft fractures Doppler studies or arteriography should be considered if there is
- Extreme displacement of the shaft
- Axillary position of the dislocated head
- Large hematoma
- Brachial plexus injury that could indicate trauma to the medial structures.
Opinion of the vascular surgeon should be taught and if required vascular team should be present in operation theater
Could occur following avascular necrosis or hardware penetrating joint. Humeral head or total shoulder replacement may be considered
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