Displaced Proximal Humeral Fractures - Sean Symons 26/10/2004

Displaced proximal humeral fractures

Part 1. Classification and Evaluation

Neer CS. J. Bone and Joint Surg., 52-A: 1077-1089

Retrospective study of 300 displaced proximal humeral fractures/fracture-dislocations 1953-1967 New York Hospital-Columbia-Presbyterian Medical Centre.

No useful classification system available

Four-segment classification developed;

Not based upon level of fracture (anatomical/surgical neck) or mechanism of injury.

Group 1, Minimum Displacement

No segment displaced more than 1cm or 45 °

85% of proximal humeral fractures

Early mobilisation

Group 2; Articular-segment Displacement

Anatomical neck separation only

Rare

May lead to malunion or AVN

Group 3; Shaft Displacement

Surgical neck; Angulated & impacted – closed reduction possible

                       Separation – pec major displaces shaft anteromedially

                       Comminution

Group 4; Greater Tuberosity Displacement

Involves tear of rotator cuff usually at rotator interval

3-part # - articular segment is internally rotated by subscapularis preventing closed reduction. Good blood supply.

4-part # articular segment loses blood supply via soft tissue attachments.

Group 5, Lesser Tuberosity Displacement

3-part # - articular segment is externally rotated & abducted by supraspinatus & infraspinatus preventing closed reduction. Good blood supply.

4-part # articular segment loses blood supply via soft tissue attachments.

Group6, Fracture-Dislocation

Antero-inferior or posterior

2 & 3 -part # humeral head maintains good blood supply

4-part # are associated with neurovascular injuries

Include displaced fractures of the articular surface (head splitting #)

When >20% of articular surface is involved redislocation occurs requiring transplantation of subscapularis tendon into defect

When >50% of articular surface is involved Hemiarthroplasty required to regain stability.

X-rays

2 views 90 ° to each other; AP 30 ° to saggital plane

                                                      Lateral in line of scapula

Displaced proximal humeral fractures

Part 2. Treatment of Three-part and Four-part Displacement

Neer CS. J. Bone and Joint Surg., 52-A: 1090-1103

117 patients with 3-part or 4-part # of proximal humerus

Average age = 55.3 years

Patients assessed by Scoring System out of 100 units (satisfactory=80)

Recommendations of treatment;

Closed reduction – only for 3-part # with low activity

Open-reduction – only for 3-part # with poor results due to poor surgical technique

Prosthesis – few complications  

only for 4-part #

Problems with treatment of Proximal Humeral Fractures in Adults:

1. When use conservative treatment?

2. What type of conservative treatment?

3. When to start rehabilitation after conservative treatment?

4. When to operate?

5. What type of surgery?

6. When to start rehabilitation after surgery?

Interventions for Treating Proximal Humeral Fractures in Adults

Cochrane Review, Handoll HHG August 2003

Proximal humeral fractures = 4-5% of all fractures

Incidence increases with age

2F:M

Osteoporosis