Proximal Humerus Fractures ORIF &

ArthroplastyReza Omid, M.D.

Assistant ProfessorDepartment of Orthopaedic

SurgeryKeck School of Medicine of USC

Introduction• 5-7% of all fractures

• 80% treated nonoperatively (Neer)

•Bimodal incidence

•Bone quality- important factor in obtaining secure fixation

Proximal Humeral Anatomy

Understanding Fracture PatternsUnderstanding Fracture Patterns–4 bony fragments4 bony fragments»Lesser TubLesser Tub»Greater TubGreater Tub»HeadHead»ShaftShaft

Neer, JBJS ‘70

Proximal Humerus FracturesFracture PatternsFracture Patterns

–StableStable»Fx not controlled by muscleFx not controlled by muscle

–UnstableUnstable»Fx controlled by attached muscleFx controlled by attached muscle

Proximal Humerus FractureFracture AnatomyFracture Anatomy

–Greater Tub – posterior, proximalGreater Tub – posterior, proximal–Lesser Tub – medial, inferiorLesser Tub – medial, inferior–Head – remaining tub or Head – remaining tub or fx energyfx energy

–Shaft – medial, superiorShaft – medial, superior

Proximal Humerus FractureFracture AnatomyFracture Anatomy

Consideration for Surgery

Bone QualityComorbidities

Functional demandVascularity???

Gerber JBJSAm 1990: 1486-94

Vascularity– anterior humeral circumflex

» Anterolateral branchOf AHC (arcuate artery)Along lateral aspect of groove

Brooks JBJSBr 1993: 132-136

•Vascularized through interosseous anastomoses

•Between metaphyseal vessels (via posterior humeral circumflex) and the arcuate artery after ligation of the anterior circumflex humeral.

Coudane JSES 2000: 548

•Arteriography done on 20 patients after proximal humerus fractures.

•80% had disruption of AHC artery•15% had disruption of PHC artery•Since AVN is rare (bw 1-34%)

after fx it suggests the PHC artery may be dominant supply

Hettrich JBJSAm 2010: 943-8

–MRI cadavers–posterior humeral circumflex

–supplied 64% of head (superior, lateral and inferior).

Hertel Criteria

Hertel et al JSES 2004:13:427

–Medial calcar segment <8mm–Medial hinge is disrupted (>2mm displacement of the diaphysis)

–Comminution of the medial metaphysis

–Anatomic neck fracture

Bastian JSES 2008: 2-8• Follow-up study by Hertel showed

that initial predictors of humeral head ischemia doesn’t predict development of AVN.

•80% of patients with “ischemic heads” did NOT collapse

• Fixation is worth considering even if signs of ischemia are present

Nonoperative Treatment

Immobilize initiallyPassive ROM 2-3 weeks

– supine FE– supine ER– pendulums

AROM at 6 weeks or when consolidated

77% good to excellent results-Zuckerman 1995

Optimal Treatment•UNKOWN????•JSES 2011: 1118-1124 (RCT ORIF vs Non-op)

•JSES 2011: 747-55 (RCT ORIF vs Non-op

•JSES 2011: 1025-1033 (RCT Hemi vs Non-op)

•JOT 2011 (RCT ORIF vs Non-op)

Three-Part FracturesFixation Options

– Percutaneous Pins– Interfragmentary Suture/Wire

–Plate/Screws– IM Nail– Blade Plate

–Hemiarthroplasty

ORIF Technique

Reduction & Grafting

•Impaction grafting of head

•Iliac crest cube•Fibular strut

Tag Tuberosities

Reduction & Grafting

Close Book

Plate

• Four precise holes for medial calcar support that provide a stable fixation in the calcar neck while preventing varus tilt and settling of the humeral head

• Proximal Screws angle towards posterior portion of humeral head to take advantage of the good

bone quality of the posterior portion • 3.5mm locking screw holes establish a

stable bone and plate construct • 3.5mm partially threaded screw options

allow for compression of fragments and ability to pull the head fragments into reduction• Polished suture holes allow for soft

tissue and tuberosity fixation23

Humeral Fracture Plates

Restore the calcar! • “Medial comminution significantly decreased

the stability of proximal humeral fracture fixation constructs. Calcar restoration with screw fixation significantly improved the stability of repaired fractures in cadaveric

specimens.”

Ponce BR. The Role of Medial Comminution and Calcar Restoration in Varus Collapse of Proximal Humerus Fractures Treated with Locking PlatesJ Bone Joint Surg Am, 2013 Aug 21;95(16):e113 1-7. doi: 10.2106/JBJS.K.00202

Fig. 1Figs. 1-A through 1-E Radiographs and diagram illustrating the fracture models and fixation constructs used. Fig. 1-A Medial comminution without calcar fixation. Fig. 1-B Noncomminuted fracture without calcar fixation. Fig. 1-C Medial comminution with calcar fixation. Fig. 1-D Noncomminuted fracture with calcar fixation. Fig. 1-E Diagrammatic illustration of the PHILOS plate.

DePuy/Synthes Philos Plate – only 2 calcar screw holes

Proximal humeral fractures: Regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws

• Implant loosening as a result of poor bone quality is a serious complication after internal fixation of displaced fractures of the proximal humerus.

• investigated the relationship between trabecular BMD and the pullout strength of cancellous screws to determine regions in the humeral head that provide stronger fixation

for cancellous screws.– trabecular BMD of the humeral head has a significant effect on the pullout strength of

cancellous screws. – Central and posterior regions are best. Avoid superior-anterior region.

Tingart Tingart et al, et al, JSES 2006JSES 2006

Designed to sit lower on the greater tuberosity Removed the 2.7mm screw holes Minimizing subacromial impingement

Thinner design to reduce soft tissue irritation 4-point bending was completed Results show LP Plate is stronger than the predicate plate

(Synthes) 4 Medial Calcar “kick stand” screws to prevent varus

tilt/settling of humeral head Anatomic fit with right and left plates and different

length plates 3-hole (89mm) 6-hole (112mm) 9-hole (135mm)

Made from 316L Stainless SteelNovember 20, 2011 26

Low Profile Plate Design

6 proximal suture holes for soft tissue/tuberosity fixation Easy in-situ needle passing through angled and

scalloped holes Also used as wire holes for initial plate fixation

4 Proximal 3.5mm screw holes Utilizing locking or compression screws

5 Calcar 3.5mm screw holes Utilizing locking or compression screws Parallel in AP view 3o divergence in S/I view and Lateral view

Distal 3.5mm screw holes Utilizing locking or compression screws Compression slot utilizing compression screws

November 20, 2011 27

Low Profile Plate Specifications

Conclusions•Best to perform repair for acute fracture•Anatomic restoration of humeral height

and version•Secure tuberosity fixation•Repair the cuff•Tenodesis of the LHB•Early protected PROM, close supervision

of the rehabilitation program