fractures of the proximal humerus are among the most common fractures of the upper limb and management options are wide according many variables mostly the age.

1. Fractures of the Proximal
Humerus

2. Epidemiology
Third most common upper extremity fracture
(distal radial & hand )
Most common mechanism:
simple low energy fall in an elderly patient
80 % of all humeral #above 60
7 % of all #..
• Young Pts – High energy trauma
• Severe soft tissue disruption
always require surgical
intervention

3. Common mechanism in
elderly patients

4. Anatomy
• Articular segment
almost spherical
diameter of curvature ranging
from 37-57 mm
• Head shaft angle averages 130
degrees
• Retroversion varies 18 - 40 degrees

5. Deforming forces of PHF

6. Vascular anatomy
• Ascending branch of anterior
humeral circumflex
( Arcuate artery of Liang)
• Recent studies
post humeral circumflex is the
main blood supply to HH

7. Study on Twenty-four fresh-frozen cadaver shoulders
with Gadolinium MRI
Posterior humeral
circumflex artery
64% of Blood
Supply to Humeral
Head

8. Risk of head ischemia
• Vascularity of articular
segment is more likely to
be preserved if ≥ 8mm of
calcar is attached to
articular segment

9. Hertel et al…2004
• Three most accurate predictors of
humeral head ischemia are:
< 8mm of calcar length attached to
articular segment
Disrupted medial hinge ≥ 2mm
Fracture through anatomical neck

10. Complex proximal humeral fractures: Hertel′s
criteria reliability to predict head necrosis
Conclusions:
Hertel’s criteria are important in the surgical
planning, but they are not sufficient.
An accurate evaluation of the calcar area
fracture in three planes is required.
All fractures involving calcar area should be
studied with CT

11. CLASSIFICATION
• KOCHERS: based on different anatomic
levels.
Anatomic neck
Epiphyseal region
Surgical neck.
Did not included #s at multiple
level, degree of displacement,
dislocations, mechanism.
Codmann”s based on physeal lines
Identifies four possible #s GT ,LT
,anatomic head, shaft

12. NEER’S CLASSIFICATION (5-types)
• The most commonly used classification was
developed in 1970 by Dr charles neer.
• The basis of the system according to
Displacement
Anatomical lines of epiphyseal union

13. Neer Classification
• Considered a separate part if
Displacement > 5mm
45 degee angulation

14. AO Classification

15. Imaging
• X-Rays
True AP (Grashey)
Scapular Y
Axillary/ Velpeau
• CT
 Articular surface
 Tuberosity displacement
 Occult medial calcar fracture
 3D reconstruction

16. Treatment
Non-operative
Most fractures of the proximal
humerus have a stable
configuration and heal
functionally with non-operative
treatment
Operative
CRPP
ORIF
Intra-medullary nailing
Arthroplasty
Hemiarthroplasty
RTSA

17. Non-Operative Treatment
• Sling immobilization followed by
progressive rehab
• Indications
Minimally displaced fractures
GT fractures displaced < 5mm
Patients who are not surgical
candidates
• Other variables to consider
Age
Hand dominance
Bone quality
General medical condition
The shoulder is very forgiving
when one doesn’t operate, but
can be very unforgiving when
one DOES operate

18. • 70 consecutive patients
• 60-85 years old
• Treated conservatively
• Conservative treatment > 75 yrs provides good pain relief with limited
functional outcome.
• Despite limited functional outcome, this appears to have no effect on
the quality-of-life perception in the population studied.

19. • 650 patients
• Mean age 65
• “High rates of radiographic healing, good functional outcomes, and a
modest complication rate”

20. Total 518 patients (average age 70.93) met inclusion
criteria. Patients were followed up for at least 1 year in all
the studies.
Conclusion
Operative treatments did not significantly improve the
functional outcome and healthy-related quality of life in
elderly patients. Instead, Operative treatment for CPHFs
led to higher incidence of postoperative complications.

21. Closed Reduction Percutaneous Pinning
• Indications
Good bone quality
Minimal metaphyseal
comminution
Intact medial calcar Outcomes
It has theoretical advantage of minimizing soft
tissue trauma, thereby promoting healing and
reducing the risk of AVN of the humeral head.

22. • To avoid injury to the axillary nerve,
• lateral pins should enter the humeral
cortex at a point at least twice the distance
from the upper aspect of the head to the
inferior head margin with the wire
angulated approximately 45 degrees to the
cortical surface.
• The end point for the greater tuberosity
pin should be >2 cm from the inferior most
margin of the humeral head.

23. Contraindications
Severe comminution and osteopenia
Inability to reduce Fracture Fragments
Fracture Dislocation
Non Compliant patients

24. ORIF
• Indications
Greater tuberosity displaced > 5mm
2-,3- and 4-part fractures in younger
patients
Head splitting fractures in younger
patients Medial support is necessary for fractures with
posteromedial comminution so Calcar screw
is the most important

25. ORIF
• Surgical pearls
Non-absorbable sutures to rotator cuff tendons
Avoid subchondral screws
Avoid varus reductions
Restore medial contact
Infero-medial screw!
Be prepared for ORIF and arthroplasty

26. Intramedullary Nailing
• Indications
Surgical neck or 3-part fractures in younger
patients
Combined proximal humerus and humeral
shaft fractures
• Outcomes compared to ORIF
Biomechanically inferior with torsional stress
Favorable rates of fracture healing and ROM

27. Shoulder Arthroplasty
• Older patients with
 4-part fracture dislocations
 Head splitting components
 Anatomical neck fractures

28. • Boyle et al, JSES 2013
Acute proximal humerus fractures
55 RSA, 313 shoulder hemi
Significantly better 5-year Oxford Shoulder Score in RSA group

29. Debate…..?
Leave it, fix it or replace it??

30. Decision Making
• Non-operative? Majority of fracture cases….
• ORIF? Viable head, good bone quality….
• Hemiarthroplasty? Nonviable head, good bone quality….
• Reverse arthroplasty? Nonviable head, poor bone
quality….
THERE IS NO SINGLE TREATMENT
OPTION THAT WILL WORK FOR
ALL PATIENTS!!

31. Decision Making
Patient Factors
• Age (operative treatment rarely indicated > 85)
• Nonfunctional limb
• Severe medical comorbidity
• Severe osteoporosis
• Smoking
• DM
• RA
Poor outcomes
Surgeon Factors
Choice of treatment
Technical expertise

32. Decision Making
Injury Factors
No entirely satisfactory classification to guide
modern treatment and predict outcome
Neer one-part fractures
Impacted two-part fractures of surgical neck
with minimal angulation
Non-operative

33. Complications of Proximal Humerus Fractures
• Posttraumatic shoulder stiffness
• AVN
• Malunion
• Nonunion
• Infection
• Complications unique to arthroplasty
Tuberosity redisplacement, nonunion or resorption
Instability/dislocation
Prosthetic loosening
Periprosthetic fracture