proximal humerus fractures/dislocations · – arm dominance – ability to salvage with an ......
TRANSCRIPT
Proximal HumerusFractures/Dislocations
www.fisiokinesiterapia.biz
History/Demographics
• Bimodal: young-high energy, elderly-low energy(osteoporosis)
• 45% of all humerus fx.• elderly females 4:1
over males• 77% of all prox. hum.
fractures female
Consequences/Associated Injuries
• Disabilities often underestimated– Loss of motion– Loss of reduction– AVN– heterotopic bone– Associated Injuries
• rotator cuff• nerve(axillary, brachial plexus)• vascular• scapula, clavicle
Anatomy
• Appearance of Ossification Centers– epiphysis 4mo– Gr. Tub. 3yr– L. Tub. 5yr
• Physeal scar closure– 20-22 yrs.
Proximal Humeral Retroversion
• 35-40 degrees relative to epicondylar axis
Blood Supply
• Axillary artery– ant. humeral circumflex
• *ascending branch (arcuate artery) is the major blood supply to the articular surface
– post. humeral circumflex
ArcuaArcuateafeeffe
Nerves
• Brachial Plexus– axillary– suprascapular– musculocutaneous
Rotator Cuff Muscles
• Supraspinatous• Infraspinatous• Subscapularis• Teres Minor
• Deltoid• Pectoralis• Long head biceps
Classification
• Neer (4 part)– 2 part
• AN (anatomic neck)• SN (surgical neck)
– 3 part• SN+GT, LT
– 4 part• SN+GT+LT
– *head splits– *articular impressions– fx. dislocations
• AO– type A
• 2 part extracapsular
– type B• 3 part partially
intracapsular
– type C• vascular isolation of
head• 4 part intracapsular
Classification• Neer
– 2 part• SN,AN,GT,LT
– 3 part• SN+GT or LT• AN+GT or LT
– 4 part• neck+both
tuberosities• +/- dislocation
– Neer’s definition of displacement: >1cm or >45 degrees
Radiographic Work Up
• Trauma Series– true scapular AP– axillary (head defects,
displacement of tuberosities
– Y or transscapular
• Other– modified axillary– AP in int. and ext.
rotation
• CT Scan– articular fractures
• impression• head split
– glenoid fractures– assess tuberosity
displacement for operative decision making
Radiographic Work UpScapular AP, Axillary, Y view, CT Scan
Treatment
• Considerations for closed treatment– patient age– displacement
• surgical neck• tuberosities• articular surface
– functional demand– arm dominance– ability to salvage with an
arthroplasty later if needed
• Methods of closed treatment– sling– sling and swath– hanging cast– abduction pillow
Fractures to Consider for Closed Treatment
• Minimally displaced 2 part fx’s (or positional reduction of significant displacement)
• GT fractures should be <5mm).
• Minimally displaced 3-and 4-part fractures
Fractures to Consider for ORIF
• Displaced GT fx (> 5 mm)
• LT fx with involvement of articular surface
• Displaced or unstable surgical neck fx
• Displaced anatomic neck fx in young pt.
• Displaced, reconstructible3- and 4-part fractures
Fractures to Consider Hemiarthroplasty
• Young/Middle age– nonreconstructable articular
surface (severe head split) or extruded anatomic neck
• Elderly– many 4 parts– some severe 3 parts– most 3,4 part fracture
dislocations– most head splits
Current Techniques of ORIF• Percutaneous Pins (Jaberg, H. 1992)• Suture, K-wire, tension band technique (Cornell,C. H.
1994, Darder, A. 1993, Hawkins, J.R. 1987, Neer, C.S. 1970)
• Flexible IM nails (Lee, C. K. 1981, Robinson, C. M. 1993, Wesley, M. S. 1977)
• Buttress Plates (Esser, R. D. 1994, Kristiansen, B. 1986, Paavolainen, P. 1983, Savoie, F.H. 1989)
• Selected Locked Rigid IM nails• Blade Plate Fixation (Weber 1984, Sehr, Szabo 1988,
Jupiter, Scheid 1999)• Proximal Humeral Locking Plates
• Surgical Approaches
– Deltopectoral
– Deltoid Splitting
– Posterior
– Percutaneous
• Fracture / Fixation
– SN, LT,3 part, 4 part /• surgeon choice
– GT, Some SN if using IM fixation
– scapula, glenoid, occasional posterior articular fracture
– Fx’s amenable to pinning or nailing
Percutaneous Pinning
• Technique: beach chair position, closed manipulation, oscillating drill, terminal thread pins, at least bidirectional pins (see JabergH. 1992), cut pins beneath skin, sling and swath, follow closely
• Associated Problems: nerve injury (axillary), pin loosening, migration, no early motion
• Best Use: limited 2 or 3 part when other techniques not favorable
Migration----
Suture or K-wire/Tension Band
• Technique: beach chair position, deltoid splitting or deltopectoral approach, k wire and suture repair of tuberosities with tension band (suture or wire) to metaphysis
• Associated Problems: cuff constriction, limited head fixation to shaft, wire migration
• Best Use: GT, LT, GT+LT, tuberosities with undispl. SN
Flexible Nails• Technique: beach chair
position, deltoid splitting approach, lateral tuberosity or cuff splitting insertion, may combine with tension band suture
• Associated Problems: limited head fixation, migration into subachromial space, cuff violation
• Best use: 2 part SN• Newer plates and nails
more favorable
Locked Rigid Nails for Proximal Humerus
• enhanced proximal fixation with twisted blades or multiple screws
Buttress Plating
• Technique: sitting or supine, deltopectoral approach, lateral to bicepts groove to minimize vascular damage
• Associated problems: poor head fixation, large dissection, iatrogenic vascular damage, impingement
• Best use: low 2 part SN +/-large GT
• * rarely used technique due to impingement and poor head fixation
• Newer locking plates now favorable
Blade Plate Technique
• Technique: beach chair positon, deltopectoral approach, metaphyseal slot lateral to bic. groove, minimal soft tissue stripping
• Associated Problems: learning curve, penetration of humeral head in osteoporotic bone
• Advantages: no impingement in high angle blade, superior head fixation to other techniques, easily combined with suture fixation of tuberosities
PROXIMAL HUMERAL LOCKING PLATE
PROXIMAL HUMERAL PLATE
PROXIMALHUMERAL
Hemiarthroplasty
• Technique: beach chair position, deltopectoralapproach, retain tuberosityfragments with cuff attachments, combine suture repair of tuberosities, bone graft from head if needed
• Associated Problems: unpredictable results from function standpoint, still requires bony healing (of tuberosities)
• Best use: elderly 3,4 part, head splits, disvascular AN
Results• SN: closed treatment has
yielded 60-90% satisfactory results
• GT: 50-100% poor results with displaced (>.5-1cm) fractures treated closed. Good results with ORIF.
• 3 Part: closed treatment (min. displacement or nonoperativeelderly pt.) yields unpredictable results (15-70% satisfactory) ORIF with good reduction: 60-80% good to excellent results
• 4 Part: poor results with closed treatment. Hemiarthroplasty gives satisfactory pain results with somewhat unpredictable functional results. ORIF in younger patient have yielded <=50% satisfactory results. Higher AVN in ORIF
• Head Split: If CTS shows segment attached to LT then ORIF. If severe fragmentation of articular surface then Hemi.
Complications
• Misdiagnosis– degree of GT displacement– missed post. Dislocation– massive rot. cuff avulsion
with high energy dislocation. Suspect when severe swelling
– head split (double shadow)best seen on axillary v. or CTS
Complications
• Nonunion– In young, treat like an
acute fracture if head viable.
– Consider hemiarthroplasty in elderly or osteoporotic.
Complications
• AVN– Significant incidence in 3
and 4 part fractures. Higher when treated with ORIF.
– Unlike hip, incidence does not correlate directly with symptoms.
– Can be minimized with decreased soft tissue stripping and no encroachment of circumflex/arcuate art.
• Adhesive Capsulitis– almost universal but
minimized with early motion
– controlled P.T. – manipulation under
anesthesia– occasional arthroscopic
release
Shoulder Dislocations
• Classified by:– Direction– Etiology– Involuntary vs
voluntary
Anterior Shoulder Dislocation• Most common• Up to 20-40%
neurologic injury (axillary, brachial plexus)
• Axillary x-ray or CT to assess for head impaction or Hill Sachs lesion
• May be associated with greater tuberosityfracture
Posterior Shoulder Dislocation• Associated with
seizures or electrical shock
• Commonly missed on X-ray
• High incidence of associated lesser tuberosity fracture Example of a posterior
dislocation
Shoulder Dislocations - Etiology
• Traumatic– Usually unidirectional
• Atraumatic– Often associated with
multidirectional instability, psychiatric problems if voluntary
Shoulder Dislocations -Pathoanatomy
• Stretching / Tearing of capsule– Usually off glenoid– Occasionally off humerus
(HAGL lesion)
• Labral damage– “Bankart” lesion refers to
avulsion of anterior-inferior labrum off glenoid rim. May be associated with glenoid rim fracture (“bony bankart”
• Humeral Head impression fracture (Hill-Sachs Lesion)
Shoulder Dislocations -Rotator Cuff Tear
• The “posterior mechanism” of shoulder instability - coined by Dr. Ed Craig (ClinOrthop 190, 1984)
• Common in older patients• Beware of inability to lift the arm in an older
patient following a dislocation
Shoulder Dislocations -Evaluation
• Inspection - note fullness of anterior chest, prominence of acromion
• Note position of arm and restricted motion
• Document detailed neurovascular exam Deltoid atrophy 6
months after shoulder dislocation
Shoulder Dislocations - Imaging
• X-rays - shoulder trauma series (CT if uncertain)
• Special views:– Stryker notch view images
Hill-Sachs lesion– West Point view images
anterior-inferior glenoid– CT scan - best if
concerned about associated fracture
– MRI - best for evaluating associated soft-tissue pathology
Torn anterior labrum
Shoulder Dislocations -Treatment
• Immediate reduction– Many techniques– Adequate sedation– Control scapula
• Immobilization– Controversial re:
position and duration
• 19 patients studies with MRI• Effect of arm position on degree of coaptation of
Bankart lesion documented for multiple positions
• Conclusion: Immobilization in external rotation provided the best reduction of the anterior labrum
Position of immobilization after dislocation of the glenohumeral joint. A study with use of
magnetic resonance imaging.
Itoi E, et al, J Bone Joint Surg Am 2001, 83-A: 661-7
Shoulder Dislocations - Outcome
• Related to Age, Direction Etiology
• Age < 30– Recurrence high after traumatic
anterior dislocation• Age > 45
– Recurrence less common
Surgical Treatment of Shoulder Dislocations
• Usually reserved for patients with recurrent instability
• Occasionally done after first time dislocation in high-demand patient
Surgical Treatment of Shoulder Dislocations
• Arthroscopic Lavage– Removal of hematoma
leads to less recurrence?
• Bankart repair• Capsulorraphy
{Either approach allows repair of labrum and tightening of capsule. Open repair remains the “gold standard”
Shoulder Dislocations -Complication
• Brachial Plexus Injury– Carefully document pre-
and post-reduction neuroexam in all!
• Recurrent dislocation– Common in more active
patients– Treated with anterior
shoulder reconstruction