Hindawi Publishing Corporation
Advances in Orthopedics
太平轮彼岸Volume2012,Article ID861598,10pages
doi:10.1155/2012/861598
Review Article
Evaluation and Management of Proximal Humerus Fractures Ekaterina Khmelnitskaya,Lauren E.Lamont,Samuel A.Taylor,Dean G.Lorich,
David M.Dines,and Joshua S.Dines
Sports Medicine and Shoulder Service,Orthopaedic Trauma Service,Hospital for Special Surgery,535East70th Street,New York, NY10021,USA
Correspondence should be addresd to Ekaterina Khmelnitskaya,khmelnitskayae@hss.edu
Received28August2012;Revid12November2012;Accepted12November2012
Academic Editor:Robert Gillespie
Copyright©2012Ekaterina Khmelnitskaya et al.This is an open access article distributed under the Creative Commons Attribution Licen,which permits unrestricted u,distribution,and reproduction in any medium,provided the original work is properly cited.
Proximal humerus fractures are common injuries,especially among older osteoporotic women.Restoration of function requires a thorough understanding of the neurovascular,musculotendinous,and bony anatomy.This paper address the relevant anatomy and highlights various management options,including indication for arthroplasty.In the vast majority of cas,proximal humerus fractures may be treated nonoperatively.In the ca of displaced fractures,when surgical intervention may be pursued,numerous constructs have been investigated.Of the,the proximal humerus locking plate is the most widely ud.Arthroplasty is generally rerved for comminuted4-part fractures,head-split fractures,or fractures with significant underlying arthritic changes.Rever total shoulder arthroplasty is rerved for patients with a deficient rotator cuff,or highly comminuted tuberosities.
1.Introduction
Proximal humerus fractures are commonly encountered fractures in general orthopaedic practices.Treatment should focus on maximizing a patient’s functional outcome and minimizing pain.Understanding the functional anatomy of the proximal humerus as it relates to fracture is paramount to achieving the goals.Intervention options range from nonoperative modalities to osteosynthesis,and in lect cas arthroplasty.This paper will review relevant anatomy, commonfixation constructs,appropriate indications for prosthetic replacement,and the authors’preferred treatment algorithm.
2.Anatomy
The glenohumeral joint is the most mobile joint in the body,resulting from a ries of complex interactions among bone,muscle,and soft tissue forces.An appreciation for this anatomy enables the surgeon to effectively restore function in the tting of fracture.八年级上册物理笔记
The proximal humerus includes the humeral head, greater tuberosity,lesr tuberosity,and the humeral shaft.In the sagittal plane,the humeral head is retroverted an average of30degrees relative to the humeral shaft[1].In the coronal plane,it is angled130to150degrees cephalad relative to the diaphysis.Fractures through the anatomic neck can result in significant vascular compromi to humeral head leading to avascular necrosis[2].
In neutral rotation,the greater tuberosity forms the lateral border of the proximal humerus.The lesr tuberosity, which sits directly anterior in this position,becomes profiled medially when the humerus is internally rotated—this creates a rounded silhouette“lightbulb sign”on radiograph. The long head of the biceps pass between the two tuberosi-ties in the intertubercular groove,approximately1cm lateral to the midline of the humerus,and its relationship is an important landmark during fracture reduction[2].
When fractured,the greater and lesr tuberosities are deformed by their musculotendinous rotator cuffattach-ments(Figure1)[2,3].
The supraspinatus muscle,innervated by the supras-capular nerve,attaches to the superior facet of the greater tuberosity with a force vector that pulls predominantly in a medial direction.The infraspinatus muscle,also innervated by the suprascapular nerve,inrts on the middle facet of
A
地奥司明片B
C
D
E
Figure1:This drawing demonstrates the deforming forces on the proximal humerus in the tting of fracture.The supraspinatus(A) exerts a force posteromedially.The infraspinatus and teres minor
(B)pull posteromedially and externally rotate.The subscapularis
(C)exerts an anteromedially directed force on the lesr tuberosity. The pectoralis major(D)internally rotates and adducts,while the deltoid(E)pulls superiorly on the metadiaphysis of the humerus. (Reprinted with permission from Gruson et al.[4]).
紫禁城是谁建的the greater tuberosity.The teres minor muscle,innervated by the axillary nerve,attaches to the inferior facet.Together, the three externally rotate and yield a posteromedially directed deforming force.Therefore,if the greater tuberosity is fractured,it is displaced posteromedially.If it remains intact,and there is a surgical neck fracture,the resulting deformity is typically varus and external rotation.Anteriorly, the subscapularis,innervated by the upper and lower sub-scapular nerves,attaches to the lesr tuberosity,resulting in anteromedial displacement of this osous fragm
ent if fractured[2,3].The pectoralis major tendon inrtion is an important landmark,especially during hemiarthroplasty. Murachovsky et al.showed that the average distance from the pectoralis major tendon inrtion to the tangent to the humeral head was5.6cm(Figure2)[5].
Torrens and colleagues confirmed this relationship and added that hemiarthroplasty rotation could also be estimated bad on the inrtion of this tendon[6].Specifically,the authors found that the anatomy of the proximal humerus can be restored by placing the prosthesis5.6cm above the upper inrtion of the pectoralis major[6].Additionally, the authors found the distance from the upper margin
of Figure2:The average distance from the pectoralis major tendon (PMT)inrtion to the tangent to th
e humeral head is5.6cm. (Reprinted with permission from Murachovsky et al.[5]).
the pectoralis major inrtion to be17.55%of the total humeral length.Thus,for a more anatomic reconstruction, the authors suggest acquiring a preoperative radiograph of the contralateral humerus and calculating the patient-specific length bad on measurements made offof the unaffected side[6].
Humeral head vascularity comes from the anterior and posterior humeral circumflex arteries.The anterior humeral circumflex artery(AHCA)runs with its two venae comunicantes as the“three sisters”before anastomosing with the posterior humeral circumflex artery(PHCA).The AHCA gives offan anterolateral ascending branch that cross the subscapularis tendon anteriorly and runs superiorly along the lateral border of the intertubercular groove before terminating as the arcuate artery[2,3].
The PHCA runs posteriorly along with the axillary nerve through the quadrangular space,defined by the subscapu-laris and teres minor muscles superiorly,the teres major inferiorly,the long head of the triceps medially,and the humeral surgical neck laterally[2].Within the quadrangular space,the PHCA splits into posterior and anterior branches, which run in concert with the branches of the axillary nerve to supply the proximal humerus and deltoid muscle.
Classically,the AHCA has been considered the most important blood supply to the proximal humerus,with condary contributions from the PHCA and muscular attachments of the proximal humerus[3,7–9].More recently,however,data suggests that the contribution of the PHCA is more substantial than previously believed.Hettrich et al.demonstrated that the majority of the blood supply to the proximal humerus actually aris from the PHCA [10].Specifically,the authors report that64%of humeral head perfusion aris from the PHCA,while the AHCA only contributed36%of humeral head perfusion.Therefore, in the tting of proximal humerus fracture,such results indicate that damage to the humeral head blood supply may be prerved,even in cas where the AHCA is disrupted (Figure3).
(a)(b)
名人英语演讲Figure3:The anterior humeral circumflex is en adherent to the proximal humerus(a),whereas the posterior humeral circumflex artery(PCA)en in(b)is less adherent with veral perforating branches along its cour,making this vesl less vulnerable to injury in the ca of proximal humerus fracture.(Reprinted with permission from Hettrich[10]).
The axillary nerve is the most frequently injured nerve in proximal humerus fractures,and the suprascapular nerve is the cond most commonly injured[11].The axillary nerve enters the quadran
gular space along with the PCHA at an average distance of1.7cm from the surgical neck[2]. In the quadrangular space,the nerve divides into anterior and posterior branches,the latter of which provides motor input to the posterior and middle heads of the deltoid before terminating as the superior lateral brachial cutaneous nerve [2].The anterior branch of the axillary nerve continues along the undersurface of the deltoid,cross the anterior deltoid raphe,the avascular region parating the anterior and middle heads of the deltoid,at an average of3.5cm from the lateral prominence of the greater tuberosity and6.3cm from the anterolateral border of the acromion(Figure4) [12].Gardner and colleagues showed that this nerve can be reliably palpated as a cord-like structure at this location. The proximity of the axillary nerve makes it particularly vulnerable to both traumatic and iatrogenic injury[13].
The suprascapular nerve runs posteroinferiorly through the suprascapular notch to supply the supraspinatus and infraspinatus muscles.The motor branch of the nerve aris about1cm from the ba of the scapular spine and cours2mm posterior to the glenoid rim[2].The nerve is particularly vulnerable to traction injury at two distinct locations:its branch-point from the upper trunk and at the suprascapular notch where it runs deep to the transver scapular ligament.
3.Clinical Evaluation
3.1.History and Physical.Evaluation of a proximal humerus fracture begins with a thorough history and physical exami-nation.While one may focus attention on the shoulder,it
is Figure4:The axillary neurovascular structure(AN)can be palpated as a cordlike structure within the anterior deltoid raphe located an average of3.5cm from the greater tuberosity(GT) prominence or6cm from the anterolateral(AL)border of the acromion,the latter of which is more reliable in the tting of proximal humerus fracture.
滔滔不绝的近义词是什么important to consider associated injuries and concomitant pathology of the shoulder girdle,upper extremity,and cervical spine.The most common mechanism is a fall from standing in an elderly,osteoporotic woman[14].Other,less common caus,include high-energy traumas such as falls from height,motor vehicle crashes,izures,and electric shock.It is possible to have concomitant glenohumeral dislocation[15].Recognition of a proximal humerus fracture dislocation is imperative.Pathologic proximal humerus fractures can be en in the tting of neoplastic or metabolic bone dia.Such consideration is especially important in young patients with this injury and a low energy mechanism.
The patient’s baline level of function,hand dominance, functional demand,and ability to participate in rehabilita-tion must be assd as the factors contribute to clinical management decisions.Patients with proximal humerus fractures commonly prent with a swollen,ecchymotic shoulder with pain and limited range of motion.The skin should be inspected for associated lesions,e
cchymosis, and prior surgical scars.Gross deformity may indicate glenohumeral dislocation.A diligent neurovascular exam is crucial,with particular attention paid to axillary nerve function.Although rare,acute neurovascular compromi may indicate the need for emergent surgical intervention, especially in high-energy injures[16].Sluggish capillary
refill,weak distal puls,and hypoesthesias are all warning signs of vascular compromi.
The trauma ries of the shoulder consists of three t views:true AP,the lateral or scapular-Y,and axillary views. The allow for adequate evaluation of fracture anatomy, comminution,and fragment displacement.The true AP radiograph is taken perpendicular to the glenohumeral joint by angling the beam40degrees away from midline to account for scapulothoracic and glenoid version.The axillary view provides an accurate view of the glenohumeral relationship and is critical to confirm location of the humeral head. Alternatively,in patients who are unable to tolerate this view condary to pain,a Valpeau view may be substituted. Computed tomography(CT)is a very uful imaging modality.It is helpful for surgical planning as it allows improved delineation of fracture displacement,asssment of comminution,and evaluation of the articular surface [16].We routinely obtain CT scans with3D reconstruction views in all operative candidates(Figures5(a)and5(b)). Magnetic resonance imaging(MRI)is rarely indicated in the acute tting but becomes a uful tool if underlying bony path
ology or malignancy is suspected.
3.2.Classification.The AO classification for proximal hume-rus fractures was initially described by Muller in1988and divides the fracture patterns into the classic27subgroups bad on the location,type,and verity of the fracture[17]. This scheme is rarely ud in the clinical tting.Numerous other classifications have been described,including the Kocher,Codman,and Jakob and Ganz systems.The most widely employed,however,is the Neer classification.Neer divides the proximal humerus into4conceptual and func-tional“parts”:the greater tuberosity,the lesr tuberosity, the articular gment(head),and the humeral shaft[18].In order to qualify as a part,the fragment must have greater than1cm of displacement or45degrees of angulation.The greater tuberosity is an exception to this rule,requiring only 0.5cm of displacement to be considered a part[18].
4.Treatment Options
4.1.Nonoperative Treatment.Nondisplaced and minimally displaced fractures may be treated conrvatively.Following two weeks of sling immobilization,passive motion of the shoulder commences.Shorter periods of immobilization are associated with lower pain scores in the short ter
m;however, at6months,there was no difference[19].More recently, Lefevre-Colau and colleagues found that early mobilization for impacted proximal humerus fractures was safe and more effective for performance restoration than a period of immo-bilization as traditional teaching would suggest[20].Patients should be followed with rial radiographs to evaluate for fracture displacement.We recommend radiographs at two weeks(prior to initiation of motion)and then again at3 weeks to ensure fracture stability.
The literature supports good to excellent outcomes for nonoperative management of the minimally displaced fractures in the elderly population.Particularly with regard to valgus impacted fracture patterns,80%of patients report good to excellent outcomes.Further,patients regained approximately80%of the abduction andflexion strength compared with the contralateral extremity[21].Court-Brown ported similarly positive results in displaced2-part translated fractures treated nonoperatively,noting that surgery did not improve outcome in elderly patients when compared to nonoperative management regardless of the degree of initial translation[22].
In a subt of patients,elderly,low demand,or tho with significant medical comorbidities,even more complex frac-tures patterns may be treated without surgery.Outcomes in nonoperatively managed3-and4-part fractures found that age was the most significant factor influencing outcomes, and no signi十宗罪肢体雪人
ficant correlation was found bad on fracture pattern or even radiographic outcomes after union[23]. 4.2.Percutaneous Pinning.Percutaneous pinning is a mini-mally invasive technique with limited indications.Amenable fracture patterns include2-part proximal humerus fractures, ideally of the surgical neck,and3-or4-part fractures with adequate bone stock[24].Theoretically,this technique limits iatrogenic vascular compromi,postoperative pain, operative time,and blood loss while improving cosmesis. Good outcomes can be achieved70%of the time in2-part fracture patterns[25].Comparison of percutaneous techniques in all fracture patterns revealed,as one may expect,that4-part fractures had the poorest results[26].
Better outcomes are reported using percutaneousfixa-tion in patients with good bone quality,an intact medial cal-car,lack of proximal shaft comminution,and stablefixation under dynamicfluoroscopy[27].Reported complications of this technique include pin track infections,avascular necrosis of the humeral head,and pin migration with resultant loss of reduction[24].Longer term followup of patients treated with percutaneousfixation revealed greater prevalence of osteonecrosis and posttraumatic osteoarthritis than previously reported[28].
4.3.Intramedullary Fixation.Intramedullary devices can be ud forfixation of2-,3-,and4-part fractures.Most success-ful outcomes occur in2-part fractures.Intramedullary nail fixation with indirect 俄罗斯的
reduction has the benefit of decread soft tissue stripping.A retrospective review of2-,3-,and 4-part fractures treated with a Polarus nail reported that lateral metaphyal comminution and a lateralized starting point into the greater tuberosity incread the risk offixation failure[29].The authors reported a very high complication rate in their ries with only eleven of the twenty fractures healing without complications.Another study reported a 45%reoperation rate in3-and4-part proximal humerus fractures treated with the Polarus nail[30].A similar cohort of patients treated with the Telegraph nail reported the best outcomes in tho with extraarticular surgical neck fractures. Similar to platefixation,complications of intramedullary nailing include screw penetration,nail impingement,hard-ware migration,and failure offixation.More recently, Lobenhoffer and Mathews[31]reported an average Constant
(a)
(b)(c)
Figure5:Radiograph(a)of a proximal humerus fracture.The CT scan with3D reconstruction(b)adds significant detail and aids in preoperative planning.Osteosynthesis was carried out(c)with the u of intramedullaryfibulas(asterisks)and particular attention paid to restoration of the medial calcar(arrow).
score of60.0in99proximal humerus fractures treated surgically with the Targon nail at7months postoperatively.
At our institution,intramedullary nailing of proximal humerus fractures is rarely indicated.However,Konrad et al. have shown equivalent outcomes with plate compared with nailfixation of three-part proximal humerus fractures[32]. Similarly,a prospective randomized trial of plate versus nail for two-part surgical neck fractures also found no difference in clinical outcomes scores at three-year followup[33].The data suggest that intramedullary devices continue to have a role in the management of certain proximal humerus fractures.
4.4.ORIF.Osteosynthesis is indicated for2-,3-,and4-part fractures in appropriate patients.Exceptions include some4-part fractures,head-splitting fractures,and fracture-dislocations,which are indicated for
prosthetic replacement. While platefixation has been shown to have superior patient outcome scores when compared with nonoperative treatment in elderly patients,a recent randomized controlled trial showed better radiographic outcomes for platefixation but equivalent functional outcomes in three-and four-part fractures[34,35].Classically,indications forfixation in4-part fractures include valgus impaction with prervation of the medial capsular blood supply[36].In our experience, however,more complex4-part patterns can successfully be treated with ORIF.Complications with osteosynthesis,how-ever,remain high.Particularly in patients with osteopenic or osteoporotic bone,high rates of intraarticular screw penetration have been reported[37].This can lead to subquent impingement from plate migration,nonunion, malunion,or intraarticular penetration of screws[38–40]. In[40]the risk of avascular necrosis(AVN)condary to vascular compromi is greater in more complex fracture patterns and may be compounded by iatrogenic soft tissue stripping.While this concern still exists,the correlation between head perfusion and development of ischemia is more complex than initially thought.Hertel et al.initially obrved that predictors of humeral head ischemia as bad on intraosous lar Dopplerflowmetry were metaphyal head extension,integrity of medial hinge,and basic fracture pattern[41].The patients were followed long term,and it was found that in fractures demonstrating intraoperative ischemia,8/10did not go on to humeral head collap from AVN,and the other2/10demonstrated collap at mean 5year followup.In
tho fractures without intraoperative ischemia,4/30still went on to humeral head collap from AVN.Clearly,humeral head ischemia is not the only factor leading to AVN in proximal humerus fracture as most fractures with intraoperative ischemia did not go on to collap[42].
Indications for open reduction internalfixation tech-niques of proximal humerus fractures have expanded with the introduction of locking plate technology.Initial data on specific lockedfixation devices such as the PHILOS plate nearly eliminated complications due to hardware failure and subacromial impingement with good func-tional outcomes if correct surgical technique is employed. Constant scores in the long term for patientsfixed with locked plates range from70to76[43–45].Sudkamp et al.found poorer Constant scores in female patients over 40years of age with varus deformity greater than20 degrees[46].A delay in the initiation of rehabilitation due to medical comorbidities has also been found to lead to poor outcomes[47].Initial fracture pattern with varus extension angulation has also been found to do poorly when compared with valgus impacted angulation pattern [48].
