import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Runs along inferior border of subscapularis muscle at surgical neck level, approximately 5-7cm distal to acromion, exiting quadrangular space with posterior humeral circumflex artery **Protection**: Place blunt retractor along inferior subscapularis border, avoid dissection >7cm distal to acromion, gentle arm manipulation, document preoperative motor (deltoid) and sensory (lateral shoulder) function **Location**: Enters coracobrachialis muscle approximately 3-8cm distal to coracoid process (average 5cm), within conjoined tendon. Variable anatomy - may enter as proximal as 2cm from coracoid **Protection**: Avoid medial dissection beyond conjoined tendon, limit proximal extension beyond coracoid, gentle retraction of conjoined tendon medially (excessive traction can cause neuropraxia) **Location**: Runs along inferior border of subscapularis (parallel to axillary nerve), typically 1cm anterior to surgical neck. Gives off arcuate artery which is PRIMARY blood supply entering humeral head medially at calcar **Protection**: Minimize soft tissue stripping of medial calcar (preserves arcuate artery entry point), gentle handling of humeral head fragments, preserve medial periosteal hinge in valgus-impacted fractures. Circumflex artery itself can be sacrificed if necessary but avoid disrupting medial periosteum **Location**: In deltopectoral interval, within fat stripe between deltoid (lateral) and pectoralis major (medial). Usually accompanied by delta branch of thoracoacromial artery **Protection**: Identify early during approach, can retract medially or laterally (traditionally lateral with deltoid), ligate if necessary with adequate collateral drainage. Preserve if possible but not critical structure **Location**: Runs in bicipital groove between greater tuberosity (laterally) and lesser tuberosity (medially), exiting inferiorly to pass anterior to humeral head into coracoid **Protection**: Key anatomical landmark - DO NOT EXCISE as identifies GT vs LT and rotation. Use for orientation (should face anteriorly), tag with vessel loop. If severely damaged or subluxed from groove, consider tenotomy or tenodesis but preserve during fracture reduction as rotational landmark ## Critical Anatomical Relationships ### Blood Supply to Humeral Head The humeral head receives blood from three sources, but the **arcuate artery is PRIMARY**: 1. **Arcuate artery** (ascending branch of anterior humeral circumflex) - enters medially at calcar through intact medial periosteum - MAIN supply (>80%) 2. Posterolateral branch of posterior humeral circumflex artery - minor contribution 3. Branches from rotator cuff insertions - minimal contribution **Clinical Significance**: In valgus-impacted 4-part fractures, the head is driven into the metaphysis maintaining medial periosteal hinge - arcuate artery entry preserved - AVN rate only 15-25% (compared to 75-90% in displaced 4-part where medial periosteum disrupted). ### Axillary Nerve Anatomical Course - Origin: Posterior cord of brachial plexus (C5-C6 roots) - Course: Exits quadrangular space with posterior humeral circumflex artery - Anterior division: Runs along **inferior border of subscapularis** at surgical neck level, **5-7cm distal to acromion** - Innervation: Deltoid (motor), teres minor (motor), lateral shoulder skin (sensory - regimental badge area) **Clinical Significance**: Most at-risk nerve in proximal humerus fractures - 40% have primary nerve injury from fracture (neuropraxia from traction/contusion), 2-3% iatrogenic injury during surgery. Document preop exam. Protect with blunt retractor placed along inferior subscapularis during plating. ### Deltopectoral Interval **Internervous plane**: Deltoid (axillary nerve C5-C6) and Pectoralis major (medial and lateral pectoral nerves C5-T1) **Key structures**: - **Cephalic vein** - in fat stripe (delta branch of thoracoacromial artery runs with it) - **Clavipectoral fascia** - deep layer, envelops conjoined tendon - **Conjoined tendon** - short head biceps + coracobrachialis (musculocutaneous nerve enters 3-8cm distal to coracoid) ### Rotator Cuff Insertions on Tuberosities **Greater tuberosity** (three facets, superior to inferior): 1. Supraspinatus (superior facet) 2. Infraspinatus (middle facet) 3. Teres minor (inferior facet) **Lesser tuberosity** (one insertion): - Subscapularis (anterior) **Clinical Significance**: Stay sutures through rotator cuff tendons (not bone - osteoporotic) allow tuberosity manipulation during reduction and fixation. Anatomical reduction critical for rotator cuff length-tension relationship and function. ## ORIF vs Hemiarthroplasty - Evidence-Based Algorithm ### ORIF Indications (Locking Plate) **Age**: <65 years (relative - consider bone quality) **Bone quality**: Good (adequate purchase for locking screws) **Fracture patterns**: - 2-part displaced surgical neck (>1cm or >45°) - 2-part greater tuberosity (>5mm displacement) - 3-part fractures - **4-part VALGUS-IMPACTED** (medial hinge intact - key indication despite being 4-part) - Selected fracture-dislocations if head viable **Expected outcomes**: Variable - highly dependent on tuberosity healing, avoiding complications. Good to excellent results 60-70% in appropriate patients. ### Hemiarthroplasty Indications **Age**: >65-70 years (relative - bone quality more important) **Bone quality**: Osteoporotic (poor screw purchase, high fixation failure risk) **Fracture patterns**: - 4-part displaced (NOT valgus-impacted) - Fracture-dislocation with head-split or severe comminution - Articular surface comminution (head-split fractures) - Anatomical neck fractures (AVN ~100%) - Chronic fractures >3-4 weeks (retracted soft tissues, difficulty reducing) **Expected outcomes**: Pain relief good (80-90%), function variable (depends on tuberosity healing 60-70% good/excellent) ### Reverse Shoulder Arthroplasty - Emerging Indication **Increasingly considered INSTEAD of hemiarthroplasty** in elderly (>70-75 years) with: - 4-part fractures - Fracture-dislocations - Poor bone quality **Advantages over hemiarthroplasty**: - Does NOT rely on tuberosity healing (deltoid is primary mover, not rotator cuff) - More predictable functional outcomes (80-85% good/excellent) - Better forward elevation and function for ADLs **Disadvantages**: - Irreversible (burns bridge to anatomic replacement) - Slightly higher complication rate (instability, scapular notching) - Range of motion ceiling (typically achieve ~120° flexion, limited rotation) ### Evidence Summary **PROFHER trial (2015)**: Nonoperative vs operative (mixed ORIF and hemiarthroplasty) for displaced proximal humerus fractures - NO difference in patient-reported outcomes at 2 years. Suggests nonoperative may be adequate for many fractures. **ΔMETA-ANALYSIS** (Brorson 2012): ORIF has higher reoperation rate than hemiarthroplasty (35% vs 12%) but better functional outcomes when successful. **Consensus**: Individualize treatment based on age, bone quality, fracture pattern, patient demands, surgeon experience. ## Essential Planning Steps ### Imaging Requirements **Standard radiographs** (minimum): 1. AP shoulder (beam perpendicular to scapular plane - ~30° oblique to body) 2. Scapular Y (true lateral of scapula) 3. Axillary lateral (beam through axilla looking up at glenohumeral joint) **CT scan with 3D reconstruction** (essential for operative cases): - Fracture pattern classification (2, 3, or 4-part) - Head-split component assessment - Tuberosity size, displacement, comminution - Bone quality (Hounsfield units can quantify) - Presence of medial hinge (valgus-impacted vs displaced) - Template plate positioning and screw trajectories **MRI** (selective - not routine): - If concern for rotator cuff tear (may influence treatment) - Vascular anatomy if AVN concern ### Neer Classification Application **1-part** (80% of proximal humerus fractures): - All fragments <1cm displacement AND <45° angulation - **Treatment**: NONOPERATIVE (sling, early passive motion) **2-part** (10% of fractures): - ONE fragment >1cm or >45° displaced (surgical neck, GT, LT, or anatomical neck) - **Treatment**: Usually ORIF if surgical neck or GT >5mm; nonop if minimal displacement **3-part** (5% of fractures): - Surgical neck + ONE tuberosity displaced - **Treatment**: ORIF in young, consider hemiarthroplasty in elderly **4-part** (5% of fractures): - Surgical neck + BOTH tuberosities displaced - CRITICAL: Is it valgus-impacted (medial hinge intact) vs displaced? - **Treatment**: Valgus-impacted - ORIF; Displaced - hemiarthroplasty or reverse ### Templating for ORIF - Identify plate size (standard proximal humerus locking plate - PHILOS, Synthes; or equivalent) - Plan screw trajectories into head (divergent angles for optimal support) - Identify if medial column deficient (plan bone grafting) - Assess tuberosity comminution (plan suture technique) ### Templating for Hemiarthroplasty - Measure humeral head size on radiographs or CT (compare to contralateral) - Determine stem size (ream humeral canal) - Plan humeral height (use opposite shoulder, measure from GT to articular surface) - Plan version (30° retroversion native, use opposite shoulder) ## Intraoperative Technical Tricks ### Reduction Techniques - The Challenging Step **Problem**: Humeral head fragment often impacted, displaced, rotated - difficult to reduce to shaft in osteoporotic bone **Solutions**: 1. **Joystick K-wire** into head fragment - allows manipulation without soft tissue stripping (risk: fragmentation) 2. **Periosteal elevator** medially under head - lever head onto shaft 3. **Suture traction** - heavy sutures through rotator cuff attached to tuberosities - pull to reduce 4. **Direct fragment manipulation** - push head from anterior while extending arm **Key**: Restore HEIGHT (varus most common error), ROTATION (use bicipital groove landmark), VERSION (20-30° retroversion) ### Provisional Fixation Options 1. **K-wires** - quick but risk head fragmentation (osteoporotic bone) 2. **Heavy sutures** (#5 Ethibond) through rotator cuff - gentle, no fragmentation risk 3. **Pointed reduction forceps** - risk crushing bone but effective ### Tuberosity Fixation - Determines Functional Outcome **Problem**: Tuberosities often osteoporotic - screws pull out **Solution**: PRIMARY fixation with heavy SUTURES, screws are supplementary **Suture techniques**: - **Through plate holes** - pass sutures through rotator cuff attached to tuberosities, then through locking plate holes - **Circumferential cerclage** - around plate and tuberosities (figure-of-8 pattern) - **Horizontal mattress** - through tuberosity bone (if quality adequate) and rotator cuff tendon **Suture material**: #5 Ethibond (thick, strong) or FiberWire (strong but can cut through bone) **Number**: Minimum 4-6 sutures total (2-3 per tuberosity) ### Medial Column Bone Grafting **Indications**: - Void after head reduction (medial calcar deficient) - Comminuted fracture with medial column gap - Osteoporotic bone (some surgeons use routinely) **Options**: 1. **Autograft from humeral head** - morselized from impacted head fragments (if available) 2. **Iliac crest autograft** - gold standard but donor site morbidity (pain, hematoma) 3. **Allograft** - morselized cancellous chips or structural strut 4. **Calcium phosphate cement** - injectable, hardens in situ, biomechanically equivalent to bone graft **Technique**: Pack graft medially beneath head, compact with inferomedial calcar screw ### Fluoroscopy - Three Essential Views **AP view**: - Assess varus/valgus alignment (medial calcar should be restored) - Check screw position in head (subchondral but not penetrating) **Scapular Y**: - Assess reduction (head should be centered over glenoid) - Check version (head should not point posteriorly) **Axillary view** (MOST IMPORTANT for detecting screw penetration): - Assess glenohumeral reduction - Check for INTRA-ARTICULAR SCREW PENETRATION (common error - must check this view) ## Evidence-Based Complication Prevention ### AVN Prevention **Risk factors**: - 4-part displaced fracture (blood supply disrupted) - Fracture-dislocation (additional vascular insult) - Excessive soft tissue stripping (iatrogenic devascularization) **Prevention strategies**: - Minimal soft tissue stripping from head fragments - Gentle handling (don't denude head of remaining periosteum) - Anatomical reduction (restore anatomy, facilitate revascularization) - Consider hemiarthroplasty if 4-part displaced in elderly (high AVN risk 75-90%) **Recognition**: Radiographs 6, 12, 24 months - increased density, subchondral collapse, sclerosis **Management**: Early AVN - activity modification, observe (may remain asymptomatic). Late with collapse - arthroplasty. ### Varus Collapse Prevention - Most Common Mechanical Failure **Prevention (CALCAR mnemonic)**: - **Inferomedial calcar screw** - biomechanically most important - **Medial column bone graft** if deficient - **Anatomical reduction** - avoid initial varus - **Locking plate** with divergent screws **Recognition**: Radiographs 6-12 weeks - progressive varus angulation, head sinking medially, inferior subluxation **Management**: Early (<6 weeks) - consider revision if good bone. Late - likely needs arthroplasty. ### Tuberosity Nonunion Prevention **Prevention strategies**: - Anatomical reduction with suture fixation (#5 Ethibond) - Protected mobilization - passive only 6 weeks - Confirm radiographic healing before advancing to active motion - Patient education - NO active motion early **Recognition**: Radiographs 6-12 weeks - persistent fracture line, fragment displacement, sclerosis **Management**: Good head + displaced GT <1cm with function - observe. Good head + GT >1cm or nonfunctional - revision ORIF with bone graft. Head AVN - reverse shoulder arthroplasty. ### Stiffness Prevention - Very Common (30-40%) **Prevention strategies**: - **EARLY PASSIVE ROM** - start day 1-3 (interscalene block provides analgesia) - PT supervision - ensure passive only (protect tuberosities) - Patient education - motion recovery slow but critical to prevent adhesive capsulitis - Communicate fixation stability to PT team **Recognition**: <90° forward flexion at 6-12 weeks despite appropriate PT **Management**: Continue aggressive passive stretching, intra-articular steroid injection, manipulation under anesthesia if severe >6 months, arthroscopic capsular release for refractory cases ### Screw Penetration Prevention **Prevention strategies**: - Careful measurement with depth gauge - Target subchondral (within 5mm of cartilage) - Fluoroscopy - **AXILLARY view** essential (best view for detecting penetration) - Feel for breakthrough when drilling **Recognition**: Intraoperative - fluoroscopy shows screw tip beyond subchondral bone on axillary view **Management**: Immediate removal, replace with shorter screw, confirm on fluoroscopy ### Step 1: Preoperative Planning and Classification Preoperative Planning and Classification: Review AP shoulder, scapular Y, and axillary lateral radiographs. CT scan with 3D reconstruction for complex fractures - essential for understanding fracture personality, displacement, head-split component, tuberosity displacement. NEER CLASSIFICATION: 1-part (undisplaced or <1cm, <45°), 2-part (surgical neck OR greater tuberosity OR lesser tuberosity OR anatomical neck), 3-part (surgical neck + one tuberosity), 4-part (surgical neck + both tuberosities). DISPLACEMENT criteria needed for count as part is more than 1cm or more than 45° angulation. Assess for head-split (intra-articular), valgus-impacted (medial periosteum intact equals blood supply preserved). Consider fracture-dislocation. Template plate size and screw trajectories. **Technical Tip**: EXAM KEY: NEER classification drives treatment. 1-PART (80% of proximal humerus fractures) - NON-OPERATIVE. 2-PART surgical neck or GT with displacement more than 5mm - ORIF candidate. 3-PART - ORIF in young, consider hemi in elderly. 4-PART - traditionally hemi, but VALGUS-IMPACTED can be fixed (medial hinge intact equals blood supply). CT ESSENTIAL for operative planning - shows head-split, tuberosity size and location, bone quality. Know blood supply: ARCUATE artery (ascending branch of anterior humeral circumflex) enters head at medial calcar - preserved if medial periosteum intact (valgus-impacted). - Missed head-split component (requires CT - changes treatment to hemiarthroplasty) - Incorrect classification leading to inappropriate treatment choice - Failure to assess bone quality (osteoporotic bone has high ORIF failure rate) - Inadequate consent discussion (high complication rate 30-50%, need for possible arthroplasty) ### Step 2: Patient Positioning - Beach Chair Patient Positioning - Beach Chair: BEACH CHAIR position: patient semi-recumbent 30-45 degrees. Head secured with headrest. Affected arm draped free to allow manipulation. Mayo stand or arm holder for arm support. Ensure ability to extend, rotate, and manipulate arm without fighting drapes. Entire shoulder, lateral neck, chest to midline prepped. Radiolucent beach chair attachment allows intraoperative fluoroscopy (AP, scapular Y, axillary). Anesthesia: general with interscalene block (excellent postop analgesia, allows awake PT day 1). **Technical Tip**: EXAM KEY: BEACH CHAIR advantages - anatomical positioning (surgeon's mental image matches anatomy), gravity assists reduction, arm free for manipulation, patient can be intubated or sedated. Ensure adequate FLUOROSCOPY access before prepping - need AP (beam perpendicular to scapular plane approximately 30° oblique to body), SCAPULAR Y (true lateral scapula), AXILLARY (beam through axilla looking up at glenohumeral joint - critical for reduction assessment). Interscalene block provides excellent analgesia allowing EARLY PT (critical for outcome). - Brachial plexus injury from arm positioning (avoid excessive extension and external rotation) - Hypotension from beach chair (ensure adequate IV access, pressors available) - Cerebral hypoperfusion if head too elevated (keep angle less than 70 degrees) - Pressure injuries from prolonged positioning (pad all bony prominences) ### Step 3: Deltopectoral Approach and Exposure Deltopectoral Approach and Exposure: Incision from coracoid to deltoid insertion (10-12cm), in line with deltopectoral groove. Identify and preserve (or ligate) CEPHALIC VEIN - usually lies in fat stripe marking interval between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves). Retract deltoid laterally, pectoralis medially. Identify CORACOACROMIAL LIGAMENT (palpate coracoid, CA lig extends to acromion) - provides superior landmark. Deep layer: CLAVIPECTORAL FASCIA enveloping conjoined tendon (short head biceps + coracobrachialis). Divide clavipectoral fascia lateral to conjoined tendon. Identify SUBSCAPULARIS inferior border (rotator interval superiorly, subscap lower border inferiorly). Axillary nerve runs along subscap inferior border - PROTECT. **Technical Tip**: EXAM KEY: DELTOPECTORAL is internervous plane - deltoid (axillary n.) and pec major (pectoral nn.). CEPHALIC VEIN: can retract medially or laterally (traditionally lateral with deltoid, but medial retraction may reduce bleeding from deltoid branches). Can LIGATE if necessary (adequate collateral drainage). AXILLARY NERVE: crosses inferior border of subscapularis approximately 5-7cm distal to acromion, at surgical neck level. PROTECT with inferior retractor placement - blunt retractor along inferior subscapularis protecting nerve. If need to extend: proximally (divide clavipec fascia to coracoid), distally (split deltoid in line with fibers but axillary nerve at risk at distance less than 5cm from acromion). - Axillary nerve (inferior subscapularis border, 5-7cm distal to acromion) - most at risk nerve - Musculocutaneous nerve (enters coracobrachialis approximately 5cm distal to coracoid if extending medially) - Anterior humeral circumflex artery (at inferior border of subscapularis, sacrifice acceptable if necessary) - Cephalic vein injury causing bleeding (can ligate if necessary) ### Step 4: Fracture Exposure and Hematoma Evacuation Fracture Exposure and Hematoma Evacuation: Identify LONG HEAD BICEPS TENDON (LHB) in bicipital groove - serves as anatomical landmark (lesser tuberosity medial, greater tuberosity lateral). Evacuate hematoma. Identify fracture fragments: HUMERAL HEAD, SHAFT, GREATER TUBEROSITY (GT - supraspinatus, infraspinatus, teres minor insertions), LESSER TUBEROSITY (LT - subscapularis insertion). Tag tuberosities with STAY SUTURES (#2 Ethibond through rotator cuff tendons, not bone - allows manipulation). Assess head: viability (bleeding bone is good sign), impaction, head-split component. Identify MEDIAL CALCAR (medial periosteal hinge) - if intact, suggests preserved blood supply. **Technical Tip**: EXAM KEY: LONG HEAD BICEPS is key landmark - identifies GT (lateral) vs LT (medial), helps assess rotation. STAY SUTURES through rotator cuff attached to tuberosities allow manipulation without grasping bone (osteoporotic). GT has 3 insertions (sup, infra, teres minor). LT has subscap. MEDIAL CALCAR (periosteum) is critical - if intact (valgus-impacted), arcuate artery enters here preserving head blood supply. If torn, AVN risk 75-90%. Gentle handling of head - already tenuous blood supply. Minimize soft tissue stripping. - Humeral head devascularization from excessive stripping (AVN risk - 75-90% in 4-part displaced) - Tuberosity fragmentation if grasped directly (osteoporotic bone crumbles) - Lost fragments if hematoma evacuated without identifying all pieces first - Long head biceps tendon injury (preserve as rotational landmark) ### Step 5: Reduction of Humeral Head and Shaft Reduction of Humeral Head and Shaft: Reduce HUMERAL HEAD to SHAFT first (before addressing tuberosities). Techniques: 1) Traction on arm with joystick K-wire into head fragment for manipulation, 2) Elevator or periosteal elevator medially to lever head onto shaft, 3) Provisional K-wire or heavy sutures for temporary fixation. Restore HEIGHT (avoid varus malreduction - causes inferior subluxation), ROTATION (use bicipital groove as landmark), VERSION (check with fluoroscopy). Varus is most common malreduction - ensure medial calcar supported. Fluoroscopy AP, scapular Y, axillary to confirm reduction. **Technical Tip**: EXAM KEY: Reduction is MOST CHALLENGING step in osteoporotic bone. VARUS malreduction is most common error - insufficient medial support causes head to sink into varus, leads to inferior humeral head subluxation, superior migration, poor outcomes. Ensure MEDIAL CALCAR supported (bone graft if deficient). ROTATION: use bicipital groove (should face anteriorly), lesser tuberosity (should face medially), relationship to forearm (thumb up equals neutral rotation). VERSION: native retroversion approximately 30°, check with fluoroscopy ensuring head doesn't point posteriorly. K-wire provisional fixation risks head fragmentation - use carefully or heavy sutures through rotator cuff. - Varus malreduction (insufficient medial support, most common error leading to failure) - Humeral head fragmentation from k-wire insertion (osteoporotic bone fractures easily) - Lost reduction during plating if provisional fixation inadequate - Malrotation not recognized (check bicipital groove orientation, fluoroscopy) ### Step 6: Proximal Humerus Locking Plate Application Proximal Humerus Locking Plate Application: Select PROXIMAL HUMERUS LOCKING PLATE (PHILOS, Synthes; or equivalent). Plate positioned on LATERAL humeral shaft, 5-10mm distal to greater tuberosity (allows GT to sit anatomically, avoids subacromial impingement). Proximal plate has multiple locking screw holes targeting humeral head in various trajectories (support head in multiple planes). Plate secured to shaft first with NON-LOCKING cortical screws (allows adjustment). Then LOCKING screws into head (3-6 screws typically, divergent trajectories create cage supporting head). Screw length critical - must be subchondral (support head) but not penetrate articular surface. Inferomedial screw (calcar screw) provides critical medial support preventing varus collapse. **Technical Tip**: EXAM KEY: Proximal humerus locking plate is FIXED-ANGLE construct - maintains head-shaft-tuberosity relationship even in osteoporotic bone. PLATE POSITION: 5-10mm distal to GT (if too proximal, GT impinges under acromion causing pain and erosion). SHAFT SCREWS first (non-locking, allows plate adjustment). HEAD SCREWS second (locking, divergent trajectories). INFEROMEDIAL CALCAR SCREW critical - provides medial support preventing varus collapse (most important screw per biomechanical studies). Screw length: SUBCHONDRAL position ideal (best purchase) but must not penetrate joint - use depth gauge, fluoroscopy, feel for breakthrough. Screw tips should be within 5mm of subchondral bone. - Articular perforation by locking screws (intra-articular hardware causes rapid arthritis) - Varus collapse if inferomedial calcar screw not placed (most common fixation failure mechanism) - Subacromial impingement if plate too proximal (causes pain, rotator cuff erosion, stiffness) - Lost reduction during plating if provisional fixation released too early ### Step 7: Tuberosity Reduction and Fixation Tuberosity Reduction and Fixation: After head-shaft construct stable, address TUBEROSITIES. Reduce GT and LT to head and shaft. Use stay sutures for manipulation. Ensure anatomical position - GT lateral to bicipital groove, LT medial. Reduction maintained with: 1) Heavy sutures (#2 or #5 Ethibond) through rotator cuff tendons, around plate, or through bone tunnels - suture fixation is PRIMARY for tuberosities (bone often too osteoporotic for screws). 2) Additional screws through tuberosities into head if bone quality adequate. Tuberosity position critical: height (restores rotator cuff length tension), rotation (GT posterolateral, LT anteromedial). Fluoroscopy to confirm no prominent bone causing impingement. **Technical Tip**: EXAM KEY: TUBEROSITY FIXATION is critical for functional outcome (rotator cuff attached to tuberosities - if malpositioned or lost to nonunion, poor function). Osteoporotic bone means SUTURES are primary fixation (stronger than screws in poor bone). Multiple suture techniques: circumferential around plate, through plate holes, through bone tunnels in shaft. #5 ETHIBOND (thick, strong) or FiberWire. Ensure GT not sitting HIGH (causes impingement, pain, stiffness). LT anatomically reduced (subscap function). If tuberosities comminuted, reconstruct with multiple sutures - like putting together jigsaw puzzle. Some advocate MEDIAL CALCAR BONE GRAFT (allograft or autograft from head impaction) to support medial column - prevents varus collapse. - Tuberosity malposition (too high causes impingement, too low causes loss of rotator cuff tension) - Tuberosity nonunion or resorption (10-20% incidence, leads to poor function and cuff incompetence) - Prominent tuberosity bone causing subacromial impingement (burr or remove if necessary) - Suture cutting through osteoporotic bone (use larger bites through rotator cuff tendon) ### Step 8: Bone Grafting for Medial Column Support Bone Grafting for Medial Column Support: Assess MEDIAL COLUMN (calcar region). If void or deficiency after reduction (common in comminuted fractures or when reducing impacted head), bone graft provides support and prevents varus collapse. AUTOGRAFT options: morselized from humeral head impaction (if have extra), iliac crest. ALLOGRAFT: morselized cancellous chips or structural allograft strut for large defects. Pack graft medially beneath head, supporting calcar. Inferomedial calcar screw then secures graft. CALCIUM PHOSPHATE cement alternative - injectable, hardens, provides structural support (some surgeons use routinely in elderly osteoporotic bone). **Technical Tip**: EXAM KEY: MEDIAL COLUMN SUPPORT prevents varus collapse (most common mechanical failure). Varus leads to inferior humeral head subluxation, loss of reduction, poor outcome. Bone graft options: 1) Autograft from head (if impacted, can morselized excess bone), 2) Iliac crest (gold standard but donor site morbidity), 3) Allograft (morselized or structural), 4) Bone graft substitutes (calcium phosphate cement - biomechanical studies show similar support to bone graft, easier to use). INFEROMEDIAL CALCAR SCREW after grafting provides compaction and support. Controversial whether routine in all cases vs only when deficient - some surgeons graft routinely in elderly osteoporotic bone. - Inadequate medial support leading to varus collapse (most common fixation failure - 10-20%) - Iliac crest donor site morbidity if autograft used (pain, hematoma, lateral femoral cutaneous nerve injury) - Thermal necrosis if using bone cement (exothermic reaction - irrigate copiously to cool) - Graft migration if not secured with calcar screw ### Step 9: Fixation Assessment and Range of Motion Check Fixation Assessment and Range of Motion Check: Remove provisional fixation. Gently manipulate shoulder through range of motion - forward flexion, abduction, rotation. No crepitus or pain should be elicited. Tuberosities should move with head as unit (indicates stable fixation). Fluoroscopy FINAL images: AP (assess reduction, varus or valgus, screw position), SCAPULAR Y (assess reduction, version), AXILLARY (assess reduction, articular screw penetration, glenohumeral relationship). Confirm: 1) Anatomical reduction head-shaft-tuberosities, 2) No varus collapse, 3) Screws subchondral but not intra-articular, 4) No subacromial impingement of plate or GT, 5) Tuberosities anatomically positioned. **Technical Tip**: EXAM KEY: ROM check ensures: 1) Stable fixation (no motion between fragments), 2) No mechanical block (impingement), 3) Construct will allow early PT. FLUOROSCOPY views essential - AP shows varus or valgus, scapular Y shows version and reduction, AXILLARY shows intra-articular screw penetration (common error - must check). If any screw appears to penetrate on axillary, REMOVE and replace with shorter screw (intra-articular hardware causes rapid arthritis). Ensure tuberosities at correct height - too high causes impingement, too low causes loss of rotator cuff tension. Document images for postop comparison and medicolegal record. - Intra-articular screw penetration not recognized (causes rapid chondrolysis and arthritis) - Unstable fixation not recognized (will fail postoperatively within weeks) - Subacromial impingement not recognized (causes pain and stiffness, difficult to correct) - Inadequate fluoroscopy documentation (medicolegal issues, cannot compare postop films) ### Step 10: Closure and Postoperative Protocol Setup Closure and Postoperative Protocol Setup: Irrigate wound copiously. Repair ROTATOR INTERVAL if opened (superior border subscap to anterior supraspinatus) - restores anterior stability. Repair SUBSCAPULARIS if taken down (usually not necessary with deltopectoral). Close CLAVIPECTORAL FASCIA with absorbable suture (2-0 Vicryl). DELTOPECTORAL INTERVAL falls together (don't suture deltoid to pec - causes stiffness). Subcutaneous layer (3-0 Vicryl). Skin (subcuticular 4-0 Monocryl or staples). Apply SLING with small abduction pillow (positions arm in slight abduction reducing tension on repair). NO drain typically needed. **Technical Tip**: EXAM KEY: Rotator interval closure controversial - some close (restores anterior stability), some leave open (less tension on tuberosity fixation). If tuberosity fixation tenuous, may leave open to reduce tension. SLING with ABDUCTION PILLOW positions arm in slight abduction (20-30°) - reduces tension on greater tuberosity, more comfortable for patient. Emphasize to patient: PASSIVE motion only initially (6 weeks typically), active-assisted at 6-8 weeks, active strengthening at 12 weeks after radiographic tuberosity healing. Too aggressive PT early causes tuberosity pulloff (10-20% complication). - Wound dehiscence if excessive tension on closure (especially in elderly thin skin) - Stiffness if deltopectoral interval sutured (creates tether, avoid this error) - Tuberosity pulloff if too aggressive early PT (most common complication 10-20%) - Inadequate patient education leading to inappropriate early active motion ### Step 11: Postoperative Rehabilitation Protocol - Critical for Outcome Postoperative Rehabilitation Protocol - Critical for Outcome: PHASE 1 (0-6 weeks): SLING immobilization with abduction pillow. PASSIVE ROM only - pendulum exercises immediate, passive forward flexion and ER to tolerance with PT supervision (start days 1-3 post-op with interscalene block). Goal: prevent stiffness without stressing tuberosity fixation. PHASE 2 (6-12 weeks): Active-assisted ROM. Wean sling. Radiographs at 6 weeks to assess tuberosity healing - if healing progresses, advance PT. PHASE 3 (after 12 weeks): Active ROM and progressive strengthening. RADIOGRAPHS: 2 weeks (wound check), 6 weeks (tuberosity healing check), 12 weeks (further healing), 6 months, 1 year (AVN surveillance). **Technical Tip**: EXAM KEY: Rehabilitation is CRITICAL for outcome - 'the operation is only half the battle, rehab is the other half'. EARLY PASSIVE MOTION prevents stiffness (major problem if delay PT - adhesive capsulitis develops quickly in shoulder 30-40% incidence). Balance between early motion (prevent stiffness) vs protecting tuberosity fixation (prevent pulloff). INTERSCALENE BLOCK allows immediate PT day 1-2 (pain-free motion). Communicate with PT: fixation stability, any concerns, protocol. TUBEROSITY HEALING assessed radiographically at 6 weeks - if delayed, slow PT progression. Common error: too aggressive PT causes tuberosity nonunion or pulloff. Err on side of caution if fixation tenuous. - Adhesive capsulitis if insufficient early passive ROM (very common 30-40%, major morbidity) - Tuberosity pulloff if too aggressive active motion early (10-20%, leads to rotator cuff dysfunction) - Varus collapse if inadequate medial support (monitor radiographs 6-12 weeks for progressive varus) - Patient noncompliance with restrictions leading to fixation failure ### Step 12: Alternative - Hemiarthroplasty Technique Alternative: Hemiarthroplasty - Indications and Technique: INDICATIONS for HEMIARTHROPLASTY over ORIF: 1) 4-part fractures in elderly osteoporotic bone (older than 65-70 years, poor bone quality), 2) Fracture-dislocations with head-split, 3) Articular surface comminution (head-split fractures), 4) Chronic fractures (older than 3-4 weeks) with retracted soft tissues. TECHNIQUE: deltopectoral approach as above. Remove humeral head (save for sizing). Prepare shaft (ream to appropriate size). CRITICAL: tuberosity management - tag GT and LT with stay sutures, preserve rotator cuff attachments, reduce around stem, fix with heavy sutures through stem holes and cerclage around stem and through bone. Height and version matched to native (use opposite side and saved head for templating). Trial, check stability, then final components. Cement vs press-fit based on bone quality. **Technical Tip**: EXAM KEY: Hemiarthroplasty vs ORIF decision based on: age (older than 65-70 favor hemi), bone quality (osteoporotic favor hemi), fracture pattern (4-part or head-split favor hemi). TUBEROSITY fixation is CRITICAL in hemi - determines functional outcome. Multiple suture techniques: through stem holes, cerclage around stem, horizontal mattress through bone. Tuberosity healing to prosthesis uncertain - nonunion rate 15-30%, higher than ORIF. HEIGHT and VERSION: critical - too low causes inferior subluxation, too high causes impingement. Too much retroversion causes posterior instability. Use OPPOSITE shoulder and SAVED head fragments for templating. REVERSE shoulder arthroplasty increasingly considered instead of hemi in elderly 4-part fractures - better functional outcomes (80-85% good to excellent), does not rely on tuberosity healing (deltoid function primary). HEMI outcomes variable - pain relief good, function variable (depends on tuberosity healing and rotator cuff integrity). - Tuberosity nonunion (15-30% in hemiarthroplasty, higher than ORIF, causes poor function) - Height or version malposition (causes instability, impingement, poor function) - Glenoid erosion over time (may require conversion to reverse or anatomic total shoulder) - Periprosthetic fracture (especially if press-fit stem in osteoporotic bone) ### Step 13: Complications Recognition and Early Management Complications Recognition and Management: AVASCULAR NECROSIS (AVN): Incidence 15-75% depending on fracture (4-part highest, 3-part intermediate, valgus-impacted lowest). Risk factors: 4-part, fracture-dislocation, disrupted medial periosteum. Monitor radiographs 6 months-2 years. Early AVN may be asymptomatic - treat with activity modification. Late AVN with collapse - consider arthroplasty. TUBEROSITY COMPLICATIONS: nonunion (10-20%), malposition, pulloff. If nonunion: revision fixation with bone graft if good head, consider reverse if head AVN. STIFFNESS: adhesive capsulitis (30-40%). Prevent with early PT. Treat with aggressive PT, manipulation under anesthesia, arthroscopic capsular release if severe and longer than 6 months. VARUS COLLAPSE: fixation failure, loss of reduction. Prevent with medial support (calcar screw, bone graft). If occurs: may require revision or arthroplasty. **Technical Tip**: EXAM KEY: Proximal humerus fracture fixation has HIGH complication rate (30-50% overall) even with good technique. AVN risk varies: 4-part (75-90%), 3-part (15-30%), valgus-impacted 4-part (15-25% because medial periosteum preserved). AVN may take 6-24 months to become radiographically apparent. TUBEROSITY NONUNION or PULLOFF major problem - leads to poor function (rotator cuff incompetence). Risk factors: osteoporotic bone, inadequate fixation, too aggressive PT. Management: if early and good bone, revision fixation; if chronic or AVN, consider reverse shoulder arthroplasty. STIFFNESS: prevention key (early passive motion), but balance against tuberosity protection. VARUS COLLAPSE: from inadequate medial support or osteoporotic bone, causes inferior subluxation and poor outcome. - AVN causing late arthroplasty need (15-75% depending on fracture pattern) - Tuberosity nonunion causing functional deficit and possible reverse arthroplasty need - Stiffness requiring manipulation or capsular release (30-40%, major morbidity) - Varus collapse requiring revision or arthroplasty (10-20% mechanical failure rate) **Immediate Postoperative (0-2 weeks)**: - Sling with abduction pillow (20-30° abduction reduces GT tension) - Pain control: Interscalene catheter 48-72 hours, then oral opioids plus NSAIDs - Wound check day 1-2 (drain if placed, neurovascular status) - Pendulum exercises start day 1 (passive shoulder circumduction, gravity-assisted) - Radiographs at 2 weeks (wound check visit, assess reduction maintenance) **Phase 1 - Passive Motion (2-6 weeks)**: - Continue sling between exercises (wean gradually after 4 weeks) - PT supervised PASSIVE ROM only: Forward flexion, external rotation (arm at side), internal rotation to tolerance - Goals by 6 weeks: 90-120° passive forward flexion, 30-40° passive ER, IR to abdomen - NO active motion (protect tuberosity fixation from rotator cuff pull) - Radiographs at 6 weeks: Assess tuberosity healing, hardware position, reduction maintenance **Phase 2 - Active-Assisted Motion (6-12 weeks)**: - IF tuberosity healing progresses on 6-week radiographs, advance to active-assisted - Wean sling (may use at night for comfort) - Active-assisted ROM: Pulley exercises, wand exercises, table slides - Gentle isometrics (deltoid, rotator cuff) if well-healed - Goals by 12 weeks: 120-140° active-assisted flexion, 40-60° ER, IR to L3-L4 - Radiographs at 12 weeks: Confirm tuberosity union, assess for AVN early signs **Phase 3 - Active Strengthening (12+ weeks)**: - Begin active ROM without assistance - Progressive resistance: Theraband, light weights (start 0.5-1 kg, increase gradually) - Rotator cuff strengthening protocol (external rotators, internal rotators, scaption) - Goals by 6 months: Near-full active ROM (140-160° flexion, 40-60° ER, IR to T12), functional strength - Radiographs at 6 months: AVN surveillance, assess tuberosity incorporation, hardware integrity **Long-term Follow-up**: - Radiographs at 1 year: AVN surveillance (may not appear until 12-24 months), tuberosity status - Return to activities: Unrestricted daily activities 4-6 months, return to sport 6-12 months (based on healing, strength) - Warn patient: Motion recovery slow (may take 12-18 months for maximal improvement), stiffness common (30-40%), AVN risk (monitor radiographically) ## References 1. **Neer CS 2nd. Displaced proximal humeral fractures. J Bone Joint Surg Am. 1970;52(6):1077-1089.** - Original description of Neer classification system (1-part, 2-part, 3-part, 4-part based on displacement >1cm or >45°). Foundational paper establishing treatment algorithms based on fracture pattern. Described blood supply to humeral head and AVN risk with different patterns. 2. **Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11:CD000434.** - Comprehensive systematic review and meta-analysis comparing surgical vs nonoperative treatment. Found insufficient evidence to determine superiority of surgery over conservative care for displaced fractures. Highlighted high complication rates with surgery (35% reoperation for ORIF). 3. **PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047.** - Landmark RCT comparing operative (ORIF or hemiarthroplasty) vs nonoperative treatment in 250 patients. Found NO significant difference in patient-reported outcome measures (Oxford Shoulder Score) at 2 years. Suggests nonoperative treatment may be adequate for many displaced fractures. 4. **Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21(3):185-191.** - Biomechanical study demonstrating the critical importance of medial column support in preventing varus collapse. Showed inferomedial calcar screw provides greatest resistance to varus collapse. Established concept that medial support (screw + bone graft if deficient) essential for construct stability. 5. **Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427-433.** - Anatomical study of humeral head blood supply. Described arcuate artery (from anterior humeral circumflex) as primary blood supply entering medially at calcar. Identified predictors of AVN: disruption of medial periosteum, length of metaphyseal head extension <8mm, disruption of medial hinge. Explained why valgus-impacted fractures have lower AVN rate. 6. **Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86(6):848-855.** - Large series of proximal humerus ORIF with locking plates. Reported 25% complication rate including AVN (14%), screw perforation (11%), tuberosity complications (8%). Emphasized importance of anatomical reduction, secure tuberosity fixation with sutures, and early passive motion to prevent stiffness. 7. **Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):401-412.** - Study of hemiarthroplasty outcomes demonstrating that tuberosity healing determines functional result. Found tuberosity nonunion or malposition in 27%, leading to poor outcomes. Emphasized critical importance of secure tuberosity fixation with heavy sutures through stem holes and around stem, anatomical positioning, and protected early mobilization. 8. **Gracitelli ME, Malavolta EA, Assunção JH, et al. Locking intramedullary nails versus locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg. 2016;25(5):695-703.** - RCT comparing locking plates vs intramedullary nails for 2 and 3-part fractures. Found no significant difference in functional outcomes but higher complication rate with nails (especially screw perforation). Supported use of locking plates as standard treatment for proximal humerus ORIF. 9. **Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective series with short-term follow-up. J Orthop Trauma. 2014;28(3):157-163.** - Prospective study comparing reverse shoulder arthroplasty vs nonoperative treatment in elderly patients with complex proximal humerus fractures. Found significantly better functional outcomes with reverse arthroplasty (Constant score 72 vs 54). Established reverse shoulder as superior option to conservative treatment in active elderly patients with 3 or 4-part fractures. 10. **Olerud P, Ahrengart L, Ponzer S, et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20(5):747-755.** - RCT of 3-part fractures in elderly comparing locking plate ORIF vs nonoperative treatment. Found no significant difference in functional outcomes but 30% complication rate in surgical group (including reoperation, AVN, tuberosity problems). Suggests nonoperative treatment may be adequate in elderly even for displaced 3-part fractures.

Proximal Humerus Fracture - Plating vs Hemiarthroplasty

Proximal Humerus Fracture - Plating vs Hemiarthroplasty