Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Sep 29 2024

Proximal Humerus Fracture Nonunion and Malunion

Images
https://upload.orthobullets.com/topic/12283/images/f2.large.jpg
https://upload.orthobullets.com/topic/12283/images/qq.jpg
  • Summary
    • Proximal Humerus Fracture Nonunion and Malunion are common complications associated with proximal humerus fractures which can lead to persistent shoulder pain, instability, and restricted motion.
    • Diagnosis is made radiographically with shoulder radiographs demonstrating malposition of the humeral tuberosities, varus/vaglus head-shaft angulation, articular incongruities, or absence of bony union.
    • Treatment ranges from nonoperative to revision ORIF to shoulder arthroplasty depending on severity of malunion, available bone stock, patient age and activity demands.
  • Epidemiology
    • Incidence
      • common
        • proximal humerus fractures account for 4% to 5% of all fractures
    • Risk factors for nonunion
      • fracture characteristics
        • 2-part (surgical neck) fracture patterns
        • humeral head split
        • displaced tuberosity fractures
      • patient factors
        • osteoporosis
        • chronic renal disease
        • chronic alcohol or steriod use
        • smoking
  • Etiology
    • Pathophysiology
      • origin of malunion
        • initial fracture displacement
        • secondary displacement after loss of reduction
        • failure of internal fixation
      • humeral head malunion
        • varus/valgus
        • impacted (>1cm displacement)
        • articular surface incongruity (e.g. head split)
      • greater tuberosity malunion
        • usually displaced posterior, superior and externally rotated
      • lesser tuberosity malunion
        • usually displaced medial
    • Associated conditions
      • rotator cuff tearing
      • osteonecrosis of humeral head
      • glenohumeral joint issues
        • stiffness
        • post-traumatic arthritis
        • subluxation or dislocation
        • subacromial impingement
  • Anatomy
    • Humeral head
      • shape
        • spheroidal in 90% of individuals
      • size
        • average diameter is 43 mm
      • orientation
        • retroverted 30° from transepicondylar axis of the distal humerus
        • neck-shaft angle usually 130° to 140°
    • Greater tuberosity
      • position important for rotator cuff muscle fuction
        • horizontal position
          • medial edge of tuberosity is 10mm lateral to humeral canal axis
        • vertical position
          • superior edge of tuberosity is 6mm inferior to upper edge of humeral head
  • Classification
      • Beredjiklian Classification
      • Type I
      • Malposition of the greater or lesser tuberosity( e.g. >1 cm from native anatomical position)
      • Type II
      • Articular incongruity (e.g.intra-articular fracture extension, osteoarthritis)
      • Type III
      • Articular surface malalignment ( e.g. >45°of deformity with respect to the humeral shaft in the coronal, sagittal, or axial planes
      • Boileau Classification
      • Type I
      • Humeral head necrosis or impaction
      • Type II
      • Chronic dislocations or fracture-dislocations
      • Type III
      • Nonunion of the surgical neck
      • Type IV
      • Severe malunion of the tuberosity
  • Presentation
    • History
      • initial evaluation
        • date and mechanism of injury
        • current and prior function
        • handedness
        • treatment to date
        • specific goals of treatment
    • Symptoms
      • pain and weakness
      • limitations
    • Physical exam
      • inspection
        • features of systemic disease
        • muscle atrophy
        • diffuse tenderness
      • motion
        • active and passive shoulder range-of-motion
          • blocks or crepitus should be noted
        • rotator cuff
          • greater tuberosity malunion = weakness with abduction, external rotation
          • lesser tuberosity malunion = weakness with internal rotation
        • instability
          • humeral head malunion = apprehension test
      • neurovascular
        • check axillary nerve function
  • Imaging
    • Radiographs
      • recommended views
        • true AP, scapular Y, axillary
      • optional views
        • apical oblique
        • Velpeau
        • West Point axillary
      • findings
        • neck-shaft angle = varus or valgus
        • greater tuberosity = superiorly and posteriorly displaced, externally rotated
        • lesser tuberosity = medialized
      • measurements
        • humeral head
          • > 45° of deformity in any plane
          • symptomatic articular incongruity
          • neck-shaft angle <120° or >150°
        • greater or lesser tuberosity
          • >1 cm from native anatomical position
    • CT scan
      • indications
        • preoperative planning
        • assess bone stock, orientation and articular surface
      • findings
        • humeral head and greater tuberosity displacement
        • glenoid version and glenoid bone stock
        • articular injury
    • MRI
      • indications
        • preoperative planning
        • soft-tissue structures
      • findings
        • rotator cuff or labral injury
        • deltoid atrophy secondary to axillary nerve injury
        • long-head biceps injury
        • osteonecrosis
  • Studies
    • Labs
      • CBC, ESR, CRP, blood cultures to rule out infection
    • Electrodiagnositcs
      • concern for nerve dysfunction
  • Treatment
    • Nonoperative
      • NSAIDS, physical therapy, occasional corticosteroid injection
        • indications
          • low-demand patient
          • painless shoulder limitations
          • unable to comply with the rehabilitation protocol
        • modalities
          • physical therapy
            • maximize ROM and strengthening program
        • outcomes
          • impacted varus and valgus fractures show good-to-excellent results
            • return to 90% of normal function
    • Operative
      • ORIF +/- osteotomy, subacromial decompression, and soft tissue technique
        • indications
          • symptomatic malunion following
            • nonoperative treatment
            • failed internal fixation
          • anatomical requirements
            • adequate bone stock for fixation
            • preserved articular surface
            • intact blood supply to humeral head
        • outcomes
          • complication rates associated with surgical management of malunions are higher than those associated with acute fractures
      • shoulder arthroplasty
        • indications
          • symptomatic malunion following
            • nonoperative treatment
            • failed internal fixation
          • anatomical requirements
            • inadequate bone stock for fixation techniques
            • articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split)
            • compromised blood supply
            • chronic dislocation
        • techniques
          • hemiarthroplasty
          • total shoulder arthroplasty
          • reverse total shoulder arthroplasty
            • greater improvement in functional outcome scores than hemiarthroplasty
            • lower complication rates than hemiarthroplasty 
  • techniques
    • ORIF +/- osteotomy, subacromial decompression, and soft tissue technique
      • technique
        • humeral head deformities
          • minor deformity techniques
            • open/arthroscopic tuberoplasty
            • +/- acromioplasty
            • +/- capsular release
            • +/- bursectomy
          • severe deformity techniques
            • varus/valgus osteotomy
            • +/- rotational osteotomy and lateral plate fixation
              • treated with corrective osteotomy/fixation if patient is young or active
              • may be augmented with strut allograft for poor bone stock
        • greater tuberosity deformities
          • <1.5 cm displacement
            • arthroscopic subacromial decompression +/- rotator cuff repair
          • >1.5 cm displacement
            • open/arthroscopic tuberosity osteotomy +/- subacromial decompression
    • Shoulder arthroplasty
      • technique
        • hemiarthroplasty
        • anatomic total shoulder arthroplasty 
        • reverse total shoulder arthroplasty 
  • Complications
    • Persistent pain and weakness
    • Stiffness
    • Loss of fixation
    • Infection
    • Bleeding
Card
1 of 0
Question
1 of 4
Private Note