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Hello, everyone. My name is Ria and I'm a penultimate year medical student at Imperial College, London. I'm so excited to welcome you to Medals proximal humerus fracture lecture as part of the trauma series. And our speaker, Doctor MAOB L Hasan is a trauma and orthopedic surgery resident, but is also trained as a general practitioner and will be here for the talk. So I'll first play a recording and then there'll be a live Q and A where you can ask him questions today. I want to talk about proximal humerus. Hello. My name is I'm a surgeon or surge resident in special. Ok. Let me talk about proximal humor structure. And first of all, we will talk about the anatomy of proximal humerus. The ossification center appear, uh the eys will appear in four months. The great to count will appear in three years and the to count will be in five years and the physi scar will be in 20 to 22 years. This is, this is the retro, this is the surgical neck and this is the anatomical neck and this is the head of the humerus. Ok. The blood supply of the humerus this is mainly coming from the ai artery, anterior which has two branches, anterior humeral circumflex artery which give a ding branch called ar artery. It is a major blood supply, the articular surface and the GT ok. The anterior humoral circumflex and also the posterior humoral circumflex artery, which is the major and the main blood supply to the humeral head. The nerve around the proximal humerus, uh branches from the brachial ple is uh the most important one is the auxiliary nerve sus and mu as in this picture, the muscle around there are the rotator cuff muscle as we know they are supraspinal infraspinous terri minor and SEIS. And also there is deltoids and long head or places all these muscles will affect the displacement of the fracture fragment. As we know the vial measure will displace the shaft anteriorly and immediately due to this insertion. So in anterior minor will externally rotate the great and selar will internally rotate the articular segment or laser. The now let's see the history and demographic of the proximal humerus fracture. It account for uh 4 to 6% of all fracture. It has by model distribution. Young will develop it after very high energy trauma and elderly will have it after low energy trauma due to the osteoporosis. Ok. 45 col consists of 45% of all humerus fracture and uh it is uh in elderly female, 2 to 1 over males and 77% of all proximal humerus fracture occur in female. The most common type of the proximal humerus fracture are the two parts surgical neck fractures. They are the most common type. It uh they are increasing age. I see with more complex fracture types. The risk factor to develop this type of fracture with the osteoporosis, diabetes, epilepsy and female gender. Why I should never under it because it has a very terrible consequences like loss of motion. It can lead to a and atopic bone cause uh uh formation and it has other associated injuries like rotator cuff tea, a nerve injury is the most common is a nerve vascular injury and clavicle. Ok. When we say LM, there are some uh predictors of humor and head ischemia. It's called her criteria. Health criteria consists of uh if you find less than eight millimeter of car car attached to articular segment, this to review uh disrupted median hi increase in fracture, complexity, displacement, more than 10 millimeter and angulation. More than 45 degree. All of these are predictor of humeral head ischemia and those do not necessarily predict subsequent avascular nec necrosis. Let's see here. This is the car lens, longer the car lens beta, the predict to he ischemia. OK. This is here, it is one and here it is. So this is the immediate thing. Here it is un displaced and here it is displaced. Ok. Let's go for classification of humerus fracture. It has two classification near classification and a of classification. Near class classification, mainly based on anatomic relationship of four part. Signing this part are the greater two present, the lesser two present the articular surface and the shaft. They consider this separate bar. If the displacement is more than one centimeter and 45 degree of angulation, the A L classification organizes the fracture into three main groups and additional subgroup based on fracture location is status of the surgical neck and the presence or absence of this location. OK. Here near uh near classification. It is uh four bar. As we say you can uh you can save uh 12 bar classification. Two classification. It consists of anatomical neck and neck. Three bar may be surgical neck and uh four bar uh surgical neck and head split articular press and fracture dislocation in near four. OK. A O type A. It is uh two bar, extracapsular fracture, type two B, type B. It is three bar, partial inter capps fracture and type C has a vascular isolation of the hip and uh four bar inter capsule fracture. Uh As you can see here in this uh leg. This is this this fracture more than more than one centimeter and more than 45 degree as near define it. Uh This is too far uh head. This is two in the neck. OK. This is here to OK here good. And uh it is a multiple combination. Two part may be with the between the surgical neck and anomic and neck. Greater part may be between the surgical neck and greater or uh uh or may be between the uh an neck great or re and four part may be between uh neck and post plus or minus dislocation. OK. Radiographic workup. For proximal fracture, you should do very strong pro series. OK. And uh you should do through SCA A V view and should do axiliary view and Y or transcapular view. And you should also do ct if there is a particular fracture, there is an impression or head sleep or humeral head or position is uncertain for you. Also, you can do CT for groin fracture for uh to assess your place for o decision making. OK. Treatment. How we are going to treat proximal humeri fracture. Consideration for uh we can do or and we can do conservative treatment or close treatment when we will consider cross treatment, patient age. OK. Displacement of the fragment of the surgical and neck of the, of the articular surface of our patient arm dominance ability to some and a later on if needed. Uh our method to of close treatment will we will use the sling or hang in cast or abduction plow or uh we will use the sling for 2 to 3 weeks and immediate physical therapy for a range of motion. OK? You are the best when you know when to consider. Let me tell you how to be the best when we consider cross treatment in a patient which you select any patient is minimally displaced two bad fracture. Ok. If the greater to the fracture should be less than five millimeter and minim place three and four part fracture and fracture in patients who are not, who are uh not a surgical candidate fracture, who is not fit for surgery should have a close treatment. Ok? And when we should go for or if, if we find displacement of the greater counter more than five centimeter, if the to tea fracture with the involvement of articular surface, if you have displaced or unstable surgical neck fracture, or if you have displaced anatomic neck fracture in patient or displaced reconstruct three and four bar fracture fracture. When we will consider he arthroplasty. If the patient is young and middle age, if he has non reconstructive articular surface and severe head split or anatomic neck, we should consider this patient for he arthroplasty. In the elderly patient, many four part fracture should be considered he arthroplasty. Some severe three part fracture and mostly four part fracture dislocation should be considered for he plasty and hi split also should be considered for Hi arts. Our technique which you use to do internal fixation. We can use, we can use K wire tension B technique, we can use flexible nail, we can use also uh lock inter nails and we can use blade blade fixation. And the most common one is the proximal humeral blocking in blades to do this. We should know surgical approaches. We have uh multiple approaches in the proximal hus. You can use DEL to approach DEL approach approach or percutaneous as you know for fracture amenable to be or the debi approach when we will use it in uh surgical neck fracture fracture for and it is also surgery to the approach is better to use for uh GT fracture. OK. For uh some uh surgical neck fracture, if using inter fixation, posterior approach should be used for scapular glenoid and occasional posterior articular fracture before going to operation room. What we should do, of course, we should take the neur vascular examination and we should discuss with your with your patient about the risk of failure and potential complication and the need for revision to arthroplasty, especially with the physiologically ordered patient. What to avoid your new ation. You should avoid excessive and deas of sub fragment. You should avoid the excessive dissection within the o group to preserve the as branch of the anterior numeral circum artery, supplying the, you should avoid varus alignment or failure to restore the medial column support and avoid interarticular screw v. As we talk about the technique uh as the first one, it is a cu been in, you should uh use it in a very limited way in a 2 to 3 bar. OK. And when other technique are not favorable uh as you know, the technique. Uh You will be your patient in a piel sharp position and you will do your growth manipulation. OK. And the problem with this technique is that it is have a very high risk of nerve injury. It specifically to the axillary nerve and can lead to losing and migration of the pains. And you will not allow your patient to move fairly as you can see here. This is nice operation, a nice picture. But the problem is that this thing injures the axillary. Yeah. Other way to uh do all this flexible ner still problems with flexible knees. As you can see here, it is limited. Uh it has limited head fixation, it can migrate into subacromial space and uh co vil the best use in two part surgical neck fracture and is uh there is a new place and nerves are more than this one. The other thing you can use uh nerves or for proximal humerus, it is combined broke. Uh You, you can use it for combined proximal humerus and humeral shaft fracture. Both of them biomechanically, it is inferior with a torsion and stress compared to bla favorable rate of fracture, healing and range of motion compared to this is the most used. One is the proximal humoral, looking clear as you can see it uh looking leg uh that uh it is a screw is diversion. OK. As you can see, diversion better and here it is converging to hold all the frag means the proximate uh and some of this you will uh put traction, uh stitch, OK? Over the rotator cuff, it will help you to manipulate the, to process this OK? And to use it very easy. And during your dissection, you should uh take care of the lung cat by itself. It will help you to outline the fracture button and it will help you to guide the fracture production. As I tell you, your reduction should be with your uh 10 attraction. So the also your uh blade position should be the a along the axis of the humeral shaft. OK? And just go to the groove and inferior to the rotator cuff insertion or a great and we should put a cortical screw here. OK. So what are we gonna position the blade if you can see here? This is the same. OK. This is our blade and uh this is 5 to 8 millimeter from the our ta in operation. The most important screw is a car screw and I will show it. Now, always remember it's con this bone. So don't drill the distal cortex head is not to be the joint. So just you should forward your be with your o with your uh own hand power, don't drill it. OK? It will go and it will dis the dis cortex and it will never be treat it like this. This is a cul screw. It is the most important screw. OK? OK. As you can see this picture, what is the problem here? The problem here, this patient has a screw ration of the articular surface which is the most common complication following log blade and screw excision. S this been the articular surface and also other technique you can do. He was uh as you know, you can the approach, you will return to fragment SCU attachment and you will combine suture repair of bone graft from hip if needed. As the other problem with uh hems block is that it has unpredictable result from functional stand bound by standpoint. And you still require bony heal, osteoporosis best or sebastian and the elderly patient. Yeah, this vascular A BM like this direction. Our result if the patient has a surgical neck fracture, close treatment has uh yielded 60 to 90%. The result if it is greater to the 5200% has good result with displaced more than five millimeter fracture, treated close and good result is or if for this patient has three bar as a result, close treatment, minimal displacement or non yield, unpredictable result in three bar. And they have a 50 to 70 we say 15 70% or if with good reduction has uh 60 to 80%. Good to excellent result for bar fracture has a good result with pain in art velocity, gives this pain result with somewhat unpredictable functional result. Or if in the younger patient have uh 50% factor result higher A BM in the morning head is believe show segment attached to the re the only if severe fragmentation of articular surface. Then we should do you also some part of our, we should do postoperative rehabilitation and it is very important part of the management. The best result is guided protocol which is called three phase program. The F is pass range of mo then active range of motion and progressive resistance and advanced program. What is the complication of risk fracture? The complication there is misdiagnosis. OK. Other thing, the degree of uh GT displacement and uh missed posterior dislocation of the shoulder, it can lead to massive which is high dislocation suspect when there is severe swelling and also screw cut out up to 14%. It is the most common complication of the or if these are pre articular ro uh play long head of biceps 10 to injury with anterior pain in the closed reduction technique and uh posttraumatic arthritis. And also it can lead to infection. Also, no union can have been and the greater risk factor for no union. Our age and smoking in the end non union should be treated like acute fracture if he is viable and consider him or elderly or osteoporotic patient or the patient can develop a BN significant incidence in three and four part fracture higher when treated with a if unlike hi incidence does not correlate directly with the symptom, not like the A BN. And it can be minimized with decreased soft tissue streaming and avoiding circumflex and art artery or association can develop adhesive capitis as a complication and almost in it is almost in but minimise with early motion and manipulation under anesthesia and occasional. Also the vision can misdiagnose for poster dislocation. It is associated with seizure, electrical shock and commonly missed on x-ray. It has a very high incidence of association with lesser fracture. like this picture can be OK. That's a conclusion. Proximal humerus fracture is a common fracture, especially in elderly osteoporotic patient. The proximal humerus is is cancel and this suspect of o fracture. It has uh many muscle attachment which determines the displacement better of the fracture. It is most uh most of them are minimally displaced in one part fracture associated with the rotator cuff tear. During your evaluation for your patient. If he has a history of trauma or minimal fall, he will have a pain and difficult to move of all. Your physical exam will find hum tenderness, decreased range of motion, loss of minor deformity. We should do x-ray and ct to identify fragment and displacement. The classification as we already know it is uh near which based on the number of uh the part. OK. It has multiple combination of fragment and the treatment as conclusion. One part fracture, uh two part a one fracture you should do and motion and two parts you should do close reduction and then uh motion and three part, you should do uh o treatment. OK. And four part better to do a uh to do your or you should uh use approach. She said approach. As we know the most common one we use in our proximal shoulder is anterior delve approach. The most common complication from the anterior vector approach is the is the, is the vi we can uh in the, in the mucus nerve with vigorous refraction of tender, we can injure the cephalic vein and we can injure the axiliary nerve and we can use it for, to the cuff and for arthroplasty and for pro fracture. Thank you very much. Do you have any question? Yes, I can hear you right now. Perfect. Um So someone in the audience has asked what the role is of the biceps tenodesis. OK. The by safe tendon is just around mark for us during our uh operation. Uh We will put our plate just posterior to it to avoid injuries, the anterior, the anterior uh circum tumor artery during our operation because it is the main loss of life of the hum brilliant. Um I am just waiting for the audience to ask any more questions if they have any. Um I had a question myself for you um for adhesive capsulitis. How is it diagnosed that that his of ps is mainly a clinical diagnosis? Ok. Uh During your history and your examination, we will sort it out. Thank you so much. That was a really interesting talk to watch. Um, as someone who's interested in orthopedics myself, I thought, um, it was really clear and I loved the diagrams as well. They're really helpful. I'm just waiting to see if the audience have any more. Ok. Thank you very much for the, for the inconvenience because they have very bad internet connection. I am so sorry for that. No problem at all. Um We're just waiting to see if the audience have any more questions. Brilliant. OK. I don't think there are any more questions in the audience. Thank you so much for that talk. It was really interesting. Magoo. Um And um I'm really grateful that you gave up your time to teach us all something and it's been so useful hearing about proximal humerus fractures. So I really appreciate it. Um Thank you so much. All right, take care. Bye. Thanks.
