CERTIFICATE BY THE GUIDE

FUNCTIONAL OUTCOME ANALYSIS OF PROSTHETIC REPLACEMENT OF COMMUNITED, DISPLACED PROXIMAL HUMERUS FRACTURES IN ELDERLY

INDIVIDUALS

A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

CHENNAI

in partial fulfilment of the regulations for the award of degree of

M.S. DEGREE EXAMINATION BRANCH - I (ORTHOPAEDICS)

REG. NO:221712104

DEPARTMENT OF ORTHOPAEDICS MADURAI MEDICAL COLLEGE – MADURAI

MAY 2020

CERTIFICATE BY THE HEAD OF THE INSTITUTION

This is to certify that the work “FUNCTIONAL OUTCOME ANALYSIS OF PROSTHETIC REPLACEMENT OF COMMUNITED,DISPLACED PROXIMAL HUMERUS FRACTURES IN ELDERLY INDIVIDUALS" which is being submitted for M.S.

Orthopaedics, is a bonafide work of Dr.A.MUTHU VIGNESH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College, Madurai.

Prof.Dr.J. SANGUMANI, MD., The Dean ,

Madurai Medical College, Madurai.

CERTIFICATE BY THE HEAD OF THE DEPARTMENT

This is to certify that the work “FUNCTIONAL OUTCOME ANALYSIS OF PROSTHETIC REPLACEMENT OF COMMUNITED, DISPLACED PROXIMAL HUMERUS FRACTURES IN ELDERLY INDIVIDUALS " which is being submitted for M.S. Orthopaedics, is a bonafide work of Dr.A.MUTHU VIGNESH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College, Madurai.

Prof. Dr.R.ARIVASAN, M.S Ortho., Professor and Head,

Department of Orthopaedics & Traumatology Madurai Medical College,

Madurai.

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation “FUNCTIONAL OUTCOME ANALYSIS OF PROSTHETIC REPLACEMENT OF COMMUNITED, DISPLACED PROXIMAL HUMERUS FRACTURES IN ELDERLY INDIVIDUALS " is the bonafide work done by Dr.A.MUTHU VIGNESH under my direct guidance and supervision in the Department of Orthopaedic Surgery, Madurai Medical College, Madurai.

Prof Dr.N.THANAPPAN M.S ORTHO, Professor and Chief Ortho unit-III,

Department of Orthopaedics & Traumatology Madurai Medical College,

Madurai.

ACKNOWLEDGEMENT

I am grateful to Prof.Dr.R.Arivasan, M.S.,Ortho, D.Ortho., Professor and Head, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College in guiding me to prepare this dissertation.

I am greatly indebted and thankful to my beloved chief, my guide & co-guide Prof Dr.N.Thanappan M.S.Ortho Ortho-III unit, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College for his invaluable help, encouragement and guidance rendered to me in preparing this dissertation.

I am most indebted and take immense pleasure in expressing my deep sense of gratitude to Prof.Dr.V.R.Ganesan M.S.Ortho.,D.Ortho, Prof.Dr.B.Sivakumar M.S.Ortho.,D.ortho, Prof.Dr.Thirumalaimurugan M.S.Ortho., for their easy accessibility and timely suggestion, which enabled me to bring out this dissertation. I take immense pleasure to thank my co-guide Dr.J.Maheswaran M.S.Ortho.,DOrtho., for his timely help and encouragement.

At the very outset I would like to thank Dr.Vanitha M.D, the Dean, Madurai Medical College and Govt. Rajaji Hospital, Madurai for permitting me to carry out this study in this hospital.

I also take this opportunity to thank Dr.M.N.Karthi M.S.Ortho., Dr.Prem kumar M.S.Ortho., Dr.J.Maheswaran M.S.Ortho., Dr.T.SaravanaMuthu M.S.Ortho., Dr.V.A.Prabhu M.S.Ortho., Dr.R.Karthik Raja M.S.Ortho., Dr.Senthil Kumar M.S.Ortho., Dr.Gokulnath M.S Ortho., Dr.Anbarasan M.S Ortho., Dr.S.Karthikeyan M.S Ortho., Dr.Singaravel M.S Ortho., Dr.Saravanan M.S Ortho Assistant Professors, Department of Orthopaedics, Madurai Medical College, for their timely help and guidance given to me during all stages of the study.

Last but not the least, I express my gratitude to the patients for their kind co-operation.

DECLARATION

I, Dr.A.Muthu Vignesh, solemnly declare that the dissertation titled “FUNCTIONAL OUTCOME ANALYSIS OF PROSTHETIC REPLACEMENT OF COMMUNITED, DISPLACED PROXIMAL HUMERUS FRACTURES IN ELDERLY INDIVIDUALS ", has been prepared by me. This is submitted to “The Tamil Nadu Dr. M.G.R. Medical University, Chennai, in partial fulfillment of the regulations for the award of M S degree branch II Orthopaedics.

Dr.A.MUTHU VIGNESH

PART A

CONTENTS Page

No.

Introduction 1

Aim and Objective 3

Review of Literature 4

Anatomy 10

Incidence & Etiology 27

Mechanism of injury 29

Risk of AVN 30

Outcome measures for proximal humerus fractures 34

Functional outcome scales 38

Signs and symptoms of proximal humerus fracture 47

Radiographic evaluation 50

Management 51

PART -B

ANNEXURES :

a. BIBLIOGRAPHY b. MASTER CHART

c. ETHICAL COMMITTEE APPROVAL

d. PLAGIARISM FIRST PAGE & DIGITAL RECEIPT

CONTENTS Page

No.

Methodology 58

Subjects 67

Statistical analysis 70

Results 82

Discussion 85

Conclusion 88

1

INTRODUCTION

Proximal humeral fractures, defined as fractures occurring at or proximal to the surgical neck of the humerus and affect 2.4%

of women over the age of 75 years. In patients above the age of 65 years proximal humeral fractures are the second most frequent upper extremity fracture, and the third most common nonvertebral osteoporotic fracture after proximal femur and distal radius fractures, accounting for >10% of fractures in this patientpopulation. Females are more commonly affected than males and it has been demonstrated that 15% to 30% of fractures occur in males. The incidence has been shown to increase exponentially at a rate of over 40% every 5 years at age 40 in females and age 60 in males. Approximately half of all proximal humeral fractures occur at home with the majority occurring as a consequence of falls on level ground. In individuals 60 years or older,over90%of proximal humeral fractures result from a fall from a standing height. The proximal humerus can fracture as a consequence of three main loading

2

modes: compressive loading of the glenoid onto the humeral head, bending forces at the surgical neck, and tension forces of the rotator cuff at the greater and lesser tuberosities.

Nonoperative treatment continues to be used for

the majority of proximal humeral fractures. The majority of proximal humeral fractures are nondisplaced or minimally displaced and nonoperative treatment is indicated. The use of nonoperative treatment can be determined by assessing fracture stability. Fracture stability can be assessed both radiographically and clinically. ORIF is the most frequently used method of surgical treatment of proximal humeral fractures. Comminuted head-splitting fractures and head depression fractures involving more than 40% of the articular surface are frequently considered to be unreconstructable.

In the elderly, especially with more complex four-part fractures and fracture dislocations, hemiarthroplasty is indicated to decrease complication rates and improve functional outcomes.

3

AIMS AND OBJECTIVES AIM:

To analyse the functional outcome of prosthetic replacement of communited, displaced proximal humerus fractures in elderly individuals.

OBJECTIVES:

1. To analyse the clinical ,radiological & functional outcome of elderly patients treated with prosthetic replacement of comminuted proximal humerus fracture

2. To assess the range of movements, functional outcome at 3months ,6 months ,12 months and 24 months

3.

STUDY DESIGN:

Prospective study

4

REVIEW OF LITERATURE

Robinson et al., Primary shoulder hemiarthroplasty

performed for the treatment of a proximal humeral fracture in medically fit and cooperative adults is associated with satisfactory prosthetic survival at an average of 6.3 years.

Although the shoulder is usually free of pain following this procedure, the overall functional result, in terms of range of motion, function, and power, at one year varies. A good functional outcome can be anticipated.

R.Castricini et al., Management of proximal humeral

fractures with Hemiarthroplasty was very satisfactory or satisfactory in 91% of our patients. Accurate patient selection, careful surgical technique, and patient compliance with the rehabilitation programme seem to be critical factors in achieving good results. A mean Constant score of 59.2 reflects good joint, and ADL function with scarce or no pain in most patients.

5

Mighell et al.,We reviewed 80 shoulders (72 shoulders in 71 patients) treated with hemiarthroplasty. At follow-up, 66 patients (93%) were pain-free and satisfied with their results;

the mean American Shoulder and Elbow Surgeons score was 76.6, the mean Simple Shoulder Test score was 7.5, the average forward flexion was 128 degrees, external rotation was 43 degrees, and internal rotation was to L2. Radiographic analyses revealed nearly anatomic tuberosity reconstruction in 58 shoulders, heterotopic ossification in 18, pseudosubluxation in 10, and superior migration in 15. Patients with superior migration had statistically lower mean American Shoulder and Elbow Surgeons scores, mean Simple Shoulder Test scores, and decreased forward flexion. Tuberosity complications occurred in 16 shoulders. Malunion of the greater tuberosity was the most common complication. Healing of the greater tuberosity more than 2 cm below the humeral head correlated with a worse functional result. Hemiarthroplasty for indicated fractures of the proximal humerus results in shoulder-level function and reproducible pain relief.

6

Demirhan et al Thirty-two patients [mean age 58 (range 37–83 years)] with a mean follow-up period of 35 months (range 8–80 months). Fifteen cases had Neer type IV, 2 had type III, and 15 patients had fracture-dislocations for which hemiarhtroplasty shoulder was done.Excellent or good results according to Neer's criteria were obtained in 24 of the 32 cases (75%), and unsatisfactory results in 8 cases (25%). Mean Constant score was 68 (range 19–98) and mean elevation degree 113 (range 30–180).

Esen et al., We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9 ± 5.57 years (age range: 59–81 years). n humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and

7

long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction.

Li JW et al., elderly patients with comminuted proximal humeral fractures (Neer IV) were treated, including 4 males and 27 females, aged from 55 to 94 years old with an average age of 71 years, with a course of 1 to 3 years.Thirty-one patients were followed up for 1 to 3 years with an average of 2 years. In HA group, there was no prosthesis loosening, fracture and subsidence, the head of artificial humerus was intact, the fracture of nodules and nodules did not heal in 1 case, Neer score was 84.18±3.55; in ORIF group, there were 8 cases of proximal humerus bone resorption, 1 case of fracture nonunion, 1 case of internal fixation loosening, Neer score was 55.91±10.78; there was significant difference in Neer score of shoulder joint function between the two groups(P<0.05).

Gupta et al., Significantly better clinical outcomes were observed for ORIF over HA and RSA (American Shoulder and Elbow Score, Disabilities of Arm, Shoulder, and Hand, Constant)

8

(P < 0.05). However, ORIF had a significantly higher reoperation rate versus HA and RSA (P < 0.001 for both). Comparing HA with RSA, there was no difference in any outcome measure. The rate of tuberosity nonunion was 15.4% in the HA group. There were more complications following closed reduction and percutaneous pinning versus ORIF, HA, and RSA (P < 0.05). ORIF for proximal humerus fractures demonstrates better clinical outcome scores but with a significantly higher reoperation rate.

HA and RSA are effective as well, but tuberosity nonunion remains a concern with HA.

Adam Schumaier et al.,Proximal humerus fractures in the elderly are common. A majority of minimally displaced fractures can be treated conservatively with early physical therapy.

Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors.

Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. With internal fixation, special attention should be paid

9

to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.

Dietrich et al.,The patient groups showed no differences in age, gender, or fracture type. Median CS was significantly better for FAPF (71 vs 41). Evaluation of pain demonstrated no differences between the two treatment modalities in the OSS.

Revision surgery was performed more often in the FAPF group (25% vs 2%).Compared to SHA, functional outcome was superior with FAPF. However, this was associated with a higher rate of revision surgery. Most patients were still able to live independently in their original environment, regardless of the type of surgery.

10

ANATOMY OF SHOULDER JOINT

Consists of 3 bones and 4 articulations Three bones are

1.clavicle 2.scapula 3.humerus Four articulations

1. acromioclavicular joint 2. sternoclavicular joint 3. glenohumeral joint 4.scapulothoracic joint Stabilizers of shoulder joint

Static - Bone geometry Glenoid labrum

Capsule & ligaments

11

Intra articular pressure Dynamic - primary stabilizer

Secondary active stabilizers Neuro muscular control Clavicle

It extends from the sternum (convex end) to the acromion(concave). Due to its S-shape, the lateral end undergoes more rotation during arm elevation compared to its medial end.

The joint capsules of both the sternoclavicular and the acromioclavicular are further stabilized by ligaments.

Scapula

It’s a flat bone and it acts as site of muscle attachment around the shoulder. It has 3 borders, 3 angles and 4 process. Its medial border is vertical and parallel to the spine. The inferior angle of scapula is at the level of spinous process of D7.

12

The four processes of scapula are coracoid process, acromion,spinous process and glenoid fossa (articular process).

It is convex in the dorsal aspect. Its divided into two fossae by the spinous process:

Supraspinous fossa Infraspinous fossa.

Humerus:

The articular area of the head of humerus, which is retroverted and medial, is separated from the greater and lesser tuberosities by its anatomical neck.

Glenoid cavity:

Glenoid fossa is at the lateral end of the scapula. It is pear shaped, having an inferior surface which exceeds the superior surface by 20%. Its alignment is anterolateral with a cranial tilt.

It is 25% the size of the head of humerus. This is why, Shoulder joint enjoys mobility at the cost of stability.

13

Glenoid labrum:

Its fibro cartilaginous rim located along the glenoid fossa s border. It attaches to peripheral margin of glenoid cavity except above. It deepens the glenoid fossa and forms pliable cushion for ball to roll. It gives attachment to glenohumeral ligaments.

Gleno-humeral ligaments

They are located in front of the joint and are construed as the capsule’s thickened areas.

 Superior gleno humeral ligament

 Middle gleno humeral ligament

 Inferior gleno humeral ligament

14

SGHL -extends from the glenoid labrum’s upper part and the coracoid base to the humeral head, precisely in between the lesser tuberosity’s superior part and the anatomical neck. Along with coraco humeral and supraspinatus, it preventsthe downward displacement of humeral head.

MGHL- extends from the glenoid fossa’s anterior margin below sghl attachment and passes to the humeral neck. It stabilizes the joint anteriorly in the mid abduction.

IGHL- extends from anterior-posterior margins of the lower glenoid labrum and forms an inferior pouch. the thick anterosuperior part is called the superior band. The inferior part is named the axillary pouch. The lower component of the IGHL

15

offers buttress -like support for the joint’s anterior and inferior parts. This segment stabilizes the joint in the upper abduction ranges, while negating subluxation and dislocation anteriorly.

Sterno clavicular joint:

The SC articulation consists of two saddle-shaped surfaces one at the sternal or medial end the clavicle and one at the notch formed by the manubrium of the sternum and first costal cartilage.

Ligaments of sternoclavicular joint:

 Capsular ligaments

16

 Sternoclavicular ligaments – anterior & posterior

 Interclavicular ligaments

 Costo clavicular ligaments



Articular disc

Articular disc:

It is a fibrocartilaginous disc to increase the congruency b/w incongruent articular surface. It diagonally transects the SC joint space and divides the joint into 2 separate cavities. It is considered part of the manubrium in elevation /depression and thus the upper attachment of the disc serves as pivot point and the disc acts as the part of the clavicle in protraction / retraction with lower attachment serving as pivot point.

17

Acromio clavicular joint:

It allows the scapula additional range of rotation on the thorax and allow for adjustments of the scapula outside the initial plane of the scapula in order to follow the changing shape of the thorax as arm movement occur. In addition, the joint allows transmission of forces from the upper extremity to the clavicle.

Ligaments of acromio-clavicular joint:

 Fibrous capsule

 Acromio-clavicular ligaments

 Coraco-clavicular ligaments

18

conoid part -oriented vertically, resists superior & inferior forces trapezoid part -oriented horizontally

Coraco-acromial ligament :

Glenohumeral joint:

It is a ball -socket joint type. The articulating surface of the head of humerus is spherical, comprising an arc of 160˚of articular cartilage. The humeral articular surface has a radius of 25mm. The glenoid articular surface’s curvature radius is 2-3mm larger than that of head of humerus. The neck shaft angle is 45˚.

Humeral head is retroverted 55˚ and glenoid is 2˚ of anteversion to 7˚ of retroversion.

19

Ligaments of Glenohumeral joint:

 Fibrous capsule

 Glenohumeral ligaments

 Coraco humeral ligament

 Transverse humeral ligament

20

Scapulothoracic joint:

It is not a true anatomic joint. The functional ST joint is part of a true closed chain with the AC and SC joint and the thorax. Example, When the arm is abducted, scapula undergoes upward rotation, external rotation and posterior tipping (allmovements in combination)

Shoulder movements:

 Flexion

pectoralis major biceps brachii anterior deltoid

21

 Extension

posterior deltoid teres major

latissimus dorsi

 Abductors

supraspinatus deltoid

trapezius & serratus anterior

 Adductors subscapularis infraspinatus

teres minor& major latissimus dorsi

 Internal rotation subscapularis

22

latissimus dorsi

anterior fibres of deltoid pectoralis & teres major

 External rotation infraspinatus teres minor

posterior fibres of deltoid

23

Vascular supply:

Perfusion of the upper extremity is mainly from the axillary artery and its branches. Perfusion of the proximal humerus arises from the axillary artery where it passes between the pectoralis minor and teres major muscles. At this level, the axillary artery gives off the humeral circumflex arteries . The ACHA runs horizontally behind the conjoined tendon over the anterior aspect of the surgical neck of the humerus to anastomose laterally with the PCHA. At the level of the biceps tendon the ACHA gives off a branch that ascends behind the long head of the biceps on the surface of the bicipital groove proximally . Within 5 mm of the articular surface it penetrates the cortical bone, becoming the arcuate artery which provides vascularity to most of the humeral head

The PCHA arises as a larger branch at the same level as the ACHA at the lower margin of the subscapularis muscle. It travels posteriorly with the axillary nerve giving off several branches that pierce the posteromedial aspect of the proximal humeral

24

metaphysis providing vascularity to the humeral head. The PCHA finally crosses the quadrilateral space winding around the surgical neck and anastomosing anteriorly with the ACHA. While some authors have found the arcuate artery from the anterolateral ascending branch of the ACHA to be the main arterial supply to the humeral head,147 several studies have shown branches from the PCHA to the posteromedial head to be at least equally important.

25

Nerve supply:

Several nerves are at risk of damage from manipulation of the

proximal humerus or surgery. The axillary nerve can be injured by the initial injury, or secondarily by percutaneous fixation. The axillary nerve is one of the terminal branches of the posterior cord of the brachial plexus. Its motor fibers innervate the teres minor and deltoid muscles; the sensory component innervates the skin overlying the lateral aspect of the proximal arm. At the level of the proximal humerus, the axillary nerve passes from anterior to posterior, accompanied by the posterior circumflex artery, inferior to the anatomic neck through the quadrilateral space surrounded by teres major superiorly, the long head of the triceps medially, teres major inferiorly, and the humeral shaft laterally. After giving off the branch to the teres minor, it passes anteriorly on the undersurface of the deltoid at a distance ranging from 2 to 7 cm distal to the acromion. This distance has been found to be inversely proportional to the length of the deltoid. It crosses the anterior deltoid raphe between the

26

anterior and middle deltoid in the form of a single terminal branch allowing for preservation of the innervations of the anterior deltoid when the nerve is isolated during the deltoid- splitting approach.

27

PROXIMAL HUMERUS FRACTURE

INCIDENCE AND ETIOLOGY:

Cofield’s summary of treatment of proximal humeral fractures is an indication of the difficulty of treating these injuries—from first evaluation to final outcome. Much controversy and confusion still exist, and no single treatment protocol or algorithm has been proved to be universally effective.

As indicated by Cofield, areas still in question include radiographic diagnosis, operative or nonoperative treatment, consideration of patient age in treatment decision making, surgical approach, fracture fixation or hemiarthroplasty, type of internal fixation, and rehabilitation protocol. Numerous authors have suggested that nonoperative treatment may be preferable for two-, three-, and four-part proximal humeral fractures in elderly patients, but pain and loss of function have been reported in high percentages of patients after this treatment approach.

Several more recent reports, however, have indicated that the functional results of operative treatment are not significantly

28

better than the results of nonoperative treatment in elderly patients, although radiograph results may be superior. Court- Brown et al. reported good or excellent results in 81% of impacted valgus fractures in elderly patients treated nonoperatively, and in a comparison of operative and nonoperative treatment of displaced two-part fractures, these authors found similar results in the two treatment groups. In one of the largest studies to date (PROFHER), with 231 patients, the authors were unable to show superiority of operative or nonoperative treatment using the Oxford Shoulder Score as the primary outcome. In a study of the geographic incidence and treatment variation of common fractures in elderly patients, Sporer et al. found large variations in the percentage of proximal humeral fractures treated operatively, ranging from 6.4% to 60%; in eight regions of the United States, at least 40% were treated operatively, whereas in 35 regions, fewer than 20% were treated operatively. The fact that 10 different fixation techniques were evaluated for a single fracture type (fractures of the surgical neck of the humerus) is further indication of the

29

complexity of treating proximal humeral fractures. Interestingly, one study showed a higher rate of operative treatment of proximal humeral fractures among upper extremity surgeons compared with trauma surgeons.

MECHANISM OF INJURY:

The proximal humerus can fracture as a consequence of three main loading modes: compressive loading of the glenoid onto the humeral head, bending forces at the surgical neck, and tension forces of the rotator cuff at the greater and lesser tuberosities. When the glenoid impacts on the humeral head during a fall in individuals with normal bone, the proximal humeral epiphysis appears to be able to resist local compressive loads. The energy is then transferred further distally, where the weaker metaphyseal bone may yield, resulting in a surgical neck fracture. In individuals with osteoporotic bone, weaker epiphyseal bone may yield simultaneously with the surgical neck, thereby leading to more complex multifragmentary fractures. Apart from bone quality fracture configuration is

30

influenced by the amount of kinetic energy conveyed to the shoulder, and by the position of the upper limb during injury.

When falling onto the outstretched hand with the shoulder in flexion, abduction, and internal rotation the glenoid forces the humeral head into valgus, hinging around the inferomedial aspect of the stronger calcar bone.

RISK OF AVASCULAR NECROSIS:

The arcuate artery from the anterolateral ascending branch of the anterior circumflex humeral artery (ACHA) has historically been considered to provide the main arterial supply to the humeral head. Fractures through the anatomic neck have therefore been considered to permanently disrupt perfusion of the humeral head. However more recent literature has shown that branches from the posterior circumflex humeral artery (PCHA) to the posteromedial proximal humeral metaphysic provide equally important blood perfusion to the humeral head.

Coudane et al.75 showed, with arteriography, that in patients

31

with complex proximal humeral fractures the PCHA was preserved in 85% of cases as opposed to only 20% of the ACHA.

In complex proximal humeral fractures, the posteromedial branches from the PCHA therefore become the main supply to the head. Several morphologic fracture features have been proposed to estimate the possibility of the disruption of this blood supply and hence to assess the risk of avascular necrosis (AVN). These features include varus displacement of the head,the size of metaphyseal fracture extension of the humeral head and the medial displacement of the humeral shaft in relation to the humeral head. Hertel et al. studied 100 intracapsular proximal humeral fractures, in which at least one component of the fracture was proximal to the anatomic neck, undergoing operative treatment. Several fracture characteristics, as possible predictors for humeral head ischemia, were studied and shown to correlate with intraoperative assessment of humeral head perfusion. Distal metaphyseal extension of the head fragment of 8 mm or less, disruption of the medial hinge between the humeral head and

32

the shaft at the level of the calcar, and fractures through the anatomic neck were independent predictors for humeral head ischemia. Although this study has been widely used to help in decision making between fixation and replacement of proximal humeral fractures, a follow-up study from the same authors found a poor correlation between intraoperative ischemia and development of AVN. This discrepancy is further supported by a study of Croby et al., in which tetracycline was administered to 19 patients with three and four-part fractures of the proximal humerus during 5 days preceding operative treatment. Humeral head biopsies were obtained from hemiarthroplasty surgery and analyzed using fluoroscopic microscopy. Fluorescence was observed in all specimens suggesting that vascular supply was not disrupted in any of the fracture patterns.

33

HERTEL’S CRITERIA

34

Outcome Measures for Proximal Humerus Fractures

In the early 1900s, E. Amory Codman, who is frequently cited as the father of shoulder surgery, introduced his “end result idea.” It was his belief that every treated patient should be followed long enough to determine whether treatment had been effective or not.7Although his idea did initially face strong resistance, outcome assessment has become the backbone of clinical research, audit, and clinical governance. Numerous measures have been used to assess outcomes after proximal humeral fracture. Historically and to the present date, results are most frequently reported on the basis of radiographic assessment and the occurrence of complications. Other frequently reported measures include pain,strength,range of motion,patient satisfaction.

35

RADIOLOGICAL ASSESSMENT:

Radiographic follow-up is usually performed at set intervals these frequently being 6 weeks and 3, 6, and 12 months after injury or surgery. Follow-up radiographs should be obtained with the same projection that was used initially to allow for accurate comparison. Healing is determined by observing bridging callus, especially in fractures treated nonoperatively or with a lower rigidity construct. However when rigid fixation is used, callus formation is not readily apparent and bridging trabeculae are sought on radiographs to determine whether healing has occurred.

Fracture alignment is assessed on intraoperative or immediate postoperative images and compared on subsequent outpatient reviews. The most frequently considered measures are tuberosity displacement and head-shaft angle. Furthermore hardware position within the proximal humerus is frequently assessed to evaluate possible cutout, failure, or loosening.

AVN of the humeral head is the most frequently evaluated radiographic long-term outcome after

36

nonreplacement reconstruction of proximal humeral fractures.

Several degrees of severity of AVN are frequently reported, ranging from isolated changes in the trabecular organization to collapse of the humeral head with loss of sphericity^. Changes in trabecular organization have been described as increased radiodensity with cystic and sclerotic regions and coarse trabeculae.

Serial radiographic assessment is a key component of longterm follow-up of arthroplasty for proximal humeral fractures. Implant loosening is monitored by assessing the appearance of progressive radiolucent lines between the implant and the bone. Furthermore osteolysis, with increased cavitation of bone adjacent to the implant, places the implant at increased risk of loosening and failure. In reverse total shoulder arthroplasty assessment of glenoid notching is required, as it may lead to glenoid component loosening and failure.

37

COMPLICATIONS

The most frequently reported complications after proximal humeral fractures are nonunion, malunion, implant failure, humeral head collapse, infection, post-traumatic arthritis, hardware penetration, axillary nerve dysfunction, revision surgery, and mortality. Multiple definitions exist for each of these. Clinical, radiographic, and laboratory criteria are used to diagnose and monitor these complications.

PAIN:

Pain is a key component of patient satisfaction. It is frequently quantified using a visual analog scale (VAS) and reported as a value from 0 to 10.

RANGE OF MOTION:

Active and passive forward elevation, abduction, external

rotation, and internal rotation are frequently reported.53 The use of a standardized technique with a goniometer is important to achieve reproducible measurements.

38

STRENGTH:

Strength is frequently reported as a measure of the weight

that can be lifted in a specific plane. The use of a dynamometer to assess strength in 90 degrees of abduction is often reported.A 25-yearold male with a normal shoulder is expected to lift 25 lb in this plane. Lower values are expected for females and older people.

FUNCTIONAL OUTCOME SCALES:

Although each of the criteria that have been outlined help in determining certain aspects of the outcomes of proximal humeral fractures, they do not allow a quantitative assessment at a given point in time. Furthermore, they do not permit a summarized assessment of the overall function of the shoulder.

Over the last decades several outcomes scales have been developed that summarize the results of the assessment of several aspects of shoulder function. Scores can then be obtained after applying an algorithm or by grouping responses. Several function scales rely mostly on criteria that are obtained by an

39

evaluator. These include range of motion, strength, specific clinical signs, radiographic alignment, and healing. Other scales focus on the subjective patient perception of shoulder function and pain. These are frequently questionnaires that are answered directly by the patient and inquire about multiple activities in which different aspects of shoulder function are involved.

Finally, some shoulder scores use a combined approach in which both evaluator-based and patient based outcomes are included.

In addition to outcomes scales that focus on the shoulder or upper extremity, modern functional assessment frequently includes evaluation of overall patient health. Although scales that assess patient function in a broader spectrum may be less accurate in measuring changes in shoulder function, they play an important role in measuring the impact of a specific shoulder condition on the overall health and quality of life of the patient.

DASH and Quick-DASH:

The DASH questionnaire is a patient-based, self-

administered outcome instrument developed to measure

40

symptoms and disability of the upper extremity. It evaluates six domains: daily activities, symptoms, social function, work function, sleep, and confidence. It consists of 30 questions regarding the level of difficulty in performing a set of activities.

Each question is rated on a Likert scale from 1 (no difficulty) to 5 (unable to do). Lower values represent higher function.

The Quick-DASH is an 11-item questionnaire derived from the DASH through item reduction using a concept-retention approach, in which the domains from the original instrument were retained while the amount of items of each domain were reduced. As for DASH, higher scores represent higher disability.

Like the DASH, Quick-DASH has two optional modules, one for function at work and one for function during sports and performing arts^.

CONSTATNT-MURLEY SCORE:

The Constant-Murley Score has a subjective patient-based component and an objective evaluator based component.

Subjective parameters include pain and shoulder function based

41

on the ability to perform activities of daily living. For pain, scoring ranges from 0 for “severe” pain to 15 for no pain. A total of 20 points can be obtained with regard to shoulder function.

The evaluator-based assessment includes active shoulder range of motion and strength. Range-of-motion is quantified by scores for elevation and external and internal rotation. A maximum of 10 points are scored when at least 151 degrees of elevation can be reached. A total of 10 points can be obtained for external rotation and internal rotation, respectively and are quantified according to rotational maneuvers that place the hand into defined positions with regard to the head, neck, and trunk. A total of 25 points can be scored for strength and are obtained by a 25- year-old male who is able to lift at least 25 lb to 90 degrees of abduction. Proportional values are assigned for the lifted weight and adjusted for age and gender. The maximum score is 100 points, with higher values representing higher function.

42

ASES Standardized Shoulder Assessment Form:

The ASES Standardized Shoulder Assessment Form consists

of an evaluator-based and a patient-based subjective component.

The patient-based component assesses pain, instability, and activities of daily living. Pain is determined with the useof a 10- cm VAS to quantify pain from 0 (no pain at all) to 10 (pain as bad as it can be). A similar VAS is used for instability. Activities of daily living are assessed with 10 questions that are answered on a four-point ordinal scale ranging from 0 (unable to do the activity) to 3 (no difficulty in performing the activity). The evaluator-based component includes range of motion, several shoulder specific clinical signs, strength, and instability. The score is obtained from the patient-based component with the following formula: (10–points on VAS for pain) × 5 + 5/3 × (total points for activities of daily living).

NEER CRITERIA:

In 1970 Neer published his criteria for the evaluation of results of proximal humeral fractures. They include four

43

variables: (1) pain, (2) function, (3) range of motion, and (4) anatomy. Pain represents a total of 35 points, ranging from

“totally disabled” (0 points) to “none” (35 points). Function represents 30 points and comprises strength, reach, and stability, each yielding up to 10 points. Range of motion represents 25 points, and is comprised of flexion (up to 6 points), extension (up to 3 points), abduction (up to 6 points), external rotation (up to 5 points), and internal rotation (up to 5 points).

Anatomy represents 10 points, ranging from 0 to 10 points with regard to rotation, angulation, articular congruity, tuberosity displacement, hardware failure, heterotopic ossification, nonunion, and AVN of the humeral head. A maximum score of 100 can thereby be obtained. Results are classified as excellent for 90 points or more, satisfactory for 80 to 89 points, unsatisfactory for 70 to 79 points and failure for 69 points or less.

ULCA:

The original UCLA shoulder scale was first published by Amstutz et al.7 for the assessment of shoulder arthroplasty. The

44

scale was subsequently modified by Ellman et al.103 for the evaluation of rotator cuff surgery. It evaluates pain, function, range of motion, strength, and patient satisfaction. Pain and function can yield a maximum of 10 points, whereas the remaining items can score a maximum of 5 points each, leading to a maximum overall score of 35 for an asymptomatic and normal shoulder.

OXFORD SHOULDER SCALE:

The Oxford Shoulder Score is a patient-based questionnaire

that includes 12 questions with regard to pain and activities of daily living. Each question can be answered on a Likert scale from 0 to 5. The total score ranges from 0 to 60 with lower scales reflecting better outcomes.

SIMPLE SHOULDER TEST:

The SST includes 11 questions regarding shoulder function and pain. Each question is answered with a yes/no option.

Affirmative questions are then counted and reflect the final score.

45

Shoulder Pain and Disability Index:

The SPADI is a patient-based questionnaire that includes 13 questions assessing the domains of pain and disability. Each question is answered using a VAS. Results are presented as a percentage of the maximum achievable score. Higher scores reflect more pain and disability^.

Subjective Shoulder Value and Single Assessment Numerical Evaluation:

Gerber et al. introduced SSV as a means to assess outcomes after surgery for massive rotator cuff tear surgery. It consists of a single question asking the patient to estimate the function of the affected shoulder as a percentage of function of an entirely normal shoulder. The same question was further validated by Williams et al. as the SANE in a cohort of patients undergoing surgery for shoulder instability.

University of Pennsylvania Shoulder Score:

The PENN shoulder scale is a 100-point shoulder-specific self reported patient-based questionnaire consisting of three subscales: pain, satisfaction, and function. Pain and satisfaction

46

are rated using a 10-point Likert scale. Pain is assessed at different levels of activity (at rest, normal activities, and strenuous activities) and can achieve a maximum of 10 points each. Satisfaction can reach a maximum of 10 points. Function is assessed using a total of 20 questions, each answered on a scale from 0 to 3. Function can thereby reach a maximum of 60 points.

The maximum total score is 100 points with higher scores representing higher function.

47

Signs and Symptoms of Proximal Humeral Fractures

Alert patients with isolated proximal humeral fractures

complain of localized shoulder pain and limitation of movement in the affected extremity. Proximal humeral fractures in polytraumatized patients are usually detected during the secondary survey following ATLS guidelines. Clinical examination usually shows soft tissue swelling and in many cases a large ecchymosis is readily apparent, especially in elderly patients. Loss of the normal convex contour of the shoulder can be seen in more severe fracture patterns and in fracture dislocations. Neurovascular injury is unusual but has to be excluded by careful clinical examination. Axillary nerve sensation should be examined.

NEER’S CLASSIFICATION:

In 1970, Neer introduced the concept of fracture

segments instead of fragments. Displaced fractures were arbitrarily defined as those in which a segment was translated by at least 1 cm or angulated by a minimum of 45 degrees. The

48

resulting four segment classification offers a descriptive system of proximal humeral fractures, with the main purpose of conceptualizing the pathoanatomy of proximal humeral fractures and the terminology to identify each category.

Fractures of less than 1 cm of displacement and less than 45 degrees of angulation are considered nondisplaced and are commonly called one-part fractures.

49

50

RADIOGRAPHIC EVALUATION

An anteroposterior view of the shoulder in the plane of the scapula, a lateral view of the scapula (Y view) ) and a supine axillary view are necessary in all patients initially to evaluate a proximal humeral fracture. If the amount of displacement of the humeral head or tuberosity fragments is unclear on radiographs, an axial CT scan with 2-mm sections is indicated .

51

MANAGEMENT NON OPERATIVE METHOD:

Neer described acceptable angulation as less than 45 degrees and less than 1 cm of displacement. Although these criteria are not absolute, they do provide a guide. An elderly, infirm patient can tolerate functional loss better than a young, active patient. The first step in treatment decision-making is to determine if displacement (<66%) and angulation (varus is poorly tolerated) are acceptable for a particular patient; the second is to determine if the humeral head and shaft move as a unit. If both of these conditions are present, the fracture is stable and in an acceptable position.

A sling is used for comfort, and a physical therapy regimen with pendulum exercises is started, usually within 1 week. If the humeral head and shaft do not move as a unit, physical therapy can be delayed for 2 to 4 weeks in patients who are poor surgical candidates because of age, low functional

52

demands, or comorbidities that preclude participation in rehabilitation.

OPERATIVE MANAGEMENT:

INDICATIONS:

-

displaced two-part surgical neck fractures, displaced (>5 mm)

-greater tuberosity fractures, -displaced three-part fractures,

-displaced four-part fractures in young patients.

1.Transosseous suture fixation:

Transosseous suture fixation techniques are well defined in the orthopaedic literature. Park et al. reported 78% excellent results in patients with two-part and three-part proximal humeral fractures treated with suture fixation. The use of strong nonabsorbable suture provides the advantage of incorporating the rotator cuff insertion to increase fixation in patients with poor bone quality .The level of soft-tissue dissection is not extensive, and relatively low rates of osteonecrosis have been

53

reported with this technique. Concerns include the ability of the patient to move the shoulder joint and loss of reduction secondary to a nonrigid construct. More recently, Dimakopoulos et al. reported good results in 188 displaced proximal humeral fractures treated with transosseous fixation .They suggested as advantages of this technique less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

PERCUTANEOUS PINNING:

Percutaneous pinning has the advantage of avoiding further damage to the soft-tissue envelope and the blood supply to the humeral head). It also is a relatively inexpensive technique, and several series have reported good results in two- part, three-part, and valgusimpacted four-part fractures. The procedure is technically challenging and requires a satisfactory closed reduction, adequate bone stock, minimal comminution (particularly of the tuberosities), an intact medial calcar, and a compliant patient. In their series of 74 older patients (average

54

age, 71 years), Calvo et al. demonstrated that reduction was associated with satisfactory outcome. However, if satisfactory closed reduction cannot be obtained, another form of reduction and fixation should be used. Loss of fixation, pin track infections, and axillary nerve injuries are common complications.

Terminally threaded Schanz pins and bicortical pins inserted from the greater tuberosity to the medial humeral shaft add stability to the overall construct. Percutaneous pinning is contraindicated for fractures with metaphyseal comminution.

INTRAMEDULLARY NAILING:

Intramedullary nailing provides more stable fixation than percutaneous pinning, although less than locked plate fixation.

The Polarus nail (Accumed, Portland, OR) has been shown to provide more biomechanical stability than pin fixation, and good clinical outcomes have been reported with this device. Newer nail designs with polyaxial screws have more stability than earlier designs, and the addition of polyethylene bushings may increase stability

55

and prevent screw back-out .Insertion of an intramedullary nail into the proximal humerus violates the rotator cuff, which can lead to postoperative shoulder pain. The advantages of the technique include preservation of the soft tissues and the theoretical biomechanical properties of intramedullary nails. A comminuted lateral cortex fracture or fractures involving the tuberosities may be a contraindication to intramedullary nailing.

A recent randomized controlled trial demonstrated that complications were fewer with a straight nail design compared with a curvilinear design.

PLATE AND SCREW FIXATION:

Plate-and-screw constructs provide the most stable fixation of the three fixation methods .Locked plates add stability, especially in osteoporotic bone. An open reduction and rigid fixation allow accurate reduction and stabilization of the tuberosities, which is important because malunion of the tuberosities is poorly tolerated and is associated with poor outcomes in posttraumatic reconstructive shoulder

56

arthroplasty. A recent prospective randomized trial by Zhu et al.

found that at 1-year follow-up patients treated with locking plates had better outcomes than those treated with locked intramedullary nailing, but at 3-year follow-up outcomes were equal. The locking nail group had a significantly lower complication rate (4%) than the locking plate group (13%).

Konrad et al. also reported similar outcomes in three-part proximal humeral fractures treated with intramedullary nailing (58 fractures) or plate fixation (153 fractures).

HEMIARTHROPLASTY:

Hemiarthroplasty, also known as humeral head replacement, is indicated when the humeral head is deemed to be unreconstructable or when its biologic viability is likely to be severely compromised. Comminuted head-splitting fractures and head depression fractures involving more than 40% of the articular surface are frequently considered to be unreconstructable. Predictors of head ischemia are further considered in the decisionmaking

57

process between operative fixation and replacement. Hertel and Bastian found that fractures through the anatomic neck of the humerus carried an increased risk of head ischemia.

Furthermore, a metaphyseal extension of the humeral head of less than 8 mm, loss of the medial hinge and displacement of the humeral head further predicted loss of humeral head perfusion at the time of surgery. While these criteria are frequently used to argue in favor of replacement surgery, intraoperative ischemia has not been correlated with clinically significant AVN of the humeral head when fixation is chosen for treatment.

Furthermore, some authors have found that AVN after proximal humerus fixation is associated with results that are comparable to those of hemiarthroplasty

58

MATERIALS AND METHODS

20 cases of Neer’s 3 part 4 part proximal humerus fractures &

fracture dislocation shoulder in elderly patients admitted at Govt Rajaji hospital ,Madurai will be taken up for study after obtaining consent

STUDY DESIGN

: Prospective study

STUDY DURATION: 2 Years

Method of collection of Data (including sampling procedure if any): Collection of data for patients presenting with fracture of proximal humerus are as follows :-

• History by Verbal communication

• Clinical examination, both local and systemic.

• Radiological examination routine and other imaging modalities.

• Investigations- Baseline and others.

• Fracture anatomy assessed with X-rays.

• Diagnosis – Clinical and Radiological.

59

• Informed written consent will be taken for Surgical procedure.

• Surgery – hemiarthroplasty shoulder

INCLUSION CRITERIA:

 Age >55 YEARS

 Neer’s III & IV PART Fracture

 Neer III & IV Part Fracture Dislocation .

EXCLUSION CRITERIA:

 Neer’s I & II Part

 Compound Fractures

 Young Adults.

 Patients Having Neurological Co Morbitites

PRE-OPERATIVE EVALUATION

 Clinical examination including Neurovascular status of affected Limb

 Baseline investigations

 Radiograph – X ray shoulder AP , Axial ,scapular view, X ray opposite shoulder,ct shoulder with 3D reconstruction

 Informed consent from the patient.

60

 Fitness from Cardio, Nephro & Anesthesia Departments Anaesthesia – regional anaesthesia/general anaesthesia

POSITION

 Beach Chair position with arm by side

OPERATIVE PROCEDURE Approach:Deltopectoral approach

The deltopectoral approach is considered the workhorse for reconstructive shoulder surgery. It is classically described as an incision starting over the coracoids process and advanced along the deltopectoral groove with subsequent identification and lateral reflection of the cephalic

vein. In the authors’ experience, an incision starting over the clavicle directed over 1 to 2 cm lateral to the coracoid process toward a point at the midline of the anterior arm 2 cm distal from the axillary crease will allow improved exposure . The deltopectoral interval is not always apparent, especially in patients with muscle atrophy or previous surgery. To identify the cephalic vein a full-thickness skin flap is developed medially at the proximal extent of the incision to about 1 to 2 cm medial to

61

the coracoid process. At this level a fat triangle is invariably found with its base at the clavicle. The cephalic vein can be readily identified traveling from this triangle distally. Most textbooks recommend dissecting the interval by retracting the cephalic vein laterally, based on the fact that lateral tributary veins are more frequent than their medial counterparts.

However, mobilizing the cephalic vein medially allows for improved exposure by avoiding proximal tethering of the cephalic vein when lateral retraction of the deltoid is required . Once the deltopectoral interval has been developed the subdeltoid space is identified and freed from hypertrophic bursal tissue. At this point, depending on the time elapsed since injury, fracture hematoma, fibrous scar tissue, or early callus formation is encountered. Careful soft tissue management is required to avoid devascularization of the fracture fragments. Of particular importance is identification of the long head of the biceps on the anterior aspect of the proximal shaft as this will facilitate fracture identification and reduction and plate placement. The biceps tendon is easily identified by digital

62

palpation just medial to the insertion of the pectoralis major tendon . Because of its proximity to the ascending branch of the ACHA extensive dissection of this tendon should be avoided.

However, the biceps tendon may have been injured with the fracture and a tenodesis may be required to remove a possible source of pain. Furthermore, the presence of the biceps tendon may make fracture reduction more difficult.

63

64

IMPLANT:

65

INTRA OPERATIVE PICTURE:

POSTPROCEDURE MANAGEMENT PROTOCOL:

 Shoulder immobilization with shoulder immobilizer

 1^st EOT and drain removal - 2^nd pod

 2^nd,3^rd EOT-- 5^th ,7^th pod

 Suture removal-12-15^th pod

 Immobilizer removal – by the beginning of 4^th week

 Pendulum exercise - by the beginning of 4^th week

 Overhead abduction - by 6^th week

66

FOLLOW UP

 Daily follow up – upto 15 days

 Weekly follow up – upto 4 weeks

 Twice monthly follow up – upto 3 months

 Monthly follow up– upto 6 month

In each follow up patient is assessed using CONSTANT SCORE and x ray shoulder

CONSTANT SCORE

67

CASE 1

NAME :MADASAMY AGE:58/M

PRE OP IMMEDIATE POST OP

3 MONTHS FOLLOW UP

1 YEAR FOLLOW UP

68

CASE 2:

NAME:KALAIVANAN AGE/SEX: 61/M

PRE OP IMMEDIATE POST OP

3^RD MONTH FOLLOW UP

12^TH MONTH FOLLOW UP

69

CASE 3

NAME :

SARAVANAKUMAR AGE/SEX:62/M

^{PRE OP}

IMMEDIATE POST OP

6^TH MONTH FOLLOW UP

70

STATISTICAL ANALYSIS

Distribution of variables in study population

Variables Frequency Percent

Agr (in yrs) 64.45±5.7

Gender Female 8 40%

Male 12 60%

Side of injury Left 9 45%

Right 11 55%

Accidental fall

11 55%

RTA 9 45%

Type of fracture 3 parts 8 40%

4 parts 12 60%

Post OP complications

Infection Absent 18 90%

Present 2 10%

Paraethesia Absent 19 95%

Present 1 5%

Age incidence:

AGE (YEARS) FREQUENCY PERCENTAGE

50-60 5 25

60-70 11 55

70-80 4 20

TOTAL 20 100

In this study most patients are in 6

^th

decade.

71

SEX INCIDENCE

SEX FREQUENCY PERCENTAGE

MALE 8 40

FEMALE 12 60

TOTAL 10 100

In this study 60% patients are female and 40% are male which shows that the proximal humerus fracture are common in female.

40%

60%

Gender distribution of study population

Female Male

72

SIDE OF INJURY

SIDE FREQUENCY PERCENTAGE

RIGHT 11 55

LEFT 9 45

TOTAL 10 100

In this study most patients have injury over right side which shows the dominant side is involved.

45%

55%

Distribution of side of injury in study population

Left Right

73

MODE OF INJURY

MODE OF INJURY FREQUENCY PERCENTAGE

Accidental Fall 11 55

RTA 9 45

Total 10 100

In this study most of the fracture occurrence are due to accidental fall at home which shows that it is the trivial trauma causing the fracture to occur.

45% 55%

Distribution of mode of injury in study population

Accidental fall RTA