proximal humerus fractures

A 57-year-old, right-hand-dominant female fell in her house while walking up the stairs with a laundry basket. She complains of immediate right shoulder pain and decreased range of motion. Her injury radiograph is seen in Figure 6–6.

 

 

 

Figure 6–6

 

Which of the following statements regarding this type of fracture is true?

1. The primary vascularity to the articular surface travels parallel to the long head of the biceps tendon.

2. The epiphyseal plate is the weakest portion of the humeral head and therefore most common fracture location.

3. There is a rare incidence of associated nerve injury.

4. The most commonly used classification is based on the anatomic relationship of four segments of bone.

Discussion

The correct answer is (D). The primary blood supply to the humeral head is from the posterior humeral circumflex artery; the vascularity to the articular component is most likely to be maintained if at least 8 mm of the medial calcar is attached to the segment. The anterior humeral circumflex artery runs parallel to the lateral tendon in the bicipital groove, as described in A. The epiphyseal plate is the anatomic neck. It is the surgical neck that is the weakened area of bone and the most common fracture site. Studies have shown as high as a 45% incidence of axillary nerve injury with proximal humerus fractures. These fracture are frequently classified by the Neer classification which uses four parts of the proximal humeral anatomy. These four parts are as follows: The articular surface, greater tuberosity, lesser tuberosity and the humeral shaft.

In choosing a surgical approach, what is true of the anatomy in the deltopectoral surgical approach?

1. The musculocutaneous nerve enters the biceps 5 cm distal to the coracoid.

2. The axillary nerve is at risk during the release of the subscapularis tendon.

3. The deltopectoral approach uses the internervous plane between the axillary nerve and the musculocutaneous nerve.

4. The anterior circumflex humeral artery runs just distal to the pectoralis major tendon.

Discussion

The correct answer is (B). The muscolocutaneous nerve enters the biceps only 5 to 8 cm from the coracoid, meaning that retraction should be done with care. It uses the internervous plane between the deltoid (axillary nerve) and the pectoralis major (medial and lateral pectoral nerves). The axillary nerve runs distal to the subscapularis tendon and proximal to the teres major and latissimus dorsi tendons. The anterior humeral circumflex artery runs anteriorly around the proximal humerus and is proximal to the pectoralis major tendon.

The patient underwent operative fixation through a deltopectoral approach. The postoperative radiographs are shown in Figure 6–7.

 

 

 

Figure 6–7

 

Objectives: Did you learn...?

 

 

The Neer classification for proximal humerus fractures? The anatomy of the deltopectoral surgical approach?