Humeral head fractures are included under proximal humerus fractures and are responsible for approx. 4-5% of all fractures incurred by human beings. Analysis of the distribution by age range shows that there are two key age peaks: Young, usually male, high speed trauma patients and elderly ladies following a low energy trauma and fractures caused by osteoporosis. In order to understand the treatment to be administered, it is important to recall the blood flow of the humeral head once again. This is covered in the joint side to about 70% by cartilage and the relevant supply of blood is undertaken via the two circumflex arteries which each intersperse anterior and posterior in the calcar region. This blood flow situation is probably jointly responsible for the relatively high frequency of post-traumatic humeral head necroses. The humeral glenoid joint is one of the most flexible joints in the human body. The reason for this is to be found in the anatomical condition that the upper arm is markedly larger when compared with the socket. This enhanced range of movement, however, simultaneously reduces the stability of the joint. Not for nothing is dislocation of the shoulder the most frequently found form of dislocation among human beings. In order to increase the stability of the joint, a glenoid lip stretches around the socket, called the labrum, which enlarges the articular surface by virtually 40-50%. The long biceps tendon passes through the joint and the position of the head of the upper arm in relation to the socket is essentially kept in place by the rotator cuff. This rotator cuff is fixed to both the greater and the lesser tubercles. Then please show in the patient who was admitted directly through our Emergency Admissions department via the emergency services. Dr. Kirchhoff... Just a moment, please. Excuse me. We have an elderly lady who had a fall at home. I’ll be with you in a moment. Please call me back. Thank you. Good bye. This is Ms. Lange. Good day. My name is Dr. Kirchoff from Trauma Surgery. Good day, doctor, I can only shake hands with my left hand as the right one hurts so much. So it is the right hand which hurts. Yes, Ms. Lange fell onto her right side today after tripping over her grandson’s toy car, right? Yes, right. Over a toy car? Yes. Just imagine; my grandson came to visit me today and we had such a nice time playing together. He is three years old and adorable. I then went into the kitchen as I wanted to fetch something for him to drink and when entering the kitchen I just did not think and tripped over the fire engine. Did you hit your head at all? No, my head was not affected at all and everything there is fine. I fell towards the right this way and the fall spun me around like this. Your back does not hurt? No, I can move everything OK. You can also stand up? Yes, yes. Right, first of all we need to have a look at your arm. >> Mhm, ja. >> Wir helfen Ihnen einmal aus dem We’ll help you take off your twinset. Let's perhaps have a look at the healthy side first. Is that OK? Thank you, that is all fine. Kathi, can you help me here, please? I’ll be very careful. It looks fine, doesn’t it? That was very quick and it regained its colour very quickly. We need to have a look at that now. Yes, you have suffered a bad graze here on the outside. Yes, I seem to have managed to have fallen onto the ladder on the fire engine somehow or something like that. Have you had any tetanus protection? Yes, I have been vaccinated by my doctor. When was that done? I had a booster two years ago. You know it should not be longer than ten years, don't you? Yes, that is exactly right. Please now give me your hand. Do you feel any pain underneath there when I press my fingers there? No, not really. Aha. Your pulse is also good. You are a bit agitated. Yes, I certainly am! Just so. If I move your elbow there, is everything OK? Yes, but it is a little tense there. Under here or somewhere else? Really more above there. OK. Very good. Is there any pain if I press here, though? Everything is OK. Very good. If I move over it like this, can you feel all that? Does it feel numb? No, I can feel that. Now this is really important: Can you tense your trapezius muscle, in the same way as if you wanted to pull up your shoulder? I’ll try. That's enough. That's great. Oh, that hurts! Yes, it hurts, doesn’t it? And if I press there, up here? That hurts. Excuse me, I’m sorry. But it is important I know. Down there if I press, there is no pain, and if I press inwards there? Yes, that is really painful. Excuse me. Do you know what? We’ll stop entirely for the moment. Hold your arm really tightly for a moment. We’re going to take an X-ray of the shoulder and of the upper arm and then we’ll continue with our talk, OK? Okay. I’ll enter the details into the computer. See you later. Thank you, doctor. Good bye. OK, just come with me and I’ll show you the way to the X-ray machine. If the description of the accident and the patient's symptoms indicate a fracture of the humerus, then the following diagnostic investigation is required: Clinical examination, particularly of the axillary nerve and of both the radial and ulnar arteries. X-ray in two planes: true ap and outlet view. An axial image would be desirable, but is usually not tolerated by patients. In all cases of lack of clarity, liberal indication with regard to computerised tomography is recommended, as the joint structures cannot always be shown to their full extent in conventional X-ray imaging. If any soft tissue injuries are suspected, such as following dislocations of the shoulder, magnetic resonance imaging is recommended. Unfortunately, you have broken your upper arm. Oh dear. Don’t worry. There is a problem with your fracture, however, as if we leave it as it is, then there is an extremely high level of probability that you will not be able to move your arm again. For that reason, I would incline towards advising you to undergo an operation. Does that mean incision will be needed? I’ll explain everything to you in very simple terms now. First of all, have a look at your X-ray images. Up here, you can see your ribs, up there your clavicle and that is actually the bone of the upper arm. And up here is what we call the head of the upper arm. If you look at this plastic model of the bone, then you can see the upper arm should always be nice and round and well-balanced in shape. In your case, however, we can see here lots of broken lines and small pieces of bone lying around. That is the fracture. There are a whole series of classifications for humeral head fractures. The Neer classification is the most widely used one in the international literature. This classification is very simple. I’ll explain them to you now in a way which means you will never forget this classification again. There are six groups in total: Type I is really very simple. These are non-dislocated fractures which can all be treated in non-operative ways. Type II are fractures in the anatomical neck of the humerus and due to the suspension of blood flow to the portion of the joint, these fractures mean an operation is indicated on an emergency basis. Type III are fractures of the surgical neck of the humerus and are very unstable. Type IV fractures involve the greater tubercle. In this regard, there is a second number dwhich is used to designate the total number of the fragments. Type V are fractures of the lesser tubercle with the same numbering and Type VI are all dislocation fractures with anterior or posterior dislocation. That is very straightforward, isn’t it? It is important, however, because clear consequences for treatment are derived from this classification. In order to find the optimum treatment in each case, the following points are important: Type of fracture, bone quality and function or properties of the soft tissue, in particular of the rotator cuff. Non-operative treatment of fractures is indicated if the dislocation of the fragments amounts to less than 1 cm, the humeral head is titled by less than 45° compared to the shaft, or for isolated, non-dislocated greater tubercle fractures, e.g. following dislocation of the shoulder. An operation is indicated in cases of fractures of the greater or lesser tubercle with a dislocation of more than 2 mm, a Type III fracture in the surgical neck of the humerus, with dislocation of more than 5 mm or 30° tilting as well as all dislocation fractures, vascular/nerve injuries, fractures of the anatomical neck of the humerus or metaphyseal debris zones. Philos plates have proven to be effective in surgical treatment. A philos plate is a typical representative of an internal fixator system with fixed-angle connections between the screw and the plate. This illustration shows the position of the screw in the plate. These screws are secured firmly in position by means of an additional thread between the screws and the plate. We call this head locking screwing. These charts help make clear the principle of effectiveness of head locking screwing once again. What can be clearly seen is that the screws in the plate are held in position by means of the additional thread between the plate and the screw, although the plate is not pressed onto the bone. This intraoperative photograph shows the positioning of the patient for the operation. We call this beach chair positioning due to its similarity with that. The anatomical landmarks for the operation are sketched out on this image. What can be clearly seen are the acromion, the coronoid process and the clavicle as well as the planned skin incision. Following the skin incision, the anatomical landmark of the cephalic vein is seen, which is lateralised and protected. Afterwards, the deltopectoral groove is bluntly entered. In the right hand half of the image, it can be seen how a self-positioning spreader has been inserted and the plate is already being fitted to the shaft following the repositioning and threading of cerclages. We now perform surgery on the whole thing. An incision is made at the front on the shoulder, about 7-8 cm in length. Then you work your way forward through two muscles, without severing these, until you have reached this bone. You then reset the bone and a special implant, what is referred to as a philos plate, a plate which has been developed uniquely for the head of the upper arm, is then attached to this bone, from the side onto the bone, and the plate is fixed in place with lots of screws once it has been fitted to the bone. With screws. At the same time, the tendons on the shoulder should be inspected as to check whether they also have any tear and, if so, it is to be treated as well. I’ll show you that in very simple terms now. This is a bone in the upper arm, this is the head and then the plate is attached here from the side. This plate is inserted far into the head of the upper arm using lots and lots of long screws and we secure it here likewise to the bone using three screws. The operation itself lasts between one and two hours, depending on how complex the fracture is. Almost no blood is lost in the course of this. You will spend roughly five days on the ward with us and then begin to undergo a course of physical therapy immediately. You will need to undertake this twice a week for at least twelve weeks. I will tell you straight away: You will need these twelve weeks as well in order to be satisfied with your surgeon. It just takes as long as required until you are happy. It's a long drawn-out matter really, isn’t it? No, but you have suffered a severe fracture and, in view of that, the twelve weeks are not really that long. Mhm, mhm. Yes. The follow-up treatment provides for four weeks wearing a Medi-sling, followed by passive abduction up to 90° in the first to the fourth week. Rotation should then follow passively, adapted according to pain. In the fifth to sixth week, abduction passively, assistive up to 90° with free flexion and an X-ray check-up is conducted after the sixth week. After this, increased rotation and flexion movements are made. Increasing strengthening exercises are undertaken from the twelfth week onwards. The results achieved by internal fixation with a locking-compression plate have been investigated in this follow-up study. This covered 72 fractures. The target parameter was the Constant Score, a very well established function score for determining shoulder function. The study found that the Constant Score mainly depended, after twelve months, on the number of fragments involved, as well as the age of the patient. Possible complications are screws becoming dislodged, the plate being positioned to cranial and screws perforating the joint space. The extent to which the humeral head has been destroyed is sometimes so great that no sensible reconstruction is possible. The indications for this primary fracture prosthesis are shown on this slide. These include a head split injury, the destruction of the calvaria by more than 40%, but also impairments of the soft tissue, such as for example a defective rotator cuff. In addition, advanced omarthrosis and widely dislocated fragments or the high biological age of the patient are included as well. This slide shows the principles of anatomical fracture end prosthesis. These are based on retaining both the greater tubercle and the lesser tubercle as important insertion points of the rotator cuff. The most frequent and feared complications of anatomical fracture end prosthesis result from this restriction of the two tubercles. These complications are shown on these X-ray images. They consist of the resorption of the greater or lesser tubercle. This results in the fact that the rotator cuff joined to both these bone points cannot realise their function and the prosthesis cannot accordingly be held centrally within the joint. Well, in that case, we will just have to grin and bear it as there is no alternative. It should really be done. As with anything in life, however, there is another side to any matter and that is also true for what we are talking about. There are various things which can go wrong in such an operation. There are what are called general operational risks and also specific operational risks. These include such things as a scar - that is clear, otherwise it would be impossible to insert a plate so deep. Yes, yes, I understand. Vessels and nerves can be injured in any operation, although it must be said that we know very precisely where the vessels where the vessels and nerves run in that part of the shoulder. Nevertheless, in the worst case, losses of sensation or function can occur in the arm and hand. This happens very rarely, however. The wound can become infected in any operation. In the case of a shoulder, that represents a catastrophe. As a final resort, follow-up operations have to be undertaken on the shoulder repeatedly until it is completely free of bacteria. Quite particular risks are involved in the case of fractures like yours. Even with this modern implant, which adheres to the bones like a rake, it can happen that the screws and the plate become loosened and then, in the worst case, the bone fracture moves into this wrong position again. It can even happen that the entire head of the upper arm becomes necrotised. The only remaining solution for the shoulder is then what is referred to as a shoulder endoprosthesis. Is a prosthesis inserted in that case? An artificial shoulder joint. Yes. Although it must be said that we carry out about 300 operations on this kind of fracture a year. The probability of something going really wrong is considerably less than 1%. Let's hope all goes well in this case as well. Let’s hope so. We’ll now send you back to ward 1/17. You will now be given a pain killer. We’ll fit a sling in the course of today so as to immobilise the shoulder and we’ll then schedule the operation for tomorrow. That's fine. You can do that already for tomorrow? Yes. Tomorrow. Better not to waste any time for your sake and that of the shoulder. Thank you, doctor. I won't offer to shake hands when saying goodbye! Yes, good. OK, until tomorrow, then. Good bye. Thank you, doctor. Good bye. The results of anatomical fracture end prosthesis are shown here. The average Constant Score was only 55 points compared with 86 points for the opposite side. This means that the function of the shoulder which underwent an operation is not recovering in either an entirely good or bad way according to the All-or-Nothing principle. Only 43% of patients manage to achieve abduction of more than 90°. The primary complications are ones associated with the tubercle. These include initial misalignment, dislocation or resorption. Significantly worse results are found in elderly patients. In response to this high rate of complications with anatomical fracture end prostheses, inverse fracture end prostheses have been developed. These follow a completely different principle. According to this, the centre of rotation is displaced by approx. 1 cm to medial and 1 cm to distal. This leads to the levering arm of the deltoid muscle becoming extended and this is accompanied by an increase in efficiency of between 25 and 30%. As the sole abductor, the delta muscle retains the function of the shoulder joint. In summary, it can be stated that what applies to humeral head fractures is: Fractures with low levels of dislocation and comorbidities should be treated non-operatively, but all other kinds of fractures by means of osteosynthesis - A fixed-angle implant and cerclages for the tubercle should be chosen for this procedure. Anatomical fracture prostheses have shown poor long-term results, meaning that inverse fracture prostheses are increasingly implanted. These have produced promising medium-term results. Long-time studies still need to be conducted in this regard.
