Proximal Humerus Fracture CRPP 23615

Proximal Humerus CRPP Indications:

• 2-, 3-, 4-part proximal humerus fractures
• Best for two part fractures involving the surgical neck , isolated greater tuberosity fractures and 3-part fractures with isolated GT involvement.
• Generally used in physiologically young patients with good bone density.

Proximal Humerus CRPP Contraindications

• Head-splitting fx
• 4-part in the elderly
• Uncooperative patients, patients unable to follow post-operative restritctions
• Pathologic fx
• Metaphyseal extension / metaphyseal comminution
• Unable to reduce closed(long-head biceps interposition)
• Poor bone density

Proximal Humerus CRPP Alternatives

• Non-operative treatment
• Hemiarthroplasty
• ORIF
• Intramedullary nailing

Proximal Humerus CRPP Pre-Op Planning / Special Considerations

• Ensure 2.5mm terminally threaded pins are available

Proximal Humerus CRPP Technique

• Pre-operative antibiotics, +/- scalene block
• General endotracheal anesthesia
• Generally placed in slight beach chair position. All bony prominences well padded.
• Ensure A/P and axillary views can be obtained. C-arm usually positioned at the head of the table.
• Prep and drape in standard sterile fashion.
• Fracture is reduced. Usually with longitudinal traction, abduction, posterior displacement and slight external rotation of the shaft fragment.
• Small incisions made for Schanz pin placement and to place freer-elevator to aid in reduction as needed. 
• A small Schanz pin can be placed into the greater tuberosity to aid in reduction.
• 4 2.5mm terminally threaded pins are placed from the shaft into the humeral head. Try to provided as much dispersion in the head as possilbe. Pins shoulde be placed above the deltoid insertion to avoid radial nerve injury. Generally 2 pins from lateral cortex, 1 from anterior cortex +/- GT pins. 
• Pins are then cut off beneath the skin.
• Irrigation
• Closure

Proximal Humerus CRPP Complications

• Loss of fixation(7%)
• Nonunion(4%)
• Pin-track infection(7%)
• Deep infection(2%)
• Complete AVN(4%)
• Subtotal avn(15%)
• Glenohumeral arthritis
• Pin protrusion
• Pin migration: use 2.5mm pins to decrease risk of migration and follow patients with weekly xrays until pins are removed.

Proximal Humerus CRPP Follow-up

• F/U with xrays every 10 days to monitor pin migration.
• Begin pendulum ROM at first visit. 
• Pins removed at 4-6 wks then start PT for ROM.
• Proximal Humerus Fracture Rehab Protocol.
• Shoulder outcome measures.

Proximal Humerus CRPP Outcomes 

• 3-part fracture = good/very good functional results; average Constant score of 91% (84% to 100%),no AVN. Results not as good for 4-part fxs with 11% AVN, and risk of further operation. (Resch H, JBJS 1997;79Br:295).
• Average Constant Score = 81 (Fenichel I, Int Orthop 2006;30:153). Constant = 73.9 (Keener JD, JSES 2007;16:330)

Proximal Humerus CRPP Review References

• Master's Fractures
• Jaberg H, JBJS 1992;74A:508