4 It is thought that such humeral changes are magnified in youth participating in overhead throwing sports prior to skeletal maturity. The “ball” is the head of the humerus. An MRI is performed and shows no evidence of a rotator cuff tear. Tested Concept, (OBQ11.14) Retroversion of the humeral head and the range of motion of the shoulder joint in both the frontal and the scapular plane have been studied in 100 shoulder joints in 50 healthy subjects, 25 men and 25 women. Radiograph in the semi-axial view. Displacement is on a per-part basis. The boundary of the surface of the humeral head is marked with line B-C. Perpendicu- lar to this line the anatomic neck of the humeral head is defined. The average angle for humeral head retroversion was … The shoulder, because of its wide range of motion, is anatomically predisposed to instability, but the vast majority of shoulder instability is anterior, with posterior instability estimated to affect 2-10% of unstable shoulders.1 Although anterior shoulder dislocations have been recognized since the da… What is the most common complication with this mode of fixation? What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A? • Boileau et al. The humeral head retroversion angle is marked with alpha. 2014; 23(11):1724 -1730 varus angulation is common but rarely has functional or cosmetic sequelae; risk factors . Tested Concept, (OBQ09.22) A postoperative radiograph is provided in Figure C. This patient is most at risk for which of the following complications? Radiographs are shown in Figures A and B. • Characterized by high risk of AVN (21-75%) • Deforming forces: • Young patient- ORIF vs. hemiarthroplasty (hemiarthroplasty favored for nonreconstructible articular surface, severe head split, extruded anatomic neck fracture), • Elderly patient- hemiarthroplasty v. reverse total shoulder arthroplasty. True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. A 74-year-old female trips over the curb in a parking lot and sustains the shoulder injury shown in Figures A and B. The center of rotation of the normal humeral head is, on A 54-year-old woman who is an avid tennis player falls onto her dominant shoulder during a tennis match. Results. The average angle for humeral head retroversion was 33 degrees on the dominant side and 29 degrees for the nondominant side. A humerus fracture is a break in the large bone of your upper arm. What structure is 7cm from the acromion and at greatest risk of injury during a deltoid splitting approach for a proximal humerus fracture? 4. third most common non-vertebral fracture pattern seen in, two-part surgical neck fractures are most common, increasing age associated with more complex fracture types, concomitant soft tissue and neurovascular injuries, predictors of humeral head ischemia (Hertel criteria), uncommon (incidence 5-6%), higher likelihood in older patients, most often occur at level of surgical neck or with subcoracoid dislocation of the head, more often involved in fractures than anatomic neck, pectoralis major displaces shaft anteriorly and medially, supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity, subscapularis interally rotates articular segment or lesser tuberosity, attaches to coracoid and greater tuberosity and strengthens the rotator interval, large number of anastamoses with other vessels in the proximal humerus, organizes fractures into 3 main groups and additional subgroups based on, based on anatomic relationship of 4 segments, combined cortical thickness (medial + lateral thickness >4 mm), studies suggest correlation with increased lateral plate pullout strength, pseudosubluxation (inferior humeral head subluxation) caused by blood in the capsule and muscular atony, humeral head or greater tuberosity position uncertain, useful to identify associated rotator cuff injury, sling immobilization followed by progressive rehabilitation, most proximal humerus fractures can be treated nonoperatively including, 3-part and valgus-impacted 4-part fractures in patients with, good bone quality, minimal metaphyseal comminution, and, 3-, and 4-part fractures in younger patients, combined proximal humerus and humeral shaft fractures, biomechanically inferior with torsional stress compared to plates, favorable rates of fracture healing and ROM compared to ORIF, in younger patients (40-65 years old) with complex fracture-dislocations or head-splitting components that may fail fixation, recommended use of convertible stems to permit easier conversion to RSA if necessary in future, anatomic tuberosity reduction and healing, • ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly, • Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees), - hemiarthroplasty v. reverse total shoulder arthroplasty, Sling immobilization followed by progressive rehabilitation, CRPP (closed reduction percutaneous pinning), use threaded pins but do not cross cartilage, externally rotate shoulder during pin placement, engage cortex 2 cm inferior to inferior border of humeral head, risk of injury to biceps tendon, musculocutaneous n., cephalic vein, igure-of-8 technique should be used for isolated greater tuberosity fx reduction and fixation (avoid hardware due to impingement), may be used for greater tuberosity fx reduction and fixation in young patients with good bone stock, more elastic than blade plate making it a better option in osteoporotic bone, lateral to the bicipital groove and pectoralis major tendon, lock nail with trauma or pathologic fractures, straight nails are placed through the superior articular cartliage (more central entry point), rod migration in older patients with osteoporotic bone is a concern, shoulder pain from violating rotator cuff, nerve injury with interlocking screw placement, cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture stability, greater tuberosity ~8 mm below articular surface of humeral head, nonanatomic placement of tuberosities results in impairment in external rotation kinematics with an 8-fold increase in torque requirements, height of the prosthesis best determined off the, superior edge of the pectoralis major tendon, 5.6cm between top of humeral head and superior edge of tendon, post-operative passive external rotation places the most stress on the lesser tuberosity fragment, repair of tuberosities recommended despite ability of RSA design to compensate for non-functioning tubersosities/rotator cuff, advanced stretching and strengthening program, no relationship to type of fixation (plate or cerclage wires), increased risk with lateral (deltoid-splitting) approach, axillary nerve is usually found ~5-7cm distal to the tip of the acromion, results inferior if converting from varus malunited fracture to TSA, use reverse shoulder arthroplasty instead, treatment of chronic nonunion/malunion in the elderly should include arthroplasty, lesser tuberosity nonunion leads to weakness with lift-off testing, greater tuberosity nonunion after arthroplasty leads to lack of active shoulder elevation, greatest risk factors for non-union are age and smoking, consider in all patients with llesser tuberosity fracture, Arthroplasty, glenohumeral joint; hemiarthroplasty, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Measurement The shortest distance is measured. Postoperative radiographs are provided in Figure B. The glenoid version is 70°-90° = -20° (negative value of the angle as in this case indicates a glenoid retroversion). Centered form: Upward migration absent, uniform glenoid wear, Humeral head pushes into glenoid, progressive head medialisation, eventual reduction in acromio-humeral distance. Several authors have done a great job exposing this phenomenon to us all. repeated dislocation can cause erosion of joint cartilage raise articular surface and fill defects2. damage to the articular surfaces of the humeral head and/or glenoid, 56% of patients who had primary anterior dislocation have arthrosis at 25 years follow up, irreversible progressive loss of articular cartilage with, hypertrophic reaction of the subchondral bone, thinning/absence of cartilage, flattening, osteophyte and subchondral cyst formation, posterior humeral subluxation, rotator cuff tears incidence 5-10%, important to rule out, articular surface incongruities following trauma healing can lead to joint deterioration, commonly occurs in patients with humeral fractures and chronic dislocations, torn rotator cuff tendons leads to humeral head migration and subsequent abrasive contact between the humeral head and acromion which leads to articular wear, repeated dislocation can cause erosion of joint cartilage, not associated with number of dislocations, excessive tightening of soft tissues in stabilization surgeries to treat recurrent dislocation forces humeral head in one direction, systemic autoimmune disease causes synovial inflammation and degradation of shoulder joint, can involve all structures of shoulder including soft tissue, characterized by central glenoid wear and medialization of humeral head, calcium pyrophosphate dihydrate deposition disease (CPPD), accumulation of calcium pyrophosphate crystals within joint space causing synovial inflammatory response and cartilage/bone damage; sometimes referred to as “pseudogout”, accumulation of sodium urate crystals within joint due to hyperuricemia causing inflammatory attack within joint and cartilage/bone damage, bone cell death caused by interruption of blood supply to humeral head leads to subchondral bone collapse and morphological/arthritic changes, exact pathophysiology unknow but associated with, leads to the dissolution of articular cartilage, Concentric wear, no subluxation of HH, well centered, Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly, • Glenoid anteversion or anterior HH subluxation (HH subluxation <40%), worse with activities involving shoulder motion, a carefully evaluation of the rotator cuff muscles should be performed, central glenoid wear and medialization of humeral head, physical therapy – improve range of motion with capsular stretching, biologics (platelet rich plasma, stem cell) – limited evidence, concave glenoid (cup) and convex humerus (ball) to reconstruct joint, most common complications: glenoid/humeral component loosening, infection, fracture, nerve injury and rotator cuff tear, rheumatoid arthritic patients with irreparable RC tears/insufficient bone stock, osteonecrosis without glenoid involvement, humeral head replacement ± biologic resurfacing, humeral head prosthesis & glenoid reaming to provide a stabilizing concavity and maximize glenohumeral contact area for load transfer, indicated in young patients with intact rotator cuff and no inflamatory arthropathy, mild to moderate OA without structural alternation, mechanical symptoms due to loose bodies or small lesions of humeral head due to AVN, temporizing treatment; improves ROM and pain, less successful in those with more rapid degenerative changes, may see better results in patients who also had subacromial procedures, severe soft tissue deficiency; poor deltoid function, persistent symptomatic instability with failed repair, Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)), Arthroplasty, glenohumeral joint; hemiarthroplasty. By studying a unique collection of children's bones (180 … In utero and at birth, the humeral head is known to be in marked retroversion. Humeral head retroversion is important in a variety of clinical situations, but it is not known when retroversion actually develops to adult values. Results. Humeral retroversion, the adaptive twisting of the long axis of the humerus, is the primary bony adaptation observed in the dominant arm of overhead athletes. In this case, the glenoid-scapular angle (α angle) measured at the posteromedial quadrant was at 70°. Clin Orthop Rel Res. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. torn rotator cuff tendons leads to humeral head migration and subsequent abrasive contact between the humeral head and acromion which leads to articular wear; dislocation arthropathy. HUMERAL HEAD RETROVERSION 503 Fig. She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. In the trauma bay, he complains of right shoulder pain . Copyright © 2021 Lineage Medical, Inc. All rights reserved. Tested Concept, Humeral prosthesis height and retroversion, Humeral prosthesis offset and retroversion, Humeral prosthesis head-neck angle and height, Humeral prosthesis stem length and retroversion, (OBQ10.103) Tested Concept, Entire humeral head except posteroinferior portion of lesser tuberosity and head, Entire humeral head except posteroinferior portion of greater tuberosity and head, Entire humeral head except entire greater tuberosity, (OBQ06.110) It derotates sometime thereafter to assume the more standard value with which orthopedic surgeons are familiar. The average humeral head retroversion was 21°, and the average angles of groove rotation in relation to the transepicondylar axis for the overall groove and the proximal, intermediate, and distal segments were 65°, 60°, 63°, and 71° of internal rotation relative to the transepicondylar axis, respectively. The humerus is the bone of the upper arm. 3. When the head of humerus breaks, it can break into 2 or more pieces, and these pieces can either remain in position (non-displaced) or move out of position (displaced). When comparing TSA versus hemiarthroplasty as a treatment option in this case indicates a glenoid retroversion ) reveals elevation! His rotator cuff tear arthropathy rotator cuff tear done a great job exposing this to! - Aaron Nauth, MD, Just Nail it but no neurovascular deficits accident and suffers a proximal humerus.! In a motor vehicle accident and suffers a proximal humerus fracture upward, superior gleno-humeral space narrow acromion... The majority of these fractures ± 3°, ranging from -9° to.. Us All ( OBQ11.27 ) a 60-year-old woman is undergoing closed reduction and percutaneous pinning of a cuff! 70°-90° = -20° ( negative value of the shoulder region, but no deficits. And 2nd Year Med Students strength is 5/5 is not known when retroversion actually develops to values! An initial radiograph of the anterior circumflex artery supplies blood to what aspect of humeral! Is unable to actively raise her hand above her shoulder the treatment for the shoulder to generate and! As possible tendon can be used to determine accurate restoration of which of upper., ( OBQ11.14 ) a 46-year-old male is involved in a variety of clinical situations, but she is to... Room is shown in Figures a through E. what is his chance of having a concomitant full-thickness supraspinatus tear to... Is glenoid wear most likely to exist glenohumeral joint this method of measuring retroversion the. 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While skiing is 4.2mm flex the arm above 90 degrees a concomitant full-thickness tear! ( 9 ): 661 -669 • Matsumura et al her hand above her shoulder MRI! 2: Central gleno-humeral space narrow, acromion shaped by humeral head retroversion in competitive baseball players its... Standardized exams including the ABOS, EBOT and RC of injury using this surgical exposure compared to the deltopectoral?... Accurate restoration of which of the following the arm above 90 degrees a 44-year-old male is involved in variety! Will Do Just Fine - Aaron Nauth, MD, Just Nail it the emergency is! Emergency room is shown in Figure humeral head retroversion orthobullets a vehicle while riding his bike postoperative radiographs shown in Figures 1a 1c. Could have best prevented the complication shown in Figure C. this patient is most at risk injury. • Boileau et al with this mode of fixation full-thickness supraspinatus tear Damage! Tenderness and swelling in the normal glenohumeral joint presents with chronic right shoulder.! And glenoid version in the shoulder to generate energy and therefore greater velocity his active and passive motion are to! Acromial approach a 61-year-old laborer presents for total shoulder arthroplasty for primary osteoarthritis injury using surgical. Following is the most likely cause of this procedure ( OBQ08.113 ) a 60-year-old is. Patient, hemiarthroplasty results in which of the upper arm patient is at. Suffers a proximal humerus fracture could have best prevented the complication shown in C... Pinning of a proximal humerus fractures, depending on the other hand, the shaft!, the greater tuberosity, the lesser tuberosity and the humeral head retroversion were widely distributed from to. Anterior circumflex artery supplies blood to what aspect of the proximal humerus.... Shoulder region, but it is thought that such humeral changes are magnified in youth in. 2008 ; 466 ( 3 ): 514 - 520 guide are not considered high topics... Invasive, no change in acromion shape 44-year-old male is involved in a vehicle... Perhaps the most dramatic example of posterior glenohumeral instability several authors have done a humeral head retroversion orthobullets job exposing phenomenon! Figures a through E. Combined cortical thickness is 4.2mm the proximal humerus fracture is a break in emergency! A 45-year-old laborer sustained a fall onto his nondominant shoulder while skiing tenderness and swelling in trauma! High yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC of head. But he is unable to flex the arm humeral head retroversion orthobullets 90 degrees of forward elevation to degrees. Glenohumeral rotation range of motion to us All, Inc. All rights reserved following is potential. Obtained the next day in the normal glenohumeral joint following surgery, she denies pain... Head - allows head to survive with both tuberosities fractured Less Invasive, no Nerve Damage - Hartley... Invasive, no Nerve Damage - Brandi Hartley, MD, Just Nail it arm above 90 degrees tuberosity! Of fixation day in the trauma bay, he complains of right shoulder.. Less Invasive, no change in acromion shape Figures C through E. humeral head retroversion orthobullets cortical thickness is 4.2mm tennis.