MDCT assessment of proximal humeral fracture according
to the updated classification system
Poster No.:
P-0058
Congress:
ESSR 2015
Type:
Scientific Poster
Authors:
A. Balanika, C. Baltas, S. Theocharakis, I. KASSOS, G.
Triantafillidou, E. Drakoulakis, G. Hesketh, G. Galani; ATHENS/
GR
Keywords:
Trauma, Diagnostic procedure, CT, Musculoskeletal system,
Bones
DOI:
10.1594/essr2015/P-0058
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Purpose
Fractures of the proximal humerus are a common major health problem for all the ages
and account 5-6% of all fractures . The impact on the quality of life is important and their
management depends on the type of fracture ,the status of the patient and the technical
difficulties of surgical rehabilitation.
Different classifications system, based on anatomical and pathological criteria have been
proposed .The updated classification system proposed by Mora Guix JM et al assess and
evaluates more than different 21 PHF characteristics and uses Codman classifications
graphs. Thereby it contributes to improved decision -making and therapeutic planning in
line with recent developments of orthopedics.
The aim of this study is to present our own experience in the assessment of acute phase
multidetector computed tomography (MDCT) findings of proximal humeral fracture (PHF)
using the updated classification system.
Methods and Materials
We retrospectively reviewed 293 MDCT shoulder examinations which were performed
in 289 patients ( 179 men,50 women, mean age 19-84 years )during a period of three
years in order to reveal PHF.
MDCT scans were obtained on a 6 channel, multislice scanner (Philips, Brilliance 6)
with 0,75-mm collimation, at 3 -mm thickness, 200mAs and 120 kVp at the time of
injury and clinical assessment. Sagittal and coronal reformatted images of the shoulder
were generated from the axial and sagittal images respectively using the glenoid as an
anatomical reference. Further humerus fracture classification using images reformatted
parallel and perpendicular to the shoulder joint space. The MDCT scans were evaluated
in consensus, by two experienced musculoskeletal radiologists, one orthopaedic surgeon
and one radiology resident.
All the fractures were further analyzed according the updated classification system and
the following parameters were assessed:
I) fracture fragment decription (two- fragments, three-fragments, four-fragments),
Page 2 of 18
II)impaction (when 50 % or more of the humeral diaphysis remains in contact with the
humeral head with impaction into cancellous bone),
III) contact (the cross sectional area of contact between the humeral head and diaphysis
according to the following scale : 0 for no contact, 1 for <20% contact, 2 for between 20%
and 50% contact, 3 for >50% contact),
IV) metadiaphyseal displacement (1 cm. displacement of humeral shaft in the lateral/
medial and /or anterior/posterior direction in relation to the humeral head),
V) angular displacement (varus/valgus humeral head angulation compared to the normal
0-
130 average cephalodiaphyseal angle in the sagital plane),
VI) displacement of the tuberosities to the humeral head (lesser or great tuberosities in
relation to the humeral head > 10 mm. for the lesser and 5 mm. for the greater),
VII) preservation of internal humeral fulcrum (intact medial cortex between humeral head
and shaft),
VIII) ceplaloglenoid angle (this angle is formed in an axial CT view by the perpendicular
line to the articular surface of the glenoid and the perpendicular line to the transverse
diameter of the superior portion of the articular surface of the humeral head) and is
0
0
classified as followed: a) good (value between 0-20 ) b) sufficient (value between 20-45
0
) and c) deficient (value >45 ).
Results
Of the 289 patients,133(46%) had a PHF with a total of 135 fractures that induce one
of the following patterns:
1) Impaction was visually graded on a 0-1 scale ( grade 0: no impaction, grade 1:
impaction).
Impacted fractures were present in 81 patients (60,9%),
2) The grade of contact was scored on a 0-3 scale ( grade 3: contact >50%,grde 2: contact
between 20-50% ,grade 1:contact <20% and grade 0: no contact).
The results were as follows: contact >50% in 94 (70,9%), contact between 20-50% in
18(13,5%),contact <20% in 6(0,04%) ,no contact in 14 (10,5%)
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3) Metadiaphyseal displacement was graded on a 0-1 scale ( grade 0: no displacement,
grade 1: displacement).
The fracture was considered as a longitudinal plane displacement in 47 patients (35,3%)
4) Angular displacement was graded on a 0-1 scale ( grade 0: no displacement, grade
1: displacement).
The fracture was considered as an angular displacement in 51 patients(38,3%),
5) No preservation of internal fulcrum was graded on a 0-1 scale ( grade 0: preservation ,
grade 1: no preservation).
No preservation was assessed in 109 patients (81,9%)
0
0,
6) The ceplaloglenoid angle was scored in a 0-2 scale ( grade 0 : good 0 -20 grde 1:
0
0
sufficient 20 -450,grade2 :insufficient >45 ).Grade 2 was present in 53 (39,8%)
7) Tuberosities -humeral head displacement was graded on a 0-1 scale ( grade 0: no
displacement, grade 1: displacement).
Tuberosisties displacement was present in 38 patients(28,5%)and
8) The fracture fragment decription was scored on 2-4 scale ( grade 2: twofragments,grade 3: three fragments,grade 4:four-fragment).
Four and three fracture fragments were present in 62 (46,6%) and in 57 (42,8%)
respectively.
Images for this section:
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Fig. 1: Coronal CT image reformation of the right shoulder in a 62-years old woman
revealead a two fragment proximal humeral fracture with no preservation of the internal
fulcrum
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Fig. 2: Coronal ct reformatted image in a 60m years -old man demonstrated a three
fragment right proximal humeral fracture with grade 1 metadiaohyseal displacement.
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Fig. 3: Aial CT image of the right shoulder in 66-years old showed grade 1 tuberositieshumeral head displacement.
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Fig. 4: Axial CT image of the right shoulder in a 19 years old woman revealed a four
fragment proximal humeral fracture with grade 1 of contact
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Page 9 of 18
Fig. 5: Sagital CT reformatted image in a 74 years old woman showed a four fragment
left proximal humeral fracture with grade 3 of contact,no impaction and no preservation
of internal fulcrum
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Fig. 6: Axial CT image ina 73 years old woman revealed a right proximal humeral fracture
with insufficient cephaloglenoid angle.
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Fig. 7: Coronal CT reformatted image of the left shoulder in a 72 years old man showed
a grade 1 displacement of the great tuberosity to the humeral head
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Fig. 8: Axial CT image in a 45 years-old man demonstrated a four-fragment ieft proximal
humeral frascture with grade 1 metadiaphyseal displacement and grade 1 of contact
Page 13 of 18
Fig. 9: Sagital CTreformatted image in a 52 years-old man showed a three fragment left
proximal humeral fracture with grade 1 angular displacement
Page 14 of 18
Conclusion
A correct definition for the interpretation of PHF fractures is crucial for the surgeon to
select the proper treatment.This implies the evaluation of patient status , the imaging
characterization and staging of the fracture and the selection of the indicated treatment.
The first consideration is the age and physical health -status of the patient with
osteoporosis being an important factor for the elderly. According to the literature , for
simple classification of a PHF fracture only three characteristics are required.In order
to obtain therapeutic decision needs to be assessed at least 12 imaging features of
the fracture. In this study we classified PHF based on Codman's description of the four
fragment and fracture features according to the following characteristics item: number of
fragments ,fractured tuberosities and articular and extraarticular involvement. In this way
all possible fractures were includedachieving a better guidance of therapeutic choice.
In cases of two fragmentsthe description should include high or low level of humeral
surgical neck fracture and tuberosity fracture (not completely fractured with one joined
the head and the other the shaft or fractured in one fragment cephalodiaphyseal). In a
three fragment fracture the fractured humeral tuberosities should be evaluated in relation
to humeral head and shaft. In four fragment fracture should also assessed the articular
or extrarticular involvement.
The differentiation of the impaction and contact between fragments as separate
characteristics of the PHF is important for assessing the stability of the fracture.
The evaluation of fracture longitudinal displacement is important for the assessment of
possible functional limitations. The degree of the tuberosities displacement is critical
for the fixation in young and adults patients. A conserved internal fulcrum indicates
the maintenance of humeral vascular supply and a favorable survival prognosis of the
humeral head. The MDCT estimation of humeral head orientation byceplaloglenoid angle
is crucial as the loss of contact between shoulder joint surfaces requires surgical repair.
Our results showed a large number of impacted fractures ,the majority with no
preservation of internal fulclrum and with an insufficient head orientation and four
fragment pattern. PHF with the above characteristics are commonly treated surgically
-especially among younger patients- delay/failure of early diagnosis are strongly
correlated with poor outcomes. MDCT in the classification of PHF according to the
updated classification system seem to be necessary for the guiding of treatment, the
estimation of prognosis and the prediction of complications .
References
Page 15 of 18
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Personal Information
A.Balanika, Phd,Msc,Consultant Radiologist,
Computed Tomography Department General Hospital of Athens "Asclepieion
Voulas"
C.Baltas,Phd,Msc,Consultant Radiologist,
Radiology Imaging Department,General Hospital of Athens "G.Gennimatas"
S.Theocharakis,Msc, Consultant Orthopaedic,
6th Orthopaedic Department,General Hospital of Athens "Asclepieion Voulas"
E.Kassos,Resident of Radiology,
Page 17 of 18
Computed Tomography Department General Hospital of Athens "Asclepieion
Voulas"
G.Triantafillidou,Resident of Radiology
Computed Tomography Department General Hospital of Athens "Asclepieion
Voulas"
E.Drakoulakis,Consultant Orthopedic
6th Orthopaedic Department,General Hospital of Athens "Asclepieion Voulas";
G.Hesketh, Consultant Radiologist
Computed Tomography Department General Hospital of Athens "Asclepieion
Voulas"
G.Galani,Consultant Radiologist
Computed Tomography Department General Hospital of Athens "Asclepieion
Voulas"
Page 18 of 18