Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study

Abstract

We studied the arterial anatomy and the effect of fourpart fractures on the vascularity of the humeral head, using barium sulphate perfusion of 16 cadaver shoulders. The main arterial supply to the humeral head was via the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There were significant intraosseous anastomoses between the arcuate artery and: 1) the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus; 2) metaphyseal vessels; and 3) the vessels of the greater and lesser tuberosities. Simulated four-part fractures prevented the perfusion of the humeral head in most cases. If, however, the head fragment extends distally below the articular surface medially, some perfusion of the head persists by the posteromedial vessels. These vessels are important in the management of comminuted fractures of the proximal humerus.

Non-operative treatment versus tension-band osteosynthesis in three- and four-part proximal humeral fractures

“…There is a high risk of osteonecrosis because of damages to the vascular supply of the dislocated head fragment [1,2]. In accordance with the literature, we found poor results for four-part fractures treated without osteosynthesis.…”

The relevance of the anatomical basis of fracture for the subsequent treatment of the anterior humeral circumflex artery and the axillary nerve

“…The artery gives off one principal branch, the arcuate artery, which ascends on the lateral border of the groove and enters the proximal humerus at the level of the greater tuberosity [9]. Previous studies have shown that this artery is the dominant blood supply to the humeral head [2].…”

“…1 The location where extreme care should be taken to protect the anterior humeral circumflex artery (point 1). Point 2 shows the prominence of the lesser tuberosity Injury to this artery, along with the axillary nerve, is common during surgical procedures to the shoulder and poses a risk to the rich network of anastomoses in the posteromedial humeral epiphysis [6,7,9]. Therefore, the objective of this study was to investigate the anatomy of these structures to improve understanding of "safe zones" during operations.…”

“…The probability of avascular necrosis after a fracture depends on the pattern of injury to the arterial anatomy of the humeral head [9] and circulation of fragments, which therefore influence the choice of fracture treatment. The fracture pattern and the distribution of the fragments in complex fractures can be visualised in three-dimensional CT scans.…”

Proximal humeral fractures

“…16,25 On the other hand, new progress in PHF studies, especially in vascularization, allows the definition of important new characteristics for treatment decision-making. [26][27][28][29][30] Because important new concepts for prognosis and treatment of PHF do not easily fit in past classification systems, some authors have proposed new imaging techniques 8,12 or new functional classifications. 14 Since 2003, new systems of fracture classifications have been published.…”