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Avascular Necrosis Humeral Head

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Introduction

- Scientific Figure on ResearchGate.
Figure 1. Humeral Head AVN With Collapse.[1]

Avascular necrosis (AVN) of the humeral head is a medical condition where the blood supply to the rounded top of the upper arm bone (humerus) is disrupted, leading to the death of bone tissue. This condition can cause humeral head collapse and arthritis, resulting in pain, decreased shoulder function, and potential joint deterioration.

Avascular necrosis of the humeral head can result from various factors, including trauma, chronic corticosteroid use, or systemic disease processes, such as sickle cell disease, systemic lupus erythematosus, or alcohol abuse[2]

Anatomy

The humeral head is the spherical upper portion of the humerus that fits into the shoulder socket (glenoid), allowing for a wide range of shoulder movements. It receives its blood supply mainly from the anterior and posterior humeral circumflex arteries. Disruption of these blood vessels can lead to avascular necrosis.[3]

Stages

Avn of humeral head have following stages

  1. Initial stage:blood supply surrounding humeral head is disrupted leads to tissue damage and necrosis begins
  2. Fragmentation: The body reabsorbs the necrotic bone and substitutes it with fragile woven bone, which is susceptible to fractures and collapse because of its weakness
  3. Reossification: the bone start getting stronger lower the risk of being collapse.
  4. Remodeling: the bone completely regrow back and final shape of bone is depends upon the damage occur may be normal or abnormal).[4]

Causes

Several factors can lead to avascular necrosis of the humeral head, including:

The mnemonic to remember the following causes is MATUU

  • Medication: Prolonged use of corticosteroids is a known risk factor for AVN.[5]
  • Alcohol Consumption: Heavy alcohol use can lead to fatty deposits that obstruct blood vessels.[6]
  • Trauma: Injuries such as fractures or dislocations can damage blood vessels supplying the humeral head.[7]
  • Underlying Medical Conditions: Diseases such as systemic lupus erythematosus, sickle cell anemia, and gout can increase the risk.[8]
  • Unknown Causes: In some cases, the exact cause of AVN remains unclear.[8]

Symptoms

The symptoms of avascular necrosis in the humeral head can develop over time and may include:

  • Pain: Often a deep, aching discomfort that worsens with activity and improves with rest.
  • Restricted Movement: Difficulty in moving the shoulder fully, accompanied by pain.
  • Weakness: Loss of strength in the shoulder and upper arm, affecting everyday activities.
  • Functional Impairment: Severe cases can lead to significant difficulties with tasks involving shoulder use.[9][10]

Diagnosis

Diagnosing AVN of the humeral head involves a thorough evaluation and various imaging techniques:

  • Physical Examination: Assessment of symptoms, range of motion, and shoulder function.
  • Imaging Tests:
    • X-rays: May show changes in bone structure and joint space.[11]
    • MRI: Highly effective for early detection, revealing changes in bone marrow and surrounding tissue.[11]
    • CT Scan: Offers detailed views of bone structure, useful for evaluating the extent of the condition.[12]

Treatment

Treatment aims to alleviate symptoms, maintain shoulder function, and prevent further joint damage.

Options include:

  • Conservative Management:
    • Medications: Pain relievers and anti-inflammatory drugs to manage symptoms.
    • Physical Therapy: Exercises to improve range of motion and strengthen shoulder muscles.
    • Activity Modification: Adjusting activities to avoid exacerbating symptoms.[13][14]
  • Surgical Options:
    • Core Decompression: A procedure to reduce pressure within the bone and enhance blood flow.
    • Bone Grafting: Replacing damaged bone with healthy bone from another part of the body.
    • Shoulder Replacement: In advanced cases, a shoulder arthroplasty (replacement) may be necessary to restore function and relieve pain.[15][16][17]

Physiotherapy Management

Goals:

  • Maintain or improve range of motion
  • Optimize shoulder function and strength
  • Pain management
  • Prevent compensatory movement patterns
  • Patient education

Pre-Operative Physiotherapy:

  • Education: Disease process, surgical expectations, post-operative rehabilitation
  • ROM exercises: Gentle passive and active-assisted exercises
  • Strengthening: Maintain rotator cuff and scapular muscle function
  • Functional training: Adapt activities of daily living

Post-Operative Rehabilitation (Following Arthroplasty):

Phase 1 (0-6 weeks): Protection and Passive Motion

  • Immobilization in sling for comfort (1-3 weeks, depending on procedure)
  • Goals: Protect repair, pain control, early passive ROM
  • Interventions:
    • Pendulum exercises (day 1-2)
    • Passive ROM: flexion, external rotation (in plane of scapula)
    • Active elbow, wrist, hand exercises
    • Scapular setting
    • Cryotherapy, pain management
  • Precautions: No active shoulder motion, no lifting, no reaching behind back

Phase 2 (6-12 weeks): Active Motion and Early Strengthening

  • Goals: Progress to active ROM, initiate light strengthening
  • Interventions:
    • Progress to active-assisted ROM (pulleys, wand exercises)
    • Active ROM in all planes
    • Isometric rotator cuff strengthening
    • Scapular stabilization exercises
    • Light functional activities
  • Criteria to progress: Adequate passive ROM, minimal pain, healing confirmed on imaging

Phase 3 (12+ weeks): Advanced Strengthening and Return to Function

  • Goals: Full active ROM, restore strength, return to activities
  • Interventions:
    • Progressive resistance exercises (bands, light weights)
    • Proprioceptive training
    • Functional and sport-specific training
    • Gradual return to work and recreational activities
    • Most patients achieve functional ROM by 3-6 months; strength continues to improve up to 12-18 months

Prognosis

The prognosis for individuals with AVN of the humeral head depends on the stage of the condition at diagnosis and the effectiveness of treatment strategies. Early detection and intervention can improve outcomes, often leading to symptom relief and functional preservation.[18]

Prevention

Preventive measures include:

  • Managing Risk Factors: Limiting corticosteroid use, reducing alcohol consumption, and controlling underlying medical conditions.
  • Early Detection: Regular monitoring and prompt attention to shoulder injuries can help in early diagnosis and management of AVN.[19]

Reference

  1. ↑ Lesser Tuberosity Osteotomy Outcomes After Anatomic Shoulder Arthroplasty in Patients With Atraumatic Avascular Necrosis - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Humeral-Head-AVN-With-Collapse-Radiographs-of-a-28-Year-Old-Woman-With-Sickle-Cell-AVN_fig2_325293181 [accessed 27 Jul 2024
  2. ↑ Cehelyk, E. K., Stull, J. D., Patel, M. S., Cox, R. M., & Namdari, S. (2023). Humeral Head Avascular Necrosis: Pathophysiology, Work-up, and Treatment Options. JBJS reviews, 11(6), 10.2106/JBJS.RVW.23.00014. https://doi.org/10.2106/JBJS.RVW.23.00014
  3. ↑ Keough N, Lorke DE. The humeral head: a review of the blood supply and possible link to osteonecrosis following rotator cuff repair. Journal of Anatomy. 2021 Nov;239(5):973-82.
  4. ↑ Hsu H, Nallamothu SV. Hip Osteonecrosis (Archived) [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499954/
  5. ↑ Heimann WG, Freiberger RH. Avascular necrosis of the femoral and humeral heads after high-dosage corticosteroid therapy. New England Journal of Medicine. 1960 Oct 6;263(14):672-5.
  6. ↑ Suman H, Sharma Y, Acharya PK, Krishna J, Patidar NK. RELATIONSHIP OF ALCOHOL AND TOBACCO WITH AVN OF FEMORAL HEAD IN ADULT INDIAN POPULATION. Alcohol.;40:55.
  7. ↑ Tyrrell Burrus M, Cancienne JM, Boatright JD, Yang S, Brockmeier SF, Werner BC. Shoulder arthroplasty for humeral head avascular necrosis is associated with increased postoperative complications. HSS Journal®. 2018 Feb;14(1):2-8.
  8. ↑ 8.0 8.1 Lee WQ, Lie HM, Lie DT. Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts. Journal of ISAKOS. 2023 Apr 1;8(2):108-13.
  9. ↑ Lee WQ, Lie HM, Lie DT. Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts. Journal of ISAKOS. 2023 Apr 1;8(2):108-13.
  10. ↑ Orfaly RM, Rockwood Jr CA, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. Journal of Shoulder and Elbow Surgery. 2007 May 1;16(3):S27-32.
  11. ↑ 11.0 11.1 Lee WQ, Lie HM, Lie DT. Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts. Journal of ISAKOS. 2023 Apr 1;8(2):108-13.
  12. ↑ Imhof H, Breitenseher M, Trattnig S, Kramer J, Hofmann S, Plenk H, Schneider W, Engel A. Imaging of avascular necrosis of bone. European radiology. 1997 Mar;7:180-6.
  13. ↑ Talamo G, Angtuaco E, Walker RC, Dong L, Miceli MH, Zangari M, Tricot G, Barlogie B, Anaissie E. Avascular necrosis of femoral and/or humeral heads in multiple myeloma: results of a prospective study of patients treated with dexamethasone-based regimens and high-dose chemotherapy. Journal of Clinical Oncology. 2005 Aug 1;23(22):5217-23.
  14. ↑ Heimann WG, Freiberger RH. Avascular necrosis of the femoral and humeral heads after high-dosage corticosteroid therapy. New England Journal of Medicine. 1960 Oct 6;263(14):672-5.
  15. ↑ Lee WQ, Lie HM, Lie DT. Diagnosis and treatment of avascular necrosis of the humeral head: Current concepts. Journal of ISAKOS. 2023 Apr 1;8(2):108-13.
  16. ↑ Franceschi F, Franceschetti E, Paciotti M, Torre G, Samuelsson K, Papalia R, Karlsson J, Denaro V. Surgical management of osteonecrosis of the humeral head: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Oct;25(10):3270-8.
  17. ↑ Tyrrell Burrus M, Cancienne JM, Boatright JD, Yang S, Brockmeier SF, Werner BC. Shoulder arthroplasty for humeral head avascular necrosis is associated with increased postoperative complications. HSS Journal®. 2018 Feb;14(1):2-8.
  18. ↑ Li Y, Li Y, Tian H. Deep learning-based end-to-end diagnosis system for avascular necrosis of femoral head. IEEE Journal of Biomedical and Health Informatics. 2020 Nov 10;25(6):2093-102.
  19. ↑ Boesmueller S, Wech M, Gregori M, Domaszewski F, Bukaty A, Fialka C, Albrecht C. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury. 2016 Feb 1;47(2):350-5.
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