Avascular Necrosis of the Humeral Head

Avascular necrosis (AVN) of the humeral head is a condition in which the blood supply to the upper part of the humerus is impaired, causing bone tissue to die. This can lead to collapse of the humeral head and secondary osteoarthritis, resulting in pain, reduced shoulder mobility and ultimately joint damage.

Causes of avascular necrosis of the humeral head are varied and may include trauma, prolonged corticosteroid use, or systemic diseases such as sickle cell disease, systemic lupus erythematosus and alcohol misuse¹.

Avascular necrosis of the humeral head

Anatomy

The humeral head is the rounded upper part of the humerus that articulates with the glenoid to form the shoulder joint and allows a wide range of shoulder movement. Its blood supply is derived mainly from the anterior and posterior humeral circumflex arteries. Injury to these vessels can lead to avascular necrosis[3].

Stages

Avascular necrosis of the humeral head progresses through several stages:

1. Initial phase: Blood supply to the humeral head becomes disrupted, leading to tissue injury and the onset of necrosis.

2. Fragmentation: The body begins to resorb necrotic bone and replace it with fragile woven bone, which is vulnerable to fracture and collapse because of its reduced strength.

3. Reossification: The bone begins to regain strength and the risk of collapse decreases.

4. Remodeling: The bone rebuilds further, and its final shape depends on the extent of the original damage. The resulting anatomy may be normal or abnormal[4].

Causes

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

A simple mnemonic for remembering common causes is MATUU:

• Medications: Prolonged corticosteroid use is a recognized risk factor for AVN[5].

• Alcohol consumption: Heavy alcohol use can contribute to fatty deposits that impair blood flow[6].

• Trauma: Injuries such as fractures or dislocations can damage the vessels supplying the humeral head[7].

• Underlying medical conditions: Diseases such as systemic lupus erythematosus, sickle cell disease and gout can increase risk[8].

• Unknown causes: In some cases, the exact cause of AVN remains unclear[8].

Symptoms

Symptoms of avascular necrosis of the humeral head often develop gradually and may include:

• Pain: Usually a deep, aching discomfort that worsens with activity and improves with rest.

• Limited movement: Difficulty moving the shoulder through its full range, often accompanied by pain.

• Weakness: Loss of strength in the shoulder and upper arm that can affect daily activities.

• Functional impairment: In severe cases, patients may have substantial difficulty with tasks requiring use of the shoulder[9][10].

Diagnosis

Diagnosis of avascular necrosis of the humeral head involves a thorough clinical assessment and appropriate imaging:

• Physical examination: Assessment of symptoms, range of motion and shoulder function.

• Imaging:

  • X-ray: May show changes in bone structure and joint space[11].

  • MRI: Highly effective for early detection and can reveal changes in bone marrow and surrounding tissues[11].

  • CT scan: Provides detailed images of bone structure and is useful for assessing the extent of disease[12].

Treatment

Treatment of avascular necrosis of the humeral head aims to relieve symptoms, preserve shoulder function and prevent further joint damage.

Treatment options include:

• Conservative treatment:

  • Medication: Analgesic and anti-inflammatory medication may be used to manage symptoms.

  • Physiotherapy: Exercises can be used to improve mobility and strengthen the shoulder musculature.

  • Activity modification: Activities may be adjusted to avoid aggravating symptoms[13][14].

• Surgical options:

  • Core decompression: A procedure intended to reduce pressure within the bone and improve blood supply.

  • Bone grafting: Damaged bone is replaced or supplemented with healthy bone tissue from another site.

  • Shoulder surgery: In severe cases, shoulder arthroplasty may be required to restore function and reduce pain[15][16][17].

Prognosis

Prognosis depends on the stage of disease at diagnosis and the effectiveness of treatment. Early detection and intervention can improve outcomes and may help relieve symptoms and preserve function[18].

Prevention

Preventive measures include:

• Management of risk factors: Limit corticosteroid exposure when medically appropriate, reduce alcohol consumption and optimize management of underlying medical conditions.

• Early detection: Regular follow-up and prompt treatment of shoulder injuries may support earlier diagnosis and management of AVN[19].

Sources

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 

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. 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. 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.