Issues in the Treatment of Proximal Humerus Fractures

Robert P Dunbar, MDAssociate Professor

Harborview Medical CenterUniversity of Washington

Seattle, WA, USA

Greetings from Seattle

Proximal Humerus Issues

• Stability

• Head Viability

• Treatment Choices

• Avoiding Problems

Goals

• Locate joint• Relieve pain• Protect soft tissues

• Restore function– Motion

Proximal Humerus Fractures• Extremely common

– Low energy “Osteoporotic fracture”– High energy

• Complicating factors– Poor bone quality– Require early motion

• Difficult to:– Obtain & maintain a good reduction– Get a good functional outcome

The Good News

• Majority of fractures are stable

• Can be successfully treated nonoperatively

Stability

• Understand fragments & their displacement– Greater tuberosity

– Lesser tuberosity

– Epi/metaphysis• Anatomic vs surgical neck

Humeral Head Blood Supply

Predictors of AVN

Hertel et al, J Shoulder Elbow Surg 2004;13:427

•Metaphyseal extension (calcar) < 8 mm.•Loss of integrity of medial hinge•Fracture Pattern (anatomic neck) 97% PPV

BEWARE of lateral displacement of head

Blood Supply Potentially Torn if medial hinged displaced

This head is likely NOT viable.

Metaphyseal head extension < 8mm

Medial Hinge notMedial Hinge not displaceddisplaced

Metaphyseal headMetaphyseal headExtension > 8mmExtension > 8mmThis head is

likely viable

• Non-Operative

• Percutaneous Fixation

• ORIF

• IMN

• Replacement

Options for Treatment

Considerations

• Age

• Bone Quality

• Fracture Characteristics

• Head Viability

• Level of Activity

• Hand Dominance

• Occupations/Hobbies

• Surgeon/Hospital Factors

Percutaneous Pinning

TechnicalPin numberTypes of pins

2.5 mm Terminally threaded Shanz pins

• Complications?

• Pin removal?

• Benefits?

ORIF

Positioning• Beach Chair • Supine

Surgical ApproachDeltopectoral

Deltopectoral Disadvantages

• Difficult getting to greater tuberosity

• Commonly displaces proximally & posteriorly due to cuff attachments

Anterolateral Acromial Approach

• Supine or beach chair• Ensure adequate fluoro prior to prep and drape

AP Proximal

Humerus

Transcapular

Lateral

Anterolateral Acromial Approach

• Incision from anterolateral corner of acromion distally down shaft

Anterolateral Acromial Approach

• Identify avascular raphe between anterior and middle heads of deltoid.

Anterolateral Acromial Approach

• Identify and incise bursa in proximal window

Anterolateral Acromial Approach

• Identify axillary nerve (~65 mm from acromion) and humeral shaft distally

Anterolateral Acromial Approach

• Incise bursa to expose fracture and reduce

Reduction - tuberosities

Reduction - tuberosities

Hertel 2005

Anterolateral Acromial Approach

• After fracture reduction, insert plate deep to axillary nerve along shaft

Reduction – head/neck

• Anatomic/surgical neck component• Rule #1: Do not leave head/neck in varus

Reduction – head/neckRestore medial contour!

THIS WILL NOT DO WELLBETTER!

Reduction

Restore proper retroversion

Reduction - varus

Get Head out of Varus1. K-wire joysticks 2. Cuff sutures3. Elevator3. Arm abduction

Technique

• Plate applied to the reduced fracture (typical)

• K-wire provisional fixation

Plate Fixed to Head then Reduced to Shaft

• Smaller/comminuted greater tuberosity

• The lesser tuberosity

• Consider:

• Independent screw fixation

• Suture repair to plate

TechniqueWhat the plate does NOT neutralize

• 8 mm distal to rotator cuff attachment

• If too proximal – impingement

• If too distal – difficulty with screw placement in head

Technical Aspects

ORIF

• Stable fixation can be

difficult to achieve

• Systematic review:

– Screw cut-out 11.6%

– Reoperation 13.7%

– AVN 7.9%

Thanasas et al., JSES 2009

Implant Limitations

Locking plates are less proneto failure due to the fixed-angled screws.

Conventional implants

Poorly control varuscollapse, screw

looseningand screw back out.

Recognizing what implants are appropriate for certain fracture types is KEY!

Locked Plating Results: Sudkamp et al, JBJS, 2009

• Multicenter 155 patients: ORIF locked plates (2 part fxs)

• 34% complications!

• Many preventable (1/2 related to the surgical technique)

– 21 intraoperative screw penetration

– 4 patients with cranial plate position (impingement)

ORIF – What’s the Problem?• Strong muscle deforming forces• Short segments

ORIF – What’s the Problem?

• Osteopenic bone

• Implant (screw) purchase

compromised

Meyer DC, et al., JSES 2004

What Can We Do?Osteobiologic Augmentation

Osteobiologic Augmentation

Fibular Strut Allograft

Lorich et al. CORR 2011

Rotator Cuff Sutures

Intramedullary Fixation

76yo

Hemiarthroplasty

Indications (relative) for Hemiarthroplasty

• Elderly patients

• Severe osteopenia

• Some 4-part fractures

• Fractures with predictable lack of viability

• Loss of medial hinge

• Lack of distal extension medially

• Head displacement laterally

• Head-splitting fractures

PROSTHESISThe key is the position & healing of the tuberosities

Keys to success: Summary

1. Accurate imaging & diagnosis– Assess displacement, stability & viability

2. Careful patient & treatment selection

3. Biologically friendly dissection

4. Reduction, reduction, reduction– Tuberosities; no neck varus; restore medial support

5. Consider augmentation in complex cases

Terima kasih banyak!

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