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Shoulder Arthroplasty for Proximal Humerus Fracture
Dr TSE Lung Fung
Department of O&T, Prince of Wales Hospital
The Chinese University of Hong Kong
Arthroplasty in Upper Limb Trauma AADO/HKSSH Conjoint Scientific Meeting 2012
Let’s start with a case……
• Mr. Lee
• M/84
• Good past health
• Retired, lives alone
• ADL independent
• Right handed
The history
• Slipped and fell while getting off bus 7/6/2008
• Landed on out stretched right hand
• Immediate pain over right upper arm
• Failed to move injury arm
• Denied preceding symptoms
• HI with mild bleeding right forehead
At other hospital…
• Admitted to ORT unit
• X ray showed right # neck of humerus, displaced
• P/E showed axillary nerve intact, no distal NV deficit, active finger movement
• Suggested for operation
• Patient strongly requested for DAMA for geographical reasons
2 days later…
• Attended PWH AED 9/6/2008, admitted our unit
• Chief complaint:
– Persistent pain right upper arm near shoulder
– 1st dorsal web space numbness
P/E on arrival
• Significant right shoulder defomity
• Right shoulder swelling +ve
• Max tenderness at proximal humerus
• Decreased ROM of shoulder due to pain
• Motor at elbow / wrist / fingers intact
• Decreased light touch sensation distal to wrist
• Radial pulse not palpable; Doppler signal +ve
• Distal skin pale, but warm, cap refill normal
X rays – shoulder / humerus
CT angiogram
Progress
• EOT done
• Intra-op findings:
– 4-part fracture of right proximal humerus
– Proximal humeral shaft impingement on axillary artery
– Artery still intact
• Partial shoulder replacement done
• Axillary artery released from kinking
• Right radial pulse revert to normal
Post-op X ray
Proximal humeral fracture
• Incidence: 5%
• Etiology: – Fell on out stretched hand
– High energy trauma
• 4 major parts: – Humeral head superior to
anatomical neck
– Lesser tuberosity
– Greater tuberosity
– Shaft of humerus
www.theodora.com/anatomy
PWH Fracture Pattern 2000-2005 Dr LF Tse/ Dr N Tang
0
10
20
30
40
50
60
70
80
90
100
no
.
16-60 61-80 >/=81
Age
prox
shaft
distal
Stable vs Unstable
• Stable – Impacted fracture
• Unstable – Two-part
– Three-part
• Surgical neck + greater / lesser tuberosity
– Four-part
• Anatomical neck + tuberosities
– Fracture dislocation
Possible associated injuries
• Brachial plexus injury (motor + sensory)
• Axillary artery injury
• Mechanism: – Direct injury by sharp bony
fragments / laceration
– Stretching / Bowstringing due to displaced fragment
Posteomedial branch anastomoses with
arcuate artery
Challenge: Geriatric Patients
• Osteopenic Bone • BMD correlates linearly with bone holding for
plates and screws • Bone failure vs implant failure • Complications:
1. Joint stiffness 2. Non-union 3. Mal-union 4.Osteonecrosis 5. Heterotrophic bone formation
Indication for shoulder arthroplasty
• Three parts or four parts fracture and fracture dislocation on very osteoporotic bone
• chronic dislocation with impression # of humeral head > 40% articular surface
• head splitting fracture
• fail ORIF or conservative treatment
• old fracture with humeral head resorbed
A little history
• 1893- French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.
• 1951- Neer I, Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.
• 1974- Neer II Prosthesis. Modified Neer I to conform to a glenoid component.
• Courtesy of Smith & Nephew
Implant
Mono-block Modular
4 sizes, XS, S, M, L
Supine or Beach Chair position
Free the shoudler joint
Arm Support
Head Stabilization
Fluocoscopy – Glenohumeral Joint
Surgical Approach
Deltopectoral Approach
Coracoid
Procedure
ZIMMER® BIGLIANI/ FLATOW® THE COMPLETE SHOULDER SOLUTION
Procedure
ZIMMER® BIGLIANI/ FLATOW® THE COMPLETE SHOULDER SOLUTION
Re-attachment of lesser and greater tuberosities and capsules
Post-op Shoulder immobilizer
Questions…?