Fracture Proximal HumerusK-Wire Fixation And External Fixation.

JAYANT SHARMAM.S., DNB.,MNAMS.

Web :www.drjayantsharma@gmail.com

Fracture Proximal Humerus

• 4-5% of all cases.

• Third most common beyond 65 years age.

• Aim of management is Early Mobilization.

Classification• A) A.O. Classification:

Based on severity of injury and AVN

• 1. Type A: No vascular isolation of articular segment is detected.

• 2. Type B: Partial vascular isolation of articular segment

• 3. Type C: Total vascular isolation of articular segment

• Codman noted that the fractures follow Epiphyseal Plates. Four possible sites are Lesser tuberosity, Greater tuberosity, head and Shaft.

• Management of these fractures continues to be a controversial subject.

• Various options are:• Non operative.• ORIF.• External fixation.• Tension band fixation.• Arthroplasty

Disadvantages Of Various Methods• A. Non Operative:• Failure to obtain early mobilization which

results in: • Higher rate of Shoulder Stiffness• Pain and • Malunion.

• B. Internal fixation:• Difficulty in achieving

rigid fixation in cancellous bone

• As cortical bone is very thin shell and weak purchase of screw results in pull out.

• Intra op bleeding.• Increased Risk of AVN.• Adhesions post

operatively, reduce ROM due to excessive dissection. Normal head thickness 19mm

Disadvantage of Arthroplasty

• Stiffness • Scarring• Hardware problems• Tuberosity malposition• Functional score are same as Ex. Fix (Norris

et.al.1995). Only 53% had ability to use arm above shoulder.

Advantages of Minimally Invasive Techniques And External fixator

• Avoids dissection of Deltoid, Rotator Cuff and biceps due to use of small pin diameter.

• Lower incidence of AVN(Ascending branch of Anterior circumflex Humeral artery is not disturbed).

• Minimal blood loss.• Less scarring of scapulo humeral interface.

• Eliminates another Surgery for Hardware removal.

• Faster rehabilitation.• Effective in polytrauma, as can be done in

Supine position.• Some authors have reported good to

excellent results in Osteoporotic fractures

• Resch H et.al, JBJS (Br) 1997, • In 3 or 4 part fracture 90 % good to excellent

results.• AVN incidence was 1%• Chen CY, Journal of Trauma 1998,• 2 or 3 part fracture showed 85%good results .

• Calvo et.al Journal of Shoulder and Elbow2007,• Excellent to good results in 2 and 4 part fractures

was 85% with percutaneous pinning and external fixation, with early mobilization.

• AVN incidence was 2%.

Complications

• 1. Non union• 2. Superficial infection• 3. Deep infection• 4. Bicipital tendinitis• 5 Reflex sympathetic dystrophy• 6. Loss of reduction.

IMPORTANT RED FLAG.

• Circumflex humeral artery branch of Axillary artery.

• This proximal branch runs through the Bicipital groove.

Operative Steps.• GA/ Brachial block• Supine position with a sand bag to

elevate shoulder.• Structures at risk:• a. Axillary nerve• b. Posterior humeral circumflex artery• c. Anterior branch of Axillary Artery.• d. Cephalic vein.• e. Biceps tendon.• f. Musculocutaneous nerve.

Operative contd...

• 2.5mm Schanz pins/ K wire at humeral head at 300 to each other in horizontal plane.

• 1st: In true lateral/ coronal plane

2nd: just lateral to bicipital groove

3rd: 300 posterior to 1st one.

A displacement of Greater tuberosity superiorly may cause Impingement.A displacement posteriorly can cause External rotation is blocked.

• Next 2.5mm pin inserted in coronal plane in line with 1st pin, approximately 4cm or 3 finger/ below the 1st pin in upper third of Humerus.

• 3rd pin placed 2cm below the above pin laterally.

• Wires are placed from lateral cortex to medial cortex into the head upto the subchondral area

Operative contd...

• Now the wires are joined through Link joints of JESS and a curved rod.

• A wire can be placed from the head to bring down the head as near to the shaft.

Joshi’s External Stabilizing System

• Assembly consists of :• 1. A simple light modular mini fixator

• 2. Invented by Dr. B. B. Joshi

• 3. Has high safety profile

• 4. Ease of application

Joshi’s External Stabilizing System.• Has an advantage of:• Fixed angle stability.

• Provides stability even in osteoporotic fractures.

• Early results are encouraging.

• No comparison with plating and hemiarthroplasty available.

COMPONENTS• A) Link joints:• 1. Basic clamping unit of JESS• 2. Cross holes at different

levels• 3. One is oval other is round

and perpendicular to oval hole

• B) Connecting rods:• Diameter vary from 2-4mm• Available in various lengths

Post op• Pouch arm sling is applied.

• Pain free ROM, ASAP.

• Pins cleaned with Povidone iodine.

• Patient follow up for 2,4,6 and 8 weeks.

• Removal at 6 or 8 week.

• Then for bimonthly till 1 year.

Physiotherapy

Nabeil Ebraham’s Technique• 4 Step technique• 2 pins of 2.5 mm inserted in Shaft.• 2 pins of 2.5 mm in Head.• Head is externally rotated to place Greater

tuberosity pin, avoids Axillary nerve, Posterior circumflex humeral artery.

• Pins are used as joystick to reduce the fragments external fixator then applied.

• Additional anterior pins are added for stability.

Nabeil Ebraham’s Technique

ILIZAROV RING FIXATION

• Cumbersome assembly.• Needs expertise and has

steep learning curve.

Take Home Message

• Early mobilization and ease of fixation is an advantage with External fixation devices.

• Elderly Patients and osteoporotic fractures are well managed with Ex. Fix.

• Avoids need of redo surgery.• Less expertise needed, Surgeon and Patient

friendly procedure.

THANK YOU FOR A PATIENT LISTENING

Constant Scoring System• Four variables that are used to assess the function of the

shoulder. • The subjective variables are• Pain • Activities of daily living (ADL) (sleep, work, recreation/sport),

which give a total of 35 points (pain: 15, ADL: 20). • The objective variables are• Range of motion• Strength, which give a total of 65 points (range of motion:

40, strength: 25

• Altogether there are 100 points. • Constant Score divides the outcome of

patients into four categories, i.e. • Excellent having a score >85, • Good having a score between 71 and 85, • Fair having a score between 61 and 70, • Poor outcome with a score of 60 or less.