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Phani K. Dantuluri, MDShoulder and Elbow & Upper Extremity Surgery
Resurgens OrthopaedicsEmory University Midtown Hospital
Emory St.Joseph’s Hospital
Proximal Humerus Fractures -What to do in young active patients?
2 Part Surgical Neck Fracture
•Five percent of all fractures
•80% minimally displaced stable fractures
•Only 20% need surgical treatment
• Often associated with poor functional outcome
•Less poor outcomes with nonop than operative treatment
Proximal Humerus Fractures
2 Part Surgical Neck Fracture
•Age
•Bone Quality
•Demands of patient
•Head Viability (Hertel)
•Tuberosities most important
•No consensus on which fractures should be operated on
Proximal Humerus Fractures
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Ascending anterolateral branch of the anterior circumflex artery
Vascular Anatomy
Greater Tuberosity Fracture More displaced Greater Tuberosity Fracture
Orthogonal Views
Displaced Greater Tuberosity Fracture
•May underestimate greater tuberosity displacement on AP view
•Y view and axillary view necessary to fully appreciate displacement
•Less displacement tolerated with greater tuberosity fractures
THE Greater Tuberosity
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• Only few criteria to determine correlation between displacement and function– Head/Tuberosity relationship
• Seems to be critical for function• Malunion difficult to manage
– Surgical neck• Forward elevation decreases in direct
proportion to fracture angulation• Varus deformity leads to subacromial
impingment• Malunion easier to manage
What fracture displacement can we accept???
• Displaced unstable fracture
• Multiple trauma• Associated UE
fracture• Vascular injury• Compliant patient
Indications for treatment
• Reestablish the tuberosities in the proper position. GT and LT in relation to the head
• GT has three of four RC muscles attached to it
• Preserve the blood supply
What do we need to do?
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Deforming Forces
Scapular AP
Axillary View
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Internal Rotation View
Difficult techniqueTedious techniqueRequires Team approachRequires learning curve
CRPP
• 2- Part Surg Neck Fx displaced/angulated• Young patient with good bone• Compliant patient
CRPP Ideal Indications
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• Non-compliant patient• Severe comminution• Marked osteopenia• (4-part fractures)• Fracture dislocations• Some 3-part fractures
CRPP Contraindications
CRPP Contraindications
CRPP Technique• Proper patient positioning is essential. Use regular table not beach chair• Preoperative trial reduction• Plan maneuver and position c-arm properly• Have all Pins (2.5 mm terminal thread pins) • Have all screws (4.0 AO cannulated)
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• Longitudinal Traction• Mechanical arm holder helpful•Posterior pressure on humerus corrects apex-anterior angulation or anterior shaft displacement
CRPP Technique
• Do reduction first• Hold pin over shoulder • Image in A-P plane• Small incision• Spread to bone• Insert first pin (a)• Insert second pin (a)• Axillary view to check• Insert third pin (b)• Insert fourth/fifth pins (c) as needed for greater tuberosity
CRPP Technique
• Trim pins under skin• Shoulder immobilizer• Pendulums O.K. if no proximal pin(s)• No passive ROM for 3-4 weeks• Serial x-rays q week for 4 weeks• Remove any proximal pin(s) at 3 weeks• Remove other pins at 4-6 weeks
CRPP Technique
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Locking Plates
LOCKING SCREWS MULTIPLE ANGLES
ORIF Locking Plates
• Beach chair position
• Separate padded Mayo Stand
• Deltopectoral approach or Lateral Approach
• Maintain vascularity of fragments
• Control Tuberosities, Use Sutures to reduce
• Reduce head portion of fracture and fix with K-wires
• May be preferable to reduce head to shaft prior to plate application
• Avoid placement of K-wires that will interfere with plate application
ORIF Locking Plates
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• Beach Chair Positioning
• Prep entire shoulder girdle
• Intraoperative Fluoro available
• Padded Mayo Stand
Positioning
Surgical Approach
• Locate Biceps tendon as guide
• Minimize stripping
• Get control of the tuberosities with suture
• Traction is key
Surgical Technique
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Contralateral Template
Provisional Reduction
• Must be below rotator cuff insertion
• Avoid impingement
• Distal enough so that calcar support screws perfect
• Orthogonal views critical for good screw spread
Plate Positioning
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Must check plate position on multiple views to verify correct placement!
Plate Application
Metaphyseal Bone Loss
Valgus Impacted Pattern
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• Go SLOWER to avoid tuberosity displacement
• Easier to deal with a stiff healed ORIF, than one with tuberosity failure
• Gentle PROM, then AAROM at 6 weeks, Strengthening at 12-16 weeks
• Monitored Hydrotherapy if possible
Elévation en ApesanteurA la Surface de l’Eau
La Brasse à plat
Hydrotherapy
Supervised
Postoperative Protocol
• Multiplanar Head Fixation
• Cannulated for Guidewire Insertion
• Minimally Invasive
Intramedullary Fixation
Intramedullary Rods
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Intramedullary Rods
Can we do better?
YES!
Next Generation Nails
Pascal Boileau, MD
TOTAL: 49%Varus MU 16%AVN 10%Screw perfs 14%Nonunion 3%
Sproul et al, Injury 2011
Problems with Locked Plates
517 Cases
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Why Complications?
Add more metal? Fibular strut?
• Sharescompressive, bending, and torsional loads with the bone
• Internal splint
• Internal scaffold
Why IM Fixation?
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Lateral to Medial Support
Central Support
Vascularity Preserving Limited Superior Approach
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Robust Healing
Issues with Distal Fixation
48
Locked Plate Hardware Failure
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Metaphyseal Comminution
Greater Tuberosity Violation
Solution: Nylon/PE Bushing
Need Locking Screws
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Reduction Tricks
Multicenter Study
• Articular Entry
All fractures healed
37/38 (97%) healed with neck-shaft angle of at least 125 degrees
2PT Surgical Neck Fx Study
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Average Constant Score 71 (97%)
Average pain score 13 (15= no pain)
Average FF 132 degrees
Results of Study
• Olerud et al, JSES 2010– 44 patients
–10% patients with “Bad” reductions (NSA<115 degrees)
–46%! lost
reduction (ave 22 degrees)
Results of Plating Surgical Neck Fxs
• Olerud et al, JSES 2010– 26 pts with initial
undisplaced GT Fx’s
19% displaced after ORIF
– Screw penetration through
HH 14%– Secondary displacement
requiring reoperation 7%
– 2 nonunions 5%
– 3 hemiarthroplasties 7%
Results of Plating Surgical Neck Fxs
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Why so many complications?
GTGT
LTLT
Fracture Deforming Forces
Cannot Neutralize with Plating
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Need Screws Perpendicular to the Fracture lines
Screws Point Away from Joint
Unhappy Triad
Pascal Boileau, MD
1. GT migration2. Humeral Head Necrosis3. Glenoid Erosion
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Importance of Tuberosity FixationHeadless Fixation
Why IM nail?
Preop AP
• Inferior displacement of humeral head
• Greater tuberosity “locked” above humeral head
IM Nail Surgical Technique
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Lesser and Greater tuberosity fractured, but held together by cuff
Shaft comminution
Preop Axillary View
Calcar reduces, indicating intact medial periosteal hinge
Intraoperative Traction View
Reduction Tricks
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Near Anatomic Reduction
Preliminary Reduction
Greater Tuberosity Humeral Head Reduction Held with 2.5mm terminally threaded Steinmann Pin
Preliminary Reduction
Placing Guide Pin (For Nail) Insertion
IM Nailing
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Nail Insertion
Over Guide Pin
IM Nail Insertion
Outlet View
IM Nail Insertion
• Nail rotated into slight retroversion to capture largest greater tuberosity fragment, under direct visualization
First Greater Tuberosity Screw
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First Greater Tuberosity
Screw Placed Fixes
tuberosity and supports
anteromedial humeral head
Greater Tuberosity Fixation
Outlet view
Greater Tuberosity Fixation
Second Greater
Tuberosity Screw
Greater Tuberosity Fixation
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Outlet View
Greater Tuberosity Fixation
Placing Distal Screw
Dynamic Slot
Distal Screw Fixation
Final Construct
Completed IM Nailing
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Final Fluoroscopic Image
Note near anatomic lesser tuberosity placement secondary to intact cuff and fixation of greater tuberosity
Postoperative Radiographs
Preoperative Radiographs
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Shaft comminution
Lesser tuberosityGreater tuberosity
One Week Postop Radiographs
Note early controlled impaction at distal screw, humeral head and greater tuberosity fracture sites
One Week Postop Radiographs
Final Outcome
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Case 1
Case 1
Head Splitting Fractures
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Case 2
Head Splitting Fractures
Head Splitting Fractures