08.05 08.20 dunbar issues-proximal-humerus
DESCRIPTION
ORTHOTRANSCRIPT
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Issues in the Treatment of Proximal Humerus Fractures
Robert P Dunbar, MDAssociate Professor
Harborview Medical CenterUniversity of Washington
Seattle, WA, USA
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Greetings from Seattle
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Proximal Humerus Issues
• Stability
• Head Viability
• Treatment Choices
• Avoiding Problems
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Goals
• Locate joint• Relieve pain• Protect soft tissues
• Restore function– Motion
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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
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The Good News
• Majority of fractures are stable
• Can be successfully treated nonoperatively
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Stability
• Understand fragments & their displacement– Greater tuberosity
– Lesser tuberosity
– Epi/metaphysis• Anatomic vs surgical neck
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Humeral Head Blood Supply
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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
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BEWARE of lateral displacement of head
Blood Supply Potentially Torn if medial hinged displaced
This head is likely NOT viable.
Metaphyseal head extension < 8mm
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Medial Hinge notMedial Hinge not displaceddisplaced
Metaphyseal headMetaphyseal headExtension > 8mmExtension > 8mmThis head is
likely viable
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• Non-Operative
• Percutaneous Fixation
• ORIF
• IMN
• Replacement
Options for Treatment
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Considerations
• Age
• Bone Quality
• Fracture Characteristics
• Head Viability
• Level of Activity
• Hand Dominance
• Occupations/Hobbies
• Surgeon/Hospital Factors
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Percutaneous Pinning
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TechnicalPin numberTypes of pins
2.5 mm Terminally threaded Shanz pins
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• Complications?
• Pin removal?
• Benefits?
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ORIF
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Positioning• Beach Chair • Supine
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Surgical ApproachDeltopectoral
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Deltopectoral Disadvantages
• Difficult getting to greater tuberosity
• Commonly displaces proximally & posteriorly due to cuff attachments
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Anterolateral Acromial Approach
• Supine or beach chair• Ensure adequate fluoro prior to prep and drape
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AP Proximal
Humerus
Transcapular
Lateral
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Anterolateral Acromial Approach
• Incision from anterolateral corner of acromion distally down shaft
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Anterolateral Acromial Approach
• Identify avascular raphe between anterior and middle heads of deltoid.
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Anterolateral Acromial Approach
• Identify and incise bursa in proximal window
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Anterolateral Acromial Approach
• Identify axillary nerve (~65 mm from acromion) and humeral shaft distally
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Anterolateral Acromial Approach
• Incise bursa to expose fracture and reduce
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Reduction - tuberosities
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Reduction - tuberosities
Hertel 2005
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Anterolateral Acromial Approach
• After fracture reduction, insert plate deep to axillary nerve along shaft
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Reduction – head/neck
• Anatomic/surgical neck component• Rule #1: Do not leave head/neck in varus
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Reduction – head/neckRestore medial contour!
THIS WILL NOT DO WELLBETTER!
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Reduction
Restore proper retroversion
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Reduction - varus
Get Head out of Varus1. K-wire joysticks 2. Cuff sutures3. Elevator3. Arm abduction
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Technique
• Plate applied to the reduced fracture (typical)
• K-wire provisional fixation
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Plate Fixed to Head then Reduced to Shaft
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• Smaller/comminuted greater tuberosity
• The lesser tuberosity
• Consider:
• Independent screw fixation
• Suture repair to plate
TechniqueWhat the plate does NOT neutralize
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• 8 mm distal to rotator cuff attachment
• If too proximal – impingement
• If too distal – difficulty with screw placement in head
Technical Aspects
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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
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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!
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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)
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ORIF – What’s the Problem?• Strong muscle deforming forces• Short segments
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ORIF – What’s the Problem?
• Osteopenic bone
• Implant (screw) purchase
compromised
Meyer DC, et al., JSES 2004
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What Can We Do?Osteobiologic Augmentation
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Osteobiologic Augmentation
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Fibular Strut Allograft
Lorich et al. CORR 2011
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Rotator Cuff Sutures
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Intramedullary Fixation
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76yo
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Hemiarthroplasty
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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
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PROSTHESISThe key is the position & healing of the tuberosities
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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
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Terima kasih banyak!
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