Issues in the Treatment of Proximal Humerus Fractures

1. Issues in the Treatment of Proximal Humerus Fractures Robert P Dunbar, MD Associate Professor Harborview Medical Center University of Washington Seattle, WA, USA

2. Greetings from Seattle

5. Proximal Humerus Issues • Stability • Head Viability • Treatment Choices • Avoiding Problems

6. Goals • Locate joint • Relieve pain • Protect soft tissues • Restore function • Motion

7. 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

8. The Good News • Majority of fractures are stable • Can be successfully treated nonoperatively

9. Stability • Understand fragments & their displacement • Greater tuberosity • Lesser tuberosity • Epi/metaphysis • Anatomic vs surgical neck

10. Humeral Head Blood Supply

11. Metaphyseal extension (calcar) < 8 mm. • Loss of integrity of medial hinge • Fracture Pattern (anatomic neck) 97% PPV Predictors of AVN Hertel et al, J Shoulder Elbow Surg 2004;13:427

12. BEWARE of lateral displacement of head Metaphyseal head extension < 8mm Blood Supply Potentially Torn if medial hinged displaced This head is likely NOT viable.

13. Medial Hinge not displaced Metaphyseal head Extension > 8mm This head is likely viable

14. Options for Treatment • Non-Operative • Percutaneous Fixation • ORIF • IMN • Replacement

15. Considerations • Age • Bone Quality • Fracture Characteristics • Head Viability • Level of Activity • Hand Dominance • Occupations/Hobbies • Surgeon/Hospital Factors

16. Percutaneous Pinning

18. Technical Pin number Types of pins 2.5 mm Terminally threaded Shanz pins

20. Complications? • Pin removal? • Benefits?

21. ORIF

22. Positioning • Supine • Beach Chair

23. Surgical ApproachDeltopectoral

24. Deltopectoral Disadvantages • Difficult getting to greater tuberosity • Commonly displaces proximally & posteriorly due to cuff attachments

25. Anterolateral Acromial Approach • Supine or beach chair • Ensure adequate fluoro prior to prep and drape

26. AP Proximal Humerus Transcapular Lateral

27. Anterolateral Acromial Approach • Incision from anterolateral corner of acromion distally down shaft

28. Anterolateral Acromial Approach • Identify avascularraphe between anterior and middle heads of deltoid.

29. Anterolateral Acromial Approach • Identify and incise bursa in proximal window

30. Anterolateral Acromial Approach • Identify axillary nerve (~65 mm from acromion) and humeral shaft distally

31. Anterolateral Acromial Approach • Incise bursa to expose fracture and reduce

32. Reduction - tuberosities

33. Reduction - tuberosities Hertel 2005

34. Anterolateral Acromial Approach • After fracture reduction, insert plate deep to axillary nerve along shaft

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

36. Reduction – head/neckRestore medial contour! THIS WILL NOT DO WELL BETTER!

37. Reduction Restore proper retroversion

38. Reduction - varus Get Head out of Varus 1. K-wire joysticks 2. Cuff sutures 3. Elevator 3. Arm abduction

39. Technique • Plate applied to the reduced fracture (typical) • K-wire provisional fixation

40. Plate Fixed to Head then Reduced to Shaft

41. TechniqueWhat the plate does NOT neutralize • Smaller/comminuted greater tuberosity • The lesser tuberosity • Consider: • Independent screw fixation • Suture repair to plate

42. Technical Aspects • 8 mm distal to rotator cuff attachment • If too proximal – impingement • If too distal – difficulty with screw placement in head

43. 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

44. Locking plates are less prone to failure due to the fixed- angled screws. Implant Limitations Recognizing what implants are appropriate for certain fracture types is KEY! Conventional implants Poorly control varus collapse, screw loosening and screw back out.

45. 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)

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

47. ORIF – What’s the Problem? • Osteopenic bone • Implant (screw) purchase compromised Meyer DC, et al., JSES 2004

48. What Can We Do?Osteobiologic Augmentation

49. Osteobiologic Augmentation

50. Fibular Strut Allograft Lorich et al. CORR 2011