Surgical management

 

1.  Two Part Fractures

 

A.  Surgical neck of humerus

 

Indications

- >1 cm displaced or > 45^o angulation

 

 

ORIF with proximal humerus plate

 

2.  Three and Four part fractures

 

Options

 

ORIF

IM nail

Hemiarthroplasty

Reverse TSR

 

ORIF with plate

 

 

Indications

 

Young patient

Sufficient bone quality

 

Results

 

Surgical technique

 

 

Set up

- GA, IV antibiotics, lazy beach chair

- mark anatomy

- ensure adequate flouroscopy images

 

Deltopectoral approach 

- cephalic usually taken laterally

- Hawkins Bell retractor/ blunt gelpies

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractors deep to tendon

- release adhesions from undersurface of deltoid

 

Extensile approach

- release CA ligament

- release proximal pectoralis major

- can release anterior deltoid insertion from clavicle if needed (intra-osseous repair latera)

 

Dangers

- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially

 

Identify structures

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

- remove hematoma

- reduce head onto shaft (head is displaced posteriorly)

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check provisonal fixation with fluoroscopy

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check fluoroscopy aain to avoid having plate too high

- keep head out of varus to avoid cutout

- long inferomedial screws / kickstand screws

 

 

Complications ORIF

 

Cutout

- medial support very important

- must avoid varus malreduction

 

Plate impingement

- need to ensure place plate low on the head

 

Screw perforation of humeral head

- most common complication

 

AVN

- fortunately uncommon

 

 

 

Vascular Injury

 

Axillary / MCN / Brachial Plexus

 

B.  Intramedullary Nail

 

Results

 

Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions

 

C.  Hemiarthroplasty / Reverse TSR

 

Indications

 

Unreconstructable

Elderly

4 part fractures

Head splitting fractures

 

 

 

Hemiarthroplasty

 

 

Issues

 

Must ensure tuberosities heal

ROM often poor / rarely > 90^o

 

ROM

 

Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100^o

- 16% moderate or severe pain

 

Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty

 

Technique

 

Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height

 

Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades

 

Deltopectoral approach

 

Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities

 

Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation

 

Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities

 

Need retroversion of 30^o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30^o

 

Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets

 

Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture

 

Place on head with 12/14 taper

 

Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole

 

Biceps tenodesis

 

Close over drain, rehab as above

 

 

Reverse total shoulder

 

Indication

- elderly patient

- poor cuff

- poor chance of tuberosity healing

 

Problems

- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding

 

Results

 

Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90^o v 60^o) and abduction (90^o v 53^o) better in reverse

- rotation better in hemiarthroplasty