IntraOperative Reduction of Proximal Humerus Fracture

- Discussion:
        - proximal first or screw insertion method - goal is bring frx out to length (anatomically reduced) and to have the plate optimally positioned (not too proximal /not too distal);
        - disimpaction:
                - longitudinal traction to limb is applied
                - periosteal elevator is inserted into the fracture gap to disimpact the fracture;
                - elevator is inserted from anteriorly and is directed medially and superiorly;
                - biciptal groove is a good initial indicator of reduction;
        - need to restore medial butress
                - homan retractor can be inserted into the fracture site to lever the fracture out of varus;
                - if medial buttressing is insufficient, esp w/ varus malreduction, there may be loss of reduction and subsequent screw perforation or plate breakage;
                - ref: Internal fixation of proximal humerus fractures using the locking proximal humerus plate.
                - cautions: oblique fractures with shortening can be especially difficult to reduce;
                - varus malalignment is unacceptable;
- temporary k wire fixation
        - k wires are inserted through the plate holes to achieve temporary reduction;
        - k wires can be inserted anteriorly from inferior to superior for temporary fixation;

- indirect suture reduction and suture fixation:
        - can be achieved by securing the plate to the head fragment first (especially important for 3 part, and 4 part fracture)
        - consider suture fixation at tendon osseous juntion (supraspinatus and infraspinatus) by applying sutures thru cuff and plate (suture holes at top of plate);
        - a single running suture may produce the most even distribution of forces across the construct;
        - as the plate is translated inferiorly, tension is applied to the suture/plate construct, and the reduction is achieved (frx is moved out of varus);
        - plate is then translated inferiorly with maximal force using a homan through one of the distal screw holes;
        - this tightens the sutures and strengthens the construct;
        - this lowers the plate so that there will not be impingement;
        - plate is secured to the shaft with a proximal locking screw to hold the reduction;
        - in study by Südkamp N, et al, additional sutures were used to stabilize the greater or lesser tuberosity in the cases of 110 frx (59%)
        - references:
                - Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study.
                - Transosseous Suture Fixation of Proximal Humeral Fractures (letter to the editor)
                - Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
                - Transosseous Suture Fixation of Proximal Humeral Fractures
                - Tension Suture Fixation Using 2 Washers for Proximal Humeral Fractures
                - Results of proximal humeral locked plating with supplemental suture fixation of rotator cuff
                - [Case-control study on suture-assisted locking plate for the treatment of proximal humeral fractures in elderly].

- proximal screw reduction:
      - alternatively insert 1-2 promimal screws (non locking) into the head, which will secure the optimal head position;
      - insert non locking screws through the distal screw holes in order to compress the head to contoured plate;
      - this will bring the head fragment out of its varus position, and into anatomic alignment; 

      - references:
             - The Biomechanics of Locked Plating for Repairing Proximal Humerus Fractures With or Without Medial Cortical Support.
             - The importance of medial support in locked plating of proximal humerus fractures.
             - Analysis of efficacy and failure in proximal humerus fractures treated with locking plates

 




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 31, 2015 9:14 am