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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Surgical Treatment of Proximal Humeral Fracture


 
- See: Anterior Approach to Shoulder and Synthes Proximal Humerus Products

- Operative Treatment Options: 
    - Lateral Plating (Locking Plating): 


    -
Percutaneous Pinning 
    - Screw Tension Band Technique:
          - reduction:
                  - in some cases cancellous bone from the humerus head is removed to allow better impaction;
          - insert 4.5 or 6.5 mm cancellous lag screw from the shaft up into the head, just shy of the subchondral bone;
          - following screw insertion, figure of 8 tension band wiring (consider No 5 Ethibond) is passed around the rotator cuff origin on greater tuberosity to a drill
                   hole made in the humeral shaft;
          - a second wire is inserted thru both the lesser and greater tuberosities;
          - reference: 
                  - Internal Fixation of Proximal Humerus Fractures using the Screw Tension Band Technique.  
    - Shoulder Replacement:
          - need for revision is significantly higher in patients who underwent hemiarthoplasty for trauma rather than for rheumatoid arthritis;
                  - upto one half of younger patients undergoing hemiarthroplasty will have subjective or objective unsatisfactory results; 
          - technical considerations with fracture:

    - IM nailing:
          - main disadvantage of IM nailing is that shoulder adduction is required for nail entry into the medullary canal where as shoulder
                  abduction is often necessary for fracture reduction;

                 



- Complications:
    - non-union:   
    - avascular necrosis:
          - Avascular necrosis of the humeral head treated by core decompression. A retrospective review
          - Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study
    - malunion:
          - need to categorize the malunion w/ functional and anatomic characteristics;
                - look for malposition of the tuberosities, incongruity of the articular surface, malalignment of the articular segment, soft tissue contractures, rotator cuff tears, instability ect;
                - w/ internal rotation contracture, Z lengthening of the subscapularis may be required;
          - w/ operative correction of malunion, a good postoperative result requires correction of both soft tissue and osseous abnormalities;
          - references:
                - Operative treatment of malunion of a fracture of the proximal aspect of the humerus
                - Humeral tuberosity fractures. Evaluation by CT scan and management of malunion. Morris  ME et al. Orthop Trans. 1987;11:242. 
    - pulmonary embolism:
          - Pulmonary embolism after operative treatment of proximal humeral fractures

    - screw cut out:
          - Fracture Displacement and Screw Cutout After Open Reduction and Locked Plate Fixation of Proximal Humeral Fractures



The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results.

Clinical use of the olecranon-manubrium percussion sign in shoulder trauma.

A posterior surgical approach to the proximal part of the humerus.

Displaced proximal humeral fractures. Seven years' experience with a modified Zickel supracondylar device.

Internal fixation techniques for proximal humeral fractures.               

Displaced proximal humeral fractures. Selecting treatment, avoiding pitfalls.

Proximal humeral fractures. Management techniques and expected results.

The two-part proximal humeral fracture: a review of operative treatment using two techniques.

Proximal humeral fractures revisited.

Treatment of displaced proximal humeral fractures in elderly patients.



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

Last updated by Data Trace Staff on Monday, May 21, 2012 9:32 am