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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;
          - Is antegrade nailing a proper option in 2- and 3-part proximal humeral fractures?


- 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
          - 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.
    - 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.