Proximal Humerus Fractures

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Transcript Proximal Humerus Fractures

Proximal Humerus Fractures ORIF & Arthroplasty

Reza Omid, M.D.

Assistant Professor Department of Orthopaedic Surgery Keck School of Medicine of USC

Introduction

5-7% of all fractures

80% treated nonoperatively (Neer)

Bimodal incidence

Bone quality- important factor in obtaining secure fixation

Proximal Humeral Anatomy

Understanding Fracture Patterns

4 bony fragments

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Lesser Tub

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Greater Tub

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Head

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Shaft Neer, JBJS

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Proximal Humerus Fractures Fracture Patterns

Stable

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Fx not controlled by muscle

Unstable

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Fx controlled by attached muscle

Proximal Humerus Fracture Fracture Anatomy

Greater Tub – posterior, proximal

Lesser Tub – medial, inferior

Head – remaining tub or fx energy

Shaft – medial, superior

Proximal Humerus Fracture

Fracture Anatomy

Consideration for Surgery

Bone Quality Comorbidities Functional demand Vascularity???

Gerber JBJSAm 1990: 1486-94 Vascularity

anterior humeral circumflex

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Anterolateral branch Of AHC (arcuate artery) Along lateral aspect of groove

Brooks JBJSBr 1993: 132-136

Vascularized through interosseous anastomoses

Between metaphyseal vessels (via posterior humeral circumflex) and the arcuate artery after ligation of the anterior circumflex humeral.

Coudane JSES 2000: 548

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Arteriography done on 20 patients after proximal humerus fractures.

80% had disruption of AHC artery 15% had disruption of PHC artery Since AVN is rare (bw 1-34%) after fx it suggests the PHC artery may be dominant supply

Hettrich JBJSAm 2010: 943-8

MRI cadavers

posterior humeral circumflex

supplied 64% of head (superior, lateral and inferior).

Hertel Criteria

Hertel et al JSES 2004:13:427

Medial calcar segment <8mm

Medial hinge is disrupted (>2mm displacement of the diaphysis)

Comminution of the medial metaphysis

Anatomic neck fracture

Bastian JSES 2008: 2-8

Follow-up study by Hertel showed that initial predictors of humeral head ischemia doesn’t predict development of AVN.

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80% of patients with “ischemic heads” did NOT collapse Fixation is worth considering even if signs of ischemia are present

Nonoperative Treatment

Immobilize initially

supine FE Passive ROM 2-3 weeks

supine ER

pendulums AROM at 6 weeks or when consolidated 77% good to excellent results-Zuckerman 1995

Optimal Treatment

UNKOWN????

JSES 2011: 1118-1124 (RCT ORIF vs Non-op)

JSES 2011: 747-55 (RCT ORIF vs Non-op

JSES 2011: 1025-1033 (RCT Hemi vs Non-op)

JOT 2011 (RCT ORIF vs Non-op)

Three-Part Fractures

Fixation Options

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Percutaneous Pins Interfragmentary Suture/Wire

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Plate/Screws

IM Nail Blade Plate

Hemiarthroplasty

ORIF Technique

Reduction & Grafting

Impaction grafting of head

Iliac crest cube

Fibular strut

Tag Tuberosities

Reduction & Grafting

Close Book

Plate

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Humeral Fracture Plates

Four precise holes for medial calcar support that provide a stable fixation in the calcar neck while preventing varus tilt and settling of the humeral head Proximal Screws angle towards posterior portion of humeral head to take advantage of the good bone quality of the posterior portion

3.5mm locking screw holes establish a stable bone and plate construct

3.5mm partially threaded screw options allow for compression of fragments and ability to pull the head fragments into reduction Polished suture holes allow for soft tissue and tuberosity fixation 23

Restore the calcar!

“Medial comminution significantly decreased the stability of proximal humeral fracture fixation constructs. Calcar restoration with screw fixation significantly improved the stability of repaired fractures in cadaveric specimens.” DePuy/Synthes Philos Plate – only 2 calcar screw holes Fig. 1 Figs. 1-A through 1-E Radiographs and diagram illustrating the fracture models and fixation constructs used. Fig. 1-A Medial comminution without calcar fixation. Fig. 1-B Noncomminuted fracture without calcar fixation. Fig. 1-C Medial comminution with calcar fixation. Fig. 1-D Noncomminuted fracture with calcar fixation. Fig. 1-E Diagrammatic illustration of the PHILOS plate.

Ponce BR. The Role of Medial Comminution and Calcar Restoration in Varus Collapse of Proximal Humerus Fractures Treated with Locking PlatesJ Bone Joint Surg Am, 2013 Aug 21;95(16):e113 1-7. doi: 10.2106/JBJS.K.00202

Proximal humeral fractures: Regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws

Implant loosening as a result of poor bone quality is a serious complication after internal fixation of displaced fractures of the proximal humerus.

investigated the relationship between trabecular BMD and the pullout strength of cancellous screws to determine regions in the humeral head that provide stronger fixation for cancellous screws.

trabecular BMD of the humeral head has a significant effect on the pullout strength of cancellous screws.

Central and posterior regions are best. Avoid superior-anterior region.

Tingart et al, JSES 2006

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Low Profile Plate Design Designed to sit lower on the greater tuberosity

Removed the 2.7mm screw holes

Minimizing subacromial impingement Thinner design to reduce soft tissue irritation

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4-point bending was completed Results show LP Plate is stronger than the predicate plate (Synthes) 4 Medial Calcar “kick stand” screws to prevent varus tilt/settling of humeral head Anatomic fit with right and left plates and different length plates

3-hole (89mm)

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6-hole (112mm) 9-hole (135mm) 26

Low Profile Plate Specifications

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6 proximal suture holes for soft tissue/tuberosity fixation

Easy in-situ needle passing through angled and scalloped holes

Also used as wire holes for initial plate fixation 4 Proximal 3.5mm screw holes

Utilizing locking or compression screws 5 Calcar 3.5mm screw holes

Utilizing locking or compression screws

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Parallel in AP view 3 o divergence in S/I view and Lateral view Distal 3.5mm screw holes

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Utilizing locking or compression screws Compression slot utilizing compression screws November 20, 2011 27

Conclusions

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Best to perform repair for acute fracture Anatomic restoration of humeral height and version Secure tuberosity fixation Repair the cuff

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Tenodesis of the LHB Early protected PROM, close supervision of the rehabilitation program