Proximal Humerus Fractures - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University
devaki
devaki21 December 2012

Proximal Humerus Fractures - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University

PDF (344 KB)
40 pages
1000+Number of visits
Description
Proximal Humerus Fractures, Heterotopic Bone, Brachial Plexus, Ossification Centers, Physeal Scar Closure, Proximal Humeral Retroversion, Epicondylar Axis, Rotator Cuff Muscles are some points from this lecture. This lec...
20points
Download points needed to download
this document
Download the document
Preview3 pages / 40
This is only a preview
3 shown on 40 pages
Download the document
This is only a preview
3 shown on 40 pages
Download the document
This is only a preview
3 shown on 40 pages
Download the document
This is only a preview
3 shown on 40 pages
Download the document
No Slide Title

Proximal Humerus Fractures/Dislocations

Docsity.com

History/Demographics

• Bimodal: young-high energy, elderly-low energy(osteoporosis)

• 45% of all humerus fx. • elderly females 4:1

over males • 77% of all prox. hum.

fractures female

Docsity.com

Consequences/Associated Injuries

• Disabilities often underestimated – Loss of motion – Loss of reduction – AVN – heterotopic bone – Associated Injuries

• rotator cuff • nerve(axillary, brachial plexus) • vascular • scapula, clavicle

Docsity.com

Anatomy

• Appearance of Ossification Centers – epiphysis 4mo – Gr. Tub. 3yr – L. Tub. 5yr

• Physeal scar closure – 20-22 yrs.

Docsity.com

Proximal Humeral Retroversion

• 35-40 degrees relative to epicondylar axis

Docsity.com

Blood Supply

• Axillary artery – ant. humeral circumflex

• *ascending branch (arcuate artery) is the major blood supply to the articular surface

– post. humeral circumflex

Arcua Arcuate afeeffe

Docsity.com

Nerves

• Brachial Plexus – axillary – suprascapular – musculocutaneous

Docsity.com

Rotator Cuff Muscles

• Supraspinatous • Infraspinatous • Subscapularis • Teres Minor

• Deltoid • Pectoralis • Long head biceps

Docsity.com

Classification

• Neer (4 part) – 2 part

• AN (anatomic neck) • SN (surgical neck)

– 3 part • SN+GT, LT

– 4 part • SN+GT+LT

– *head splits – *articular impressions – fx. dislocations

• AO – type A

• 2 part extracapsular – type B

• 3 part partially intracapsular

– type C • vascular isolation of head • 4 part intracapsular

Docsity.com

Classification • Neer

– 2 part • SN,AN,GT,LT

– 3 part • SN+GT or LT • AN+GT or LT

– 4 part • neck+both

tuberosities • +/- dislocation

– Neer’s definition of displacement: >1cm or >45 degrees

Docsity.com

Radiographic Work Up

• Trauma Series– true scapular AP – axillary (head defects,

displacement of tuberosities

– Y or transscapular • Other

– modified axillary – AP in int. and ext.

rotation

• CT Scan– articular fractures

• impression • head split

– glenoid fractures – assess tuberosity

displacement for operative decision making

Docsity.com

Treatment

Considerations for closed treatment – patient age – displacement

• surgical neck • tuberosities • articular surface

– functional demand – arm dominance – ability to salvage with an

arthroplasty later if needed

Methods of closed treatment – sling – sling and swath – hanging cast – abduction pillow

Docsity.com

Fractures to Consider for Closed Treatment

• Minimally displaced 2 part

fx’s (or positional reduction of significant displacement)

• GT fractures should be <5mm).

• Minimally displaced 3- and 4-part fractures

Docsity.com

Fractures to Consider for ORIF

• Displaced GT fx (> 5 mm) • LT fx with involvement of

articular surface • Displaced or unstable

surgical neck fx • Displaced anatomic neck

fx in young pt. • Displaced, reconstructible

3- and 4-part fractures

Docsity.com

Fractures to Consider Hemiarthroplasty

• Young/Middle age

– nonreconstructable articular surface (severe head split) or extruded anatomic neck

• Elderly – many 4 parts – some severe 3 parts – most 3,4 part fracture

dislocations – most head splits

Docsity.com

Current Techniques of ORIF

• Percutaneous Pins (Jaberg, H. 1992) • Suture, K-wire, tension band technique (Cornell,C. H.

1994, Darder, A. 1993, Hawkins, J.R. 1987, Neer, C.S. 1970) • Flexible IM nails (Lee, C. K. 1981, Robinson, C. M. 1993,

Wesley, M. S. 1977) • Buttress Plates (Esser, R. D. 1994, Kristiansen, B. 1986,

Paavolainen, P. 1983, Savoie, F.H. 1989) • Selected Locked Rigid IM nails • Blade Plate Fixation (Weber 1984, Sehr, Szabo 1988,

Jupiter, Scheid 1999) • Proximal Humeral Locking Plates

Docsity.com

• Surgical Approaches – Deltopectoral

– Deltoid Splitting

– Posterior

Percutaneous

• Fracture / Fixation – SN, LT,3 part, 4 part /

• surgeon choice – GT, Some SN if using IM

fixation – scapula, glenoid,

occasional posterior articular fracture

– Fx’s amenable to pinning or nailing

Docsity.com

Percutaneous Pinning

• Technique: beach chair position, closed manipulation, oscillating drill, terminal thread pins, at least bidirectional pins (see Jaberg H. 1992), cut pins beneath skin, sling and swath, follow closely

• Associated Problems: nerve injury (axillary), pin loosening, migration, no early motion

• Best Use: limited 2 or 3 part when other techniques not favorable

Migration----

Docsity.com

Suture or K-wire/Tension Band

• Technique: beach chair position, deltoid splitting or deltopectoral approach, k wire and suture repair of tuberosities with tension band (suture or wire) to metaphysis

• Associated Problems: cuff constriction, limited head fixation to shaft, wire migration

• Best Use: GT, LT, GT+LT, tuberosities with undispl. SN

Docsity.com

Flexible Nails

• Technique: beach chair position, deltoid splitting approach, lateral tuberosity or cuff splitting insertion, may combine with tension band suture

• Associated Problems: limited head fixation, migration into subachromial space, cuff violation

• Best use: 2 part SN • Newer plates and nails

more favorable

Docsity.com

Locked Rigid Nails for Proximal Humerus

• enhanced proximal fixation with twisted blades or multiple screws

Docsity.com

Buttress Plating

• Technique: sitting or supine,

deltopectoral approach, lateral to bicepts groove to minimize vascular damage

• Associated problems: poor head fixation, large dissection, iatrogenic vascular damage, impingement

• Best use: low 2 part SN +/- large GT

• * rarely used technique due to impingement and poor head fixation

• Newer locking plates now favorable

Docsity.com

Blade Plate Technique

• Technique: beach chair positon, deltopectoral approach, metaphyseal slot lateral to bic. groove, minimal soft tissue stripping

• Associated Problems: learning curve, penetration of humeral head in osteoporotic bone

• Advantages: no impingement in high angle blade, superior head fixation to other techniques, easily combined with suture fixation of tuberosities

Docsity.com

Hemiarthroplasty

• Technique: beach chair position, deltopectoral approach, retain tuberosity fragments with cuff attachments, combine suture repair of tuberosities, bone graft from head if needed

• Associated Problems: unpredictable results from function standpoint, still requires bony healing (of tuberosities)

• Best use: elderly 3,4 part, head splits, disvascular AN

Docsity.com

Results • SN: closed treatment has yielded

60-90% satisfactory results • GT: 50-100% poor results with

displaced (>.5-1cm) fractures treated closed. Good results with ORIF.

• 3 Part: closed treatment (min. displacement or nonoperative elderly pt.) yields unpredictable results (15-70% satisfactory) ORIF with good reduction: 60- 80% good to excellent results

• 4 Part: poor results with closed treatment. Hemiarthroplasty gives satisfactory pain results with somewhat unpredictable functional results. ORIF in younger patient have yielded <=50% satisfactory results. Higher AVN in ORIF

• Head Split: If CTS shows segment attached to LT then ORIF. If severe fragmentation of articular surface then Hemi.

Docsity.com

comments (0)
no comments were posted
be the one to write the first!
This is only a preview
3 shown on 40 pages
Download the document