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
»Lesser Tub
»Greater Tub
»Head
»Shaft
Neer, JBJS ‘70
Proximal Humerus Fractures
Fracture Patterns
–Stable
»Fx not controlled by muscle
–Unstable
»Fx controlled by attached muscle
Proximal Humerus Fracture
Fracture Anatomy
–Greater Tub – posterior,
–Lesser Tub – medial,
–Head – remaining tub
energy
–Shaft – medial, superior
proximal
inferior
or fx
Proximal Humerus Fracture
Fracture Anatomy
Consideration for Surgery
Bone Quality
Comorbidities
Functional demand
Vascularity???
Gerber JBJSAm 1990: 1486-94
Vascularity
– anterior humeral circumflex
» 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
• 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.
• 80% of patients with “ischemic
heads” did NOT collapse
• Fixation is worth considering even if signs
of ischemia are present
Nonoperative Treatment
Immobilize initially
Passive ROM 2-3 weeks
– supine FE
– 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
– Percutaneous Pins
– Interfragmentary Suture/Wire
–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
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
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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 th
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
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


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)
6-hole (112mm)
9-hole (135mm)
 Made from 316L Stainless
Steel 20, 2011
November
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Low Profile Plate
Specifications
 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
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
Utilizing locking or compression screws
Parallel in AP view
3o divergence in S/I view and Lateral view
 Distal 3.5mm screw holes


Utilizing locking or compression screws
Compression slot utilizing compression screws
November 20, 2011
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Conclusions
• Best to perform repair for acute fracture
• Anatomic restoration of humeral height and
version
• Secure tuberosity fixation
• Repair the cuff
• Tenodesis of the LHB
• Early protected PROM, close supervision of the
rehabilitation program