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1、Fixation of Proximal Humerus Fractures with Locking Plates,Neer Classification,Based on Parts Shaft Head Greater and lesser tuberosity Part = 1 cm displacement OR 45 degrees angulation,AO/ASIF Classification,Based on likelihood of vascular injury Type A: Unifocal, intact vascular supply Type B: Bifo
2、cal, possible injury to blood supply Type C: Articular fx involving anatomic neck, Osteonecrosis most likely in this group,Most Proximal Humeral Fractures Can Be Treated Without Surgery,Stable fracture Non displaced or minimally displaced two-part and three-part fractures Sling Shoulder immobilizer
3、Early ROM,Indications for Locking Plates for Proximal Humerus Fractures,Three and four part salvageable fractures Valgus impacted for four part Three part fractures in varus Elderly, osteoporotic Very proximal (Mighell: two part anatomic neck fractures in the patient younger than 40 years) Two part
4、surgical neck fx with 30of varus is relative indication for fixed angle to avoid tuberosity impingement,Surgical approach,DP approach AL acromial approach,Vascular Supply,Ascending branch of anterior humeral circumflex,Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures
5、 Gardner et al. JOT October, 2006,In DP approach AHCA is directly in the surgical field,Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures Gardner et al. JOT October, 2006,Note only small terminal motor branches of the axillary nerve are directly lateral,Vascular Impli
6、cations of Minimally Invasive Plating of Proximal Humerus Fractures Gardner et al. JOT October, 2006,AVN rates up to 16% for 3-4 part fractures vs 9% for minimally invasive Locking plate studies show AVN rates 4-13% DP approach large dissection and muscle retraction DP is an indirect approach to pla
7、ting zone,6 cadaveric specimens AL acromial approach 10 cm incision from AL acromion Raphe b/w anterior and middle heads split 6 cm typically found axillary nerve found 3 hole Synthes locking proximal humerus plate Latex polymer injected into axillary artery,Findings: No vessels exposed that penetra
8、te head Avoid AHCA in the groove “bare spot” hypovacular zone found on GT Anterior raphe incision is colinear with the “bare spot in all specimens,Plate to anterior vessel 4 mm Plate to posterior vessel 7mm Average width 30 mm,Vascular Implications of Minimally Invasive Plating of Proximal Humerus F
9、ractures Gardner et al. JOT October, 2006,Advantages of AL approach Direct approach to GT Avoids blood supply Allows conversion to hemiarthroplasty,21 y/o MVA open fx,The Importance of Medial Support in Locked Plating of Proximal Humerus Fractures Gardner et al. JOT March 2007,What factors influence
10、 the maintenance of fracture reduction after locked plating of proximal humerus fractures? Role of medial column support,The Importance of Medial Support in Locked Plating of Proximal Humerus Fractures Gardner et al. JOT March 2007,35 patients 3 part and 4 part fx or 2 part with 100% displacement or
11、 varus and medial comminution RTC sutures thru plate 5 locking screws to head/ non-locked “humeral head height” relative to plate measured at 3 and 6 months,HUMERAL HEAD HEIGHT,The Importance of Medial Support in Locked Plating of Proximal Humerus Fractures Gardner et al. JOT March 2007,Adequate med
12、ial support(+MS): Medial pillar not comminuted and reduced Shaft medialized and impacted into head Oblique locking screw into inferomedial head within 5mm subchondral bone,The Importance of Medial Support in Locked Plating of Proximal Humerus Fractures Gardner et al. JOT March 2007,Regardless of the
13、 reduction achieved 1 or several inferomedial screws important w/ medial comminution or medial malreduction No relation with age, sex, cement augmentation, fracture type,Medial pillar not comminuted and reduced,3.5 months,7 months,2 months,Analysis and Efficacy and Failure in Proximal Humerus Fractu
14、res Treated With Locking Plates Agudelo et al Nov/Dec JOT 2007,Multi center (5) over nealy 5 years Approaches varied (DP and AL) Implants varied 136 pts with follow up Varus malreduction defined as head-shaft angle of 120 degrees,Analysis and Efficacy and Failure in Proximal Humerus Fractures Treate
15、d With Locking Plates Agudelo et al Nov/Dec JOT 2007,Statistically significant association b/w loss of fixation and varus malreduction (120) 30.4% when head shaft angle 120 11% when head shaft angle 120,Endosteal Implants,Assist in indirect reduction of medial cloumn Provide mechanical support for m
16、edial column and humeral head Fibular allograft of 6cm Inserted thru lateral fx into shaft Push screw thru plate Incorporates in 6 12 weeks,5 years 42 patients over 42 fx 3 radiographic failures 7.1429% vs 36% Any takers for a follow up study?,The Geisinger Experience,Insert Graft Between Tuberosities at this Step,Alternative Use of Allograft,Conclusions,Position so you can get images then drape Know both approaches Avoid dissection of bicipital groove If medial column com
