Simple and Complex Fractures of the Humerus

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1 Simple and Complex Fractures of the Humerus

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3 Filippo Castoldi Davide Blonna Marco Assom Editors Simple and Complex Fractures of the Humerus A Guide to Assessment and Treatment

4 Editors Filippo Castoldi Department of Orthopaedics and Traumatology 2nd University Clinic CTO Hospital Turin Turin Italy Marco Assom Department of Orthopaedics and Traumatology Mauriziano-Umberto I Hospital University of Turin Medical School Turin Italy Davide Blonna Department of Orthopaedics and Traumatology Mauriziano-Umberto I Hospital University of Turin Medical School Turin Italy ISBN ISBN (ebook) DOI / Springer Milan Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Italia 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

5 To all my wonderful family, who always offer me such great support. Filippo Castoldi To my daughter, Eleanor, and my wife, Alessandra, for the time that I have stolen. Davide Blonna To my wife, Graziella, who is a constant source of support, my father, who raised me, and my mom and nan, who cannot be here. Marco Assom

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7 Foreword The last years have witnessed drastic changes in all surgical specialties, including orthopedics and, specifically, surgery of the upper extremity. The new horizons extend from endoscopic surgery of the rotator cuff to diverse options for prosthetic replacement of the shoulder and elbow and improved surgical management of both proximal humerus and distal radius fractures. These changes, and comparable advances in other surgical specialties, have initiated a clear trend toward superspecialization a trend amplified, at least for complex pathologies, by data demonstrating a clear correlation between case load, (number of procedures performed by a single surgeon during a defined period), complications, and functional results. The interest of nonmedical professionals in these developments has been stimulated by publications showing the impact of complications on global health care costs and implying that hospitals might profit from more effective treatment of complications. Against this background it is imperative that efficacious learning instruments are made available, these being the basis of optimal surgical performance. The evolution of information technology (IT) allows easy Internet access to almost all data. A few mouse clicks enable the user instantly to access the most recent papers from the most prestigious scientific journals. The same is true for video streams of surgical procedures performed by specialists from all over the world. It therefore seems legitimate to ask whether the era of conventional books has come to an end, particularly as these products are sometimes already obsolete by the time they are published and do not display the details expected by subspecialists. The present monograph takes these facts fully into account. Traumatic and post-traumatic pathologies of a defined anatomic area are described in detail. Deep knowledge, experience, and balanced clinical judgment are the basis of this publication; they justify the publication of a book about fractures of a single skeletal segment in the era of IT. The description of validated solutions chosen by experts continues to have a clear didactic and educational value, including in comparison with Internet sources of information. Rightly or wrongly, today s generation of surgeons is asking for didactic material, which is immediately applicable in daily practice. The monograph describes the entire spectrum of treatment options for fractures and post-traumatic conditions and illustrates them with images of high quality. It helps the reader to identify the problems, to consider different options, and to learn and understand the preferred solutions of experts. vii

8 viii Foreword Despite the eminent importance of the surgical procedure, it is mandatory to remember that prior to the surgical act in all surgical specialties there is the indication, an intellectual activity: Decisions are more important than incisions. Even for a passionate surgeon, the list of options has to include the wisdom of surgical abstention. Only by understanding the great importance of this process of reflection and the need for avoidance of excessively broad indications can the surgical community prevent further loss of decision-making power and reduction of its status to a level where it becomes simply the recipient of orders for a limited segment of the diagnostic and therapeutic supply chain. I would like to thank Filippo Castoldi and his co-authors for having prepared a learning instrument that takes into account the above-mentioned lessons. Pietro Regazzoni Em. Chief of Trauma Surgery University Hospital Basel Basel, Switzerland

9 About the Editors Filippo Castoldi, MD, is Associate Professor of Orthopedics and Traumatology at the University of Turin, Italy. His main interests are shoulder, elbow, and knee pathologies and their treatments areas in which he undertook training during prolonged periods of study in Europe and the United States. Dr. Castoldi is the lead author of a number of scientific papers that have addressed the development of new techniques and clinical and basic science research. He is the winner of several international awards and has been a faculty member of national and international meetings and courses on surgery for the aforementioned pathologies. He is currently Chief of the 2nd Orthopedics and Traumatology University Clinic at the Orthopedics and Traumatology Center in Turin. Davide Blonna, MD, has been a consultant in Orthopedics and Traumatology since 2008 and currently works as a shoulder and elbow surgeon at the Mauriziano Hospital, Turin, Italy. He has always been interested in shoulder and elbow surgery, conducting periods of study abroad, including in England and the United States. He is the lead author of various scientific articles focused primarily on minimally invasive treatment of fractures of the proximal humerus and elbow arthroscopy. Dr. Blonna has been the recipient of several international awards, including for best educational videos and best scientific papers. He is a member of the education committee of the European Shoulder and Elbow Society and the sport committee of SIGASCOT. Marco Assom, MD, has been a consultant in Orthopedics and Traumatology since He has been interested especially in the shoulder since 1993, following periods of study in Lyon and Zurich, and he mainly performs open and arthroscopic surgeries for the treatment of shoulder and knee diseases. Dr. Assom is the lead author of publications on various new techniques and orthopedic implants that have become international landmarks in the treatment of proximal humeral fracture, tibial plateau fracture, and posterior shoulder dislocation. He currently works as a surgeon at the Mauriziano Hospital, Turin, Italy, where he is Chief of the Shoulder and Elbow unit. ix

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11 Contents Part I Proximal Humerus 1 Surgical Main Anatomy of the Shoulder Surgical Main Anatomy of the Shoulder Superficial Layer Deeper Layer References Proximal Humerus Fractures: Understanding and Managing the Fracture Introduction Classification Understanding the Fracture Age and Functional Requirements of the Patient Integrity of Calcar Medial Hinge Degree of Tuberosities Displacement Head Impaction into Valgus or Varus Displacement of Humeral Shaft Head Splitting or Glenohumeral Dislocation Bone Quality (Comminution of Tuberosities and Surgical Neck) Conclusive Remarks References Operating Theater Setup Preparing the Script Set Design Costumes and Props Reviewing the Script References Closed Reduction Principles Anatomic Considerations Which Type of Fracture? Closed Reduction Technique Authors Preferred Technique References xi

12 xii Contents 5 Proximal Humerus: Surgical Approaches Introduction Anterior Approaches Deltopectoral Approach Anterior Extended Deltopectoral Approach Variations to the Anterior Approach Combined Anterior Approach Anteromedial Approach Lateral Approaches Transdeltoid or Lateral Approach Variations to the Lateral Approach Anterosuperior Approach Extended Anterolateral Approach Lateral Mini Approach Posterior Approach Technique Limitations Risks Variations to the Posterior Approach Extended Posterior Proximal Humeral Approach Posterior Subdeltoid Approach Posterolateral Approach Posterosuperior Approach Axillary Approach Indications Technique Limitations References Percutaneous Fixation: When and How Anatomic Considerations Relationship Between Humeral Diaphysis and Epiphysis, Anatomic Segments, and Their Displacement Direction Vessels and Nerves Biomechanical Considerations Authors Opinion What Kind of Fractures? Authors Opinion Surgical Technique and Postoperative Care Augmentation of Pins by External Fixation Authors Opinion Complications Pin Migration Avascular Necrosis Infection Loss of Fixation Malunion

13 Contents xiii Nonunion Peripheral Neurological Injury Results References ORIF in Three-/Four-Part Fractures Introduction Classifications Plate Fixation Surgical Technique Surgical Approaches Indications for Open Fracture Reduction and Internal Fixation with Plate and Screws (ORIF) Surgical Patterns Important Tips Postoperative Treatment Our Experience: Complications References Intramedullary Nail for Proximal Humerus Fractures: An Old Concept Revisited Introduction Complications and Technologic Problems Observed with Existing IM Nails for Proximal Humerus Fractures Specific Complications and Problems in Detail Rotator Cuff Tears (and Shoulder Pain) Iatrogenic GT Fractures Acromial Impingement Secondary to Protrusion of the Proximal End of the Nail Surgical Neck Nonunions Failures of Proximal Fixation Proximal Screw Penetration of the Articular Cartilage Injury to Anatomic Structures Nail Toggling and Fracture Malreduction Nail Malrotation and Surgical Neck Malunions Concept, Design, and Rationale of the Aequalis IM Nail Nail Design Proximal Locking Screws Distal Divergent Screws Radiolucent and Accurate Instrumentation Surgical Technique: Pearls and Pitfalls Two-Part (Surgical Neck) Fractures Three-Part (Greater Tuberosity) Fractures Valgus Impacted Four-Part Fractures

14 xiv Contents 8.13 Varus Impacted Four-Part Fractures Postoperative Management Early Clinical Experience with the Aequalis IM Nail References Anatomic Shoulder Arthroplasty for Fracture: Indications and Technique Introduction Indications and Preoperative Planning Age Bone Quality Fracture Pattern Rotator Cuff Surgeon Experience X-rays Surgical Technique Positioning/Exposure Humeral Preparation Postoperative Management References Reverse Total Shoulder Arthroplasty for Fracture: Indications and Technique Introduction Indications and Preoperative Planning Age Bone Quality Fracture Pattern Timing of Surgery Surgical Technique Positioning/Exposure Glenoid Preparation Humeral Preparation Postoperative Management Results References Surgical Neck Fracture Epidemiology Radiographic Assessment and Classification Treatment: Conservative or Surgical? Closed Reduction and Percutaneous Pinning Angular Stable Internal Fixation: Locking Plate or Nail? Authors Preferred Method of Treatment References The Tuberosities Introduction Greater Tuberosity Epidemiology, Pathogenesis, and Classification. 143

15 Contents xv Clinical and Imaging Diagnosis Treatment Conclusions Lesser Tuberosity References Malunion of Humeral Tuberosity Fractures Introduction Etiology Clinical Examination Diagnostic Imaging Treatment Results References Nerve Injuries in Proximal Humeral Fractures Introduction Anatomy Epidemiology and Etiology of Nerve Injuries in Proximal Humeral Fractures Fractures and Dislocations Iatrogenic Fixation of Proximal Humeral Fractures Shoulder Arthroplasty Nerve Injuries in Children Clinical and Instrumental Diagnosis Prognosis Prevention of Iatrogenic Lesion Treatment References Fracture-Dislocations Introduction Clinical and Radiological Evaluation Radiology Associated Injuries Rotator Cuff Injuries Neurological Injuries Vascular Injuries Impression Fractures and Glenoid Fractures Treatment Two-Part Fracture-Dislocations Three-Part Anterior Fracture-Dislocations Three-Part Posterior Fracture-Dislocations Four-Part Anterior and Posterior Fracture-Dislocations Treatment-Related Classification of Four-Part Fracture-Dislocations

16 xvi Contents Technical Note Regarding the Bone Block and Titanium Block Techniques Postoperative Management References Treatment of the Sequelae Introduction Classification Fracture Sequelae Type 1: Posttraumatic Avascular Necrosis Hemi- Versus Total Shoulder Arthroplasty Fracture Sequelae Type 2: Chronic Locked Dislocations or Fracture-Dislocations Fracture Sequelae Type III: Surgical Neck Nonunion Fracture Sequelae Type IV: Severe Malunion of the Tuberosities Severe Varus or Valgus Malunion of the Humeral Head References Conservative Treatment of Proximal Humeral Fractures: Prognostic Factors and Outcome Introduction Outcome of Conservative Treatment Prognostic Value of Facture Pattern and Fragment Displacement Patient-Related Prognostic Factors References Part II The Diaphysis 18 The Diaphysis: Nonsurgical Treatment Introduction Relevant Anatomy The History of Conservative Treatment of Humeral Shaft Fractures Four Different Types of Conservative Measures Can Be Used The Hanging Arm Cast Coaptation Splint Thoracobrachial Immobilization Functional Bracing Discussion of Current Nonoperative Management Limitations to Functional Bracing Do Exist (Relative Contraindications) References Radial Palsy and Humerus Fractures Introduction Anatomy Diagnosis and Prognosis

17 Contents xvii 19.4 Treatment Surgical Procedure Proposed Algorithm Treatment References Internal Fixation of Diaphyseal Humeral Fractures: Plate or Intramedullary Nail? Introduction Indications to Surgical Treatment Plate and Screw Fixation Intramedullary Nailing Comparative Studies Meta-Analysis References Humeral Shaft Fractures and External Fixator External Fixation in Humeral Shaft Fractures Introduction Diagnosis and Classification Surgical Indications References Periprosthetic Fractures Background Clinical and Imaging Evaluation for Periprosthetic Fractures Classification System Surgical Techniques: Treatment Options and Outcomes/Results for Site Periprosthetic Humeral Fractures Periprosthetic Scapular Fractures Postoperative Restrictions/Rehabilitation Complications References Part III Distal Humerus 23 Distal Humerus: Surgical Anatomy Introduction Ulnar Nerve: Open Surgery Ulnar Nerve: Arthroscopic Surgery Radial Nerve: Open Surgery Radial Nerve: Arthroscopic Surgery References Surgical Approaches Based on Fracture Patterns Introduction Lateral and Medial Approaches Hotchkiss Approach Kocher Approach

18 xviii Contents Extensile Posterolateral Exposure Anterior Approach Posterior Approaches Olecranon Osteotomy Triceps Splitting Triceps Reflecting or Bryan-Morrey Triceps-On or Triceps- Preserving or Paratricipital Approach Triceps-Reflecting Anconeus Pedicle (TRAP) Approach Discussion and Conclusion References Suggested Readings Principles of Fixation for Distal Humerus Fractures Which Type of Fixation? Which Type of Plates? How Many Plates? Which Plate Configuration? Studies Supporting the Parallel Configuration Studies Supporting the Perpendicular Configuration Studies Showing No Difference Between the Two Options Authors Preferred Approach References Elbow Prosthesis in Distal Humeral Fractures Introduction Indications TEA DHH Contraindications Surgical Technique TEA DHH Postoperative Care Complications References External Fixation: When and How Introduction Indications Acute Elbow Instability Chronic Elbow Instability Severe Elbow Arthropathy Control of Motion Contraindications

19 Contents xix 27.3 Relevant Anatomy Surgical Technique Setup and Patient Positioning Axis Identification and Frame Orientation Humeral Pin Insertion Ulnar Pin Insertion Distraction Postoperative Care Complications Minor Complications Major Complications Nerve Injuries References The Malunion and Nonunion of Distal Humerus Fractures Distal Humerus Malunion Extra-articular Malunion Intra-articular Malunion Outcomes of Malunion Distal Humerus Nonunion Internal Fixation Joint Replacement Outcomes of Nonunion Prevention of Malunion and Nonunion Treatment of Malunion and Nonunion References Terrible Triad Definition Pathogenesis Principles of Biomechanics Applied to the Terrible Triad Fracture of the Coronoid Type I Type II Type III Extent of the Fracture of the Radial Head Potential for Spontaneous Healing of Primary and Secondary Stabilizers of the Elbow Assessment of Residual Instability Treatment Closed Reduction Conservative Treatment Surgical Approach Complications References