PROXIMAL HUMERUS FRACTURE TSHT 2017

Transcription

1 PROXIMAL HUMERUS FRACTURE TSHT 2017 ANIL DUTTA, M.D. ASSOCIATE PROFESSOR Displacement > 1 cm Angulation > 45 degree SHOULDER AND ELBOW SURGERY UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER SAN ANTONIO DISCLOSURE consultant for Wright Medical ALTERNATIVE DESCRIPTIONS Five Part Theory Binary Description Mittlmeier et al, 2003 Hertel et al, 2004

2 HERTEL ET AL, 2004 TREATMENT OPTIONS The combination of metaphyseal head extension <8mmwith medial hinge disruption >2 mm as well as an anatomic neck fracture pattern had a positive predictive value of 97% for humeral head ischemia Nonoperative (early exercises) Open Reduction and Internal Fixation Percutaneous or limited fixation Hemiarthroplasty Reverse Total Shoulder Arthroplasty TREATMENT GUIDANCE: PERCUTANEOUS PINNING/ FLEXIBLE NAIL Vascular status Bone quality Fracture pattern Comminution Patient factors age level of activities medical condition

3 TENSION BAND WIRING OPEN REDUCTION AND INTERNAL FIXATION SUPERIOR APPROACH Allows for more direct access to the fracture Less invasive Less screw fixation for more unstable fractures

4 RECONSTRUCTION OF MEDIAL HINGE HEMIARTHROPLASTY Osterhoff JSES 2011 : IM fibula allograft prevented varus collapse TREATMENT OPTIONS: IM NAIL TREATMENT OPTIONS: HEMIARTHROPLASTY

5 FRENCH EXPERIENCE : HEMI FOR FX GOTHIC ARCH TECHNIQUE Errors that distort this arch Incorrect height (too high) No reconstruction of medial calcar Incorrect medial eccentricity of head or head sizing too big GOTHIC ARCH NHO ET AL,JAAOS, 2007

6 CURRENT STATE OF THINGS : 2 Open Reduction and internal fixation with locked plating is being embraced by the larger orthopedic surgery community CURRENT STATE OF THINGS : 1 CURRENT STATE OF THINGS : 3 Reverse Arthroplasty is increasingly embraced by the shoulder surgery community. Becoming the front line treatment. SUPERIOR APPROACH TO LOCKED PLATING INCREASINGLY BEING UTILIZED

7 CURRENT STATE OF THINGS : 4 CASES INTRAMEDULLARY NAILING LESS FAVORED BUT CONTINUES TO EVOLVE WITH IMPLANT DESIGNS CURRENT STATE OF THINGS: 5 NON OPERATIVE MANAGEMENT HEMIARTHROPLASTY FALLING OUT OF FAVOR : POSSIBLE LOST ART 57 y/o F, RHD, sustained LUE injury skiing) came with c/o Lt shoulder and elbow pain PMHx: not significant ROS: Lt shoulder and elbow pain, with ROM limitation 0f the Lt arm On exam TTP over the Rt prox hum, ecchymosis, limited ROM of the shoulder, she can flex/ext the elbow with full sup/pron and normal sensory exam.

8 CASE # 1

9 NON OPERATIVE MANAGEMENT GREATER TUBEROSITY FRACTURE 1. FOCUS ON PENDULUM AND ADDUCTED EXTERNAL ROTATION EARLY ON 2. ELBOW, WRIST, AND HAND FOR EDEMA CONTROL 3. DON T BE FRUSTRATED BY DELAY IN ACTIVE ELEVATION (NERVE OR CUFF WEAKNESS) Pt is a 39 yo RHD male with a one day h/o L shoulder pain. Pt was lifting some heavy objects last night and did not feel any pain at the time but after sleeping on his L side for 3 hrs woke up with severe L shoulder pain PMH: None ROS: Lt shoulder pain, with limitation in ROM NON OPERATIVE MANAGEMENT 4. LATE RECOVERY OF DELTOID CAN SAVE THE DAY 5. AVOID IMPINGEMENT ARCS (START LOW STAY LOW or START HIGH AND STAY HIGH 6. SCAPULA MOTION NOT ALL BAD Physical Exam: Moderate edema and ecchymosis without gross deformities at the shoulder TTP over the anterior and lateral proximal humerus Can fire deltoid but unable to abd or elevate shoulder. PROM is FF 45, Abd 30, IR L5, ER 20 BCR in all digits, with normal sensation

10 INITIAL INJURY INITIAL FIXATION TREATMENT: ORIF with deltoid splitting approach 4.0 mm partially threaded cancellous screws and Piton suture anchor.

11 OPEN REDUCTION INTERNAL FIXATION SUPERIOR APPROACH

12 ORIF WITH INTRAMEDULLARY NAIL 71 y/o M involved in a T bone MVC with ejection Intubated on the scene. Sustained multiple injury including swelling to L shoulder and L leg. PMHx: Unknown PE: Not following commands, abrasion over the proximal humerus, palpable crepitation and soft tissue swelling 65 YO FEMALE WITH BMI 45 GROUND LEVEL FALL HEMIARTHROPLASTY FOR 4 PART FX

13 STAGING ORIF VS HEMI STAGED RECONSTRUCTION 50 y/o M RHD, s/p fall off ladder on his Rt shoulder, 07/2010, injured his Rt shoulder PMHx: none PE: skin intact, ecchymosis midhumerus, + crepitation, soft compartments, flex/ext his fingers, intact sensation, fires his deltoid

14 This image cannot currently be displayed. LATE AVASCULAR NECROSIS 10/2010 CONVERSION TO HEMI

15 LATE NON UNION CONVERSION TO HEMI LATE NON UNION REVERSE FOR ACUTE FX Gallinet et al, OrthopTrSurgRes09: 40 pts, restrospective, 21 Hemi, 19 Reverse. Better results with reverse but hemi results worse than literature Young, Poon, et al. ANZ J Surg 10 : equivalent results with reverse and hemi REPAIR tuberosities if possible

16 CONVERSION OF FAILED HEMI TO REVERSE Levy, Frankle et al. JBJS 07 :Convert failed hemi to reverse : Add allograft improves results THANK YOU PLATFORM SYSTEMS