6.1.8 Intraarticular impacted proximal humeral fracture with displacement 11-C2

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1 Author Mihel Pleko Intrrtiulr impted proximl humerl frture with displement 11-C2 1 Cse desription 75-yer-old very tive womn, fell on the stirs in her house. Lived lone efore the ident, did ll housework nd grdening y herself. Unstle pinful frture of her left proximl humerus, nondominnt rm. 11 C2.1 frture with vlgus imption of the rtiulr segment, posterior superior dislotion of the greter tuerosity, n dditionl frture of the lesser tuerosity with multiple frgments, nd medil displement of the humerl shft. Mrked osteoporosis. Fig e AP view. Axil view. CT sn in frontl plne. d e CT sn in sgittl plne showing omminution nd dislotion of the greter tuerosity. d e 271

2 6.1 Humerus, proximl Indition Unstle intrrtiulr proximl humerl frture with vlgus imption of the rtiulr segment, posterior nd superior displement of the multiple frtured greter tuerosity, medil displement of the shft, mrked osteoporosis, severe pin, no dditionl nerve lesion or vsulr dmge. Conservtive tretment is not good option in this se due to mrked displement. It would only e onsidered if opertive tretment would pper too risky due to omoridity in low demnd ptient. Closed redution nd perutneous pinning with dditionl srew fi xtion is possile ut, due to the multiply frtured greter tuerosity nd dditionl osteoporosis, perutneous srew fi xtion my provide insuffiient stility nd ould led to seondry displement. Due to displement of the shft, losed nd perutneous pinning redution my e diffiult. An dditionl immoiliztion for 3 4 weeks s well s seond opertion for pin removl would e neessry. Considering this nd the ptients request for erly independene, reful open redution under visul ontrol nd internl fi xtion with loking proximl humerl plte nd dditionl tension nding is hosen. This offers the dvntge of open redution nd preservtion of the periostel ridges to the frture frgments nd stle fi xtion with erly funtionl rehilittion. Quik pin relief is hieved. Preopertive plnning Equipment Loking proximl humerl plte (LPHP), 5 holes (lterntively: 8 holes) 3.5 mm self-tpping loking hed srews (LHS) 3.5 mm ortex srew 1.8 mm K-wires Nonsorle sutures (Size of system, instruments, nd implnts n vry ording to ntomy.) Ptient preprtion nd positioning Generl nesthesi is reommended, lterntively slene lok n e used. Fig Ptient is pled in eh hir position. The rm is freedrped for intropertive moility. An imge intensifier is helpful. 272

3 6.1.8 Intrrtiulr impted proximl humerl frture with displement 11-C2 2 Surgil pproh Fig Deltopetorl pproh. Perform 12 m inision from the oroid proess to the deltoid insertion, split the deltoid nd the petorlis mjor. Use the ephli vein s lndmrk nd leve the ephli vein with the deltoid to the lterl side. Cutious lunt preprtion of the sudeltoid spe with the fingers. Identify the tendon of the long hed of the ieps rhii musles nd nhor strong nonsorle sutures through the suprspintus, infrspintus, nd suspulris tendon t the tendon-one interfe. These sutures llow gentle mnipultion of the humerl hed frgments. Frture lines should e identified ut not ompletely exposed. 3 Redution Fig Redue the humerl hed frgments y gently pulling the sutures nhored in the suprspintus, infrspintus, nd suspulris tendon. Redue the rtiulr segment y using smll elevtor. In unstle situtions temporry pinning my e dvisle. 273

4 6.1 Humerus, proximl 3 Redution (ont) Fig Redue the shft pproximtely y n indiret redution mneuver. Pull nd rotte the distl prt of the humerus. Control of the redued frgments. 4 Fixtion Fig Adpt the 5-hole loking proximl humerl plte (LPHP) to the proximl prt of the humerus nd fix it temporrily with 1.8 mm K-wires through the suture holes. Ple the upper end of the plte 5 7 mm elow the tip of the greter tuerosity nd out 5 mm posterior to the iipitl groove. Cheking the orret position of the implnts with the imge intensifier is dvisle. 274

5 6.1.8 Intrrtiulr impted proximl humerl frture with displement 11-C2 4 Fixtion (ont) Fig Insert 3.5 mm ortex srew through the first hole elow the supitl frture line. By tightening the srew the humerl shft will e gently redued towrds the plte, ginst the medilizing musle fores of the petorlis mjor musles. Fig Insert the threded drill guide into the two proximl prllel loking holes nd use the 2.8 mm drill it for the preprtion of the holes. Do not perforte the rtiulr surfe. Lsermrks nd plsti ring on the drill it filitte diret reding of the drilled depth. 275

6 6.1 Humerus, proximl 4 Fixtion (ont) Fig Insert two 3.5 mm self-tpping loking hed srews (LHS) into the upper holes using the torque-limiting tthment to the srewdriver. Chek idel length of these loking hed srews y imge intensifier in order not to penetrte the rtiulr surfe (leve out 3 mm etween the tip of the srew nd the rtiulr surfe). Insert the threded LCP drill guide into the holes t the humerl shft. Use 2.8 mm drill it nd, fter mesurement of the length, insert iortil 3.5 mm self-tpping LHS into eh hole using the torque-limiting tthment on the srewdriver. Notie tht minimum of two iortil 3.5 mm self-tpping LHS should e pled in the shft frgment. The hole t the end of the plte my e equipped with monoortil 3.5 mm, self-drilling, self-tpping LHS. Insert the threded LCP drill guide into the remining three divergent drill holes in the proximl prt of the plte using the guiding lok. After drilling, insert 3.5 mm selftpping LHS using the torque-limiting tthment on the srewdriver in eh of these holes. Chek ll srew lengths refully with the imge intensifier. 276

7 6.1.8 Intrrtiulr impted proximl humerl frture with displement 11-C2 4 Fixtion (ont) Fig Fix the nhored sutures through the suture holes in the plte nd tie them tightly to neutrlize the musle fores of the rottor uff. Fig Chek shoulder moility nd frture stility y pssive motion. Perform wound losure fter irrigtion nd dringe. Postopertive x-rys show good redution nd positioning of the implnt. 5 Rehilittion Additionl immoiliztion: ndge for 2 3 weeks. Physiotherpy: pssive nd tive-ssisted moiliztion s of the seond postopertive dy. Unrestrited tive moiliztion fter 3 4 weeks. Phrmeutil tretment: pinkillers in the erly postopertive period, therefter when needed. Fig X-rys t one yer follow-up show omplete heling of the frture without signs of vsulr nerosis. One srew seems to penetrte the rtiulr surfe without using ny linil symptoms. 277

8 6.1 Humerus, proximl 5 Rehilittion (ont) d Fig d Stisftory funtionl result t one yer follow-up. The ptient is free of pin nd without restrition in everydy tivities. 6 Pitflls 7 Perls + Approh Too extensive exposure of the frture frgments my dmge vsulrity nd led to high rte of vsulr nerosis. Redution Brisk redution mneuvers with redution foreps my dmge lood supply nd ny residul intt periostieum on the frgments. Inorret positioning of the plte my led to suromil impingement nd restrited rnge of motion. Fixtion Inorret length of the LHS leds to perfortion of the rtiulr surfe of the humerl hed. 3.5 mm ortex srews my led to redued stility in osteoporoti one nd premture loosening. Lk of suffiient medil uttress without djustment of the rehilittion protool my led to implnt filure. Approh Open proedure without extensive exposure of the frture lines my help to preserve the lood supply of the segments. Alterntive: smll nterolterl splitting of the deltoid musle. Redution Indiret redution mneuvers help to preserve lood supply nd residul periostieum in this open proedure. Optiml positioning of the ntomilly preshped plte, ontrolled y imge intensifition, prevents hrdwre impingement nd enles unrestrited rnge of motion. Fixtion Optiml length, espeilly of the LHS, voids perfortion of the rtiulr surfe. LHS, in omintion with 3-D orienttion, led to improved stility even in osteoporoti one, ut ext loking remins essentil. Reonstrution of the medil uttress leds to suffiient stility for erly funtionl rehilittion. Fig In the se of homogeneous frgment of the lesser tuerosity, the suture through the suspulris tendon my e repled y 3.5 mm ortex srew from the lesser tuerosity to the humerl shft. 278