Proximal Humerus Fractures: Locked Plates and Strut Grafts

Educational Objectives

The goal of this program is to improve management for fractures of the proximal humerus. After hearing and assimilating this program, the clinician will be better able to:

1. Identify critical factors that affect the surgical outcome of proximal humerus fractures.

Summary

Open reduction and internal fixation: doubles risk for AVN compared to closed treatment; >3-fold increased incidence of AVN in another study; Neer recommended minimal osteosynthesis in 3-part humerus fractures and replacement in 4-part humerus fractures; prosthetic replacement — Zyto et al (1998) reported ≈33% of patients experienced moderate to severe pain and disability; Goldman et al (1995) reported 27% of patients experienced more than slight pain; 73% of patients experienced disability; arthroplasty (typical results) — forward flexion 100°; internal rotation to low back; limited external rotation; poor functional outcome scores for HA; ORIF complications include AVN, loss of reduction, and patient noncompliance

Blood supply to humeral head: studies — 1) Gerber et al (1990) reported proximal humerus relied on anterior humeral circumflex (AHC) artery; AVN inevitable without AHC artery; 2) another study looked at arteriography for 20 patients with complex proximal humerus fractures; AHC artery disrupted in 80% of patients; posterior humeral circumflex (PHC) artery intact in 85% of patients; suggests PHC artery provides critical blood supply to humeral head; 3) Hettrich et al (2010) reported 3-fold greater caliber for PHC artery compared to AHC artery; more significant uptake of gadolinium intake into humeral head from PHC artery compared to AHC artery; PHC artery supplies predominant blood supply to humeral head; decision making — perfusion of head critical but not only component in choosing treatment; consider bone quality, ability to achieve stable fixation, and ability to anatomically reduce tuberosities

Surgical approach: deltopectoral approach — uses anterior incision to treat humeral head and tuberosity fractures that displace posteriorly; minimize anterior medial dissection to protect blood supply; requires more retraction of deltoid to access area for plating; approach between anterior and middle heads of deltoid — more direct approach for reduction and fixation; avoid splitting deltoid 5 cm distal to acromion to avoid injury to axillary nerve; approach relies on axillary nerve consisting of one branch; anterior branch of axillary nerve crosses raphe between anterior and middle heads of deltoid, then arborizes anteriorly and posteriorly

Surgical technique: locked plates — use multiple mini-blade plates with locked screws; fixation difficult in elderly patients with poor bone quality; depth of screw insertion critical; last 5 mm of bone critical for fixation to maintain reduction; most techniques place screws that fail to reach subchondral bone; implant does not fail; bone fails to hold implant

Gardner et al (2007): reported on 35 proximal humerus fractures treated with locked plate; 100% healed; calcar reduction or augmentation with inferior screws occurred in 18 patients who maintained reduction to healing; loss of head height ≈6 mm in 17 patients without calcar reduction or screw augmentation; calcar reduction or support most critical factor in surgical treatment

Hettrich et al (2012): reported on augmentation of head with endosteal plate to create 2-trestle bridge; implant easily introduced and manipulated within intramedullary canal; desired properties included structural, drillable, biologic, and resorbable (if possible); endosteal support from allograft fibula used for repair of 3-part proximal humerus fractures; work done within canal; no interruption of vascularity to head; speaker uses pilon plate to cup head; place calcar screw to capture allograft inferiorly and superiorly; working length of screws from fibula to subchondral bone of humeral head; results — 100% healed; loss of reduction <1 mm; no hardware-related complications

Conclusion: function follows form; stable reconstruction and fixation mandatory; begin aggressive active and passive range of motion and continuous passive motion on postoperative day one; recognize limitations of locked plating; reduction of calcar critical; augment calcar when anatomic reduction not possible; aggressively treat osteoporosis

Readings

Suggested Reading

Berkes MB et al: Catastrophic failure after open reduction internal fixation of femoral neck fractures with a novel locking plate implant. J Orthop Trauma, 2012 Oct;26(10):e170-6; Boraiah S et al: Assessment of vascularity of the femoral head using gadolinium (Gd-DTPA)-enhanced magnetic resonance imaging: a cadaver study. J Bone Joint Surg Br, 2009 Jan;91(1):131-7; Boraiah S et al: Outcomes of length-stable fixation of femoral neck fractures. Arch Orthop Trauma Surg, 2010 Dec;130(12):1523-31; Boraiah S et al: Predictable healing of femoral neck fractures treated with intraoperative compression and length-stable implants. J Trauma, 2010 Jul;69(1):142-7; Ehlinger M et al: Distal femur fractures. Surgical techniques and a review of the literature. Orthop Traumatol Surg Res, 2013 May;99(3):353-60; Gardner MJ et al: Complete exposure of the articular surface for fixation of patellar fractures. J Orthop Trauma, 2005 Feb;19(2):118-23; Gardner MJ et al: The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma, 2007 Mar;21(3):185-91; Gautier E et al: Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br, 2000 Jul;82(5):679-83; Gerber C et al: The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am, 1990 Dec;72(10):1486-94; Hettrich CM et al: Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma, 2012 Apr;26(4):212-5; Hettrich CM et al: Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am, 2010 Apr;92(4):943-8; Lazaro LE et al: Effect of computerized tomography on classification and treatment plan for patellar fractures. J Orthop Trauma, 2013 Jun;27(6):336-44; Lazaro LE et al: Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment. J Bone Joint Surg Am, 2013 Jul;95(14):1-8; Rademakers MV et al: Intra-articular fractures of the distal femur: a long-term follow-up study of surgically treated patients. J Orthop Trauma, 2004 Apr;18(4):213-9; Reinhardt KR et al: Plasma 25-hydroxyvitamin d levels in operative patella fractures. HSS J, 2013 Feb;9(1):17-20; Thomson AB et al: Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing. Orthopedics, 2008 Aug;31(8):748-50; Zyto K et al: Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg, 1998 Mar-Apr;7(2):85-9.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Acknowledgements

Dr. Lorich was recorded at the 15th Annual Chicago Trauma Symposium, held August 1-4, 2013, in Chicago, IL. For information about the 16th Annual Chicago Trauma Symposium, scheduled for September 4-7, 2014, please visit chicagotraumasymposium.com. Information about future events from sponsoring organizations can be found by visiting our website, audio-digest.org, and clicking the “upcoming meetings” tab at the bottom of the page. The Audio-Digest Foundation thanks Dr. Lorich and the 15th Annual Chicago Trauma Symposium for their cooperation in the production of this issue.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR371504

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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