The Experience of Open Reduction and Internal Fixation for Proximal Humeral Fracture. Fracture Displacement Predictable Because of Rotator Cuff

Transcription

1 The Experience of Open Reduction and Internal Fixation for Proximal Humeral Fracture 陳建志高雄醫學大學附設醫院骨科 Rockwood and Green's Fractures in Adults, 6th edition 4 Parts of Codman Fracture Displacement Predictable Because of Rotator Cuff Articular Surface Greater Tuberosity Lesser Tuberosity Humeral Shaft Master Techniques in Orthopaedic Surgery Fractures,2 nd edition Rockwood: The Shoulder, 4th ed. Rockwood: The Shoulder, 4th ed. 1

2 Physician s prefer and experience Nondisplaced or Neer one-part fractures represent 85% Anatomic recreation of the native Anatomy Risk of complications yes No NonOp ORIF Hemi Rockwood and Green's Fractures in Adults, 6th edition Mechanical Considerations reducible fracture pattern Adequate bone stock Biological Considerations Vascularity of the humeral head Injury Internal fixation I. R. MURRAY, JBJSB 2011 Neer s four-part classification system AO / OTA Classification angulation >45 displacement >1 cm Radiographic Evaluation Shoulder Trauma Series AP Y Scapular Lateral Axillary Lateral CT 3D reconstruction Locked posterior dislocation Glenoid margin Anterior or posterior tuberosity displacement Rarely obtained because of pain Invalid for measuring angulation 2

3 The three-dimensional anatomy of proximal humeral fractures Edelson G, J Shoulder Elbow Surg Jul-Aug;18(4): Positioning / Imaging Image intensification- (C- arm) Reduction, Plate position, Stability, Length of the locking screws. AP view Lateral view, Axial view 3

4 Deltopectoral Approach Konrad G. etc al, JBJSA 2009 Landmark: The tendon of the long head of the biceps identified at the upper border of the pectoralis muscle Bicipital groove Landmark for rotation Lesser tubersity Rotator cuff interval Identify greater and lesser tuberosities Reconstruct the 3D images in mind non-absorbable loop directly at the tendonbone junction Help reduction Direct suture fixation to humeral shaft or implant Michael Plecko, Aurel Kraus, Operat Orthop Traumatol 2005 Reduction Technique Michael Plecko, Aurel Kraus, Operat Orthop Traumatol 2005 Reduction Technique longitudinal traction and lateral pull Konrad G. etc al, JBJSA 2009 Michael Plecko, Aurel Kraus, Operat Orthop Traumatol 2005 Konrad G. etc al, JBJSA

5 Lateral cortex contact: Valgus alignment Medial overhanging The fixed angle plate is the reduction tool 5

6 Surgical technique The Plate should be positioned 5 to 8 mm distal to the upper end of the greater tuberosity 2 to 4 mm lateral to the bicipital groove, ensuring that a sufficient gap is maintained between the plate and the tendon of the long head of the biceps. Surgical technique Check the position of plate Check length of each screw Check the stability of the construct The inferomedial support: In young patients with good bone quality, bridge the zone of metaphyseal comminution Plecko M, Kraus A, Operat Orthop Traumatol 2005 in elderly patients with poor bone stock impact the shaft into the humeral head.-- even medial translation Locking screws placed in the inferomedial region Placing a second straight plate Gardner MJ et al. J Orthop Trauma Gardner MJ et al. J Orthop Trauma J Orthop Trauma Volume 22, Number 3, March 2008 Checking list Medial Hinge:+ Head-shaft angle:+ Inadequate G.T.fixation Screw penetrate joint Malposition of plate maybe rotational malreduction 6

7 Head-shaft angle:+ Gothic Arch:+ Case presentation A 46 y/o female patient, TA, left, 2 parts Case presentation A 59y/o male patient, TA, left, 4 parts Case presentation A 54 y/o male patient Drunken, seizure attack and falling down Right proximla humeral posterior fracture dislocation 6 months later 7

8 2011/4/11 Case presentation A 22 y/o female patient Traffic accident Right proximla humeral surgical neck anatomic neck Plating or Nailing?? A 60y/o male patient, TA, greater tuberosity and proximal third shaft Comminuted fracture Case presentation 8

9 3 months 9 months Discussion The use of locking plates for ORIF if a good reduction can be obtained and maintained, ORIF >> hemiarthroplasty the likelihood of persistent functional impairment and a relatively higher risk of complications in patients with threeand four-part fractures Ong et al. Clinical Orthopaedics and Related Research,2011 Vallier HA. J Orthop Trauma Marti R, et al. In: Kolbel R, Helbig B, Blauth W, eds. Shoulder Replacement. Berlin, Germany: Springer-Verlag; 1987: Moonot P, et al. J Bone Joint Surg Br Schai P, et al J Shoulder Elbow Surg Two factors had significant influence on final outcome: initial direction of the humeral head angulation (Valgus is better than varus) length of the intact metaphyseal segment attached to the articular fragment Johannes D. J Shoulder Elbow Surg (2009) Solberg et al J Orthop Trauma 2009 Predicting failure after surgical fixation of proximal humerus fractures Parameters: age, local BMD, anatomic reduction, and restoration of the medial cortical support The failure rate significantly increased with the number of risk factors D. Krappinger et al. / Injury, Int. J. Care Injured 2011 The pattern of the fracture and displacement A poorer outcome increasing distance between the articular surface and the acromion in fractures with posteromedial impaction fractured greater tuberosity displaced posteromedially Lateral impaction fractures The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures A. M. Foruria, JBJSB

10 100 intracapsular fractures assess during surgery by assessment of backflow after drilling the humeral head and laser doppler flowmetry. Fracture Patterns Avascular necrosis of the humeral head may occur up to 5 years after the injury or the surgical intervention. Gerber C, et al.j Shoulder Elbow Surg Humeral head necrosis does not necessarily result in unsatisfactory functional outcome. Lee CK. Hansen HR. J Trauma Hertel et al, J Shoulder Elbow Surg 2004 The Tips and Tricks for Osteosynthesis Anatomical union of the tuberosities to the humeral head seems to be more important for satisfactory functional outcome than presence of avascular necrosis Lee CK. Hansen HR. J Trauma Identify viable head fragments Prevent varus malalignment Restore inferomedial stability Secure tuberosity fixation Early rehabilitation Thanks for Your Attention! The absence of comorbidity and the restoration of the medial metaphysis were the most reliable predictors 10