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Perkutane Versorgung proximaler Humerusfrakturen

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Epaule & Coude

Peter Millett, MD, (Vail, CO) reviews proximal humeral fracture pathophysiology and treatment options. The presentation reviews nonoperative treatment, percutaneous pinning and humeral SuturePlate fixation options. Case examples are reviewed with strategic pearls, goals and postoperative protocols.

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Presentation Videos

Humeral Fracture Repair: Percutaneous Pinning and SuturePlate™

So with proximal humerus fractures, the key is really to assess the parts and see how displaced they are. There's typically four parts that can be involved the shaft the lesser tuberosity, greater tuberosity and then the articular segment. It's always important to remember the blood supply. The blood supply comes in through the intertubercular sulcus with the ascending branches of the anterior humeral circumflex vessels. And you want to try and avoid this area here because for dissection, when you have these types of fractures so that you preserve the blood supply and avoid osteonecrosis, the goals of surgery are anatomic reduction if you can, although the humerus can can adapt to a slightly non anatomic reduction. But at least getting the tuberosity into a good position stable fixation maximal function and achieving a pain free shoulder. So there's minimally invasive techniques which we just heard about closed reduction and percutaneous pinning, open reduction internal fixation with plates and hemiarthroplasty, which Arthrex offers all solutions for all these different approaches. One of the things that we looked at a few years ago was that most of us don't agree on how to treat these. This is a study that Charlie Pettit did. He was one of our fellows a few years ago, and we took a series of of patients of x rays. And we investigated decision making of shoulder and trauma fellowship, trained orthopedic surgeons and managing proximal humerus fractures. And we hypothesized that there would be a good agreement or that there would be poor agreement, and that it would be independent of their fellowship training. And what we found was that Interobserver agreement was not great. If if we just said whether they do non-operative treatment or operative treatment, it was better. But if we ask for what type of operative treatment, it wasn't really that it wasn't really that consistent. And then when we even looked at Intraobserver agreement, we showed the same x ray to the same person at a minimum of six weeks apart. Only the best was the shoulder surgeon said about 87% of the time they were, they said the same treatment, but sometimes the trauma surgeons 60% of the of the time changed their mind within six six weeks. So that's why you see that there's a lot of different approaches to these fractures. And this was published a few years ago. So I think you need different options because obviously we don't all agree about how the best way to treat these are and we we may change our mind depending on what day of the week it is. So we have different options to approach these different types of fractures. Percutaneous pinning I think is nice for minimally displaced fractures. And you can use it for more complex fractures if the bone quality is good. And the advantages are that it preserves the articular vascularity, there's perhaps less scarring and stiffness and better cosmesis. The ideal indications, I think, are two part surgical neck fractures that are displaced or angulated young patients with good bone and a compliant patient because the the pins sometimes can be irritating. So you need somebody who's going to be compliant. The Arthrex system allows fixation of two, three and four part fractures. And there's 2.8mm terminally threaded guide pins that prevent the pins from backing out, and there's 4.5mm screws with a broad head to hopefully allow for compression of the of the tuberosity to the to the head segment. And this is a fairly typical construct here for a three part valgus impacted fracture, tip the head out of valgus, reduce the greater tuberosity, and you can fix the shaft to the head segment. And then fix the tuberosity to the to the head segment. And this is just an example here of some reduction devices that are in the set. There's a Cobb elevator and a tamp. You can make little percutaneous reduction portals and tip the head out of valgus which is the most common position it's in. Correct that and then the tuberosity. You can pull that back in place with a curette and reduce it. And this is just a case example. This is a 48 year old gentleman obviously has pretty good bone prior to his to his fall skiing. And you see a displaced three part fracture with the greater tuberosity off in the head and pretty significant valgus. And you can achieve a pretty significant a pretty reasonable reduction pushing the pushing the head out of valgus. Fixing the shaft to the head. And then fixing the tuberosity, as you see here with some screws. Just another example here. This is a more a little bit easier case, but showing how you make a reduction portal, elevate the head out of valgus and hold that position. And then the next step then is to really place your screw your pins. Usually place two lateral pins and one anterior to posterior pin. And then you can reduce the the greater tuberosity with the cannulated screws. This just shows the final final floral views with the Arthrex system. I typically will cut the pins underneath the skin. There will frequently be swelling that occurs and that as the swelling goes down, the pins maybe come a little bit prominent, but you want to try and cut them as close as you can. And then typically we'll remove the pins after three weeks and fluoro the shoulder at that point. If everything's stable, then we'll start passive motion and allow active motion somewhere at 5 to 6 weeks. We'll move on to the SuturePlate, which can be used in two, 3 or 4 part fractures as well. I think if you have medial comminution, that's a contraindication for percutaneous pinning. And you really need to have some more rigid type of fixation. The SuturePlate you heard about, it's anatomically designed as a polyaxial locking plate with a and screw system. And this is how it's applied. You try and get some type of reduction, reasonable reduction. You can use the plate to help reduce it actually, so that the tuberosity doesn't have to be perfect. And you can use the plate actually to help reduce it. The key is to get the plate in the right height. And this this oblong screw hole allows you to adjust the plate height. And you can use some K-wires to achieve provisional reduction and then fix the plate. Sometimes when there's a lot of medial comminution, I'll also add a small anterior plate just to, because there's a lot of loading on the medial side of this plate, and it can neutralize that that varus bending moment. And then here you can see how the sutures can be placed after the after the plate's in place. This is just a case example here of a surgical neck fracture. Fairly straightforward, but there's comminution medially. This is our setup. Beach chair position with fluoro. And here you see the three and five hole plates that are available. If there's significant medial comminution I'll usually use the five hole plate because there's a large bending moment on it. I think it's a little bit stouter plate. And you can see the different options with with the plate here with three and five hole. If you're going to use the five hole plate, you have to do have to make a longer incision. And you sometimes have to elevate a little bit of the deltoid insertion laterally in order to get the plate to sit properly. And if you place it, if you if you don't elevate the deltoid, the plate may not sit properly. Or it may be you may place it too far anterior. So we'll open the deltopectoral interval. The clavipectoral fascia is usually quite edematous and hemorrhagic in cases like this. And we'll find the biceps tendon. That really helps with our landmark. And we want to try and stay lateral to that. The blood vessels all come in medially, so we want to try and stay lateral so that we don't disrupt any of the blood supply to the head. And here you can see we're kind of obtaining our provisional reduction. We'll put the plate on and then we'll floor it. It's not exactly perfect just yet as far as the reduction goes. But that's okay. We can the height is the height is appropriate at this point. So we can secure the plate distally to the to the shaft. And the same principles apply with even more complex fractures. Sometimes you'll use a long screw here just to, to provisionally get it reduced. And then you can see it's it's still not quite perfect medially, but I reduced it with my finger and held it provisionally. And now I've placed some K-wires in. And now we've achieved an anatomic reduction. And then essentially now it's just a matter of drilling and filling all the holes. And the key screw is really that, that inferior most screw. That's this one here. That one's the one that's going to go right up into the inferior portion of the humeral head and in a more complex fractures or where there's a lot of medial comminution, you want to try and get that, that, that screw low into the head because that provides the most support. And then you can use the sutures to the greater tuberosity and to the lesser tuberosity to neutralize the forces on the, on the plate or on the, on the fracture and just help to provide additional stability. These are just the FiberWire sutures, and it's really nice to be able to put the sutures in after the plate's in place, which is an advantage of this system here. And here you can see we've avoided any medial dissection and protected the blood supply to the to the humeral head, and we can secure the lesser tuberosity. Just the final. The final fluoroscopic view. You always want to check the the. You want to do a dynamic evaluation of these because the screw the screws have a tendency to possibly be out and you want to try and get them as close as subchondral bone as you can without perforating. So it's really important to document that before you leave the o.R. Just another example. This is a 45 year old had fallen. His non-dominant arm had this greater tuberosity fracture dislocation and attempted reduction in the emergency room, and unfortunately went from a two part to a to a three part fracture. And so one thing I would just encourage is if you see this type of an injury I like to try and do these under fluoro with general anesthesia or at least a significant muscle paralysis, because I've seen that happen a couple times now. So this patient was taken for an operative reduction and internal fixation. Postoperatively we start passive motion, if they're stable, if it's an unstable fracture or the bone quality is just not great, we'll sometimes we'll wait about six weeks before we start any passive motion. But if we can, we'll start range of motion within a safe zone of tissue tension. Water therapy can be helpful and assisted. Active range of motion at six weeks and strengthening somewhere around 8 to 12 weeks. The results from this we looked up our initial 53 patients with the locking plate. We had pretty good, pretty good results. We did have six complications with two broken plates. These were both the three hole plates where there was medial comminution and four nonunions in that series. I've done 25 suture plates in the last few years. Mean age of 55. Patient satisfaction. Median after a minimum of one year was nine out of ten. Same score of 92 and a score of 89. So pretty good. The keys to success are to restore the anatomy, to achieve healing, restore the function, and to avoid complications. And I think most of the time, if you use these principles, I think you're going to end up with a with a pretty decent result for your patient. But these these are probably some of the most challenging fractures of all the ones that that I personally treat and see. So thank you.

A complete review of Percutaneous Pinning: Indications, patient selection, surgical set-up, imaging, reduction and fixation pearls, post-op protocol, and overall results. Click the links below to see the rest of the presentation:
<ul>
 <li><a href="http://www.arthrex.com/resources/presentation/hGp1QPAfZkOJJgE-HsIoNA/proximal-humeral-fractures-pathophysiology-and-treatment-options-part-1-of-4-bradford-parsons-md-shoulder-symposium-2013" data-new-window="true" target="_blank" rel="noopener noreferrer">Proximal Humeral Fractures: Pathophysiology and Treatment Options (Presentation 1 of 4)</a></li>
 <li><a href="http://www.arthrex.com/resources/presentation/hmxSOe8rO0elagE-HsUNcg/proximal-humeral-fractures-humeral-locked-plating-part-3-of-4-bradford-parsons-md-shoulder-symposium-2013" data-new-window="true" target="_blank" rel="noopener noreferrer">Proximal Humeral Fractures: Humeral Locked Plating (Presentation 3 of 4)</a></li>
 <li><a href="http://www.arthrex.com/resources/presentation/n41QsRl0r0eyWgE-HrvtFQ/proximal-humeral-fractures-hemiarthroplasty-part-4-of-4-bradford-parsons-md-shoulder-symposium-2013" data-new-window="true" target="_blank" rel="noopener noreferrer">Proximal Humeral Fractures: Hemiarthroplasty (Presentation 4 of 4)</a></li>
</ul>

Proximal Humeral Fractures: Percutaneous Pinning (Presentation 2 of 4)

So let's talk about percutaneous pinning. So here's a valgus impacted fracture. This is what we want to get when we're all said and done. My indications for percutaneous pinning are things that I think I can reduce and pin close. So simple two parts where there's no significant variance or posteromedial Calcar Comminution. Then I think that's an option, especially in the younger patient, like the salt or two type of injury in a in a teenager as well, the valgus impacted four parts. It's the second one that I'll commonly do with a percutaneous pin. Again, very simple. I have done three parts. My partner has done head splits. They are possible, but a lot more challenging and technically demanding to do those more, more, more difficult, more comminuted fractures. This is not a good option in the patient who can't tolerate, you know, being careful with their arms. So you've got somebody who's not going to fall along with demands, then probably not a good choice because you can't really do anything with the arm. You got to keep it in the sling for four weeks. Also, osteoporotic fractures probably not a good choice either, because the pins can shift in that soft bone and you can lose your reduction. So it so it tends to be younger people with good bone two and four part valgus impacted fractures. This is the setup that I use. I use a large c-arm for percutaneous pinning, so I don't have to fiddle with the machine coming in and out. It comes from the contralateral side. I have a beach chair position, my standard sort of working areas. As I mark out the acromion, I make a small working portal off the anterolateral side, which is right along the biceps groove with the arm and neutral rotation that allows me access to the fracture plane between the greater and the lesser. We'll talk about that when we do plating. I'm going to put my retrograde pins down here. Well distal to the five centimeter line course of the axillary nerve. All right. So I'm going to work down low on either side of the biceps tendon. Retrograde pins up into the head. And the x up on the lateral aspect of the acromion is my working portal to put my cannulated screws down, which go from tuberosity down into calcar. Arthrex has come up with a nice set that has all the things you'd want to use if you're doing a percutaneous technique, so there are ramps and elevators to work within the fracture plane and lift the head up out of valgus. As this schematic shows, there are little these guides to be able to put your pins in through the soft tissues, so you're not binding up the biceps or other structures more distally, which are very nice there, sleeves that sort of cannulate up and you can do parallel pins, as this guide shows. There are reduction hooks to help pull the tuberosities back down as you're going to hold them in place. And then again, cannulated lifelong screws. I think up to 55mm. It gives you lots of length options to go down and fix. And although this schematic shows you fixing into the head, I have found that really if I'm going to fix the tuberosity, I want the tuberosity screw to come down here to the calcar. So I get bicortical purchase, which I think is important if you're going to do a percutaneous technique. So here's a case that I've done. So the valgus impacted forepart. You can see the Mickey Mouse ears appearance. Get your AP externally rotated view. You can see how the tuberosity is well above the humeral head. That's a problem that's going to lead to poor function and pain. So this is an operative indication. Here we are tamping the head up. So tamp the head up. You can see pretty much everything falls into place. That's all I've done so far. So now I put retrograde pins in to hold the head in position. I then put my cannulated wires down again, going into the calcar with two screws to hold those tuberosities. You don't always have to fix the lesser if the lesser is fairly stable. What typically happens in these valgus impacted foreparts is that the biceps groove, the top of the biceps groove has a sleeve that connects lesser to greater. So once you get the head to button up through that hole and back in place, the tuberosities often fall together. And if you fix the greater, the lesser stays along for the ride. Now, if you do have a lesser that's free and mobile, when you externally rotate the arm, you see it moving well, you can simply put another screw in in a uni cortical fashion into the into the posterior aspect of the head if need be. We cut the pins below the skin so there's no issue with infection. If your pins when you're putting them in, you have to be careful you don't penetrate the articular surface, because if you do, they will loosen and migrate. And if you have any infection, obviously now it goes into the joint. So take the time to carefully advance the pins so they don't go through the subchondral bone. They get cut beneath the skin. They stay in a sling for four weeks. No therapy. All right. I don't want them doing a lot with their biceps or anything else. They just sort of hang out in the sling. We go back to the operating room at four weeks. I make the small incision. I pull the pins out, leave the screws in. We do a gentle manipulation under anesthesia to see what their stiffness level is. They start therapy and progressive strength down the road. Jay keener looked at a multicenter study that we were involved with. I was a fellow at Penn at the time. And and then Evan's patients at Sinai. 27 patients treated with percutaneous pinning at one year. All had healed at that time. We had one, even some mild post-traumatic arthritis with a potpourri of different fractures. The issue, though, is you can have complications in loss of fixation is the concerns. Or here's a patient of mine with a three part fracture I fixed. I got a nice reduction. Pretty happy about that. I was proud of myself patting myself on the back. He goes home the next day, falls at night, comes back in and sees me and of course, you know, pulled off his tuberosity. So now I had to re-operate on him. And he's not done so well. So you have to pick your patients carefully. This patient was probably a little bit older than I should have done. Wasn't quite as steady on his feet as as perhaps we needed him to be. And as a result, had a loss of fixation. We did a follow up study looking at our rates of success, but mostly even. And what we found is after a couple of years, AVM can still happen. And it's not a consequence of the surgery. I think it's a consequence of the pathology. You know, if you're going to get even from any fracture and you treat it with a percutaneous technique, you would think that would be the least likely to propagate a risk of avian. So in these fractures, we found that some patients developed avian even as late as three years. The good news is the ones that developed avian that was symptomatic, converting this to an arthroplasty was simple, because it's almost like they didn't have surgery, and their outcomes on scores of those patients was almost approached. The level of a hemiarthroplasty done for avian or or post-traumatic arthritis. So it takes a little bit of a technique curve, but it is an option. I think you got to decelerate rehab and you have to watch for avian. All right.

Percutaneous Humeral Fracture Repair

Low Profile Screw, Titanium, 4.5 mm x 30 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 30 mm

Low Profile Screw, Ti, 4.5 mm x 30.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 30 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 30MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 35 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde 4.5 mm x 35 mm

Low Profile Screw, Ti, 4.5 mm x 35.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 35 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 35MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 40 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 40 mm

Low Profile Screw, Ti, 4.5 mm x 40.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 40 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 40MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 45 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 45 mm

Low Profile Screw, Ti, 4.5 mm x 45.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 45 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 45MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 50 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 50 mm

Low Profile Screw, Ti, 4.5 mm x 50.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 50 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 50MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 55 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 55 mm

Low Profile Screw, Ti, 4.5 mm x 55.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 55 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 55MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 60 mm, Cannulated Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 60 mm

Low Profile Screw, Ti, 4.5 mm x 60.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 60 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 60MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 65 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 65 mm

Low Profile Screw, Ti, 4.5 mm x 65.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 65 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 65MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 70 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 70 mm

Low Profile Screw, Ti, 4.5 mm x 70.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 70 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 70MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 75 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 75 mm

Low Profile Screw, Ti, 4.5 mm x 75.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 75 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 75MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw, Titanium, 4.5 mm x 80 mm, Cannulated, Partially Threaded

Kanülierte Schraube, Titan, Teilgewinde4.5 mm x 80 mm

Low Profile Screw, Ti, 4.5 mm x 80.0 mm, Cannulated, Partially Threaded

Low Profile Screw, Ti, Ø 4.5 mm x 80 mm, canulado, conrosca parcial

PARAFUSO DE BAIXO PERFIL, 4.5MM X 80MM, CANULADO, PARCILAMENTE ROSQUEADO

Low Profile Screw Unterlegscheibe, 10.0 mm, Titan

Percutaneous Pinning, Guidewire, Disposable, 1.6 mm

Percutaneous Pinning, Guide Wire, Disposable

Perforación percutánea, aguja guía, desechable

PINO PERCUTÂNEO, FIO-GUIA (269.6MM X Ø1.02MM)

PINO PERCUTÂNEO, FIO-GUIA (269.6MM X Ø1.

Percutaneous Pinning, Terminally Threaded Pin, 2.8 mm

Percutaneous Pinning, 2.8 mm Pin, Gewinde endständig

Percutaneous Pinning, Terminally Threaded Pin, 2.8 mm

Perforación percutánea, aguja con extremo de rosca, Ø 2.8 mm

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