The Percutaneous Humeral Fracture Repair System provides the necessary instrumentation and implants to percutaneously reduce and fixate two, three, and four part proximal humeral fractures using 2.8 mm Pins and 4.5 mm Cannulated Screws.

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Perkutane Versorgung proximaler Humerusfrakturen

Brad Parsons, MD, (New York, NY) reviews proximal humerus fracture management options including percutaneous pinning, plating, hemiarthroplasty and reverse total shoulder arthroplasty.

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Management of Proximal Humerus Fractures

One of the things I like about fractures is that they offer a spectrum of different challenges. And so each fracture is different, each pattern is different. You have to plan ahead and think about what you have to try to treat. And that makes it both challenging and fun to try to help these patients out. And we also get to treat a variety of different patients. We're going to manage the fracture and the patient on the left, probably much differently than we would on a younger, more active person like on the right. In general, many fractures of the shoulder can be treated non-operatively. For me, when I look at the patients I'm going to treat surgically, it's really based on fracture morphology. So I look at the anatomy of the tuberosity related to the humeral head. If the tuberosity is above the humeral head, as it's shown in this valgus impacted fracture, that's a fracture that typically in an active person desiring reproducible overhead elevation will be operated on. And I think tuberosity malunion is really probably the source of the biggest trouble for folks, especially in abduction. As I said, Arthrex has options now for both fixation in terms of the percutaneous pinning and the SuturePlate. And then obviously the arthroplasty options, which we'll get into in a little bit when I take a patient with a fracture to the operating room, my setup is such that I'm prepared to do an orif. I'm prepared to do an arthroplasty. And if they're an older patient, I may have a hemi and a reverse in the room together. And so I think one of the things, especially if you work in a community setting where you don't have all this stuff right on your shelf, have your vendor there with everything to go. And that's one of the nice things about having one company with one rep who's familiar with all this. They can make your life and your nurses life a lot easier, because they have all the stuff there and you're not trying to find, you know, a different person for the reverse than you would for the plate. In general, my setup is I use a beach chair position. I use a deltopectoral approach. I don't like splitting the deltoid. I don't like finding the axillary nerve and separating it between the anterior middle heads. Yes, that gives you a better look at the lateral humerus. But I don't like devascularization or disturbing the neuroanatomy of the deltoid. I use a pneumatic arm holder like the TRIMANO, and I use a lot of sutures in the cuff and then a routine An absolute mandatory part of the procedure is having fluoroscopy. So you're not doing soft tissue stripping, but you're working within the fracture planes. When I first came into practice 13 years ago, percutaneous pinning was a big wave or big sort of cool idea in shoulder fracture work. And one of my mentors and partners have pioneered a lot of this stuff. And so Arthrex came and we helped develop a percutaneous pin set. And I will be honest with you, this has lessened in my practice volume as the SuturePlate has been shown to be such a reliable option. But I think if you're faced with a valgus impacted fracture in a young patient that's within 3 or 5 days from injury, this is a very reliable technique. It's been published with good one year data and three year data and follow up with reliable outcomes. And the tray has all the different equipment you would need with percutaneous guides to put in retrograde pins, cannulated screws of up to 60mm in length, and then all the different devices you need to do the percutaneous reduction. So it makes it much easier to do this than when I first started doing it, and had to get pins and Pins and different equipment from all these different trades. But as I said, if I'm fixing a fracture, 95% of them that I fix now, I will use the SuturePlate and not use a percutaneous technique. And what came to draw me to the SuturePlate and why I like it better than all the other plates that I've tried. And I've tried pretty much every one on the market, give or take, is a few different features. I like the fact that the locking screws are polyaxial so you can put them into the bone. For example, if a head split or something else, you can divide the screw fixation into the various parts of the proximal humerus where you need to gain purchase. Really, the big key for me, and what I love most about this plate is the chamfer design of the suture eyelets. You can put all your sutures in the rotator cuff, reduce your tuberosities, reduce your fracture, provisionally fix it with K-wires, put your plate on, put all your screws in, and then at the end of the case, pass those same sutures as tension band reinforcement and you don't have to try to fiddle sliding a plate down sutures, which is what you pretty much have to do with every other plate on the market. So it allows a very nice ease of use. It comes in two lengths, and you've got both cortical and cancellous screws, depending on what part of part of the bone you're fixing. A couple of pearls I've learned over the years, I used to start putting in a posterolateral pin through the deltoid. On the picture on the left. It's the circle on the left that's almost always in the way of the plate. So now I make an anterolateral or anteromedial pin that's percutaneously placed into the calcar up in the greater tuberosity. It stays out of the way of the plate. You can leave it there, the whole case, and take it out at the end. I'll put the kickstand screw, which is the biomechanically most important screw, especially for varus fractures. As the last screw in, I do it under fluoroscopy to try to get it low along the calcar and have a maximum length. We know we don't want to penetrate the joint a lot of these fractures. It's the posterior superior screw. That's the one that's most troublesome for for being to penetrate the joint. So a couple of tricks I've learned. I'm making arthrotomy at the base of the coracoid in the rotator interval, big enough that I can stick my index finger in, and I feel the entire arc of the humeral head at the end of the case, and I make sure there's no screws in the joint. If you don't want to do that, you can maximally externally rotate and take a gray sheet view of the shoulder. And that's the image profile that will most likely catch a posterosuperior screw. That's out. The other trick I've learned from Herbert Resh is to shorten the screws 2 or 4mm, because the humeral head may settle a little bit as it heals, and you can avoid late penetration by doing that. And it's very rare you have a fracture where you need that maximum length of screw right up to the subchondral plate. Arthrex has also options such as Quickset to help you fill voids in the humeral head. On this varus fracture, that head is going to be quite crushed and collapsed. And so you can fill that void with Quickset. And that's been shown by Joe Zuckerman and others that you may help minimize that settling effect of the proximal humerus by having that added augmentation to your fracture fixation. And then every fracture I fixed at the end of all the hardware placement, this is the critical step in my mind. You put all those sutures as you place to reduce your tuberosities into the plate, two in the gap, one in the supra, two in the infra, and it acts like a tension band. And it's been biomechanically shown to help reinforce your fact fixation. It gives you robust fixation, your tuberosities so you can avoid malunion or failure of your hardware. So here's a case example. This is a gentleman in his 50s. He has his head splitting fracture. This is a tough fracture to treat. I had an arthroplasty in the room. He's younger guy I wanted to try to fix it if I could. Again using the SuturePlate you can see on the axillary x ray is a pretty good reduction of his articular surface. Half the screws in the front piece, half the screws in the back piece. That's where that variable angle really helps and in allowing for a good outcome. And maybe we can play the video on the left if you could. And so this is his range of motion at six months. And so thankfully he's done well and had a good outcome. But there are going to be cases where you can't fix it. The bones to comminuted the patient's bone is too fragile. There's other physiologic issues, like maybe a preexisting rotator cuff tear that you didn't suspect. And so you want to have an arthroplasty in every one of these cases. And so for the classic indications of arthroplasty, it's that four part fracture dislocation where the head's got a nearly 100% rate of osteonecrosis. It's the head splitting fracture that you can't fix. Some more comminuted fractures in elderly folks. We all know that Hemi is the bane of shoulder fracture work for many people, and it's because it's hard. It's not hard to put a hem in. It's hard to get the tuberosities to heal, and it's hard to get a reliable outcome for many folks. And the literature is full of patients. One third of whom did quite poorly and have pseudo paralysis and two thirds did fairly well. And we all have probably seen cases like this where the tuberosities dissolve, hardware is broken, the shoulder is unstable, and it's a difficult situation. Arthrex is one of the few companies that has a fracture dedicated Hemi. And what's nice about this implant is there's multiple sutures around the periphery of the underside of the head to help you secure your tuberosities at an anatomic fashion. It's got an adjustable height. So let's say you decide to cement this prosthesis and it's a little too low. You can jack the height up a little bit and restore that shenton's line of the shoulder without having to explant the stem. That's a huge advantage. And so this is a patient that I treated and this is her outcome. Maybe you can play that video as well. At one year. No. I swear it's good. We'll move on. So when do I do I hand me these days. It's rare. Honestly, it's the younger patient in their 50s or maybe early 60s with good tuberosities, but maybe too young and active for a reverse. But I can't fix their fracture because it's just too comminuted or in my hands. I don't have the technical skills to do that. But the reality is, we all have seen over the last ten years or so, that reverse is probably much more predictable for many of our fracture patients, and gives a much more reliable overhead elevation of at least 100 to 120 degrees, even in elderly, more infirm patients. We did a meta analysis at Sinai looking at the hemi versus reverse data out there in the literature, and with the exception of external rotation, which is essentially equivocal between the two groups, reverse outperformed in every category. And so you've got an older patient who's got a bad fracture. I don't even think about Hemi anymore. It's either OIF or I've got the reverse ready to go. And I think Arthrex again has an implant that allows us some flexibility to be able to handle these challenging injuries. And one of the things, as Kevin alluded to, I think there's a few factors about the Arthrex reverse that makes it attractive for fracture work? One it's got one millimeter stem sizing and so you can fit it in virtually every patient. Also the ability of that that box morphology in the metaphyseal area allows you to press fit. I've always been a cement the humerus kind of guy. And it's not until just recently where I've gotten the confidence, having used this Stem in a lot of cuff deficient arthritis patients for reverse, where I felt like I could press this, press this in a fracture setting. The base plate has lots of different sizes, three sizes to allow you to again fit to different anatomy. You've got your options either lateral offset or eccentric. And I'll show you some cases of that. And then the suture cuff is a huge advantage having the ability to put sutures in the periphery, gaining anatomic reduction and fixation of your tuberosities makes your outcome much more predictable. We all know that repairing the tuberosities with reverse for fracture is important. You should do it. It allows for a better restoration of rotation and probably better overall function in your outcome. This implant offers two inclination angles. I routinely, or most of the time will use 135. And I'll show you some data about that and why? I will use a 155 implant and an arm ambulator. So I'm going to use a walker. Fractures their arm. I'll use that for that patient, but for the most part it's 135. Other thing I look at is their scapular neck. If they have a long lateral lateral scapular neck like on the left, you can put a 155 in and probably not have much concern for notching. But if they've got a very acute angle of their scapular neck. Again, reason why I might consider a 135 to minimize the chance for notching. Tony Romeo did a look at the available literature on 135 versus 155 for for a variety of of etiologies, including fracture. And what you can see, there's no question notching is markedly lower with a 135. External rotation is better with a 135. So you've got a person who's active in their 70s and 80s or even 60 and a fracture you can't fix. I think in that patient, you probably want to consider a 135 plus four to optimize their functional outcome. Even with fracture dedicated stems you can have difficulty with tuberosity fixation. So here's a patient with a stem that I used years ago. And you can see the lesser tuberosity is not anatomically positioned. It's not well held. As I was tying sutures, they tore around this prosthesis. And that's a problem, because now I'm worried about the patient's implant stability. I'm worried about their functional outcome. And so I think if you're going to do fractures with a reverse, you want to have the ability to robustly and really anatomically fix those tuberosities. And so here's what the suture, the suture cup allows. It allows for multiple sutures in a horizontal fashion, which we know is strongest and allows you to get that anatomic restoration of the normal tuberosity relationship. And so here's a patient of mine. I'm pretty happy with the way that tuberosity sits. And I think the patient thankfully has done well. And so we know we want those multiple points of fixation again to get that anatomic restoration of function. Here's an interesting patient that I treated about six months ago. She came to me with this fracture. She's 88 but she's independent lives by herself. And what I didn't appreciate because I didn't have a good Cat scan, is that she actually had an anterior glenoid rim fracture, and you can't really see it on the x ray, but her entire anterior inferior rim was broken, and so I had to purposely put purposely put her base plate a little higher and use the eccentric nanosphere. And this is her function at six months. And even though she looks mad at me, she's pretty happy. And you know, it's happy that she can raise her arm and has done very well. So having that eccentric option, those various options is tremendous. And this is a case from two weeks ago where I finally had the courage not to cement the prosthesis. I gave a talk for Arthrex about three months ago, and everybody's making fun of me because I still cement everything. And so this is my first index cement list and patient doing well so far. And Brian Cohen has done over 100 reverses without cement with good results and no, no concerns of subsidence. So in conclusion, fractures certainly represent a challenging spectrum of pathology for all of us. I think one of the nice things about what Arthrex offers is it allows us the opportunity to restore the anatomy and an anatomic way, even with reverse, and it gives us the options to be able to go soup to nuts with fracture management, with one vendor, one team. It makes it easier for everybody involved in the care of your patients.

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.

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

Percutaneous Pinning Technique

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Perkutane Versorgung proximaler Humerusfrakturen

Percutaneous Humeral Fracture Repair

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

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AR-8945-30PT

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AR-2524

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