Operative Techniques: Orthopaedic Trauma Surgery E-book
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Description

Operative Techniques: Orthopaedic Trauma Surgery, by Emil Schemitsch, MD, FRCS(C), is a multimedia orthopedics resource that offers the how-to step-by-step guidance you need—in both atlas and online video formats—to perform all of the latest and best procedures. The large full-color photos and diagrammable illustrations, concise text, and companion web video make it simple to find exactly what you need, when you need it. The result is a detailed, easy-to-use reference that no orthopedic surgeon should be without.
  • Includes access to a companion website where you can search the full text of the book, view videos of experts performing techniques, and link to PubMed for further reference.
  • Covers the hottest topics including compartment syndrome, and the latest techniques in locking plates, management of complex periarticular fractures, difficult upper extremity fractures and acute total joint arthroplasty to help you stay on top of your field.
  • Features step-by-step intraoperative photographs demonstrating each technique and radiographs showing presenting problems and post-surgical outcomes so you’ll know exactly what to do.
  • Highlights key anatomical structures through full-color photographs and interpretive diagrams that present a real-life perspective of cases.
  • Presents surgical tips, pearls and pitfalls from the authors enabling you to enhance your technique and optimize outcomes.
  • Outlines positioning, exposures, instrumentation, and implants to equip you to be more thoroughly prepared for every procedure.
  • Features a hands-on, clinical emphasis, providing just the information and guidance you need.
  • Offers post-operative management guidelines and discussions of expected outcomes to help you avoid mistakes and offer quality patient-focused care.

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Publié par
Date de parution 11 juin 2010
Nombre de lectures 0
EAN13 9781455712793
Langue English
Poids de l'ouvrage 20 Mo

Informations légales : prix de location à la page 0,0691€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

Exrait

OPERATIVE TECHNIQUES: orthopaedic trauma surgery

Emil H. Schemitsch, MD, FRCS(C)
Professor of Surgery, Head, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

Michael D. McKee, MD, FRCS(C)
Professor, Division of Orthopaedics, Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
SAUNDERS
Copyright
SAUNDERS ELSEVIER
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
OPERATIVE TECHNIQUES: ORTHOPAEDIC TRAUMA SURGERY
ISBN: 978-1-4160-4935-7
Copyright © 2010 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: healthpermissions@elsevier.com . You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions .


Notice
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Operative techniques : orthopaedic trauma surgery / [edited by] Emil H.
Schemitsch, Michael D. McKee.
p. ; cm.—(Operative techniques series)
Includes bibliographical references and index.
ISBN 978-1-4160-4935-7
1. Orthopedic surgery—Atlases. 2. Wounds and injuries—Surgery—Atlases. I. Schemitsch, Emil H. II. McKee, Michael D. III. Series: Operative techniques.
[DNLM: 1. Bone and Bones—injuries—Atlases. 2. Bone and Bones—surgery—Atlases. 3. Fractures, Bone—surgery—Atlases. 4. Life Support Care—methods—Atlases. 5. Orthopedic Procedures—methods—Atlases. 6. Wounds and Injuries—surgery—Atlases.
WE 17 O603 2010]
RD733.2.O64 2010
617.4′7—dc22
2010015060
Publishing Director: Kimberly Murphy
Design Direction: Steven Stave
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication
This book is dedicated to my wife Maureen and our four wonderful children, Laura, Geoffrey, Christine and Thomas.

Emil H. Schemitsch
For my wife Debra, and our four children, Sacha, Tyler, Robbin and Everett.

Michael D. McKee
CONTRIBUTORS

Henry Ahn, MD, FRCSC, Assistant Professor, University of Toronto Spine Program, Department of Surgery, University of Toronto, Consultant Spine Surgeon, St. Michael’s Hospital, Toronto, Ontario, Canada, Stabilization of Thoracic, Thoracolumbar, and Lumbar Fractures

Ghassan B. Alami, MD, Clinical Fellow, University of British Columbia, Clinical Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada, Tibial Shaft Fractures: Intramedullary Nailing

Sahal Altamimi, MD, FRCS(C), Clinical Fellow, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada, Supracondylar Humeral Fractures: The Role of Arthroplasty

George S. Athwal, MD, FRCSC, Assistant Professor of Surgery, University of Western Ontario, Consultant, Hand and Upper Limb Centre, London, Ontario, Canada, Terrible Triad Injuries of the Elbow

Greg K. Berry, MDCM, FRCSC, Assistant Professor, Faculty of Medicine, McGill University, Staff Orthopaedic Surgeon, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada, Open Reduction and Internal Fixation of Olecranon Fractures; Proximal Tibia Fractures: Intramedullary Nailing; Fractures of the Talus

Mohit Bhandari, MD, MSc, FRCSC, Canada Research Chair in Musculoskeletal Trauma, and Associate Professor, Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada, Femoral Neck Fractures: Open Reduction and Internal Fixation

Piotr A. Blachut, MD, FRCSC, Clinical Professor, Department of Orthopaedics, University of British Columbia; Vancouver General Hospital, Vancouver, British Columbia, Canada, Radial Head Fractures: Open Reduction and Internal Fixation; Treatment of Open Fractures

Richard A. Boyle, MD, MBBS(Hons), FRACS, Orthopaedic Surgeon, Institute of Rheumatology and Orthopaedics, Royal Prince Alfred Hospital, Sydney, Australia, Femoral Neck Fractures: Arthroplasty

Henry M. Broekhuyse, MD, FRCS(C), Clinical Associate Professor, University of British Columbia, Active Staff, Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, British Columbia, Canada, Plate Fixation of Tibial Shaft Fractures

Richard E. Buckley, MD, FRCS(C), Clinical Professor, Orthopedic Trauma Surgery, University of Calgary, Head, Orthopedic Trauma, Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada, Calcaneus Fractures: Open Reduction and Internal Fixation

Chad P. Coles, MD, FRCSC, Assistant Professor, Dalhousie University, Orthopaedic Surgeon, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada, Humeral Shaft Fractures: Open Reduction and Internal Fixation and Intramedullary Nailing; Femoral Shaft Fractures: Intramedullary Nailing

Paul J. Duffy, MD, FRCS(C), Assistant Professor, University of Calgary, Academic Staff Surgeon, Foothills Medical Centre, Calgary, Alberta, Canada, Distal Radius Fractures: External Fixation

Willliam N. Dust, MD, BMedSc, FRCSC, FACS, Professor of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, Pelvic External Fixation

Alun Evans, MD, MSc, FRCS(Tr and Ortho), Trauma and Orthopedic Fellow, Dalhousie University, Trauma Fellow, and Staff, Orthopedic Division, Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada, Unstable Intertrochanteric Hip Fractures: Open Reduction and Internal Fixation; Anterior Pelvic Internal Fixation

Wade Gofton, MD, MEd, FRCSC, Assistant Professor of Surgery, University of Ottawa Hospital, Ottawa, Ontario, Canada, Intertrochanteric Hip Fractures: Intramedullary Nailing; Subtrochanteric Femur Fractures: Intramedullary Nailing

Christina Goldstein, MD, Resident, Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada, Femoral Neck Fractures: Open Reduction and Internal Fixation

Chris Graham, MD, FRCSC, Assistant Professor, University of Manitoba, Staff Orthopaedic Surgeon, Health Sciences Centre, Winnipeg, Manitoba, Canada, Operative Treatment of Fractures of the Patella; Operative Management of Ankle Fractures

Pierre Guy, MD, MBA, FRCSC, Assistant Professor, Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, Glenoid Fracture: Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation; Proximal Humerus Fractures: Open Reduction and Internal Fixation and Arthroplasty; Treatment of Open Fractures

Jeremy A. Hall, MD, MEd, FRCSC, Assistant Professor, University of Toronto, Staff Orthopaedic Surgeon, St. Michael’s Hospital, Toronto, Ontario, Canada, Open Reduction and Plate Fixation of Displaced Clavicle Fractures; External Fixation of Distal Tibial Fractures

Edward J. Harvey, MD, MSc, FRCSC, Associate Professor, Division of Orthopaedic Surgery, McGill University, Staff Surgeon, Head, Section of Trauma and Section of Upper Extremity Surgery, Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada, Distal Radius Fractures: Open Reduction and Internal Fixation; Scaphoid Fracture Fixation

Michael A. Hickey, MD, Chief Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada, Supracondylar Femur Fractures: Retrograde Intramedullary Nailing

Richard Jenkinson, MD, FRCSC, Lecturer, University of Toronto, Orthopaedic Surgeon, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches

Michael Kelly, MD, Clinical Fellow, University of British Columbia, Clinical Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada, Tibial Shaft Fractures: Intramedullary Nailing

Graham J.W. King, MD, MSc, FRCSC, Professor, University of Western Ontario, Chief of Orthopaedics, St. Joseph’s Health Centre, London, Ontario, Canada, Terrible Triad Injuries of the Elbow

Hans J. Kreder, MD, MPH, FRCS(C), Professor, Department of Orthopaedic Surgery and Health Policy Evaluation and Management, University of Toronto, Chief, Holland Musculoskeletal Program, and Marvin Tile Chair and Chief, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, Subtrochanteric Fractures: Plate Fixation; Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches; Total Hip Replacement for Intertrochanteric Hip Fractures

Paul R.T. Kuzyk, MD, MASc, FRCS(C), Clinical Fellow, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada, Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus; Open Reduction and Internal Fixation of Forearm Fractures

G. Yves Laflamme, MD, FRCS(C), Assistant Professor, Department of Surgery, University of Montreal, Assistant Professor and Head of Orthopaedic Trauma, Hôpital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada, Open Reduction and Internal Fixation of the Acetabulum: Posterior Approaches; Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion; Acute Total Hip Arthroplasty for Acetabular Fractures; Optimizing Perioperative Fracture Care

Abdel-Rahman Lawendy, MD, FRCSC, Assistant Professor, Division of Pediatric Surgery, Division of Orthopaedics, Department of Surgery, University of Western Ontario; Victoria Hospital, London Health Sciences Centre, Associate Scientist, Lawson Health Research Institute, London, Ontario, Canada, Compartment Syndrome

Kelly A. Lefaivre, MD, Assistant Professor, University of British Columbia, Orthopaedic Surgeon, Division of Orthopaedic Trauma, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada, Proximal Tibia Fractures: Open Reduction and Internal Fixation

Ross K. Leighton, MD, FRCS(C), FACS, Professor of Surgery, Dalhousie University, Professor of Surgery, and President of Doctors Nova Scotia, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada, Unstable Intertrochanteric Hip Fractures: Open Reduction and Internal Fixation; Anterior Pelvic Internal Fixation

Allan S.L. Liew, MD, FRCS(C), Assistant Professor of Surgery, University of Ottawa, Director of Orthopaedic Trauma, The Ottawa Hospital, Ottawa, Ontario, Canada, Tibial Plafond Fractures: Open Reduction and Percutaneous Plating

Mark D. MacLeod, MD, FRCSC, Associate Professor, Department of Surgery, University of Western Ontario, Orthopaedic Surgeon, London Health Sciences Centre, London, Ontario, Canada, Proximal Tibia Fractures: External Fixation I: Temporary Knee Bridging External Fixation; Proximal Tibia Fractures: External Fixation II: Circular External Fixation

Dean G. Malish, MD, FRCSC, Clinical Instructor, Department of Orthopaedics, University of British Columbia, Vancouver, Clinical Staff, Division of Orthopedics, Kelowna General Hospital, Kelowna, British Columbia, Canada, Radial Head Fractures: Open Reduction and Internal Fixation

Scott J. Mandel, MD, FRCSC, Assistant Clinical Professor, McMaster University, Hamilton, Ontario, Canada, Proximal Humerus Fractures: Hemiarthroplasty Operative Technique; Knee Dislocations

Gerard March, MD, PGY5—Orthopaedic Resident, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada, Proximal Humerus Fractures: Hemiarthroplasty Operative Technique

Rod Martin, MD, FRCSC, Clinical Professor, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada, Proximal Humerus Fractures: Hemiarthroplasty Operative Technique

Paul A. Martineau, MD, FRCSC, Assistant Professor, Division of Orthopaedic Surgery, McGill University, Staff Surgeon, Section of Upper Extremity Surgery and Section of Sports Medicine, Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada, Distal Radius Fractures: Open Reduction and Internal Fixation; Scaphoid Fracture Fixation

Randy Mascarenhas, MD, Orthopaedic Surgery Resident, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada, Operative Treatment of Fractures of the Patella

Paul K. Mathew, MD, FRCSC, Assistant Clinical Professor, McMaster University, Consultant, Cambridge Memorial Hospital, Cambridge, Ontario, Canada, Terrible Triad Injuries of the Elbow

Robert G. McCormack, MD, FRCS(C), DipSportsMed, Associate Professor, University of British Columbia, Vancouver, Associate Department Head, Royal Columbian Hospital, New Westminster, British Columbia, Canada, Humeral Shaft Fractures: Open Reduction and Internal Fixation and Intramedullary Nailing

Michael D. McKee, MD, FRCS(C), Professor, Division of Orthopaedics, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada, Open Reduction and Plate Fixation of Displaced Clavicle Fractures; Supracondylar Humeral Fractures: The Role of Arthroplasty; Radial Head Arthroplasty

Peter J. O’Brien, MD, Associate Professor, Department of Orthopaedics, University of British Columbia, Head, Division of Orthopaedic Trauma, Vancouver Coastal Health Authority, Vancouver General Hospital, Vancouver, British Columbia, Canada, Proximal Tibia Fractures: Open Reduction and Internal Fixation; Tibial Shaft Fractures: Intramedullary Nailing

Kostas P. Panagiotopoulos, MD, FRCSC, Clinical Instructor, University of British Columbia, Vancouver, Orthopaedic Surgeon, Lion’s Gate Hospital, North Vancouver, British Columbia, Treatment of Open Fractures

Steven Papp, MSc, MDCM, FRCSC, Assistant Professor, University of Ottawa, Orthopaedic Trauma, Ottawa Civic Hospital, Ottawa, Ontario, Canada, Radial Head Arthroplasty; Intertrochanteric Hip Fractures: Intramedullary Nailing; Subtrochanteric Femur Fractures: Intramedullary Nailing

Brad Petrisor, MD, MSc, FRCSC, Assistant Professor, Department of Surgery, McMaster University, Orthopaedic Trauma Service, Hamilton Health Sciences: General Hospital, Hamilton, Ontario, Canada, Supracondylar Femur Fractures: Retrograde Intramedullary Nailing; Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

Brad Pilkey, MD, FRCSC, Assistant Professor and Director of Orthopaedic Trauma, University of Manitoba, Adult Orthopaedic Surgeon and Director of Orthopaedic Trauma, Health Sciences Centre, Winnipeg, Manitoba, Canada, Perilunate Injuries: Combined Dorsal and Volar Approach

Rudolf Reindl, MD, FRCSC, Assistant Professor, Orthopaedic Surgery, McGill University; McGill University Health Centre, Montreal, Quebec, Canada, Cervical Spine: Anterior and Posterior Stabilization

Dominique M. Rouleau, MD, MSc, FRCSC, Associate Professor, University of Montreal, Director of Orthopaedic Clinical Research, Hôpital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada, Optimizing Perioperative Fracture Care

Marie-Ève Rouleau, MPS, University of Quebec at Montreal, Montreal, Quebec, Canada, Optimizing Perioperative Fracture Care

David W. Sanders, MD, MSc, FRCSC, Associate Professor, Division of Orthopaedic Surgery, University of Western Ontario, Orthopaedic Trauma Surgeon, Victoria Hospital, London Health Sciences Centre, London, Ontario, Canada, Compartment Syndrome

Emil H. Schemitsch, MD, FRCS(C), Professor of Surgery, and Head, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada, Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus; Open Reduction and Internal Fixation of Forearm Fractures

Rajrishi Sharma, MD, Chief Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada, Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

David J.G. Stephen, MD, FRCS(C), Associate Professor, Department of Surgery, University of Toronto, Director of Orthopaedic Trauma, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, Anterior Approaches to the Acetabulum

Trevor B. Stone, MD, FRCS(C), Clinical Professor, University of British Columbia, Faculty of Medicine, Department of Orthopaedics, Royal Columbia Hospital, Vancouver, British Columbia, Canada, Pelvic External Fixation

Ayman M. Tadros, MD, FRCSI, Orthopaedic Trauma Fellow, Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, Glenoid Fracture: Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation

Max Talbot, MD, FRCSC, Assistant Professor, McGill University, Staff Surgeon, Montreal General Hospital, McGill University Health Centre, Major, and Medical Director, Canadian Forces Trauma Centre (East); National Defence, Government of Canada, Montreal, Quebec, Canada, Proximal Tibia Fractures: Intramedullary Nailing; Fractures of the Talus

James Vernon, MSc, MBBS, Orthopaedic Surgery Resident, University of Manitoba, Winnipeg, Manitoba, Canada, Operative Treatment of Fractures of the Patella

James P. Waddell, MD, FRCSC, Professor, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada, Femoral Neck Fractures: Arthroplasty

Don W. Weber, MD, FRCS(C), Assistant Clinical Professor of Orthopaedics, University of Alberta, Site Chief of Orthopaedics, University of Alberta Hospital, Edmonton, Alberta, Canada, Supracondylar Femur Fractures: Open Reduction and Internal Fixation

Neil J. White, MD, FRCSC, Chief Resident, Foothills Medical Centre, Calgary, Alberta, Canada, Distal Radius Fractures: External Fixation

Jeff Yach, MD, FRCS(C), Assistant Professor of Surgery, Queen’s University at Kingston, Orthopaedic Trauma Service Chief, Kingston General Hospital, Kingston, Ontario, Canada, Open Reduction and Internal Fixation of Intra-articular Iliac Fracture-Subluxation (Crescent Fracture); Open Reduction and Internal Fixation of Sacral Fractures
PREFACE
Fracture surgery occupies a special place in the hearts and minds of orthopaedic surgeons. This book is designed to be a user-friendly and clinically relevant text on common fracture surgery procedures. Every orthopaedic surgeon may be required to have knowledge or involvement in some aspect of fracture care despite their subspecialty practice. The text is designed for those who wish to review the surgical treatment of the conditions that commonly confront them while on call.
As fracture surgery becomes more and more sophisticated, it is obvious that the technical component of operative intervention is critical to clinical success or failure. Therefore, there continues to be an important need to understand the technical aspects of fracture surgery. Many pearls of wisdom are detailed by the authors in order to deal with the multiple potential pitfalls seen in patients with complex fracture patterns.
Each chapter has been written by a member of the Canadian Orthopaedic Trauma Society (COTS) who is an expert in that particular area. COTS is a group of orthopaedic trauma surgeons with outstanding surgical skills who are recognized leaders in their field. In addition, through prospective and randomized trials, they are at the forefront of developing the evidence that exists for management of the patient with a fracture. Each chapter provides comprehensive technical descriptions supported by the best evidence in that area.
We believe that the production qualities of this text are the highest possible. The illustrations in particular are outstanding and clearly define the complex technical aspects of fracture surgery. We would like to thank all the members of COTS who were contributors to this volume for their outstanding efforts in making it a success. We feel this text should prove to be the “resource of choice” for modern fracture care over the next several years. It will serve those who are novices in the field who wish to concentrate on principles, those experienced surgeons who wish to “fine–tune” their approach, and everyone in between.

Emil H. Schemitsch, MD, FRCS(C), Michael David McKee, MD, FRCS(C)
FOREWORD
The change in treatment of the orthopedic trauma patient has been very impressive over the last 20 years and the “standard of care” has changed significantly over a short time.
The Canadian Orthopaedic Trauma Society (COTS), as a subsection of the Canadian Orthopaedic Association, has been a major world contributor to this change. The Canadian literature accounted for 30% of the level one evidence in orthopaedic trauma published in 2008 ; the majority performed by COTS (either individually or collectively).
The success of this group as “the major player” in conducting prospective multicenter randomized trials has been well recognized by the Canadian Orthopaedic Association, the Orthopedic Trauma Association and was detailed in an invited article for the journal “Injury” in September 2009. 1 The COTS group has won every possible award from these world organizations as a testament to their excellence in the field of clinical randomized trials and their impact on changing the way we treat fractures in our day to day practice. 1
As such, Emil Schemitsch, MD was approached to put together a new text on today’s treatment methods that could be used by residents and staff as a resource for “one way” to perform the “best practice” for their patients. The following text is just such a resource. I have been truly amazed with the ability of our members and our publisher, Elsevier Inc., and Bermedica Production, Ltd. to present the material in a very easy-to-use format. This has been further enhanced with truly fantastic clinical photos (and artist’s renditions) to make the clinical presentation very user friendly. The idea of presenting a method of approaching each area with pearls and pitfalls should be a great help to everyone involved in the patients care and I believe this text will become a “must have book” for each and every resident with an additional text close by each orthopaedic trauma operating theatre.
The COTS group is the finest group of orthopaedic trauma surgeons with which I have ever had the pleasure to be associated. Their dedication to their patients and to their specialty is only surpassed by their surgical skills and desire to share that information with the orthopaedic world as invited speakers locally, nationally, and internationally. This they perform on a daily basis via didactic teaching, skills labs instruction and now this wonderful text on Orthopedic Trauma Surgery. This text should prove to be the “resource of choice” for current orthopedic trauma care over the next five years and will be used by all health care providers concerned with the care of the orthopaedic fracture patient.
The COTS group would like to dedicate this book to our families who continue to support us despite the long hours and many missed family events, due the erratic nature of our specialty. Their support is essential to our continued success .
I know you will find this text very readable and helpful on a daily basis .

Ross K. Leighton, MD, FRCS(C), FACS, President of COTS, President elect of the COA, Professor of Surgery, Department of Surgery, Dalhousie University, Division of Orthopedics, QE II HSC, Halifax, Nova Scotia, Canada

1 The Canadian Orthopaedic Trauma Society: A model for success in orthopaedic research. Injury. 2009;40:1131–6.
Table of Contents
Instructions for online access
Copyright
Dedication
CONTRIBUTORS
PREFACE
FOREWORD
SECTION I: UPPER EXTREMITY
Procedure 1: Open Reduction and Plate Fixation of Displaced Clavicle Fractures
Procedure 2: Glenoid Fracture
Procedure 3: Proximal Humerus Fractures
Procedure 4: Proximal Humerus Fractures
Procedure 5: Humeral Shaft Fractures
Procedure 6: Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus
Procedure 7: Supracondylar Humeral Fractures
Procedure 8: Terrible Triad Injuries of the Elbow
Procedure 9: Radial Head Fractures
Procedure 10: Radial Head Arthroplasty
Procedure 11: Open Reduction and Internal Fixation of Olecranon Fractures
Procedure 12: Open Reduction and Internal Fixation of Forearm Fractures
Procedure 13: Distal Radius Fractures
Procedure 14: Distal Radius Fractures
Procedure 15: Scaphoid Fracture Fixation
Procedure 16: Perilunate Injuries
SECTION II: LOWER EXTREMITY
Procedure 17: Femoral Neck Fractures
Procedure 18: Femoral Neck Fractures: Arthroplasty
Procedure 19: Unstable Intertrochanteric Hip Fractures
Procedure 20: Intertrochanteric Hip Fractures
Procedure 21: Subtrochanteric Fractures: Plate Fixation
Procedure 22: Subtrochanteric Femur Fractures
Procedure 23: Femoral Shaft Fractures
Procedure 24: Supracondylar Femur Fractures
Procedure 25: Supracondylar Femur Fractures
Procedure 26: Knee Dislocations
Procedure 27: Operative Treatment of Fractures of the Patella
Procedure 28: Proximal Tibia Fractures
Procedure 29: Proximal Tibia Fractures: Intramedullary Nailing
Procedure 30: Proximal Tibia Fractures: External Fixation I
Procedure 30: Proximal Tibia Fractures: External Fixation II
Procedure 31: Tibial Shaft Fractures
Procedure 32: Plate Fixation of Tibial Shaft Fractures
Procedure 33: Tibial Plafond Fractures
Procedure 34: External Fixation of Distal Tibial Fractures
Procedure 35: Operative Management of Ankle Fractures
Procedure 36: Fractures of the Talus
Procedure 37: Calcaneus Fractures
Procedure 38: Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation
Procedure 39: Compartment Syndrome
SECTION III: SPINE, PELVIS, AND ACETABULUM
Procedure 40: Pelvic External Fixation
Procedure 41: Anterior Pelvic Internal Fixation
Procedure 42: Open Reduction and Internal Fixation of Intra-articular Iliac Fracture-Subluxation (Crescent Fracture)
Procedure 43: Open Reduction and Internal Fixation of Sacral Fractures
Procedure 44: Anterior Approaches to the Acetabulum
Procedure 45: Open Reduction and Internal Fixation of the Acetabulum
Procedure 46: Cervical Spine
Procedure 47: Stabilization of Thoracic, Thoracolumbar, and Lumbar Fractures
Procedure 48: Treatment of Open Fractures
Procedure 49: Fixation of Periprosthetic Femoral Fractures Using Locked Plates Combined with Minimally Invasive Insertion
Procedure 50: Acute Total Hip Arthroplasty for Acetabular Fractures
Procedure 51: Total Hip Replacement for Intertrochanteric Hip Fractures
Procedure 52: Optimizing Perioperative Fracture Care
INDEX
SECTION I
UPPER EXTREMITY
PROCEDURE 1 Open Reduction and Plate Fixation of Displaced Clavicle Fractures

Jeremy A. Hall, Michael D. McKee



Indications


PITFALLS

• Operative treatment of clavicle fractures must consider both patient and fracture factors.
• Relative contraindications:
Noncompliance
Advanced age (>60 years)
Medical comorbidities, especially diabetes
Alcoholism
Prior radiation to area
Poor skin/soft tissue condition


Controversies

• Controversy still exists regarding operative versus nonoperative treatment of clavicle fractures as nonoperative treatment has been the standard of care since the 1960s.
• Debate continues regarding intramedullary versus plate fixation.
• Questions remain regarding less than 2 cm of shortening as an indication.


Treatment Options

• Options for treatment of displaced clavicle fractures include open reduction and internal fixation or use of a sling for comfort.
• For operative treatment, open reduction and internal plate fixation is preferred as intramedullary fixation controls length and rotation poorly.
• For nonoperative treatment, a simple sling is preferred.
• A figure-of-8 bandage can lead to brachial plexopathy if not applied appropriately, and has little influence on fracture outcome.

Open fracture
Fracture with associated upper extremity neurovascular compromise
Clavicle fracture with associated scapulothoracic dissociation
Completely displaced midshaft clavicle fracture in young active individuals, especially with shortening
Displaced lateral third clavicle fracture
Lateral third intra-articular clavicle fracture
Associated displaced glenoid fracture (floating shoulder)

Examination/Imaging

The overlying skin and soft tissues are examined for deficits, old scars, or previous incisions.
The length of the injured clavicle is measured from the sternoclavicular joint to the acromioclavicular joint, and compared to the opposite uninjured side both clinically and radiographically.
A carefully documented neurovascular examination of the upper extremity is done to exclude preoperative injury.
Anteroposterior and 20° cephalad upshot views of the clavicle are obtained to assess fracture configuration.
• Figure 1 shows an anteroposterior radiograph of a completely displaced midshaft clavicle fracture with significant displacement and rotation at the fracture site.

FIGURE 1

Surgical Anatomy

The clavicle forms an anterior strut to maintain the position of the shoulder on the thoracic cage ( Fig. 2 ).
• It is an S-shaped bone with a cephalad-to-caudad bow.
• The subclavian vessels and brachial plexus pass posterior/posteroinferior to the clavicle before passing inferior to the coracoid and into the arm.
• The apex of the lung lies posterior/posteroinferior to the clavicle.
• Superficially, cutaneous braches of the intermediate supraclavicular nerve fan out over the anterior-superior region of the middle third of the clavicle.
The sternoclavicular joint is a diarthrodial joint allowing movement in both the horizontal and vertical planes, as well as 20–40° of rotation relative to the manubrium, and is stabilized by the joint capsule.
The acromioclavicular joint is a planar joint allowing approximately 20° of rotation relative to the acromion. This joint is stabilized by the capsule and intracapsular ligaments, as well as the conoid and trapezoid coracoclavicular ligaments.
Together, these joints allow movement of the clavicle of up to 60° in the vertical plane and 20° in the horizontal plane, and up to 40° of rotation.

FIGURE 2

Positioning


PEARLS

• A bump under the shoulder girdle will aid in fracture reduction, as it allows the shoulder and lateral fragment to lateralize or “fall away” from the fracture site.
• Positioning the head and endotracheal tube away from the operative site will allow greater access to the clavicle.
• Tape across the forehead may be used to further stabilize the head position.


PITFALLS

• Keep the head and endotracheal tube out of the way to allow unhindered superior access for the drill, tap, and screwdriver.


Equipment

• Commercially available shoulder positioning frames, such as the Tennent shoulder table, can be used.

Use of a general anesthetic is preferred.
The patient is placed in the beach chair position using a footboard to support the weight of the body and cushioned safety straps over the knees to prevent knee flexion ( Fig. 3 ).
A small bump is placed under the posteromedial aspect of the shoulder girdle.
The clavicle is prepared and draped using a pediatric laparotomy drape with the arm at the side.
The operative arm may be free draped, but this is not typically necessary.

FIGURE 3

Portals/Exposures


PEARLS

• A superior subcutaneous approach to the clavicle allows for fracture visualization without significant soft tissue dissection.
• A two-layer exposure allows for a two-layer closure, providing greater soft tissue coverage of the hardware and fracture. This results in a reduced infection rate and, if a superficial infection does occur, the hardware is still covered by soft tissue.

The clavicle is exposed along the anterosuperior subcutaneous border.
A 5- to 10-cm incision is centered over the fracture site ( Fig. 4 ). As experience improves, smaller incisions are possible and preferred.
If noted, superficial branches of the intermediate supraclavicular nerve are identified and protected.
The skin edges are undermined in the subcutaneous plane to facilitate a mobile window of exposure.
The fascia and periosteum are often disrupted, and this defect is extended medially and laterally to create anterior and posterior soft tissue flaps for fracture visualization.

FIGURE 4


Instrumentation

• Low-profile, precontoured plating systems are preferred.
• A pelvic reconstruction plate is often too weak, especially in patients greater than 70 kg.
• Bulky straight compression plates are often too prominent.


Controversies

• An anteroinferior approach to the clavicle has been described and has the advantage of directing drills and screws away from neurovascular structures, and allows for longer screws.

Procedure

STEP 1


PEARLS

• A posteriorly directed force on the shoulder and distal fragment will aid in obtaining proper fracture length.
• Reduction forceps on the proximal and distal fragments may also be used to attain the proper fracture length.


PITFALLS

• Carefully dissect the fracture fragments to maintain soft tissue attachments—do not devascularize the fragments to get them reduced.
• Dissection along the inferior aspect of the clavicle fragments must be cautious given the proximity of the lung, subclavian vessels, and brachial plexus.

The fractured ends are exposed and débrided of interposed hematoma and soft tissues.
The fracture ends or butterfly fragments are reduced and held in place with Kirshner wires ( Fig. 5 ) while lag screws are placed perpendicular to the fracture plane (if possible).

FIGURE 5


Instrumentation/Implantation

• Many clavicle fixation sets are equipped with mini-fragment screws for lag screw applications.


PEARLS

• Precontoured clavicle plates can be used as a guide to the reduction of complex or comminuted fractures.
• Extra-long drills, taps, and screwdrivers will aid in the insertion of screws around the head and neck, especially for medial-third clavicle fractures.


PITFALLS

• Beware the proximity of the lung, subclavian vessels, and brachial plexus when drilling, tapping, and measuring screw length—beware “plunging.”
• Careful retractor positioning about the fracture is necessary to protect delicate surrounding structures.

STEP 2

To stabilize the fracture fragments, a precontoured, low-profile clavicle plate is placed along the superior edge of the clavicle and affixed using appropriately sized screws ( Fig. 6A ).
A minimum of six cortical screws and a lag screw or eight cortical screws on either side of the fracture is preferred ( Fig. 6B ).

FIGURE 6


Instrumentation/Implantation

• Precontoured plates are useful adjuncts to the treatment of clavicle fractures and come in a variety of lengths and contours.
• Lateral-third fractures and intra-articular fractures involving the acromioclavicular joint may necessitate the use of a subacromial hook plate if adequate lateral fixation is not provided by precontoured clavicle plates.
• Pelvic reconstruction plates may be adequate fixation for smaller individuals (70 kg or less).


Controversies

• The debate continues regarding superior versus anteroinferior plate positioning and intramedullary fixation techniques.
• The authors prefer superior plate positioning using precontoured, low-profile clavicle plates as this exposure facilitates relatively straightforward fracture reduction and this plate position provides the greatest axial and torsional stability.

STEP 3

Stability of the fracture fixation is assessed.
The wound is irrigated and a Valsalva maneuver is performed to evaluate for pleural integrity.
The fascia and skin are closed in two layers ( Fig. 7 ).

FIGURE 7

Postoperative Care and Expected Outcomes


PEARLS

• Two-layer closure provides better soft tissue coverage over the plate and fracture.


PITFALLS

• The Valsalva maneuver may provide evidence of intraoperative pneumothorax, but this is not a guarantee. A postoperative chest radiograph should be performed if ventilation concerns arise (very rare).

Postoperatively, the wound is dressed and the arm is placed in a sling for comfort.
Postoperative radiographs are taken for assessment and documentation ( Fig. 8 ).
Range-of-motion exercises begin on the first postoperative visit at 2 weeks, followed by strengthening exercises at 6 weeks given favorable radiographs.
Sports are delayed until 8–12 weeks.

FIGURE 8


PEARLS

• Many patients will describe numbness in the infraclavicular region as a result of traction or injury to the intermediate supraclavicular nerve(s); patients should be warned preoperatively of this possibility.
• This deficit typically resolves with time, and neuroma formation is extremely rare.


PITFALLS

• Early aggressive range of motion or patient noncompliance may lead to early failure of fixation.

Evidence

Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg [Br] . 2007;89:1-10.
This prospective, randomized multicenter study compared sling treatment to open reduction and internal fixation of completely displaced middle-third clavicle fractures. The authors concluded that operative treatment in young active individuals provided improved functional outcome and a lower symptomatic malunion and nonunion rate, with a low incidence of operative complication. (Grade A recommendation) .
Hill E, McGuire M, Crosby L. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg [Br] . 1997;79:537-539.
This prospective cohort study evaluated the outcomes of 242 consecutive fractures of the clavicle treated nonoperatively; 66 were displaced middle-third clavicle fractures, and 52 patients were available for review. Radiographic and patient-oriented outcomes were reported and showed a 15% nonunion rate and a 31% unsatisfactory result in patients with completely displaced middle-third clavicle fracture. (Grade B recommendation) .
McKee MD, Wild LM, Schemtisch EH. Midshaft malunions of the clavicle. J Bone Joint Surg [Am] . 2003;85:790-797.
This case series reported 15 patients with middle-third symptomatic clavicle malunions who underwent clavicular osteotomy and fixation. Radiographic and patient-oriented outcomes were collected pre- and postsurgery. Postoperatively, the mean clavicular shortening improved from 2.9 to 0.4 cm, and the mean DASH score improved from 32 to 12 points, suggesting clavicle fracture malunions that cause significant residual morbidity can be ameliorated with surgical correction. (Grade C recommendation) .
Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg [Am] . 2004;86:1359-1365.
This prospective observational cohort study evaluated the prevalence of nonunion after nonoperatively treated clavicle fractures. The authors reported an overall nonunion rate of 6.2%; however, completely displaced fractures with comminution had a higher risk of nonunion. (Grade B recommendation) .
PROCEDURE 2 Glenoid Fracture

Pierre Guy, Ayman M. Tadros



Open Reduction and Internal Fixation and Arthroscopically Assisted Fixation


Indications


PITFALLS

• Prioritize commonly associated life-threatening injuries: head, spine/spinal cord, chest, brachial plexus, vascular
• Indication individualized to injury, patient health, and functional demand
• Contraindications to open reduction and internal fixation: infections, pre-existing shoulder arthritis, or severe comminution not allowing stable fixation


Controversies

• Anterior rim fractures may be treated nonoperatively if the glenohumeral joint remains concentric.
• No clear evidence is available comparing operative and nonoperative treatment. Indications are based on principles of articular injury treatment, not on high-level comparative trials.

General indications
• Open fractures
• Neurovascular injuries that need exploration
• Symptomatic pseudoarthrosis
Specific indications: relative to the portion of the glenoid involved
• Glenoid fossa fractures (intra-articular glenohumeral joint)
♦ Articular step 4 mm or more.
♦ Articular gap more than 10 mm (risk of nonunion)
♦ Glenoid rim fracture involving greater than ¼ of fossa anteriorly, greater than ⅓ posteriorly
♦ Associated with persistent dislocation or subluxation of the humeral head
• Glenoid neck fractures (extra-articular fractures)
♦ Translational displacement greater than 2 cm
♦ Significant angulation: transverse or coronal plane greater than 20–40° or glenopolar angle (GPA) less than 20° (normal, 30–45°) ( Romero et al., 2001 ). The GPA is measured on an anteroposterior radiograph as the angle between the line connecting the most cranial with the most caudal point of the glenoid cavity and the line connecting the most cranial point of the glenoid cavity with the most caudal point of the scapular body (the lateral boder of the scapula) ( Fig. 1 ).
Relative indications
• Associated displaced clavicle fracture (>2 cm) shortening or comminution
• Associated acromioclavicular, coracoacromial, or coracoclavicular injury
• Associated double disruption of the superior shoulder suspensory complex

FIGURE 1

Examination/Imaging

PHYSICAL EXAMINATION

Goal: identify/rule out associated injuries
Assess for concurrent:
• Neurologic injury: head, spine/spinal cord, brachial plexus
• Vascular injury
♦ Inspection and palpation for pulse and perfusion signs
♦ Side-to-side comparison of blood pressure (particularly in presence of first rib fracture); if abnormal, consider angiography/computed tomography (CT) angiography
• Open fracture and/or ipsilateral limb–shoulder girdle injury: to define timing of care
• Other system injury: primary and secondary surveys

PLAIN RADIOGRAPHY

Chest radiograph
• Important in assessing commonly associated chest trauma
• May represent the first chance to identify scapular fracture or scapulothoracic dissociation
• Not sufficient for assessment and preoperative planning for scapular fractures
Cervical spine imaging: radiography or CT as per center’s protocol
Shoulder trauma series
• Obtain anteroposterior (x-ray beam tangential to glenoid/perpendicular to the plane of the scapular body), trans-scapular lateral, and transaxillary views.
• Consider a “bumped-up view” if a standard axillary view with the arm abducted is not clinically feasible ( Fig. 2A–C ).
Assess scapula-glenoid fractures and detect associated shoulder girdle injuries: clavicle; proximal humerus; disruptions of the acromioclavicular, glenohumeral, sternoclavicular, and scapulothoracic articulations; suspensory ligamentous complex injury.
It is important to differentiate true fossa fractures from anterior and posterior rim fractures.
• Anterior and posterior rim fractures (type I; see Surgical Anatomy ) are larger than Bankart “bony avulsions,” which occur when the humeral head loses its congruity as it dislocates anterior to the glenoid. Rim fractures result from a relatively eccentric lateral force that drives the humeral head against the anterior or posterior portion of the glenoid fossa depending on arm position.
♦ Figure 3A–C shows an anterior rim fracture with maintained concentric glenohumeral alignment in a 63-year-old female accountant who was treated nonoperatively (Case 1).
♦ Figure 4A–C shows an anterior rim fracture with loss of glenohumeral alignment in a 36-year-old male who sustained this injury while skimboarding, when he noticed his shoulder dislocate and self-reduce (Case 2).
• In contrast to type I, true glenoid fossa fractures (types II–VI; see Surgical Anatomy ) follow a more centrally applied lateral force producing, in most cases, a transverse fracture of the glenoid, which then extends in one of several directions depending on the direction of the load.
♦ Figure 5A–C shows a displaced extra-articular fracture of the scapula in a 31-year-old overhead worker (electrician) who sustained this injury while mountain biking (Case 3). He has a significant past history of an acromioclavicular joint injury treated with late distal clavicle resection.
♦ Figure 6A–C shows a displaced comminuted, intra-articular fracture of the scapula (glenoid fossa type VI) in a 39-year-old male who sustained this injury catching his front wheel and falling from his bicycle (Case 4).
♦ Figure 7 shows a displaced intra-articular transverse fracture of the glenoid fossa (type III) with associated clavicle and first rib fractures in a 36-year-old male triathlete who sustained this injury while road cycling (Case 5). He was neurovascularly intact with symmetric blood pressure in both upper extremities.

FIGURE 2

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING

Two-dimensional CT reconstruction may be useful in preoperative assessment if done in orthogonal planes to the glenoid to assess fragments and their relative displacement.
• Figure 8A–C shows two-dimensional CT views of the large anterior rim injury sustained by the skimboarder in Case 2.
• Figure 9A–D shows two-dimensional CT views of the type III injury sustained by the triathlete in Case 5.
Axial CT slices with three-dimensional reconstruction are the most useful modality in fracture assessment and preoperative planning. Centers could decide to make these part of chest trauma CT studies (time, resource utilization, radiation minimization).
• Figure 10A and 10B shows three-dimensional CT views of the small anterior rim injury sustained by the 63-year-old accountant in Case 1.
• Figure 11A and 11B shows three-dimensional CT views of the large anterior rim injury sustained by the skimboarder in Case 2.
• Figure 12 show a three-dimensional CT view of the extraarticular glenoid neck/body fracture sustained by the mountain biking electrician in Case 3.

FIGURE 8

FIGURE 9

FIGURE 10

FIGURE 11

FIGURE 12


Treatment Options

• Nonoperative treatment is advocated for undisplaced/minimally displaced fractures, severely comminuted unreconstructible fractures (when stable fixation cannot be expected), and cases in which no functional use of the limb is expected.
• Operative care includes open techniques, closed reduction and percutaneous fixation techniques, and arthroscopically assisted techniques. Figure 14A and 14B shows postoperative radiographs confirming preserved glenohumeral alignment of the anterior rim fracture in the 63-year-old accountant in Case 1.

FIGURE 14
• Figure 13A and 13B shows three-dimensional CT views of the type VI injury sustained by the bicyclist in Case 4.
Magnetic resonance imaging may be of value in detecting associated rotator cuff tears or ligament injuries; however, it is not practical in an acute trauma setting.

FIGURE 13

Surgical Anatomy

Bony anatomy
• Internal fixation is limited by the osseous anatomy of the scapula, which is mostly thin.
• The thick regions suitable for internal fixation are the glenoid process, the coracoid process, the acromion/scapular spine, and the lateral border of the scapular body ( Fig. 15 ).
Soft tissue anatomy
• The scapula is covered by muscle and surrounded by nervous and vascular structures. These must be avoided, protected, and/or mobilized during the surgical dissection.

FIGURE 15

CLASSIFICATION OF GLENOID FRACTURES

Important for surgical decision making
Glenoid fossa fractures (intra-articular)
• Goss (1992, 1995 ) modified Ideberg’s original classification, which is useful in planning approaches.
• Types of glenoid fossa fractures ( Fig. 16 ):
♦ IA—anterior rim fracture; IB—posterior rim fracture
♦ II—fracture line through the glenoid fossa exiting at the lateral border of the scapula
♦ III—fracture line through the glenoid fossa exiting at the superior border of the scapula
♦ IV—fracture line through the glenoid fossa exiting at the medial border of the scapula
♦ VA—combination of types II and IV; VB—combination of types III and IV; VC—combination of types II, III, and IV
♦ VI—comminuted fracture
Glenoid neck fractures (extra-articular)
• Their typical displacement is toward the midline with angulation in the transverse and coronal planes.
• Indications for open reduction and internal fixation (ORIF) are based on Ada and Miller’s (1991) recommendations and follow Goss’ ( Fig. 17 ) classification ( 1994 ) of glenoid neck fracture displacement (translation and angulation).
♦ Type I includes all minimally displaced fractures.
♦ Type II includes all significantly displaced fractures (translational displacement ≥1 cm; angulatory displacement ≥40°)
• Of note, some relative displacement of the lateral border of the scapula to the glenoid may contribute to the apparent medial translation of the glenoid ( Obremsky et al., 2007 ; Patterson et al., 2007 ).

FIGURE 16

FIGURE 17

Positioning


PEARLS

• Final position should allow safe access to the approached side (posterior or anterior), limb mobilization, and adequate intraoperative imaging.

Posterior approach
• The prone or lateral decubitus position with the operative side up may be used.
• The lateral decubitus position is favored in most trauma patients.
♦ Figure 18A shows a patient in the lateral decubitus position on a beanbag for a planned posterior approach and the use of a Mayo stand to support the operated arm.
♦ Figure 18B shows the use of table-based practitioners, as well as the position of the surgical team.
Anterior approach: beach chair position
Arthroscopic surgery: beach chair or lateral decubitus position with traction and slight shoulder abduction and flexion

FIGURE 18

Portals/Exposures

The choice of the approach depends on the type of fracture.
• Type IA fractures may be approached anteriorly or arthroscopically.
• The other glenoid fossa fracture types and operatively treated glenoid neck fractures are preferably approached posteriorly, supplemented by a superior approach for lag screw fixation for transverse fossa fractures as needed.
• Isolated type III fractures may be reduced indirectly percutaneously and fixed by percutaneous superior-to-inferior screw placement (see Fig. 21C in ORIF procedure below).

FIGURE 21


PITFALLS

• Given the frequency of associated life-threatening injuries to the chest, head, and cervical spine, which might preclude proper patient positioning, the final surgical approach and positioning decision should be made in collaboration with the anesthesiologist, intensivist, and general surgeon.
• The beach chair is the preferred position for arthroscopy to allow conversion to an open technique if required.
Posterior approach
• Two posterior surgical approaches have been described for ORIF of glenoid fractures.
• Extensile exposure described by Judet (authors’ preferred approach) (see Video 1):
♦ The skin incision extends from the posterolateral acromion angle, along the whole length of scapular spine to the superomedial corner, then curves distally along the medial border of the scapula ( Fig. 19A ).
♦ A skin flap is then elevated, exposing the posterior deltoid and infraspinatus muscles ( Fig. 19B ).
♦ The deltoid-infraspinatus muscle interval is then developed and the posterior deltoid is sharply detached from the lateral scapular spine to its tip ( Fig. 19C ; see also Video 2).

FIGURE 19


Equipment

• A conventional operating table with beanbag stabilization is suitable for management of most fractures, allowing surgical access and intraoperative imaging (see Fig. 18A ).
• A well-padded Mayo stand is used as a mobile adjustable armrest for the operated limb (see Fig. 18B ).
♦ The safe infraspinatus–teres minor interval (respectively supplied by the suprascapular and axillary nerves; see Fig. 19C ) is then developed, exposing the lateral border of the scapula to the inferior aspect of the glenoid and safely freeing the infraspinatus for further dissection.
♦ The infraspinatus and teres minor muscle bellies are then detached from the medial border of the scapula and from the infraspinatus fossa ( Fig. 19D ).
♦ The infraspinatus is carefully reflected laterally and superiorly, keeping it moist and avoiding traction to its neurovascular pedicle originating from the spinoglenoid notch ( Fig. 19E ). Also note careful elevation of the supraspinatus.
♦ A posterior arthrotomy can help in monitoring articular reduction.


PITFALLS

• Care must be taken to avoid nerve injuries: the suprascapular, axillary, and XIth cranial accessory nerve in a posterior exposure and the brachial plexus and artery axillary in an anterior exposure. Converting to a more extended approach may be necessary to relieve nerve tension
• One concern with the more limited posterior approach, which abducts the arm at 90°, is that this places the axillary nerve more lateral and closer to the surgical site.
• Fluid extravasation during arthroscopically assisted procedures should be monitored closely.
The limited posterior approach (popularized by van Noort)
• An alternative to Judet’s exposure, avoiding elevation of the infraspinatus, was described by van Noort et al. (2004) : “An angular incision is made, starting medially along ⅔ of the scapular spine, then curving 2 cm medial from the posterior edge of the acromion and proceeding caudad for 10 cm…By abducting the arm 90 deg, the inferior border of the deltoid is raised, which allows easy retraction” ( Fig. 20A and 20B ).
• Minimal release of its medial attachment to the scapular spine may be needed.
• The plane between the infraspinatus and teres minor muscles, respectively supplied by the suprascapular and axillary nerves, is developed, exposing the lateral border of the scapula to the inferior aspect of the glenoid.

FIGURE 20


Controversies

• Arthroscopically assisted ORIF has not been compared or shown superiority to a standard deltopectoral approach.
• A small posterior glenohumeral vertical arthrotomy is then made to allow joint visualization.
• A retractor is inserted into the joint to retract the humeral head anteriorly.
Anterior approach
• A standard deltopectoral approach is used.
• A subscapularis tenotomy is usually carried as per the traditional open Bankart repair, protecting the vessels running along the inferior portion of the tendon.
• A longitudinal or H-shaped capsulotomy allows joint visualization for reduction and fixation.
Superior approach
• A superior approach is typically used for placement of a lag screw following reduction via open anterior or posterior approaches or indirectly percutaneously (see Fig. 21C ).
• As these injuries commonly have associated clavicle or acromioclavicular joint injuries, which will be repaired, the afforded surgical access can also be used for ORIF of the clavicle.
Arthroscopically assisted glenoid fracture fixation
• A standard posterior camera portal and two anterior working portals, centered 2 cm medial and 1 cm inferior to the anterolateral border of the acromion, just lateral to the coracoid process, are used (see Video 3).

Procedure: Open Reduction and Internal Fixation

STEP 1


PEARLS

• Add arthrotomy to monitor reduction during a posterior approach.
• Consider indirect reduction through manipulation of the coracoid for type III fractures.
• In arthroscopically assisted cases, the first steps best involve establishing a posterior and an anterosuperior portal for initial irrigation and hematoma evacuation to assist reduction.

Clear the fracture lines, removing hematoma and loose fragments, with preservation of sufficient soft tissue attachments.
Reduce articular fracture(s) first if present, apply provisional fixation with Kirschner wires (K-wires), and monitor reduction with imaging or direct visualization. Figure 21A and 21B shows percutaneous reduction of the glenoid using a joystick attached to the acromion in the triathlete in Case 5.

STEP 2


PEARLS

• Small-size implants (2.0–2.7 mm) achieve sufficient purchase and prevent overcrowding.
• Articular fixation may also be combined with buttress plate fixation to increase initial construct rigidity.

Definitive rigid articular fracture fixation is performed, typically using lag screws.
Most fixation is from posterior to anterior (posterior approach). Anterior and arthroscopic approaches typically use fixation from anterior to posterior.
As most fractures have a transverse component, now is a good time to place a lag screw from superior to inferior from a superior (possibly percutaneous) approach, just posterior to the lateral end of the clavicle. Figure 21C shows fixation of the fracture in the triathlete in Case 5 by a screw placed through a superior approach.
Implants would typically start posterior to the lateral aspect of the clavicle, directed from superior to inferior through the muscle belly/musculotendinous junction of the supraspinatus muscle, to fix the transverse component of a fossa fracture (see Fig. 21C ).

STEP 3


PITFALLS

• Avoid large implants around the joint to prevent overcrowding.
• Consider version and the GPA of the glenoid when aligning the articular fragment and body.

Internal fixation is completed, stabilizing the articular segment to the scapular body and spine.
Final imaging is done to confirm reduction and safe implant position.
• Figure 22A and 22B shows postoperative radiographs confirming reduction of the neck fracture to the mountain biker in Case 3.
• Figure 23A and 23B shows postoperative radiographs confirming reduction of the type VI injury to the bicyclist in Case 4.
• Figure 24A–C shows postoperative radiographs confirming reduction and safe implant position of the injuries to the triathlete in Case 5.
Wound closure
• Posterior approach: at completion of fixation, closure consists of a heavy resorbable suture to repair the medial origin of the infraspinatus and teres minor to the medial border of the scapula, and to similarly repair the posterior deltoid to the spine.
• Anterior approach: the capsule and tenotomy are closed in layers.

FIGURE 22

FIGURE 23

FIGURE 24


Instrumentation/Implantation

• Small-size implants (2.4–2.7 mm in diameter) are used in the periarticular area, while 3.5-mm implants may be used to join larger segments.

Procedure: Arthroscopically Assisted Glenoid Fracture Fixation

This procedure is used for type IA fractures, as illustrated by the skimboarder in Case 2.

STEP 1

Arthroscopic portals are established.
The joint is thoroughly irrigated, followed by diagnostic arthroscopy.
Any clot is mobilized by introducing a probe hook through the working cannula, and loose fragments are identified and removed.
The fracture site is débrided using shavers.

STEP 2


PEARLS

• Two provisional K-wires is used per anterior working portal.
• If cannulated screws are used, maintain at least one stable fixation device (K-wire) while the screw is inserted over the other wire.
• Use long guidewires and short cannulas.

The fracture is reduced and provisionally fixed using K-wires.
Reduction is confirmed by direct visualisation or arthroscopy.

STEP 3

Definitive fracture fixation is achieved by:
• Screws introduced percutaneously, preferably cannulated over provisional wires ( Fig. 25A and 25B ).
• Alternately or in addition, nonabsorbable sutures may be passed through the labrum and the capsule of the displaced articular fragment, then through the fragment and glenoid. An anterior-to-posterior suture technique is used, with the knot tied over the infraspinatus (similar to the Caspari technique for anterior Bankart instability).
Final reduction is controlled arthroscopically and radiographically (see Fig. 25 ) and follow-up x-rays are taken ( Fig. 26A and 26B ).

FIGURE 25

FIGURE 26

Postoperative Care and Expected Outcomes


PEARLS

• The ability to achieve a rigid internal fixation construct will allow early ROM to prevent postoperative stiffness.

The shoulder on the operated side is immobilized with a sling until pain subsides to allow a three-phase rehabilitation program.
Phase 1
• If an excellent reduction and stable fixation has been achieved, simple “stooping” range-of-motion (ROM) exercises are instituted for 4 weeks postoperatively. They include pendulum and passive-assisted ROM exercises. The arm is allowed to come to approximately 90° of forward elevation and 30° of external rotation, with internal rotation allowing the patient’s thumb reach to the thoracolumbar junction.
• During this initial phase, the patient is examined clinically and radiographically with a scapula series (anteroposterior, lateral, and axillary view radiographs) 2 weeks postoperatively, to assess the surgical site, stability of fixation, and glenohumeral joint reduction and congruity (see Fig. 24 ).


PITFALLS

• Secondary displacement or fixation failure during the first 6 weeks postoperatively should be investigated for a possible infection.
• Heterotopic ossification and adhesive capsulitis may occur following management of these fractures. Although no specific prophylactic regimen has been recommended for heterotopic ossification, early mobilization should diminish the incidence of stiffness.
Phase 2
• This phase starts with the second postoperative visit at 4 weeks following surgery.
• If fracture fixation stability is confirmed clinically and radiographically, active ROM is allowed, as well as active external and internal rotation.
Phase 3
• At approximately 10–12 weeks following surgery, the patient is reassessed. If the fracture has united, then resisted exercises are allowed.
• Note: If the fracture is highly comminuted or absolute rigidity cannot be achieved, phase 1 ROM exercises are extended up to 6 weeks postoperatively, with careful radiographic fracture evaluation to exclude failure of fixation. If the fixation remains stable, active ROM and resisted exercises progress according to clinical and radiographic assessments.
• Rehabilitation aims for maximum ROM and strength. This generally takes 16–24 weeks. Heavy manual labor jobs and athletic activities are prohibited at least until 6 months following surgery.
The outcomes are overall favorable following ORIF under the present recommended indications, with 70–98% of patients being pain free. Functional outcome appears tightly linked to the outcome of the patients’ frequently associated system injuries, and to the development of postsurgery/injury complications (e.g., stiffness).

Evidence

There are no higher level evidence studies to guide treatment decisions. There have been no comparative studies (randomized controlled trials or comparative cohorts) of operative versus nonoperative care. Most publications consist of small retrospective single-cohort studies with radiographic and surgeon-based endpoints. Some retrospective cohorts with functional outcomes scores and a few small prospective cohort studies have been published. Classification systems, aimed at decision making, have been developed from these clinical studies based on the diagnostic and therapeutic, and in some cases functional, outcomes data.

CLASSIFICATION SYSTEMS
Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg [Am] . 1992;74:299-305.
Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg . 1994;3:42-52.
Goss TP. Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg . 1995;3:22-33.
Obremsky WT, Armitage B, Corr B. Glenoid fractures do not medialize. Paper #54, Annual General Meeting, Orthopedic Trauma Association, Boston, 2007.
Patterson JMM, Galatz L, Toman J, Torretta P III, Ricci WM. CT evaluation of extra-articular glenoid neck fractures: Does the glenoid medialize or does the scapula lateralize? Paper #55, Annual General Meeting, Orthopedic Trauma Association, Boston, 2007.
Romero J, Schai P, Imhoff AB. Scapular neck fracture: the influence of permanent malalignment of the glenoid neck on clinical outcome. Arch Orthop Trauma Surg . 2001;121:313-316.
The authors reported that a GPA less than 20° was associated with poorer functional outcome, hence suggesting it as a relative indication for ORIF. .

ANATOMY
Mallon WJ, Brown HR, Vogler JB3d, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop Relat Res . 1992;277:142-154.

NONOPERATIVE TREATMENT
Ada JR, Miller ME. Scapular fractures: analysis of 113 cases. Clin Orthop Relat Res . 1991;269:174-180.
Khallaf F, Mikami A, Al-Akkad M. The use of surgery in displaced scapular neck fractures. Med Princ Pract . 2006;15:443-448.
Maquieira GJ, Espinosa N, Gerber C, Eid K. Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder. J Bone Joint Surg [Br] . 2007;89:1347-1351.
Nordqvist A, Petersson C. Fractures of the body, neck, or spine of the scapula. Clin Orthop Relat Res . 1992;283:139-144.

FLOATING SHOULDER
Herscovici D, Fiennes AG, Allgöwer M, Rüedi T. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg [Br] . 1992;74:362-364.

LIMITED POSTERIOR APPROACH
Van Noort A, Van Loon CJM, Rijnberg WJ. Limited posterior approach for internal fixation of a glenoid fracture. Arch Orthop Trauma Surg . 2004;124:140-144.

ARTHROSCOPY
Bauer T, Abadie O, Hardy P. Arthroscopic treatment of glenoid fractures. Arthroscopy . 2006;22:569.

Figure 3 modified from Romero J, Schai P, Imhoff AB. Scapular neck fracture: the influence of permanent malalignment of the glenoid neck on clinical outcome. Arch Orthop Trauma Surg. 2001;121:313–6. Figure 15 modified from Mallon WJ, Brown HR, Vogler JB 3d, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop Relat Res. 1992;(277):142–54. Figure 16 modified from Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg [Am]. 1992;74:299–305. Figure 17 modified from Goss TP. Fractures of the glenoid neck. J Shoulder Elbow Surg. 1994;3:42–52. Figure 20 modified from Van Noort A, Van Loon CJM, Rijnberg WJ. Limited posterior approach for internal fixation of a glenoid fracture. Arch Orthop Trauma Surg. 2004;124:140–4.
PROCEDURE 3 Proximal Humerus Fractures

Pierre Guy



Open Reduction and Internal Fixation and Arthroplasty


Indications

GENERAL INDICATIONS

The decision to operate depends on the patient’s physiologic age/functional demands, fracture fragment displacement, and expected ability to reduce fragments and maintain fixation (as reflected by the “bone quality”).
Absolute indications: open fractures, neurovascular injuries that need exploration.

SPECIFIC INDICATIONS


PITFALLS

• Beware of posterior displacement of GT fractures not seen on standard radiograph (low threshold for computed tomography scan).
• Beware of LT fractures, which may be associated with posterior dislocation (instability, seizure disorder, alcohol withdrawal).
• Anatomic neck fractures may be missed with GT fracture-dislocation.


Controversies

• Precise determination of “number of parts” in a given fracture remains challenging; 3/4-part fractures are grouped because of similar operative treatment.
• Indications for primary arthroplasty are controversial. Arthroplasty may be decided intraoperatively if stable fixation is not possible, or pre-/intraoperatively in cases of significant articular fragment involvement: head-splitting fractures, acute/chronic fracture-dislocations.

Undisplaced (1-part) fractures are treated nonoperatively.
Displaced 2-part fractures (see Surgical Anatomy ): most are treated with open reduction and internal fixation (ORIF).
• Greater tuberosity (GT) fractures
♦ Greater than 5 mm displacement in physiologically young active individual, overhead worker/athlete
♦ Greater than 10 mm displacement in older adult
• Lesser tuberosity (LT) fractures (rare)
♦ Greater than 10 mm displacement
• Surgical neck fractures
♦ Greater than 75% translation or 10–20 mm shortening, extensive metaphyseal comminution, varus alignment in physiologically young active individual
• Anatomic neck fracture
♦ Greater than 45° angulation
♦ Usually associated with fracture-dislocation when 2-part fracture
Displaced 3/4-part fractures (see Surgical Anatomy )
• Valgus impacted fractures
♦ Young: ORIF
♦ Older sedentary: nonoperative
• Fracture-dislocations, all other 3/4-part fractures
♦ ORIF if feasible
♦ Arthroplasty when ORIF not possible (see Controversies box discussion of osteonecrosis in Postoperative Care and Expected Outcomes )

Examination/Imaging


Treatment Options

• Nonoperative treatment: predictable results are achieved with residual deficit for undisplaced fractures and some displaced fractures in the elderly treated nonoperatively.
• ORIF is favored as a first-line strategy; arthroplasty is reserved for unrepairable fractures and cases that are unstable postfixation.

General examination
• Rule out other injuries.
• Assess for fitness to undergo surgery.
• Inspection: rule out open fracture and severe hemorrhage; assess for dislocation.
• Palpation: rule out vascular or neurologic injury.
Plain radiography: shoulder trauma series
• Anteroposterior (x-ray beam tangential to glenoid/perpendicular to the plane of the scapular body; Fig. 1A ), trans-scapular lateral ( Fig. 1B ), and transaxillary ( Fig. 1C ) views will establish the diagnosis in most cases.
♦ Figure 2A–C shows radiographs of a GT fracture (Case 1).
♦ Figure 3A and 3B shows an extensively comminuted surgical neck fracture in a polytraumatized 29-year-old female (Case 2).
♦ Figure 4A–C shows an unreducible isolated surgical neck fracture in a 25-year-old female (Case 3).
♦ Figure 5A and 5B shows a proximal humeral impacted valgus fracture in a 47-year-old female presenting after a fall from standing height onto her shoulder (Case 4).
♦ Figure 6 shows a preoperative view of a proximal humerus fracture-dislocation (Case 5).
• Consider “bumped-up view” (aka “chicken wing” view) if the standard axillary view with the arm abducted is not clinically feasible (usually quite painful).
♦ To obtain an axial (axillary) view while the patient still comfortably wears a sling, the x-ray cassette is placed superior to the shoulder while the x-ray beam is centered in the axilla starting below the level of the x-ray table, aiming cephalad and anterior ( Fig. 7A–C ).
♦ This view is advantageous as the patient may still wear a sling and, in the trauma setting, may still need to remain supine.
• Additional anteroposterior views of the proximal humerus in internal ( Fig. 8A ) and external ( Fig. 8B ) rotation that show the humerus free of the overlapping adjacent scapula help quantify the initial diagnosis and assist with assessment of healing in follow-up.
♦ Figure 9 shows a displaced proximal humeral fracture ( Fig. 9A and 9B ) and its reduction ( Fig. 9C and 9D ) in a 27-year-old female after a fall onto the left shoulder while snowboarding (Case 6). Note the use of internal ( Fig. 9A ) and external ( Fig. 9B ) rotation views to define the fracture preoperatively.
Computed tomography (CT)
• Axial CT supplemented with two- and three-dimensional reconstruction is the most useful modality in fracture assessment and preoperative planning.
♦ Figure 10 shows axial ( Fig. 10A–C ) and three-dimensional reconstructed ( Fig. 10D–F ) CT images of the proximal humerus impacted valgus fracture in Case 4.
• Multiplanar imaging may be useful in identifying the displaced fragments (e.g., isolated GT fracture) and for preoperative planning.
Magnetic resonance imaging
• This may be of value in detecting associated rotator cuff tears or adjacent ligament injuries (acromioclavicular, coracoclavicular); however, it is not practical in the acute trauma setting.
• The decision to operate is based on bony injury diagnosis and patient factors.
• Soft tissue lesions (cuff tears) are sought intraoperatively and repaired as needed, or investigated at a later stage.

FIGURE 1

FIGURE 2

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

FIGURE 8

FIGURE 9

FIGURE 10

Surgical Anatomy

The proximal humerus is composed of four parts as described by Codman ( Fig. 11 ).
• Classification of proximal humerus fractures is important in surgical decision making.
• Codman described the proximal humerus and its injuries, separating them in up to four parts representing the embryologic and growth development in this region.
Figure 12 shows the osseous anatomy and muscle attachment to the proximal humerus and the surrounding neurovascular structures.
• Rotator cuff tendons: suprapinatus, infraspinatus, teres minor (to GT), subscapularis (to LT)
• Nerves: axillary nerve, brachial plexus (not shown)
• Vascular: anterior humeral circumflex artery, lateral ascending branch
Trabecular and subchondral bone distribution in the proximal humerus is critical to fixation decisions.
• Sites of increased accumulation of trabecular bone (in the “calcar” area) and subchondral density in the epiphysis reflect regions of better implant purchase.

FIGURE 11

FIGURE 12

Positioning


PEARLS

• Complete routine imaging preoperatively.
• Draping the image intensifier into the operative field makes it readily accessible.
• Positioning it from the contralateral side (if the image intensifier gantry so allows) facilitates the imaging process (see Fig. 13 ).

FIGURE 13

The beach chair or supine position may be used, independent of chosen surgical approach.
A radiolucent table facilitates intraoperative imaging, and the image intensifier’s position should also be planned as it is an important part of the procedure.
• Options for image intensifier position are on the side contralateral to the injury ( Fig. 13A and 13B ) or from proximal ( Fig. 14A and 14B ).

FIGURE 14

Portals/Exposures


PITFALLS

• Avoid excessive raising of the head in the beach chair position in the elderly (potential risk to cerebral and/or retinal perfusion).
• Plan for possible arthroplasty requiring free movement (extension) of the shoulder.


Equipment

• Always plan for arthroplasty equipment to be available.


PEARLS

• Arm abduction relieves tension from the deltoid on the lateral humerus, and facilitates drilling and implant positioning in the deltoid split approach.


PITFALLS

• Axillary nerve palpation and protection for the deltoid split can be done safely by progressively mobilizing surrounding tissues.


Controversies

• Safety of deep submuscular dissection and axillary nerve mobilization in the deltoid split approach concerns all. Recent publications describe its clinical use and delineate its boundaries for implant placement.

Deltoid split lateral approach ( Fig. 15A ; see Video 1)
• Indications
♦ Isolated fractures of the greater tuberosity or of the surgical neck
♦ 3/4-Part fractures (mainly valgus impacted)
• Incision ( Fig. 15B )
♦ The proximal incision is made from the anterolateral corner of the acromion to a maximum of 5 cm distally in line with the anteromedial deltoid raphe. The subdeltoid bursa is opened, and any hematoma evacuated ( Fig. 15C )
♦ The proximal extension separates the anterior deltoid from the anterior trapezius at the lateral clavicle.
♦ The distal incision is made at the deltoid tuberosity.
• Cuff tendons are identified and “tagged” with suture. The rotator cuff interval may be opened to improve deep fragment/joint visualization.
• Internal and external rotation allows inspection, reduction, and fixation of the tuberosities.
• If distal dissection is required for lateral plate placement, blunt finger dissection along the lateral cortex of the shaft will identify the axillary nerve (“like a piano cord”) and carefully mobilize it. This nerve may be visualized directly but is always palpated and protected by the surgeon’s finger.
• Thick deltoid/trapezius soft tissue flaps are reattached at closure.
Deltopectoral anterior approach ( Fig. 16A )
• Indications
♦ Displaced 3/4-part fractures
♦ Fracture-dislocations
♦ Planned or high-probability arthroplasty
• A classic approach is used for exposure, with some specific fracture care steps carried out for reduction and fixation.
• An incision is made from the coracoid tip to the deltoid tuberosity. The cephalic vein is usually retracted laterally. The clavipectoral fascia is incised lateral to the conjoint tendon ( Fig. 16B ).
• Any hematoma is evacuated. The biceps tendon and tuberosities (on each side of it) are identified and cuff tendons are tagged.
• The arm is abducted to open the subdeltoid space, which is developed. A Hohmann retractor is placed above the tip of the coracoid to expose it superiorly.
• Distal extension is possible by detachment of the anterior half of the distal deltoid insertion.

FIGURE 15

FIGURE 16

Proximal Humerus Fracture Repair: General Techniques


PEARLS

• The GT fragment is often retracted posteriorly.


PITFALLS

• GT fracture may be associated with anterior dislocation, and LT fracture with posterior dislocation.
• Examine the proximal humerus with image intensification under anesthesia; confirm the absence of dislocation and rule out anatomic neck fracture.


Instrumentation/Implantation

• Large-diameter (#2, #5) absorbable suture

Closed or limited open reduction may be attempted. If adequate reduction can be achieved, less rigid, percutaneous Kirschner wire (K-wire) techniques may follow.
Since the description of a less invasive deltoid split approach for plate fixation of proximal humerus fractures by Lill et al. (2004) , less rigid percutaneous K-wire techniques have lost some degree of their popularity. More rigid standard and locked plates that counter the loads applied to the different parts of the proximal humerus ( Fig. 17 ) are the most commonly used implants for fixation of proximal humeral fractures ( Fig. 18A and 18B ).
There are many implants or fixation options for the proximal humerus. A careful preoperative study of individual fragments and their deforming forces will allow the surgeon to appropriately plan definitive fixation.

FIGURE 17

FIGURE 18

Procedure: ORIF of Isolated GT and LT Fractures


PEARLS

• Place provisional fixation in the largest, thickest fragment if comminuted.


Instrumentation/Implantation

• Large-diameter (#2, #5) absorbable suture
• K-wires

STEP 1: INITIAL FRACTURE REDUCTION STEPS

A GT fracture is operated through a deltoid split approach, and an LT fracture through a deltopectoral approach.
Any hematoma is evacuated, and fragments are localized.
Large-diameter (#2, #5) absorbable sutures are placed to the tuberosity at the osteotendinous junction of the cuff tendon.
The fracture edge is débrided as a reduction reference.

STEP 2: REDUCTION AND PROVISIONAL FIXATION

Reduction and provisional fixation is accomplished with K-wires.
Reduction is controlled by use of the image intensifier.

STEP 3: DEFINITIVE FIXATION

Fixation depends on location of the fracture.
• GT—large cannulated screw over guidewire (preferred); tension band wire also acceptable.
• LT—often a thin shell, best fixed with sutures or screw and spiked washer.
Intraoperative imaging is used to confirm reduction and safe implant position, as seen in Figure 19 for Case 1.
The anterior edge of the supraspinatus tendon is sutured to the superior edge of the subscapularis to close the rotator interval ( Fig. 20A and 20B ). Serial sutures are placed and sequentially tied.
Postoperative images show the completed repair and can be used to assess healing, as seen for Case 1 ( Fig. 21A and 21B ).

FIGURE 19

FIGURE 20

FIGURE 21


PEARLS

• Purchase far (medial) cortex with cannulated screw for GT fixation (see Fig. 20 ). Beware of location of axillary nerve.
• Repair the rotator interval (suture space between adjacent rotator cuff tendons) when torn to supplement fracture repair.


PITFALLS

• Avoid leaving the head of a screw prominent (subacromial impingement).
• Assess impingement directly or fluoroscopically (see Fig. 22 ).

FIGURE 22


Instrumentation/Implantation

• Implants should counter the loads expected at the tuberosities (tension from the cuff; see Fig. 18 ).
• These are well addressed with large cannulated screw, tension wire, and/or large-diameter sutures.

Procedure: ORIF of Surgical Neck

STEP 1: INITIAL FRACTURE REDUCTION STEPS


PEARLS

• The long head of the biceps tendon may be trapped in a surgical neck fracture, explaining the inability to reduce the fracture.


PITFALLS

• In extensively comminuted cases, the more distally located proximal shaft may not be seen through the deltoid split approach.

After closed reduction has been attempted and reduction or instability are judged unacceptable, the surgeon should proceed to ORIF.
A deltopectoral or deltoid split approach may be used.
Any hematoma is evacuated, and the long head of the biceps tendon identified.
Associated tuberosity fracture must be ruled out (direct visualisation vs. image intensifier).
The shaft-to-head/neck fragment is reduced.

STEP 2: REDUCTION AND PROVISIONAL FIXATION


PEARLS

• Place provisional fixation well away from the planned implant location (bicipital groove).


PITFALLS

• The anterior cortex (at the junction of the shaft and LT) is often comminuted from the shaft driving proximally and anteriorly. Therefore, it may not be reliable as a reduction reference.


Instrumentation/Implantation

• K-wires

Provisional K-wire fixation is accomplished.
K-wires are placed away from the planned position of the lateral plate, typically in the bicipital groove from distal anterior to proximal posterior ( Fig. 22 ).

STEP 3: DEFINITIVE FIXATION


PEARLS

• Use low-profile, anatomically contoured plates (locking or standard) to avoid subacromial impingement.

A standard or a locking plate may be used, depending on implant purchase, surgeon preference, or implantation instruments.
• Figures 23 and 24 show definitive fixation of two cases of comminuted surgical neck fractures unreducible by closed means due to “buttonholing” of the proximal shaft into the biceps/coracobrachialis.
• In Case 2, minimally invasive fixation was achieved through a deltoid split approach ( Fig. 23A and 23B ).
• In Case 3, a deltopectoral approach was used to reduce and plate the fracture ( Fig. 24A–D ).
Intramedullary nails may be considered for fixation if extensive surgical neck comminution involves the shaft, or for pathologic surgical neck fractures.
Postoperative images show the completed repair. Note that internal and external rotation views can be used to assess healing, as seen for Case 2 ( Fig. 25A and 25B ) and Case 3 ( Fig. 26A and 26B ).

FIGURE 23

FIGURE 24

FIGURE 25

FIGURE 26

Procedure: ORIF of 2-Part Anatomic Neck Fractures and 3/4-Part Valgus Impacted Fractures, Fracture-Dislocations, and Other 3/4-Part Fractures


PITFALLS

• An image intensifier is useful to:
Rule out intra-articular hardware.
View the sagittal plane (flexion/extension) along with the usual anteroposterior view.


Instrumentation/Implantation

• Implants should counter the loads expected in the surgical neck region (varus/valgus bending, axial torsion). These are well addressed by plates (see Fig. 17 ).

All of these injuries can be managed through a deltopectoral approach.
Consideration may be given to a deltoid split approach for some 3/4-part fractures and for valgus impacted fractures.
Fracture-dislocations involving a displaced/dislocated anatomic neck fragment, and cases in which there is a high probability of arthroplasty (see next procedure), are best managed through the deltopectoral approach.

STEP 1: INITIAL FRACTURE REDUCTION STEPS


Controversies

• Indications for operative care are incompletely defined. Many authors are prone to recommend nonoperative treatment.
• The superiority of locking plates remains unproven.

Any fracture hematoma is evacuated, and the long head of the biceps tendon identified.
The tuberosities are mobilized and large-diameter absorbable sutures (#2, #5) are applied to the osteotendinous junction of the cuff tendon as per isolated GT/LT fracture procedure above.
The articular fragment (AF) is located, and relocated into the joint (as needed).

STEP 2: REDUCTION AND PROVISIONAL FIXATION


Controversies

• Fixation of fracture-dislocation cases with ORIF and avascular necrosis (see Controversies box discussion of osteonecrosis in Postoperative Care and Expected Outcomes ).


PEARLS

• Best purchase of suture fixation is obtained at the osteotendinous junction of the cuff tendon to the tuberosity.
• Consider opening the rotator cuff interval (to be closed later [see Fig. 21 ]) to mobilize the tuberosities and to best visualise the AF.
• The AF should be located and reduced back to its proper alignment to the glenoid, taking care to protect its inferomedial medial blood supply if still attached. The surrounding structures (brachial plexus and artery) also must be protected from injury.


PITFALLS

• Poor implant purchase in fixation of some cases.

The goal is to restore AF alignment to the medial shaft “calcar humerale” and to restore the tuberosities’ height and offset, resulting in proper alignment to the glenoid surface (valgus and retroversion).
Techniques depend on displacement of AF versus other parts.
• Valgus impacted
♦ Indirect reduction is attempted using a buttress plate applied to the lateral shaft and GT ( Fig. 27A and 27B ), loading the GT from lateral to medial, reducing it and the AF into place.
♦ In the intraoperative radiographs in Figure 28A–C , a K-wire has been placed superior to the plate to prevent plate proximal migration.
♦ In severely impacted cases in which a buttress plate will not reduce the AF, the surgeon must work between the tuberosities to elevate the AF to restore shaft/tuberosity/glenoid alignment and length alignment at the level of the calcar, then reapproximate the tuberosities to secure AF reduction.
• Varus
♦ Apply a precontoured plate to the lateral cortex.
♦ Reduce the AF and tuberosities out of varus using K-wires placed at the superior edge of the plate and into the GT/AF ( Fig. 29A and 29B ).
• Dislocated
♦ Once the AF has been retrieved from its position, the medial calcar blood supply must be protected and the AF realigned to the glenoid.
♦ AF-glenoid alignment is fixed using a fine, smooth K-wire exiting between the tuberosities to provisionally maintain articular reduction ( Fig. 30 ). The wire may be placed through the fracture line separating the tuberosities so as to not block their reduction.
The tuberosities are reapproximated and provisionally fixed to each other with sutures or K-wires, and to the AF and/or shaft with K-wires.
The proximal segment is realigned with the shaft. If a reduction plate has not already been applied, provisional K-wires are placed from the shaft to the AF/tuberosity fragment, away from the planned lateral plate location (bicipital groove is preferred) (see Figs. 22 and 30 ).
Consideration should be given to placing a provisional K-wire along the calcar to maintain AF-shaft reduction ( Fig. 31A–C ).

FIGURE 27

FIGURE 28

FIGURE 29

FIGURE 30
(COURTESY OF DR. G. KOHUT)

FIGURE 31

STEP 3: DEFINITIVE FIXATION


PEARLS

• Extend/incise the rotator cuff interval to allow tuberosity mobilization.
• Place provisional fixation well away from the planned implant location (bicipital groove).
• When realigning the AF to the glenoid, consider fixing AF-glenoid alignment with a fine, smooth K-wire exiting between tuberosities (see Fig. 30 ) and/or a provisional K-wire from the shaft along the calcar (see Fig. 32 ) to maintain articular reduction.
• Consider placing a K-wire superior to the plate and into the GT/AF to prevent proximal plate migration from distal soft tissue pressure (see Fig. 27 ).

FIGURE 32


PITFALLS

• There is a risk of displacement during radiographic confirmation of alignment with provisional fixation. Set up the image intensifier to combine shoulder range of motion and image intensifier positioning for adequate imaging.
• Remember reduction of flexion/extension at the surgical neck.

Plates are preferred to nails, percutaneous wires, or osteosutures.
A laterally applied plate and screw construct and supplemental sutures for tuberosities usually offer the desired rigidity of construct.
• Figure 32A–D shows the proximal humerus impacted valgus fracture in Case 4 treated through the deltoid split approach by buttress plate reduction and locked plate fixation.
• Figure 33A and 33B shows the displaced proximal humerus fracture in Case 6 treated with fracture reduction and fixation with a standard cloverleaf plate and screws. Note the use of internal and external rotation views to confirm reduction and safe implant position.

FIGURE 33


Instrumentation/Implantation

• Use the plate as a reduction tool for some valgus/varus cases.
• K-wire provisional fixation
• Figure 34A–C shows the proximal humerus fracture-dislocation in Case 5 treated by ORIF. The implant supports anatomic reduction and rigid fixation of the proximal segments and bridge fixation of the surgical neck section using a locking plate. The clinical results at 9 months are shown in Figure 35A–D .
Postoperative images show the completed repair. Note that internal and external rotation views can be used to assess healing, as seen for Case 4 ( Fig. 36 ), Case 5 ( Fig. 37A and 37B ), and Case 6 ( Fig. 38 ).

FIGURE 34

FIGURE 35

FIGURE 36

FIGURE 37

FIGURE 38


PITFALLS

• An image intensifier is useful to:
Rule out intra-articular hardware.
View sagittal plane (flexion/extension) reduction across the surgical neck along with the usual anteroposterior view.
Assure absence of implant impingement (dynamic fluoroscopy).


PEARLS

• Best outcomes result from anatomic reduction of tuberosities during ORIF or arthroplasty and maintenance of fixation until healing has occurred.
• Repair is best achieved with a combination of large-diameter (#2, #5) absorbable sutures and low-profile plates (± locking).
• Consider adding a ceramic bone graft substitute (calcium phosphate–based compound) to fill any metaphyseal void and add rigidity to the fixation construct.

Procedure: Arthroplasty for 3/4-Part Fracture-Dislocations


Instrumentation/Implantation

• Implants should counter the loads expected in the various parts of the proximal humerus: the tuberosities (tension), surgical neck (varus/valgus bending, axial torsion), and articular segment (compression). These are well addressed by a combination of sutures, screws, and plates.

Should fixation be unstable or not possible, arthroplasty is recommended.
Success factors related to timing of surgery (<14 days), tuberosity reduction and healing, and implant position ( Fig. 39 ) have been identified (see Rehabilitation Program in Postoperative Care and Expected Outcomes ).

FIGURE 39

STEP 1


Controversies

• The superiority of locking plates over standard implants remains unproven.

Fracture-dislocations involving a displaced/dislocated anatomic neck fragment, and cases in which there is a high probability of arthroplasty, are best managed through the deltopectoral approach.
Figure 40 shows a proximal humerus fracture-dislocation in a 65-year-old female presenting 3 days postinjury. Surgeons were unable to obtain rigid fixation when attempted due to poor implant purchase.

FIGURE 40

STEP 2


Instrumentation/Implantation

• Implants should allow proper position relative to tuberosities and shaft.
• Instrumentation should continue for retroversion (>10°, <40°).
• Neutral version may be considered post chronic-recurrent posterior dislocations.
• Tuberosities should be rigidly fixed to shaft and to implant.

During arthroplasty, avoiding cement interposition between tuberosities and assuring bony contact between tuberosities (using humeral head cancellous bone as graft) have proven successful.
Intraoperatively, an image intensifier or plain radiograph can be used to confirm arthroplasty position. For the case shown in Figure 39 , tuberosity reduction and absence of impingement were confirmed fluoroscopically ( Fig. 41A and 41B ).

FIGURE 41

Postoperative Care and Expected Outcomes

Operative and nonoperative cases benefit from a clear, progressive mobilization and strengthening rehabilitation program.
Operative cases should impart sufficient immediate rigidity to allow early pendulum range-of-motion (ROM) exercises. The same protocol is used for nonoperative cases, starting 10–14 days postinjury.

REHABILITATION PROGRAM

Phase 1: Weeks 0–3
• Pendulum (stooping) exercises
• Gentle active-assisted ROM
• Avoid external rotation for 6 weeks
• Wear sling for 2–3 weeks
Phase 2: Weeks 3–9
• If there is clinical evidence of healing and lack of radiographic fragment displacement
• Active-assisted ROM, forward elevation and abduction
• Active ROM, unassisted, at 6 weeks
• Isometric strengthening at 6 weeks
Phase 3: Weeks 10+
• If there is radiographic healing but stiffness
• Add “manual therapy” passive ROM
• Add isometric concentric and eccentric strength


PITFALLS

• Common complications: stiffness, osteonecrosis
• Less common: neurologic injury (avoided by thoughtful knowledge of local anatomy and placement of retractors).


Controversies

• Primary fixation versus primary arthroplasty due to risk of osteonecrosis
Some authors are prone to recommend primary arthroplasty for displaced proximal humerus fractures, particularly fracture-dislocations and fractures involving displacement across the anatomic neck, because of the risk of developing osteonecrosis. The overall rate of avascular necrosis (AVN) in displaced 3/4-part proximal humerus fractures approaches 35%, with a reported range of 6–75%. Despite its high occurrence, AVN is frequently asymptomatic, with 77% of patients still showing good to excellent functional results. This rate compares favorably with the 80% of cases with “acceptable” results in the primary arthroplasty literature.
The author’s preferred approach therefore involves internal fixation as a primary treatment strategy for surgical cases, with the aim of restoring the anatomic relationship between the different fracture parts through stable fixation constructs. Maintaining the proper alignment of fragments until healing predicts the best outcomes in proximal fractures cases overall, and in cases that develop osteonecrosis after the best salvage options. In fact, the functional outcome of AVN is significantly affected by malunion: malunited cases with AVN show worse function, and cases with AVN requiring an arthroplasty show a worse result if there is associated nonunion or malunion. These findings would then support ORIF if a stable, anatomic construct can be achieved.
• Stiffness prevention/management: Early ROM rehabilitation has been the accepted strategy for operative and nonoperative cases since Codman’s description of “stooping” exercises. These are progressed to more resisted exercises as healing appears. This early motion protocol is being challenged by early limited-motion pool exercises and passive support rehabilitation protocols that aim to protect the tuberosity healing, avoiding nonunion or malunion. No comparative trial has reported the superiority of one protocol over the other.

Evidence

There is little high-level evidence to guide the care of patients with proximal humerus fractures. A few large retrospectives series describing nonoperative care have defined the expected outcome with the nonoperative treatment strategy, implying that this is the course to take in the care of the elderly. Operative and nonoperative care have not been compared and reported in a clinical trial setting. Some randomized controlled trials (RCTs) have compared rehabilitation protocols, recommending early motion, while another RCT has compared arthroplasty to tension band wire fixation. The present rigid fixation strategies, particularly with the use of fixed-angle implants, have not been included in RCTs.

NONOPERATIVE CARE
Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston: Thomas Todd and Company, 1934. (Reprinted: Malamar, FL: Krieger, 1984.)
Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus: the results of nonoperative treatment. J Bone Joint Surg [Br] . 2002;84:504-508.
(Level IV evidence [retrospective large case series]) .
Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus: epidemiology and outcome in the older patient. J Bone Joint Surg [Br] . 2001;83:799-804.
(Level IV evidence [large case series]) .
Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand . 2003;74:580-585.
(Level IV evidence [large case series]) .

DELTOID SPLIT APPROACH
Lill H, Hepp P, Rose T, et al. [The angle stable locking proximal humerus plate (LPHP) for proximal humeral fractures using a small anterior-lateral deltoid-splitting approach—technique and first results]. Zentralbl Chir . 2004;129:43-48.
(Level IV evidence [case series]) .
Smith J, Berry G, Laflamme Y, et al. Percutaneous insertion of a proximal humeral locking plate: an anatomic study. Injury . 2007;38:206-211.
(anatomic study) .

ORIF RESULTS
Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg [Br] . 2004;86:848-855.
(Level IV evidence [retrospective large case series]) .

ARTHROPLASTY SUCCESS FACTORS
Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg . 2002;11:401-412.
(Level IV evidence [case series]) .
Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma . 2003;17:181-188.
(Level IV evidence [case series]) .

OSTEONECROSIS
Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg . 1998;7:586-590.
(Level IV evidence [retrospective case series]) .
Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg [Am] . 2002;84:1919-1925.
(Level IV evidence [retrospective case series]) .

Figure 41 modified from Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma. 2003;17:181–8.
PROCEDURE 4 Proximal Humerus Fractures

Gerard March, Rod Martin, Scott J. Mandel



Hemiarthroplasty Operative Technique


Indications


PITFALLS

• Contraindications to consider with hemiarthroplasty for proximal humerus fractures include:
Active soft tissue infection
Chronic osteomyelitis
Rotator cuff muscle paralysis or massive rotator cuff tear
Severe glenoid damage either from fracture or osteoarthritis for which patient would require total shoulder replacement
Patient who is unable to participate in postoperative rehabilitation program (relative contraindication)

Prosthetic replacement of the proximal humerus for fractures is reserved for situations of poor bone stock and fracture patterns that will not allow stable internal fixation or will affect viability of the humeral head.
Indications for proximal humerus replacement include:
• Four-part humeral head fractures (associated with a high rate of avascular necrosis)
• Fracture-dislocation of the glenohumeral joint in an older, low-demand patient
• Humeral head-splitting or head-shearing fracture
• Fractures of greater than 40% of the humeral head articular surface
• Three-part humeral head fractures with poor bone quality
• Anatomic neck fractures in an older, low-demand patient


Controversies

• Note that isolated deltoid muscle paralysis is not considered a contraindication to arthroplasty for proximal humerus fractures—outcomes can be “of limited goals” but satisfactory.
• While preservation of the humeral head in 3-part fractures may be the preferred method of treatment, arthroplasty will have a more positive outcome in cases with:
Significant injury to articular segment
Blood supply injury
Severe osteoporosis or other bone quality issue
• It has been recommended that a subset of patients with “valgus impacted 4-part fractures” be treated with open reduction and internal fixation.
In these injuries, the humeral head is impacted upon the humeral shaft and, while the tuberosities are fractured, they are still in close approximation to the head and shaft.
Note that in these patients the head is not dislocated or displaced laterally and some contact with the glenoid is maintained.
If lateral displacement is found, then the medial periosteal vessels that perfuse the articular segment may be ruptured and avascular necrosis is more likely to result. Hence internal fixation would not be the treatment of choice.
This subset of 4-part fractures would not be considered true 4-part fractures under the Neer classification.

Examination/Imaging

DETAILED HISTORY AND PHYSICAL


Treatment Options

• Closed reduction with or without immobilization
• Open reduction and internal nonlocking fixation
• Open reduction and internal locking fixation
• Reverse ball-and-socket arthroplasty
• Intramedullary fixation

It is important to establish any history of seizure or head injury.
A complete neurovascular examination is performed, with a focus on the rotator cuff muscles.
• It must be remembered that the axillary nerve and artery are at a high risk for injury.
♦ Injuries to the axillary artery are to be considered limb threatening and must be dealt with as an emergency.
♦ Evaluation under emergent arteriography with possible vascular surgery consultation is necessary.
• Follow-up of any neurologic deficit should be completed with electromyographic analysis at 4–6 weeks. It should be noted, though, that neurologic evaluation should not delay definitive management of the fracture.

IMAGING STUDIES

Trauma series radiographs of the injured shoulder are obtained. These include:
• True anteroposterior view of the scapula, 30–40° oblique to the coronal plane of the body ( Fig. 1 )
• Trans-scapular lateral or scapular Y view
• Axillary view, taken with the arm abducted 20–30° and the x-ray tube placed in the axilla with the plate above the shoulder
Computed tomography is useful if the radiographs are not satisfactory for determining location of fracture lines, fracture displacement, or the quality of the articular surface. Figure 2 shows a three-dimensional reconstruction of the fracture shown in Figure 1 .
Note the importance of imaging of the contralateral shoulder. This is helpful in determining the appropriate length, which is important for prosthesis placement.

FIGURE 1

FIGURE 2

Surgical Anatomy

The patient’s age or medical condition can affect the quality of the bone and the vascular supply to the humeral head ( Fig. 3 ). In this setting internal fixation may become less attractive and prosthetic arthroplasty may be the preferred option.
• The arcuate artery, a continuation of the ascending branch of the anterior humeral circumflex artery, enters the humerus at the area of the intertubercular groove, and its branches supply both the greater and the lesser tuberosities.
• A smaller contribution to the blood supply of the humeral head comes from the posterior humeral circumflex arteries.

FIGURE 3

Positioning


PEARLS

• A sterile, padded Mayo stand can help with arm abduction; it lessens tension on the deltoid, making it easier to place sutures around/through the greater tuberosity posteriorly.


PITFALLS

• Full mobility of shoulder must be provided, especially in extension, to deliver the humeral shaft forward into the wound to clean the canal and insert cement.

The overall positioning goal is to have global access to the injured shoulder.
The involved shoulder should be elevated from the table and properly supported.
Commonly a table in the modified beach chair position is used that has a cutaway section at the shoulder allowing for greater access to the affected shoulder posteriorly ( Fig. 4A and 4B ).
The patient should be sitting at an approximate angle of 45°.
The head is secured in a neutral position.
The area is appropriately prepped and draped from the midclavicle to below the axilla. The arm is draped free, allowing for full movement throughout the procedure.

FIGURE 4

Portals/Exposures


Equipment

• Surgical table allowing for a modified beach chair position
• Positioning holder for the arm for hands-free positioning (optional)
• Padded Mayo stand

All 2-part, most 3-part, and some 4-part acute proximal humerus fractures are well treated by closed reduction as well as by open reduction and internal fixation techniques.
A long deltopectoral approach is used for a hemiarthroplasty.

INCISION

The incision starts just inferior to the clavicle ( Fig. 5A and 5B ).
It extends over the coracoid process, and ends laterally at the humeral shaft.
The incision may be extended to the clavicle or more distally along the humerus as needed.

FIGURE 5

DISSECTION

The cephalic vein is immediately identified in the deltopectoral muscular interval ( Fig. 6A and 6B ).
• Usually a fat stripe can be found on top of the vein and is a useful landmark to help locate it.
• Retraction of the cephalic vein is usually lateral.
Identification of the coracoid and its originating muscles (conjoined tendon) will define the medial limits of dissection.
• A broad retractor may be placed under the conjoined tendon and muscles in order to protect the medial neurovascular structures ( Fig. 7A and 7B ).
• A self-retaining retractor similar to a Charnley (Hawkins-Bell) retractor may be used.
The lateral limit of dissection is defined by placing a second broad retractor under the deltoid.
The glenohumeral joint can be easily identified by finding the long head of the biceps distally and following it proximally back to the superior aspect of the glenoid.
• Note that some surgeons prefer to routinely sacrifice the biceps during an arthroplasty procedure in order to remove it as a possible source of postoperative pain. However, this is not our preferred method.

FIGURE 6

FIGURE 7

FRACTURE EXPOSURE

Generally fracture hematoma needs to be identified and gently removed.
Large bone fragments should be retained as they may be important in ultimately determining the appropriate prosthetic height.
Identification of fracture fragments is usually dependent upon their position relative to the long head of the biceps.
The rotator interval can be breached at the area of the bicipital groove. Typically the trauma of the fracture has already separated this area.
The split in the rotator cuff at the bicipital groove can be carried proximally in the rotator interval between the supraspinatus and subscapularis to access the head fragment if impacted.
• The supraspinatus attaches to the greater tuberosity.
• The subscapularis attaches to the lesser tuberosity.
The humeral head normally lies between the tuberosities and is removed and used for sizing of the prosthetic head ( Fig. 8A and 8B ).
• It is important to evaluate the head for any soft tissue attachment prior to removing it: robust soft tissue attachment portends head viability and may be an indication for fixation rather than replacement.
• The humeral head may be used as a source of bone graft.
• If the humeral head fragment has been displaced laterally, it is possible to remove the fragment without disturbing the rotator interval, the greater tuberosity, or the lesser tuberosity fragments.
The biceps tendon should be preserved and tagged.
The tuberosity fragments are then mobilized and tagged with a heavy nonabsorbable suture such as #5 Ethibond suture or Mersilene tape ( Fig. 9A and 9B ). Adequate mobilization is often underestimated and is needed for ultimate fixation and repair in proper positioning.
The patient should now be evaluated for subacromial impingement or the presence of a subacromial spur, which can be removed.
The rotator cuff should also be examined for any tears and tagged for repair after prosthesis insertion.

FIGURE 8

FIGURE 9


Instrumentation

• Self-retaining retractors
• Large blunt hand-held retractors (Richardson)


PEARLS

• While retraction of the cephalic vein is commonly lateral, it is often suggested to retract the vein in “the direction in which it wants to go,” be it medially or laterally. Anatomically there are fewer tributary veins medially versus laterally, hence retraction laterally would decrease the amount of trauma and bleeding in the venous system.
• Large Gelpi retractors are used to aid with deep exposure. The surgeon must be careful with placement if they have sharp tips.
• Note that dissection should not be undertaken medial to the coracoid.
• If greater exposure is needed,
The proximal third of the pectoralis major insertion upon the humerus can be detached for greater access to the shoulder. If the pectoralis insertion is released, it should be tagged or marked for proper repair and reattachment at the end of the procedure. In this case one should avoid the release of the deltoid origin on the clavicle.
The leading edge of the coracoacromial ligament may be resected to improve exposure of the rotator cuff muscles. If the ultimate structure of the coracoacromial ligament is compromised, shoulder instability may be problematic.
• Identification of the long head of the biceps will also aid with the determination of the greater and lesser humeral tuberosities (see Fig. 7B ).
The lesser tuberosity fragment is typically found medial to the long head of the biceps.
The greater tuberosity fragment is typically found lateral to the long head of the biceps.
• Whenever possible, the periosteal attachments between the tuberosities and the diaphysis are preserved to best maintain blood supply.


PITFALLS

• One should note that dissection of the deltoid origin off of the clavicle and acromion is not necessary and may ultimately decrease functional outcome of either open reduction and internal fixation or arthroplasty for proximal humerus fractures. If greater exposure is needed, it is recommended that the deltoid insertion be partially elevated.
• If there has been an anterior dislocation of the humeral head fragment into the area inferior to the coracoid and deep to the muscular attachments, dissection should be undertaken carefully as adhesions are commonly present, expecially if there has been a delay in definitive management.
Sharp fracture edges can present a risk to nearby neurovascular structures in this case.
Blind dissection could be disastrous. Methodical blunt dissection from lateral to medial is preferred.
• If there has been a posterior dislocation of the humeral head fragment, the humeral shaft and tuberosity fragments are gently retracted laterally, allowing access to the posterior joint capsule. If adhesions and scarring have occurred in this situation, the humeral head fragment may need to be morselized in order to facilitate removal. Alternatively, a small posterior approach can be made to remove the native humeral head.

Procedure

STEP 1: SHAFT PREPARATION

One needs to carefully examine the proximal aspect of the humeral shaft to ensure that a nondisplaced fracture is not present.
• If a shaft fracture is found, it is crucial to secure the shaft before prosthesis placement.
• Typically, successful placement of the humeral prosthesis component supplements the shaft fixation and yields a solidly fixed construct.
The proximal humeral shaft is delivered through the surgical wound via extension and external rotation.
The medullary canal is prepared with rasps and reamers gently as bone quality within the typical patient population is highly osteoporotic ( Fig. 10 ).
One may also place drill holes in the proximal humeral shaft in order to allow tuberosity fixation with heavy nonabsorbable sutures.
• The drill holes should be placed in the area of the greater and lesser tuberosities.

FIGURE 10

STEP 2: PROSTHESIS PLACEMENT—HEAD SIZE


PEARLS

• A Raytec sponge loosely wrapped about the stem will allow the stem to be wedged in large endosteal resorbed canals so a trial reduction can be performed.
• Ideally, the top of the humeral head should interact concentrically with the glenoid surface and extend 4–6 mm above the top of the greater tuberosity.


PITFALLS

• Note that, due to the nature of the fracture, resting the humeral head prosthesis directly on the proximal humeral shaft will usually lead to overall humeral height loss and, more importantly, an inability to appropriately reattach the greater and lesser tuberosities.

Head size of the prosthesis may be gauged by taking a radiograph of the contralateral shoulder or by using the humeral head if it was removed intact.
• It is important, as with other arthroplasty operations, not to “overstuff” the replaced joint with a head that is too large to allow for normal function.

STEP 3: PROSTHESIS PLACEMENT—HEIGHT

Prosthesis height can be determined by preoperative templating against radiographs of the contralateral limb.
• Generally speaking, placing the prosthesis against the remaining humerus will lead to dysfunction through effective deltoid shortening.
• Intraoperative observation of soft tissue tension, such as the long head of the biceps or deltoid muscle, can also be used as a guide.
In most patients, the humeral head should be elevated above the proximal shaft to a position that will allow space for both the greater and the lesser tuberosities to be reattached.
• The degree of elevation can be simulated by using the spacers supplied with the prosthesis system.
• The spacers will support the trial prosthesis to the appropriate height, allowing for trial reduction of the tuberosities and estimation of soft tissue tension.
Ultimately, the humeral head should move inferiorly on the glenoid.
• The superior edge of the humeral head should not fall distal to the midpoint of the glenoid.
• A new method describes using the upper border of the pectoralis major insertion (PMI) as a reproducible reference for humeral head height: the top of the humeral head should be 5 to 6 cm above the upper border of the PMI.


Instrumentation/Implantation

• Fracture jig to help determine head height and retroversion (optional)

STEP 4: PROSTHESIS PLACEMENT—RETROVERSION


PEARLS

• If there has been a posterior fracture-dislocation, it is recommended that the humeral retroversion be decreased by 5–10° (i.e., 20–25°).
• Similarly, if there has been an anterior fracture-dislocation, it is recommended that the humeral retroversion be increased by 5–10° (i.e., 35–45°).

Retroversion can be correctly determined by aligning the lateral fin of the prosthesis to the area of the bicipital groove.
• Note that a large portion of the bicipital groove can be distorted by the fracture itself; often the most distal aspect of the groove can be identified, however.
Additionally, appropriate rotational orientation can be determined via version rods that are attached to the humeral insertion tool.
• With the trial prosthesis head reduced to the glenoid, these rods typically allow the neutral forearm with the elbow flexed at 90° to be referenced to a retroversion arc between 20° and 40°.
• Having the forearm bisect these rods aims for the ideal retroversion measurement of 30°.
• Less retroversion (i.e., 20°) will allow for easier reduction of the greater tuberosity to the prosthesis, and thus less stress on the repair.
The reduced prosthesis should be stable through a range of 40–50° of external and internal rotation.

STEP 5: CEMENTING THE PROSTHESIS


Controversies

• Generally 30–40° of retroversion is considered appropriate. Less retroversion may make tuberosity reduction easier and may be indicated for those fractures with associated posterior dislocation.


PEARLS

• Perform a trial reduction of the tuberosities and confirm head height before cementing.
• Always cement the humeral component. Uncemented prostheses are at increased risk of aseptic loosening.
• It is important to ensure that the nonabsorbable sutures for tuberosity attachment are passed through the predrilled holes in the proximal shaft prior to cementing.
• The use of an offset head can relieve tension on the rotator cuff if a patient’s anatomy is such that leads to an eccentrically placed stem. Offset is useful because the center of the shaft is usually lateral and anterior to the center of the humeral head.


PITFALLS

• Failure to control tuberosities or ensure that the joint will reduce before cementing can result in failure of repair.
• Malposition of the prosthesis may involve abnormal version or incorrect height—either too proud or too inferior. Malposition is sometimes difficult to avoid since many of the reference points of palacement, such as the bicipital groove, are destroyed in the injury process.
Note that, with the elbow bent at 90° and the arm in neutral at 0° of internal or external rotation, the implanted humeral head should face directly toward the patient’s glenoid fossa.
If the prosthesis is too proud, it can lead to impingement against the acromion or the superior glenoid.
If the prosthesis is too inferior, the deltoid muscle may be dysfunctional due to abnormal decreased tension, leading to an inability to laterally elevate the arm. Additionally, the greater tuberosity can become relatively proud and can also lead to impingement on the acromion.

Once the appropriate measurements of head size, height, and retroversion are complete, the selected prosthesis can be cemented in place ( Fig. 11 ).
In most situations there is not sufficient bone stock distally or support proximally to allow a press-fit, and cement fixation is therefore necessary.
• Applying partially set cement to the proximal portion of the component while leaving the distal stem cement-free should keep cement that might otherwise compromise healing out of the fracture site.
• The prosthesis should extend at least two cortical diameters distal to the fracture.
• A cable plate or biologic strut graft may also be a consideration for fractures that extend distally in the shaft.
Note that the worst outcomes are associated with the combination of a prosthesis that is too proud and too retroverted, with a greater tuberosity that was placed too low.
While the cement cures, it is important to stabilize and support both the humeral shaft and the prosthesis both axially and rotationally.

FIGURE 11

STEP 6: TUBEROSITY REPAIR


Instrumentation/Implantation

• Cement instrumentation (vacuum mixing equipment, antibiotic cement)


PEARLS

• Fixation of the tuberosities can be supplemented with cancellous bone graft taken from the excised humeral head or allograft/biologic graft substitutes.


PITFALLS

• Tuberosity migration, resorption, and failure of proper reduction is the most common reason for poor functional outcome.

Reconstruction of the tuberosities has been increasingly recognized as the crucial influence on functional outcome.
The modular design of most modern hemiarthroplasties allows for improved tensioning of the soft tissue and repair of the tuberosities.
Tuberosities must be attached both to the prosthetic fin and to the shaft of the proximal humeral bone.
One should use the nonabsorbable sutures that have been previously placed in the tuberosity fragments to pull the fragments forward into the operative zone ( Fig. 12 ; see also Fig. 9A and 9B ).
Tuberosities are fixed under tension and are typically repaired with either stainless steel wire or heavy suture such as #5 Ethibond. Alternatively, #5 Mersilene tape can be used (2-0 nonabsorbable suture is then used to secure knots in the Mersilene so it will not unravel) ( Fig. 13A and 13B ).
• The greater tuberosity is usually fixed first using three to four heavy nonabsorbable sutures.
• The lesser tuberosity is fixed next with two heavy nonabsorbable sutures.
Healing of the tuberosities can be supplemented by bone graft to enhance healing to the shaft.
Once the tuberosities are fixed, the arm should be supported in a slightly flexed and abducted position.
The biceps tendon should now be repositioned within the bicipital groove that has been reconstituted with the fixed tuberosities.
The rotator interval that was opened in the initial dissection is now closed above the biceps tendon, and any rotator cuff tears repaired. The stability of the repair is then tested by gentle range of motion with direct visualization.

FIGURE 12

FIGURE 13

STEP 7: CLOSURE

If taken down in the initial dissection, the insertion of the pectoralis muscle is now repaired.
The wound is then closed in layers, moving from the deltopectoral interval to the subcutaneous tissue, and finally skin closure.
If a suction drain is to be used, it should exit laterally in the proximal deltoid to avoid injury to the axillary nerve.
• Drains should not be left in for more than 48 hours as risk of infection increases greatly.

Postoperative Care and Expected Outcomes

POSTOPERATIVE CARE

Shoulder mobility is key to optimal function.
Postoperative radiographs should be taken to confirm correct positioning of the tuberosities.
• Additional radiographs before discharge will confirm that tuberosity displacement has not occurred with the commencement of in-hospital passive range-of-motion exercises.
Shoulder rehabilitation focuses on the following protocol:
• Early passive range of motion is instituted until bone stability is achieved.
♦ The limits of early range of motion are generally decided by intraoperative assessment of stability.
♦ Generally, gravity-assisted pendulum exercises progress to passive range of motion in forward flexion and supine external rotation.
♦ Elbow, wrist, and hand motion are strongly encouraged throughout the rehabilitation experience.
• Assisted strength-training exercises typically start at 6 weeks postoperatively with radiographic and clinical evidence of healing tuberosities.
♦ Strength training starts with isometric exercises and progresses to gentle resistance.
♦ Patient exercises are continued daily for up to 3 months as continued healing is documented with both radiographic and clinical follow-up.
♦ Regular activities of daily living are encouraged.
• Finally, a continuous intense stretching and strengthening program will maximize a patient’s function and ultimate outcome.
♦ Progressive resistance exercises utilizing Therabands and/or light weights are introduced along with an aggressive range-of-motion stretching program.
♦ Maximum return of function may take from 12 to 24 months.

EXPECTED OUTCOMES

Expected outcomes are reported to be a function of the stability of tuberosity repair, protection of tuberosity reduction in the immediate postoperative period, and long-term physiotherapy.
It has been reported that the humeral offset, or distance from the geometric center of the humeral head to the lateral edge of the greater tuberosity, has a direct relationship to the clinical outcome of shoulder hemiarthroplasties.
• The degree of humeral offset seems to be related to the range of abduction obtained through the glenohumeral joint.
• Humeral offset cannot be so great, however, as to place the soft tissue envelope under tension and lead to stiffness or repair failure, and generalized reduced motion.
• The most common complaint of an unsatisfactory outcome is related to weakness and an inability to raise the arm above the horizontal level.
Patient characteristics that were associated with poor outcome included advanced age, presence of preoperative neurologic deficit, alcohol consumption, and smoking status.
Factors that become important in predicting clinical outcome at the 6-week follow-up include radiographic evidence of eccentric placement of the prosthesis or displacement of either tuberosity.
• It should be noted that, with follow-up radiographs, a disappearing greater tuberosity may be due to posterior migration as opposed to osteolysis.
• Computed tomography is helpful to evaluate this, as bone may not be obvious behind the prosthesis if it is medially displaced.


PEARLS

• The goal before discharge has been quoted as 130° of forward elevation and 30° of external rotation. A more realistic goal is return to light activities of daily living (e.g., self-care and feeding).
• If one wishes to use a sling immobilizer in the immediate postoperative period, it is recommended to keep the patient in a neutral position as opposed to internal rotation. This will limit the strain on the greater tuberosity repair.
• If the patient has sudden loss of range of motion in the postoperative period, one should consider an acute rotator cuff tear or tuberosity avulsion. Note that operative revision has only a limited chance of a positive outcome in patients with gradual loss of rotator cuff function and possible tuberosity resorption.


PITFALLS

• Pain relief has been a reliable outcome (73–97%); however, function restoration has been more variable (average 38–68/100 Constant score).


Complications

• The most common complications postoperatively include tuberosity displacement, prosthesis problems, stiffness, and infection.
• Tuberosity displacement
Tuberosity displacement occurs more commonly in older patients with osteoporotic bone, and the greater tuberosity is at greater risk for displacement compared to the lesser tuberosity. Greater tuberosity displacement superiorly can actually lead to a mechanical block to shoulder motion in the subacromial space.
If migration or total displacement of the greater tuberosity occurs early, consideration should be given to early surgical repair.
• Prosthetic loosening
Due to the typical patient population, the bone quality of the proximal humerus is usually osteopenic and hence prosthetic loosening is a recognized complication.
With loosening, the prosthesis can lose all rotational stability and the amount of retroversion can change. It is a recognized complication that glenoid damage can occur secondary to prosthesis loosening and subsequent rotational instability.
All patients presenting with loose arthroplasty components should be worked up for the presence of infection.
• Postoperative stiffness
Postoperative stiffness is a common complication—most patients will lose some degree of motion.
Postoperative stiffness is most commonly due to an inability or lack of patient compliance with the postoperative rehabilitation program, or scarring.
• Infection is an uncommon complication, but unfortunately outcomes with an infected arthroplasty are almost universally unsatisfactory.

Evidence

Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg . 2002;11:401-412.
Moeckel BH, Dines DM, Warren RF, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg [Am] . 1992;74:884-889.
Plausinis D, Kwon YW, Zuckerman JD. Complications of humeral head replacement for proximal humeral fractures. Instr Course Lect . 2005;54:371-380.
Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg [Am] . 2003;85:1215-1223.
Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res . 1983;179:116-128.
Torrens C, Corrales M, Melendes E, Solano A, Rodriguez-Baeza A, Caceles E. The pectoralis major tendon as a reference for restoring humeral length and retroversion with hemiarthroplasty for fracture. J Shoulder Elbow Surg . 2008;17:947-950.
PROCEDURE 5 Humeral Shaft Fractures

Chad P. Coles, Robert G. McCormack



Open Reduction and Internal Fixation and Intramedullary Nailing


Indications

INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION (ORIF)


PITFALLS

• Compromised soft tissue envelope (burns, abrasions, etc.)
• Occult proximal or distal fracture extension
• Periprosthetic fractures involving prior elbow or shoulder arthroplasty
• Osteoporotic bone


Controversies

• A primary radial nerve palsy can be treated expectantly, and in isolation is not an indication for surgery. Even a secondary nerve palsy, after reduction and splinting, is not considered an absolute indication for surgery by many surgeons.
• Randomized trials have consistently shown that, for routine humeral shaft fractures, ORIF with plate fixation has superior results compared to IM nailing. The main reason for the difference is the higher incidence of postoperative pain and functional limitations, as well as increased rates of reoperation and fracture nonunion with humeral nails. ORIF remains the “gold standard” in the treatment of diaphyseal fractures of the humerus.

Failure of nonoperative treatment
• Malreduction (>3 cm shortening, 30° angulation or rotation)
• Nonunion
Polytrauma
Open fracture (type II or greater)
Ipsilateral upper extremity fracture
• Floating elbow or shoulder
• Associated intra-articular fracture
Vascular injury
Pathologic fracture
Bilateral humeral fractures
Neurologic indications
• Brachial plexus injury
• Parkinson’s disease
• Head injury
Relative indications
• Segmental fracture
• Transverse fracture
• Obesity
• Secondary radial nerve deficit

INDICATIONS FOR HUMERAL INTRAMEDULLARY (IM) NAILING

Pathologic fractures
Segmental fractures
Some complex fractures

Examination/Imaging

Examination
• Initial assessment and resuscitation of the trauma patient by Advanced Trauma Life Support® or similar protocol
• History and physical examination, including prior injuries or surgery involving the injured extremity
• Vascular examination, including brachial, radial, and ulnar pulses and capillary refill
• Neurologic examination and documentation of motor and sensory function of the axillary, musculocutaneous, median, ulnar, and in particular radial nerves
• Examination of hand, wrist, elbow, and shoulder to exclude associated injury
Imaging
• Plain radiographs, including anteroposterior (AP) ( Fig. 1A ) and lateral ( Fig. 1B ) views of the humerus, are the mainstay of diagnosis and decision making. These should include the elbow and shoulder joints, as well as any other suspected ipsilateral injuries detected on physical examination.
• A full-length radiograph may be helpful in planning for complex injury patterns.
• More advanced imaging with computed tomography or magnetic resonance imaging is rarely, if ever, required.

FIGURE 1


Treatment Options

• Fractures of the midshaft or more proximal humerus are best addressed through an anterolateral approach. This allows excellent proximal access, including fixation of proximal humerus fractures, but has limited distal access approaching the antecubital fossa.
• Fractures distal to the midshaft of the humerus are best addressed through a posterior approach. This allows excellent distal exposure, from the elbow joint distally to the surgical neck of the humerus, with proximal dissection limited by the crossing of the axillary nerve.
• Alternatively, a lateral approach may be used for distal fractures, with the advantage of supine positioning.
• Less frequently, a medial approach may be appropriate when there is an associated vascular injury that requires surgery or when the soft tissue envelope precludes the other approaches (e.g., burn patient). It is also advocated by some for the morbidly obese patient.

Surgical Anatomy


PEARLS

• Anterolateral approach
The cephalic vein serves as an anatomic landmark to the deltopectoral interval proximally.
Adequate visualization and mobilization of the radial nerve will result in a lower risk of nerve injury than blind retraction and potential stretching.
Proper identification of the radial nerve, and certainty that the nerve is not entrapped in the fracture site or beneath the plate, will avoid the need to re-explore the nerve in the event of postoperative nerve palsy.
• Posterior approach
The lateral brachial cutaneous nerve assists in locating the radial nerve proper.
Adequate visualization and mobilization of the radial nerve is mandatory to ensure the nerve is not entrapped in the fracture site or beneath the plate, to avoid the need to re-explore the nerve in the event of postoperative nerve palsy. Careful but thorough mobilization will result in a lower incidence of nerve injury than blind retraction and potential stretching.
Careful documentation in the dictated operative notes of the location of the crossing radial nerve in relation to the number of holes in the plate will assist in localization of the nerve in the event that revision surgery is required in the future.
• Lateral approach
Identify the radial nerve distally, at the elbow, between the brachioradialis and brachialis.
• Medial approach
Mobilize the ulnar nerve off the triceps to allow anterior retraction.

Anterolateral approach ( Fig. 2A )
• The cephalic vein is a useful landmark to the interval between the deltoid (axillary innervation) and pectoralis major (pectoral nerve innervation) proximally.
• The musculocutaneous nerve runs along the undersurface of the biceps and should be identified and retracted medially with the biceps muscle (musculocutaneous innervation).
• The radial nerve pierces the intermuscular septum, entering the anterior arm approximately 12 cm proximal to the lateral epicondyle, and should be identified in the interval between the brachioradialis and brachialis.
• The brachialis has dual innervation from the radial and musculocutaneous nerves.
Posterior approach ( Fig. 2B )
• The radial nerve crosses the posterior humerus obliquely in the spiral groove, from approximately 20 cm proximal to the medial epicondyle to 12 cm proximal to the lateral epicondyle, and then pierces the intermuscular septum, entering the anterior arm.
• The lateral brachial cutaneous nerve is a useful landmark in identifying the radial nerve.
• Reflecting the entire triceps muscle (radial innervation) off the lateral intermuscular septum and retracting it medially exposes the posterior surface of the humerus from the lateral condyle distally to the axillary nerve proximally.
Lateral approach ( Fig. 2C )
• The humeral shaft can be exposed laterally between the biceps and triceps muscles.
• The radial nerve should be identified in the interval between the brachioradialis and brachialis.
Medial approach ( Fig. 2D )
• The medial approach is within an intraneural plane, with the ulnar nerve posterior to the intermuscular septum, and the median nerve and brachial artery located anteriorly.
• The ulnar nerve is tethered to the triceps.

FIGURE 2

Positioning

FOR ORIF


PEARLS

• Anterolateral approach
Ensure the patient is positioned far enough laterally on the operating table to allow imaging of the humerus through a radiolucent armboard.
Freely drape the arm with exposure to the elbow and shoulder to allow extensile exposure, if needed.
• Posterior approach
Prone positioning requires a secure airway, neutral position of the neck, and adequate eye protection.
For lateral positioning, consider the use of a chest (axillary) roll to avoid brachial plexus compression ( Fig. 6 ), and pad pressure points appropriately.
Ensure that patient positioning allows adequate imaging before sterile draping.
Freely drape the arm with exposure to the elbow and shoulder to allow extensile exposure, if needed.

FIGURE 6

Anterolateral, lateral, and medial approaches
• The patient is positioned supine, near the edge of the operating table, with the arm on a radiolucent armboard ( Fig. 3 ).
• A fluoroscopic imager can be brought in from the head of the table to provide AP and lateral images intraoperatively.
Posterior approach
• The patient can be positioned prone ( Fig. 4A ), or preferably in the lateral position, with the arm draped over a radiolucent bolster ( Fig. 4B ).
• A fluoroscopic imager positioned at the head of the table can provide AP and lateral images intraoperatively ( Fig. 5A and 5B ).
• For lateral positioning, consider use of a chest (axillary) roll to avoid brachial plexus compression ( Fig. 6 ).

FIGURE 3

FIGURE 4

FIGURE 5

FOR IM NAILING

Retrograde IM nailing
• The patient is positioned lateral or prone.
• A fluoroscopic imager can be brought in from the head of the table.
Antegrade IM nailing
• The patient is positioned supine, or in the beach chair position with a radiolucent armboard.
• A fluoroscopic imager can be brought in from the head of the table or the contralateral side.

Portals/Exposures


PITFALLS

• Anterolateral, lateral, or medial approach
With the patient’s head near the edge of the surgical table, inadequate stabilization of the head may result in dangerous, and easily unrecognized, change in position under the surgical drapes!
• Anterolateral approach
Distal exposure is difficult as one approaches the antecubital fossa. This limits the use of this exposure for more distal fracture patterns.
Failure to identify the radial nerve may result in iatrogenic injury.


Equipment

• Anterolateral, lateral, or medial approach
A radiolucent board, extending from beneath the mattress and padded with blankets, provides an excellent working platform while allowing intraoperative imaging.

Anterolateral approach
• An appropriately sized incision is made along a line drawn from just distal to the coracoid process, extending along the lateral edge of the biceps, toward the lateral side of the biceps tendon at the elbow ( Fig. 7 ).
• Proximally, the cephalic vein and deltopectoral interval are identified, exposing the proximal aspect of the humeral shaft ( Fig. 8 ).
♦ The anterior portion of the deltoid insertion may need to be reflected subperiosteally.
♦ The tendon of the long head of the biceps must be protected. The biceps is reflected medially, and the musculocutaneous nerve, running in the interval between the biceps and brachialis, must be identified and protected as it is retracted medially with the biceps.
• Distally, the radial nerve is identified as it enters the anterior arm between the brachoradialis and brachialis to avoid iatrogenic injury. The brachialis is then split longitudinally, from proximal to distal, in line with the humerus, exposing the midportion of the humeral shaft ( Fig. 9A and 9B ).
Posterior approach
• We prefer the modified posterior approach as described by Gerwin et al. (1996) .
• A midline posterior skin incision is used ( Fig. 10 ). A full-thickness lateral skin flap is raised off the posterior triceps ( Fig. 11 ).

FIGURE 7

FIGURE 8

FIGURE 9

FIGURE 10

FIGURE 11


PITFALLS

• Posterior approach
In the prone position, dislodgement of the endotracheal tube and loss of airway is always a possibility. If this occurs the patient must emergently be returned to the supine position for airway management!
Proximal extension is limited by the crossing of the axillary nerve, precluding the use of this exposure in fractures extending to the proximal humerus.
• The lateral brachial cutaneous nerve (see Fig. 11 ) is identified, protected, and followed proximally to identify the radial nerve proper ( Fig. 12 ).
• The triceps muscle is elevated off the lateral intermuscular septum and reflected medially, and the radial nerve is carefully mobilized and protected with a Penrose drain or Vessiloop ( Fig. 13A and 13B ).
• If necessary, proximal dissection may be carried between the triceps and deltoid. The proximal limit of this exposure is the crossing axillary nerve at the level of the surgical neck.

FIGURE 12

FIGURE 13


Equipment

• Posterior approach
For prone positioning, a padded radiolucent board is used.
In the lateral position, either a beanbag or hip arthroplasty positioning frame is used to maintain position. A padded bolster is used to support the operative arm.


Controversies

• While some prefer the prone position for the posterior approach, lateral positioning is likely safer from an airway and positioning perspective. It is also preferred by anesthesiologists in the potentially unstable multiple-trauma patient.
• Posterior approach
A triceps-splitting approach is preferred by some surgeons, but proximal exposure is more difficult with the crossing of the radial nerve, and the extensive splitting traumatizes the triceps muscle.
Lateral approach
• A midlateral incision is made, extending to the lateral epicondyle.


PITFALLS

• Medial approach
Careful dissection posterior to the vascular structures is the key to the exposure.
• The radial nerve is identified in the interval between the brachialis and brachioradialis. The brachioradialis is detached along the lateral humerus and reflected anteriorly with the radial nerve. This allows distal exposure to the level of the capitellum for fixation of distal fractures with a laterally applied implant.
• Proximal dissection is between the biceps and triceps, along the intermuscular septum, exposing the lateral humerus.
Medial approach
• A longitudinal medial incision is used from the medial epicondyle extending proximally.
• Careful dissection is performed anterior to the intermuscular septum, in the interval between the ulnar nerve posteriorly and the median nerve and brachial artery anteriorly.
• The ulnar nerve is tethered to the triceps and needs to be mobilized.

Procedure: Open Reduction and Internal Fixation

STEP 1


PEARLS

• Use pointed reduction forceps to avoid the soft tissue stripping, or crushing, associated with larger fracture clamps.
• Temporary Kirschner wires may assist in maintaining reduction.
• Smaller lag screws may be placed in spiral, or more comminuted, fractures prior to neutralization with a plate.

Minimize soft tissue stripping at the fracture site with extra-periosteal exposure and the least amount of muscle elevation possible.
Reduce the fracture and stabilize it with pointed reduction clamps or temporary Kirschner wires, depending on fracture configuration ( Fig. 14 ).
Transverse fracture patterns may require clamping of fracture segments directly to the plate.

FIGURE 14

STEP 2


PITFALLS

• Excessive soft tissue stripping may lead to delayed union or nonunion.


Controversies

• The use of narrow plates with holes in a straight line has been associated with longitudinal splitting of the humerus, due to the stress riser of the linear perforations. Broad plates, with offset holes, minimize this risk but are not well suited to the small dimensions of many humeri. The use of longer narrow plates, without filling every hole, or screws inserted at differing angles, should help avoid this devastating complication.
• Locked plates may be of benefit in osteoportic bone, for very distal or proximal fractures with limited points of fixation, or in revision or nonunion situations. They are rarely required for typical humeral shaft fractures, and given the significant cost difference, use should be carefully considered and justified. Improperly applied locked implants may lead to nonunion if proper compression is not achieved at the fracture site.

Select an appropriate-length plate. Longer implants distribute stress over a larger area, and provide stronger fixation.
The number of cortices of screw purchase is not as important as the distribution of screws along the length of the plate, with points of fixation close to the fracture, and at the far end of the plate. As a minimum, six cortices of fixation should be achieved on each side of the fracture.

STEP 3


PEARLS

• Longer plates provide stronger fixation.
• Not every screw hole needs to be filled, but rather a good spread of screws is desired.
• A minimum of six cortices of fixation on each side is recommended.


PITFALLS

• Shorter plates may not provide adequate stability, and may not extend beyond areas of subtle fracture lines and comminution, leading to loss of fixation.


Instrumentation/Implantation

• Conventional large fragment plates and screws are typically employed. Either a broad plate with staggered holes or a narrow plate with linear holes is used, based on the size of the bone.
• Occasionally, in the setting of significant osteoporosis or short fixation segments, the use of locking plates may be appropriate. These are not a substitute for good fracture reduction and fixation technique.

Contour the plate to fit the bone. This is critical to maintaining an anatomic reduction. For compression plating of a transverse fracture, slight overcontouring of the plate will prevent gapping of the far cortex when compression is applied ( Fig. 15 ).
Temporarily clamp the plate in place and confirm position and fracture reduction using fluoroscopy.
Secure the plate using cortical screws and proper compression technique, as appropriate ( Fig. 16 ).
Obtain final images to confirm reduction and safe position of implants ( Fig. 17 ).
Confirm the location of the radial nerve, and document as discussed (see Surgical Anatomy ).

FIGURE 15

FIGURE 16

FIGURE 17

Procedure: Humeral Intramedullary Nailing


PEARLS

• For transverse fractures, overcontouring of the compression plate will prevent gapping of the far cortex when compression is applied.


PITFALLS

• A poorly contoured plate will lead to malreduction and potentially compromised outcome!


Instrumentation/Implantation

• A large plate-bending press and torque irons are essential.

RETROGRADE NAILING

More applicable to middle and distal third of diaphysis (avoid if supracondylar extension)
Technique points
• Triceps splitting is required.
• A large entry hole is made 2 to 3 cm proximal to the olecranon fossa.

ANTEGRADE NAILING

More applicable to proximal third to middle diaphysis
Technique points
• The deltoid split is less than 5 cm.
• Avoid tight-fitting nails.
• Locking screws should be inserted with an open approach.


PITFALLS

• Beware the narrow canal (avoid if less than 9 mm).
• Better to err on the side of a shorter than a longer nail.


PEARLS

• Initial fixation should be sufficiently secure to permit use of the extremity for crutch mobilization in the polytrauma patient.


PITFALLS

• Inadequate intraoperative documentation of the position and safety of the radial nerve may result in uncertainty and unnecessary re-exploration in the event of postoperative radial nerve palsy.


PEARLS

• Maintain anatomic reduction during reaming (reduced risk to radial nerve).
• If absolutely anatomic reduction cannot be obtained prior to and during reaming, exposure of the radial nerve at the level of the fracture is recommended to ensure that the nerve is not within the fracture site during reaming and nail insertion.
• There is an overall lower complication rate with retrograde nails.
Antegrade nailing has a higher incidence of postoperative shoulder problems.
Retrograde nailing has a higher incidence of postoperative elbow problems.

Postoperative Care and Expected Outcomes

Light dressings are applied. No splint is required.
Early, active and active-assisted range-of-motion exercises are encouraged.
Use of the extremity for crutch mobilization of the polytrauma patient has been shown to be safe, given sufficient initial fixation.
With adequate mobilization and exposure of the radial nerve, postoperative nerve palsy is rare. As long as the nerve was documented intraoperatively to be in continuity and not trapped in the fracture site or beneath the plate, then a postoperative nerve palsy can be treated expectantly.
The expectation with ORIF is a high rate of fracture union (98%), with good functional recovery (>95% good to excellent results).

Evidence

Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience. J Bone Joint Surg [Br] . 1985;67:293-296.
Level IV case series showing good functional results with ORIF in 34 cases of humeral shaft fracture, with only one nonunion, one failure of fixation, and one infection. .
Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis. Acta Orthop . 2006;77:279-284.
Level II meta-analysis of 3 RCTs indicating lower reoperation rate and less shoulder pain with ORIF than IM nail. (Grade B recommendation) .
Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma . 2000;14:162-166.
Level II RCT of 84 patients randomized to ORIF or IM nail, with similar rates of healing. Increased incidence of shoulder pain with IM nail. .
Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg [Am] . 1996;78:1690-1695.
Level IV case-series of the modified posterior approach, and anatomical study describing the anatomy of the radial nerve in relation to posterior approaches to the humerus. .
Gupta R, Raheja A, Sharma V. Limited contact dynamic compression in diaphyseal fractures of the humerus: good outcome in 51 patients. Acta Orthop Scand . 2000;71:471-474.
Level IV case-series of ORIF of the humerus for various indications, yielding good results, but inadequate evidence to influence treatment recommendation. .
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg [Br] . 2000;82:336-339.
Level I RCT comparing 44 patients randomized to either ORIF or IM nail, showing fewer complications and reoperations with ORIF. .
Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma . 1996;10:81-86.
Level IV case series describing the lateral approach to the humerus. .
Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY. Results of non-operative and operative treatment of humeral shaft fractures: a series of 104 cases. Chir Main . 1998;17:195-206.
Level III retrospective comparative study of 104 humerus fractures managed with and without surgical stabilization. .
Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg [Am] . 2000;82:478-486.
Level IV, very large case-series of nonoperatively managed humeral shaft fractures showing good results can be obtained (33% loss to follow-up). .
Scheerlinck T, Handelberg F. Functional outcome after intramedullary nailing of humeral shaft fractures: comparison between retrograde Marchetti-Vicenzi and unreamed AO antegrade nailing. J Trauma . 2002;52:60-71.
Level III retrospective comparative study of 22 retrograde and 30 antegrade intramedullary nails, showing better shoulder function with retrograde nailing. .
Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg [Br] . 2005;87:1647-1652.
Level III systematic review article describing radial nerve palsies following humerus fractures favoring expectant treatment for 6 months prior to surgical exploration. (Grade B recommendation) .
Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma . 2000;49:278-280.
Level IV case series showing early weightbearing for crutch mobilization through the humerus following ORIF to be safe practice. .
PROCEDURE 6 Open Reduction and Internal Fixation of Intra-Articular Fractures of the Distal Humerus

Paul R.T. Kuzyk, Emil H. Schemitsch



Indications


Controversies

• Elderly patients with comminuted fractures may benefit from primary total elbow arthroplasty.

Displaced intra-articular distal humerus fractures

Examination/Imaging


Treatment Options

• Open reduction and internal fixation is the “gold standard” treatment for these intra-articular fractures.
• Total elbow arthroplasty may be considered for elderly, low-demand patients with comminuted fractures.
• Closed management consisting of 2 weeks of rigid splinting follwed by unrestricted range of motion in a hinge brace (i.e., “bag of bones” technique) may be effective for very elderly low-demand patients who have medical contraindications to surgery.

Clinical examination should include: inspection of the skin for any lacerations indicating an open fracture; evaluation of median, ulnar, and radial nerve function; and examination of the wrist and shoulder for any associated injuries.
Anteroposterior and lateral radiographs are required for preoperative planning. A traction radiograph of the elbow provides an excellent view of comminuted fractures; however, this is difficult to obtain as it is painful for the patient.
High-quality computed tomography scans with coronal and sagittal reformats may also be useful for planning reduction and internal fixation in comminuted fractures.

Surgical Anatomy

Muscular anatomy ( Fig. 1A ): medial head, lateral head, and long head of the triceps; triceps tendon, intermuscular septum, flexor carpi ulnaris, anconeus, and extensor carpi ulnaris
Neurologic anatomy (see Fig. 1A ): radial nerve, ulnar nerve, and posterior antebrachial cutaneous nerve
Bony anatomy ( Fig. 1B ): medial and lateral epicondyles, trochlea, capitellum, olecranon fossa, and olecranon

FIGURE 1

Positioning


Equipment

• Axillary roll
• Sterile stockinette for the hand
• Sterile tourniquet

The patient may be placed in the lateral decubitus position with the operative side facing upward ( Fig. 2A ) or, alternatively, the patient may be placed in the prone position ( Fig. 2B ).
The operative arm is placed over a padded bolster so that the elbow may hang freely at an approximate angle of 90°.

FIGURE 2

Portals/Exposures

Triceps-splitting approach
• A midline skin incision is made extending along the subcutaneous border of the ulna, over the olecranon and proximally in the midline of the humerus ( Fig. 3A ). Generous subcutaneous dissection is performed both medially and laterally to expose both epicondyles.
• The ulnar nerve is identified over the posterior aspect of the medial epicondyle (see Fig. 3A ). The nerve is released both proximally and distally and retracted with a vessel loop.
• The triceps tendon and muscle are split in the midline ( dotted line in Fig. 3A ). The radial nerve must be identified and protected if the triceps muscle split is extended proximal to the distal third of the humerus.
• Any traumatic defects in the triceps tendon should be incorporated into the triceps split. These traumatic defects are often encountered with open fractures as the bone tears through the triceps tendon before piercing the skin.
• The triceps tendon should be sharply dissected off the olecranon, preserving a continuous layer medially and laterally that can be easily repaired at the end of the procedure ( Fig. 3B ).
♦ The medial and lateral edges are retracted to expose the distal end of the humerus.
♦ A towel clip can be used to retract the olecranon posteriorly, allowing for better visualization of the fracture.
Triceps-sparing approach
• A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted (see Fig. 3A ).
• The ulnar nerve is followed proximally along its course over the intermuscular septum.
♦ The medial (ulnar) window is created by dissecting out the ulnar nerve and mobilizing the medial head of the triceps laterally to expose the humerus ( Fig. 4A ).
♦ The ulnar window provides some exposure of the medial humerus that may be adequate for simple fracture patterns.
• Greater exposure of the lateral side of the humerus is obtained by creating a lateral window.
♦ The lateral window is created by mobilizing the lateral head of the triceps off the lateral intermuscular septum toward the ulnar side ( Fig. 4B ).
♦ Distally, the anconeus muscle is detached from the radius to allow for greater exposure.
Olecranon osteotomy approach
• A midline skin incision is made similar to that used for the triceps-splitting approach and the ulnar nerve is released and retracted ( Fig. 5 ).
• A hole maybe predrilled through the olecranon to allow for anatomic reattachment of the olecranon at the end of the operation. This hole is made with a 3.2-mm drill bit for fixation with a 6.5-mm cancellous screw ( Fig. 6A ).
♦ Alternatively, two 1.5-mm Kirschner wires (K-wires) may be used to predrill holes through the olecranon and anterior cortex of the ulna, then removed prior to performing the osteotomy ( Fig. 6B ). This is useful if if the osteotomy is to be fixed using a tension band technique.
• The osteotomy should be made through the nonarticular portion of the olecranon, which is located between the olecranon articular facet and the coronoid articular facet (the bare area).
♦ Subperiosteal dissection along the medial and lateral sides of the olecranon allows the surgeon to view the ulnohumeral joint and locate the bare area. An apex distal chevron osteotomy is then marked on the olecranon (see Fig. 6A ).
♦ An oscillating saw is used to cut two thirds of the way through the olecranon. An osteotome should be used to complete the osteotomy through to the articular surface.
♦ The triceps is released off the posterior aspect of the humerus and retracted with the distal portion of the olecranon to expose the distal humerus ( Fig. 7 ).

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7


PEARLS

• The olecranon osteotomy approach provides the best exposure of the articular surface of the distal humerus. Approximately 52% of the articular surface may be seen through the olecranon osteotomy approach. The triceps-splitting approach provides exposure of 37% of the articular surface, and the triceps-sparing approach provides exposure of 26% of the articular surface.
• Choice of approach to the distal humerus is determined by the type of distal humerus fracture. Simple articular fractures (AO type C1 and C2) may be addressed through the triceps-sparing approach. More complex articular fractures (AO type C3) require a triceps-splitting or olecranon osteotomy approach.


Controversies

• The most common complication associated with olecranon osteotomy is prominent hardware that requires a second procedure for removal. Nonunion of the osteotomy has also been reported; however, this is an uncommon complication. Some surgeons suggest plate fixation of the osteotomy as this reduces the chance of nonunion.

Procedure


PEARLS

• Obtain anatomic reduction of the trochlear groove.


PITFALLS

• Do not use lag screws if there is significant comminution of the articular surface. Over-reduction of the trochlear groove will lead to incongruity of the ulnohumeral articulation.


Instrumentation/Implantation

• Small fragment set with reduction forceps and K-wires.

STEP 1

Once the distal humerus has been appropriately exposed, the elbow should be flexed greater than 140° to provide greater access to the distal humerus.
The fracture fragments should be identified and cleaned of hematoma or intervening soft tissues.
Reduction should begin with restoration of the articular surface ( Fig. 8A ).
• Restoration of the normal anatomic alignment of the trochlea is most important.
• Congruency of the ulnohumeral articulation is required for normal range of motion and stability of the elbow. Care should be taken not to over compress the trochlear notch and thereby cause incongruency of the ulnohumeral joint.
The reduction of the articular surface should be held provisionally with pointed reduction forceps and K-wires ( Fig. 8B ). Several 4.0-mm cancellous screws may then be used to rigidly stabilize the articular surface. The surgeon must take care to ensure that these screws do not enter the olecranon fossa or protrude through the articular surface and into the joint.

FIGURE 8

STEP 2


PEARLS

• Two rigid plates are required for any bicondylar distal humerus fracture to provide adequate stability for early postoperative range of motion.


Instrumentation/Implantation

• Small fragment set
• 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates
• K-wires

After reduction of the articular surface, the nonarticular supracondylar component of the fracture is reduced and the articular surface is provisionally fixed to the humeral shaft using K-wires ( Fig. 9A ).
Rigid fixation of the fracture using two plates (one on each column) is mandatory ( Fig. 9B ). Either precontoured 3.5-mm periarticular distal humerus plates or 3.5-mm reconstruction plates may be used to provide rigid fixation.
Biomechanical studies suggest that plates may be placed either parallel (i.e., one plate medial and one plate lateral) or perpendicular (i.e., one plate medial and one plate posterolateral) to provide rigid constructs.

FIGURE 9

STEP 3


Controversies

• Arrangement of the plates to provide greatest biomechanical stability is a matter of ongoing debate. Parallel plate (medial and lateral side of the humerus) and perpendicular plate (medial and posterolateral humerus) configurations seem to provide greatest stability.


PITFALLS

• Good visualization of the olecranon fossa is required prior to closure to ensure there are no screws within the fossa which may block extension.

Prior to closure, the elbow should be taken through a range of motion (flexion, extension, pronation, and supination) to ensure the elbow is stable and that there are no blocks to motion. The reduction and the position of the hardware should be checked using fluoroscopy.
If a triceps-splitting approach was used, care must be taken to ensure the triceps tendon is appropriately repaired.
• After repair of the distal humerus fracture, drill holes are placed in the olecranon to allow for repair of the triceps tendon ( Fig. 10A ).
• Heavy nonabsorbable suture is used to repair the triceps tendon ( Fig. 10B ). Interrupted sutures are placed through the drill holes in the olecranon.
If an olecranon osteotomy was used, this must be rigidly fixed. There are three reported methods for fixation of an olecranon osteotomy:
• One 6.5-mm cancellous screw and a tension band wire ( Fig. 11A )
• Two 1.5-mm K-wires with a tension band wire ( Fig. 11B )
• A 3.5-mm reconstruction plate contoured to fit the olecranon ( Fig. 11C )
Subcutaneous transposition of the ulnar nerve may be considered if the nerve is under tension or directly overlying the plate.

FIGURE 10

FIGURE 11

Postoperative Care and Expected Outcomes


PITFALLS

• Early postoperative range of motion is require to prevent posttraumatic elbow stiffness.

Early gentle range of motion should begin on the first postoperative day to prevent elbow stiffness.
• If a triceps-splitting approach or olecranon osteotomy approach was used, then active elbow extenson should be restricted for 6 weeks.
• Patients may be fitted for an extension brace to wear at night to prevent flexion contracture.
• In selected cases (i.e., associated head injury) nonsteroidal anti-inflammatory medication may be given to prevent heterotopic ossification.

Evidence

Coles CP, Barei DP, Nork SE, Taitsman LA, Hanel DP, Bradford Henley M. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma . 2006;20:164-171.
In this case series of 67 patients with intra-articular distal humerus fractures treated with olecranon osteotomies, no nonunions were encountered, 3% required revision of osteotomy fixation due to malreduction, and 8% required removal of osteotomy fixation due to prominent hardware. The authors concluded that olecranon osteotomy can be useful in the visualization of complex articular injuries, allowing accurate articular reduction. (Grade C recommendation; Level IV evidence) .
Dakouré PW, Ndiaye A, Ndoye JM, Sané AD, Niane MM, Séye SI, Dia A. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat . 2007;29:671-674.
This cadaveric study examined the amount of articular surfaced exposed by three different posterior approaches to the elbow. The median exposed articular surface for the triceps-sparing approach, the triceps-splitting approach, and the olecranon osteotomy was 26%, 37%, and 52%, respectively. .
Doornberg JN, van Duijn PJ, Linzel D, Ring DC, Zurakowski D, Marti RK, Kloen P. Surgical treatment of intra-articular fractures of the distal part of the humerus: functional outcome after twelve to thirty years. J Bone Joint Surg [Am] . 2007;89:1524-1532.
In this case series, 39 patients were evaluated at a mean follow-up of 19 years (range, 12–30 years). The authors found that long-term results of open reduction and internal fixation of intra-articular distal humerus fractures were similar to those reported in the short term (70% good to excellent results), suggesting that the results are durable. They found that functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis. Approximately 40% of patients required a repeat operative intervention. (Level IV evidence) .
Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma . 2007;21:58-62.
In this case series of 17 patients with intra-articular distal humerus fractures that were treated with an olecranon osteotomy fixed with a 3.5-mm reconstruction plate, there were two reoperations related to the osteotomy. The authors concluded that plate fixation of an olecranon osteotomy provides a construct with predictable healing and few complications. (Grade C recommendation; Level IV evidence) .
McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br] . 2000;82:646-651.
This retrospective comparative study evaluated functional outcome of 26 open distal humerus fractures (13 treated using a triceps-splitting approach and 13 treated using an olecranon osteotomy). The authors concluded that immediate open reduction and internal fixation of open intra-articular fractures of the distal humerus is a safe and effective technique with a low rate of complications and good limb-specific outcome. Patients whose fractures were fixed by a triceps-splitting approach, incorporating any traumatic defects in the triceps into the approach, had improved limb-specific and pain scores compared with those who had an olecranon osteotomy. (Grade B recommendation; Level III evidence) .
McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg . 2009;18:3-12.
This study found that total elbow arthroplasty for the treatment of comminuted intra-articular distal humerus fractures in elderly patients (age > 65 years) resulted in more predictable and improved 2-year functional outcomes compared with open reduction and internal fixation. (Grade A recommendation; Level I evidence) .
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg [Am] . 2000;82:1701-1707.
This study provided evidence that open reduction with internal fixation of intra-articular distal humerus fractures is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. There was a significant decrease in the elbow range of motion and muscle strength of these patients as compared to the contralateral elbow at the time of final follow-up (mean 37-month follow-up), indicating that intra-articular distal humerus fractures are severe injuries with long-term sequelae. (Grade C recommendation; Level IV evidence) .

Figures 1 , 5 , 6 , and 7 modified from Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2003. Figures 2 , 4 , and 11B modified from AO Surgery Reference Online ( www.aofoundation.org ). Figures 3 and 10 modified from McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus: the effect of the surgical approach. J Bone Joint Surg [Br]. 2000;82:646–51. Figures 8 and 9 modified from Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg [Am]. 1985;67:226–39.
PROCEDURE 7 Supracondylar Humeral Fractures

Sahal Altamimi, Michael D. McKee



The Role of Arthroplasty


PITFALLS

• Young active patients with high functional demands
• High-grade (Gustilio II and III) open fractures
• Poor soft tissue coverage or skin lesions
• Presence of active infection
• Lack of familiarity with the technique of TEA


Controversies

• Type I Gustilio open fractures seen within 12 hours of injury can be treated by early incision and drainage and primary TEA. Alternatively, a two-stage procedure with early incision and drainage and insertion of an antibiotic spacer followed by TEA can be done.


Indications

Total elbow arthroplasty (TEA) provides good to excellent results in carefully selected patients with comminuted distal humeral fractures.
Poor bone quality and osteoporosis, which are often found in elderly patients, can lead to inadequate fixation and mechanical failure following open reduction and internal fixation (ORIF). In addition, articular comminution and cartilage fragmentation may preclude anatomic reduction. The ideal candidate for TEA is an elderly patient with a comminuted intra-articular distal humeral fracture.
Distal humeral fractures in patients with underlying rheumatoid arthritis or pre-existing arthrosis are best managed with primary TEA.
Several factors play an important role in decision making for primary TEA versus ORIF. These include:
• Intra-articular comminution and cartilage fragmentation
• Physiologic age and functional demands of the patient
• Pre-existing joint arthrosis or underlying rheumatoid arthritis
• Bone quality and degree of osteoporosis
• Surgeon experience and familiarity with TEA

Examination/Imaging


Treatment Options

• Nonoperative (“bag of bones” technique)
• Open reduction and internal fixation
• Primary TEA
• Distal humeral hemiarthroplasty

A common pitfall is to focus immediately on the obvious injury. Examination of the shoulder and wrist is a must.
The skin should be visualized circumferentially, so that an open fracture is not missed.
Ecchymosis and deformity are usually apparent.
A careful neurologic evaluation that includes motor and sensory functions of the ulnar, radial, and median nerves is critical.
The vascular status of the arm should be evaluated by palpation of the distal pulses and assessment of capillary refill.
The forearm compartments should be assessed as well.
Plain radiographs are universally the initial study of choice.
• Standard anteroposterior and lateral radiographs of the elbow are adequate in most cases.
• Figure 1 shows the preoperative anteroposterior ( Fig. 1A ) and lateral ( Fig. 1B ) radiographs of a 68-year-old woman with a comminuted intra-articular distal humerus fracture.
• It is important to note the degree of displacement, angulation, intra-articular comminution, and bone quality.
Additional traction views or computed tomography maybe obtained in selected cases. Typically, when TEA is chosen, advanced imaging studies are not required.

FIGURE 1

Surgical Anatomy

The ulnar nerve is derived from the C8 and T1 nerve roots ( Fig. 2 ).
The nerve runs down the anterior compartment of the arm medial to the brachial artery and gives off no branches in the upper arm.
At the middle of the arm, it pierces the intermuscular septum and travels along the medial head of the triceps.
At the elbow, the nerve passes posterior to the medial epicondyle.
Before entering the forearm, the ulnar nerve gives off capsular branches to the elbow joint, the first motor branch to the flexor carpi ulnaris (FCU), and branches to the ulnar half of the flexor digitorum profundis.
In the proximal forearm, the nerve runs between the two heads of the FCU.

FIGURE 2

Positioning


PEARLS

• Ensure that the elbow can be moved through a full range of motion over the bolster before beginning the procedure


PITFALLS

• A foam pad should be place under the lower leg to protect the common peroneal nerve.


Equipment

• Beanbag
• Arm bolster
• Axillary roll
• Foam pads or gel
• Sterile tourniquet


Controversies

• Alternatively, TEA can be done in the supine position. The injured arm can be placed across the patient’s chest or, with the shoulder flexed, beside the patient’s head.

We prefer to place the patient in the lateral decubitus position with the injured arm up ( Fig. 3 ). The affected elbow is supported over a bolster.
• This position facilitates extensile exposure of the humerus and allows the elbow to flex beyond 90°.
A deflatable beanbag is used to secure the patient in place. Great care is taken to pad all bony prominences.
The arm is prepped and draped to the shoulder so that a sterile tourniquet can be applied as high as possible.
After the extremity is exsanguinated, the tourniquet is inflated. The pressure is set at 250 mm Hg, or 275 mm Hg for an obese arm.

FIGURE 3

Portals/Exposures


PEARLS

• A Hohmann retractor can be used on either side of the humeral shaft to “lift up” the shaft for exposure, rather than levering on the soft tissue excessively. This is especially important on the lateral side where the radial nerve courses proximally.
• In most cases, the radial head will be left intact. However, in the setting of a distal humeral fracture in a joint afflicted with pre-existing inflammatory arthritis, the radial head should be resected. This helps improve exposure.

A straight posterior midline skin incision is made (see Fig. 3 ).
• Dissection is carried down to the triceps fascia proximally and subcutaneous border of the ulna distally.
• Full-thickness medial and lateral fasciocutaneous flaps are elevated.
The ulnar nerve is identified, mobilized, and protected throughout the procedure.
• The nerve is carefully dissected proximally to the medial intermuscular septum and distally to its first motor branch ( Fig. 4A and 4B ). The capsular branch to the elbow is sacrificed to mobilize the nerve.
• The distal portion of the intermuscular septum is excised to prevent a pressure point of the nerve.
A triceps-sparing approach is used ( Fig. 5 ).
• The medial and lateral border of the triceps are defined and elevated from the distal humerus. The triceps is left attached distally to the olecranon.
• The flexor-pronator origin and medial collateral ligament are released off the medial epicondyle.
• The lateral epicondyle is also freed of the extensor-supinator attachment and lateral collateral ligament.
• Next, all free distal fracture fragments, including medial and lateral epicondyles, are excised. Figure 6 shows the articular fragments from the patient in Figure 1 .

FIGURE 4

FIGURE 5

FIGURE 6


PITFALLS

• Ulnar neuropathy can be avoided with meticulous surgical technique. If ulnar nerve transposition is performed, excision of the intermuscular septum is necessary.
• Olecranon osteotomy should be avoided in the treatment of distal humerus fracture with TEA. The osteotomy will jeopardize the stability of the ulnar component.


Instrumentation

• Steven’s scissors for ulnar nerve dissection
• Penrose drain to protect the ulnar nerve
• Two Hohmann retractors


Controversies

• There are several techniques to deal with the triceps tendon. These include a “triceps-on” or triceps-sparing approach, a midline split, or a medial-to-lateral peel.
• Initially, or with complex cases, a midline split is utilized as this is technically simpler. As experience and skill with TEA grows, a “triceps-on” approach is utilized. Excision of the distal fragments creates a “working space” that allows canal instrumentation and component insertion without detaching the triceps from the olecranon (see Fig. 5 ).

Procedure


PEARLS

• Typically, we use a 6-inch humeral stem in TEA for distal humerus fractures instead of a 4-inch humeral stem, which is routinely used for standard TEA.


PITFALLS

• Correct rotational alignment of the humeral component is important—this can be assured by using the flat posterior surface of the distal humerus just proximal to the olecranon fossa, as a guide.


Instrumentation/Implantation

• High-speed burr
• Serial rasps
• Two Hohmann retractors
• Trial humeral component


Controversies

• There is increasing enthusiasm for using a distal humeral hemiarthroplasty in the setting of comminuted distal humeral fracture. While it is a promising technique, it does require reconstruction of the condyles and ligaments for stability, and there are few reported results.

STEP 1: HUMERAL PREPARATION

A working space is created after removal of all comminuted distal humerus fragments.
The distal humerus is delivered, typically lateral to the triceps tendon, with two Hohmann retractors.
The medullary canal is prepared by reaming and rasping of the canal to the appropriate size.
Progressive rasping is continued until cortical resistance is met.
Next, a trial humeral prosthesis is inserted to a depth that replicates the normal axis of rotation ( Fig. 7 ). The top of the olecranon fossa can usually be determined: the anterior flange of the humeral component should abut the cortical bone at the top of the fossa as the distal humerus narrows in the anteroposterior plane.
In the setting of complex distal humerus fracture, the fracture fragments are excised and the ligaments released. Therefore, a linked prosthesis is necessary to provide adequate stability in varus/valgus and rotational planes.

FIGURE 7

STEP 2: ULNAR PREPARATION

The arm is fully flexed and rotated to facilitate exposure of the olecranon.
The tip of the olecranon is resected and the ulnar canal is opened with a high-speed burr.
Rush pin inserters of progressively larger size are used to carefully identify the ulnar canal. This is followed by serial rasping of the medullary canal. It is important to avoid proximal ulnar perforation.
A trial ulnar component is inserted.


PEARLS

• Careful insertion of rasps without twisting or applying a torque is essential.
• If the trial component is not fully seated, the opening of the medullary canal is enlarged with a high-speed burr.
• This is the most difficult part of the procedure when a “triceps-on” exposure is used, and careful attention to surgical technique is mandatory.

STEP 3: TRIAL REDUCTION


PITFALLS

• Poor rasping techniques may lead to proximal ulna perforation.


Instrumentation/Implantation

• Micro-sagittal saw
• High-speed burr
• Rush pin inserters (to open medullary canal)
• Serial rasps
• Trial components

After insertion of the humeral and ulnar trial implants, the elbow joint is reduced ( Fig. 8 ).
Range of motion of the elbow and component position are carefully assessed.
• Achievement of full flexion and extension should be obtained at this time.
• The depth of the humeral component is checked and marked.
Once the surgeon is satisfied with the trial reduction, the definitive implants are opened.

FIGURE 8

STEP 4: INSERTION AND CEMENTING OF THE FINAL PROSTHESIS


PEARLS

• If the elbow will not extend fully, the components are usually not seated deeply enough. This can be corrected by repeat rasping and inserting the components more deeply, or on occasion by changing to a smaller component. Excessive resection of bone is to be avoided if possible.
• Lack of flexion usually indicates some type of anterior impingement.


PITFALLS

• Care must be taken to not allow the elbow to hyperextend with the trial components in place. While this is rare, it indicates the components are too deeply inserted. It may be necessary to use a longer stemmed humeral component and leave it slighty “proud,” restoring adequate soft tissue tension anteriorly.


PEARLS

• Antibiotic-impregnated cement is routinely used to minimize the risk of infection.

Several trial reductions should be performed so that the surgeon and assistant are familiar with the sequence of insertion to be followed.
The intramedullary canals of the humerus and the ulna are irrigated with pulsatile lavage, then dried.
A cancellous bone plug or plastic cement restrictor is placed in the humeral canal to enhance the cementing technique and prevent proximal flow of cement.
Antibiotic-impregnated cement is injected into the humerus and the ulna with a cement gun.
The ulnar and humeral prostheses are inserted disarticulated.
A trapezoidal wafer of bone graft harvested from the excised distal humerus is placed behind the anterior flange of the humeral component.
The new elbow joint is reduced and coupled together with the locking mechanism ( Fig. 9 ).
• Figure 10 shows postoperative anteroposterior ( Fig. 10A ) and lateral ( Fig. 10B ) radiographs after TEA with a linked prosthesis.

FIGURE 9

FIGURE 10

STEP 5: WOUND CLOSURE


PITFALLS

• Poor cementing technique can result in early mechanical failure.
• The nozzle of the cement gun is usually too large to be inserted into the medullary canals deeply enough. Therefore, it can be replaced with smaller diameter suction tubing to ensure adequate delivery of the cement into the depth of the canal.


Instrumentation/Implantation

• Antibiotic-impregnated cement (1 bag)
• Vacuum mixing container
• Cement gun
• Suction tubing

If the triceps has been split or peeled from the olecranon, it is reattached with drill holes through the bone and #2 nonabsorbable suture.
Since the medial condyle is already excised, formal anterior ulnar nerve transposition is not necessary. The nerve is left in a tension-free position medially.
The common origins of the flexor-pronator and extensor-supinator groups are sutured to the edge of the triceps medially and laterally with #1 Vicryl. In this way, a continuous sleeve of soft tissue is re-established around the prosthesis.
It is very important to release the tourniquet before final wound closure. Meticulous hemostasis must be ensured.
A suction drain is not routinely used.
The subcutaneous tissue is closed with absorbable 2–0 suture. The skin is closed with staples.
The arm is placed in a well-padded anterior splint in maximum extension and kept elevated.


Controversies

• Use of a suction drain is optional.
• The position of full extension decreases swelling, is favorable for neurovascular structures, and helps to minimize flexion contracture.

Postoperative Care and Expected Outcomes


PEARLS

• Early unrestricted active elbow flexion and extension exercises are encouraged with the “triceps-on” approach.
• If the triceps tendon was detached in the approach, active and resisted elbow extension is restricted for 6 weeks.

Postoperative antibiotics are continued for 24 hours.
The splint is removed on the first postoperative day.
Typically, with the “triceps-on” approach, early unrestricted active range-of-motion exercises are initiated under the supervision of a physiotherapist.
• Range-of-motion exercises of the hand, wrist, and the shoulder are encouraged.
Usually the patient is discharged home on the second or third day postoperative with written instructions for home exercise.
• Active use of the arm for activities of daily living is encouraged.
Patients can expect a 90% rate of good or excellent results, with a mean Mayo Clinic Elbow Performance Index score of 85–90.
• Clinical photographs taken 3 months after successful TEA show excellent range of motion of the elbow in flexion ( Fig. 11A ) and extension ( Fig. 11B ).
Potential complications of TEA include wound breakdown, infection, ulnar nerve neuropathy, aseptic loosening, and elbow stiffness.

FIGURE 11


PITFALLS

• Patients are counseled to limit weight lifted with the involved arm to 5–10 pounds to increase the longevity of the prosthesis.

Evidence

Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg [Am] . 1997;79:826-832.
This represents the first report of primary TEA as treatment for distal humerus fractures. Between 1982 and 1992, 20 patients with acute distal humerus fracture were treated with primary TEA. Fifteen patients had an excellent result and five patients had a good result based on Mayo Clinic Elbow Performance Index scores. This report introduced the clinical potential of this technique. (Level IV evidence) .
Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma . 2003;17:473-480.
In this retrospective study, 24 women with intra-articular distal humeral fractures (12 treated with ORIF and 12 treated with TEA) were assessed for a minimum 2 years’ follow-up. The outcomes of ORIF were 4 excellent, 4 good, 1 fair, and 3 poor, compared to 11 excellent and 1 good in the TEA group. The authors concluded that TEA is a viable treatment option for distal humerus fracture in women older then 65 years of age, and may have advantages when compared to ORIF. (Level III evidence) .
Gambirasio R, Riand N, Stern R, Hoffmeyer P. Total elbow replacement for complex distal humerus fracture. J Bone Joint Surg [Br] . 2001;83:974-978.
The authors reported the result of TEA for distal humeral fracture. The functional outcome was investigated in 10 elderly patients with a mean follow-up of 17.8 months. All patients were women and none had inflammatory arthropathies. The mean Mayo Clinic Elbow Performance Index score was 94 points, with high patient satisfaction, and there were no reoperations. (Level IV evidence) .
Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg [Am] . 2004;86:940-947.
This retrospective review is a follow-up of the same groups in the Cobb and Morrey (1997) report, and supports recommendations for TEA in carefully selected patients with distal humerus fracture. Clinical and functional outcome were evaluated in 43 fractures with an average 7-year follow-up. The average Mayo Clinic Elbow Performance Index score was 93 of a possible 100 points. (Level IV evidence) .
McKee MD, Pugh DM, Richards RR, Pedersen E, Jones C, Schemitsch EH. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg [Am] . 2003;85:802-807.
The effect of condylar resection on elbow, forearm, and hand strength has always been a concern. This study assessed objective muscle strength in 32 patients who had linked TEA (16 with intact condyles and 16 with resected condyles). The authors concluded that condylar resection had no significant effect on forearm, wrist, and grip strength. (Level IV evidence) .
Veillette CJ, McKee MD, the Canadian Orthopaedic Trauma Society. A multicenter prospective randomised controlled trial of open reduction and internal fixation versus total elbow arthroplasty for displaced intra-articular distal humerus fractures in elderly patients. J Shoulder Elbow Surg . 2009;18:3-12.
In this study, the functional outcome, complications, and reoperation rates were assessed in 42 patients. The authors concluded that TEA provides improved functional outcome compared with ORIF based on both Mayo Clinic Elbow Performance Index and DASH scores. (Level I evidence) .
PROCEDURE 8 Terrible Triad Injuries of the Elbow

Paul K. Mathew, Graham J.W. King, George S. Athwal



Indications

An elbow dislocation associated with radial head and coronoid fractures that renders the articulation incongruous and/or unstable

Examination/Imaging


Treatment Options

• Nonoperative treatment can be implemented only if all of the following criteria are met:
The ulnohumeral and radiocapitellar joints are concentrically reduced following closed reduction of the elbow dislocation.
The elbow can be extended to 30–45° before becoming unstable, suggesting there is sufficient stability to allow early range of motion.
The radial head or neck fracture is undisplaced or minimally displaced and is not causing a mechanical block to forearm rotation or elbow flexion/extension.
The coronoid fracture is small, typically a type I fracture.

The elbow is inspected for obvious dislocation or open injury necessitating immediate reduction and/or surgical treatment.
The joint is palpated for bony alignment and areas of tenderness to locate pathology.
The elbow is moved actively and passively to evaluate for stability or a block to motion.
The arm is examined above and below the joint for tenderness and mobility. Specifically, examination must ensure that no distal radioulnar joint tenderness is present as this may suggest a concomitant interosseous membrane injury (Essex-Lopresti lesion).
A detailed neurologic examination is performed to evaluate the function of the axillary, musculo-cutaneous, median, ulnar, and radial nerves.
The vascular status is assessed by evaluation of capillary refill and distal pulses.
Radiographs
• Prereduction and postreduction ( Fig. 1A and 1B ) anteroposterior and lateral radiographs are obtained to examine fracture characteristics and concentricity of the elbow joint.
• Regardless of the radiographic projection, a line drawn through the center of the radial neck should intersect with the center of the capitellum.
• Lateral radiographs can be used to determine the height of a coronoid fracture.
Computed tomography (CT)
• CT is obtained following joint reduction to better evaluate fracture patterns, comminution and displacement.
• Three-dimensional images can improve visualization and understanding of the fracture pattern and fracture line propagation.
♦ The three-dimensional CT image in Figure 2A demonstrates a radial head and neck fracture.
♦ A three-dimensional anterior CT image shows an anterolateral coronoid fracture ( Fig. 2B ).

FIGURE 1

FIGURE 2

Surgical Anatomy

BONES

The proximal ulna
• The greater sigmoid notch, with its central guiding ridge, articulates with the trochlea and is made up of the coronoid and olecranon ( Fig. 3A ).
♦ The coronoid process provides an important anterior and varus buttress to the elbow joint and consists of the tip, body, anterolateral facet, anteromedial facet, and sublime tubercle (insertion for the anterior bundle of the medial collateral ligament).
• The lesser sigmoid notch articulates with radial head, forming the proximal radioulnar joint.
• The crista supinatoris, located just distal to the radial notch on the lateral aspect of the proximal ulna, provides the insertion for the lateral ulnar collateral ligament ( Fig. 3B ).
The proximal radius
• The radial head ( Fig. 3C ), which is elliptical in shape and offset from the neck, articulates with the capitellum and lesser sigmoid notch.
♦ Hyaline cartilage covers the majority of articular margins and all of the articular dish.
♦ The anterolateral portion of the articular margin does not articulate with the proximal ulna and is devoid of hyaline cartilage (so-called “safe zone”).
• The bicipital or radial tuberosity is distal to the radial neck and serves as the attachment site for the biceps tendon (see Fig. 3C ).

FIGURE 3

LIGAMENTS

Lateral collateral ligament (LCL)
• The LCL consists of the lateral ulnar collateral, radial collateral, and annular ligaments ( Fig. 4A ).
• It is an important varus and posterolateral rotational stabilizer of the elbow.
• Its origin on the lateral epicondyle is isometric.
• The lateral ulnar collateral ligament originates on the lateral epicondyle and attaches to the crista supinatoris.
• The radial collateral ligament originates on the lateral epicondyle and fans out to attach to the annular ligament.
• The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid (radial) notch.
Medial collateral ligament (MCL)
• The MCL consists of the anterior bundle, posterior bundle, and transverse ligament ( Fig. 4B ).
• It is an important valgus and posteromedial rotational stabilizer of the elbow.
• Its origin on the anteroinferior aspect of the medial epicondyle is distal to the axis of rotation and therefore tension increases in flexion.
• The anterior bundle originates from the medial epicondyle and inserts on the sublime tubercle of the coronoid.
• The posterior bundle originates from the medial epicondyle and inserts on the ulnar aspect of the greater sigmoid notch.
• The transverse ligament has no known function.

FIGURE 4


PEARLS

• With the arm across the chest, use a 3-L intravenous fluid bag placed under the ipsilateral scapula to protract the shoulder. A second assistant may be needed on the opposite side of the operating table.
• When using an arm table, make sure the torso is shifted close to edge of the operating table to move the elbow into the center of the table. A rolled drape placed underneath the medial or lateral aspect of the elbow with the shoulder in internal or external rotation, respectively, facilitates positioning.
• When using the lateral decubitus position, ensure the armholder is well padded and is situated over the biceps muscle to avoid pressure points. If using a bean bag for positioning leave the suction attached to maintain deflation during surgery. Tilt the operating table 10 degrees towards the operative side after the patient is secured to prevent the arm from slipping back off the arm support.
• Positioning supine with the arm across the chest and lateral decubitus positioning have an advantage over the arm table for unstable injuries as gravity tends to reduce the elbow in the former two positions, while rotation of the shoulder to gain access to the medial and lateral sides of the elbow when using an arm table tends to subluxate the elbow and stress collateral ligament repairs and fracture fixation.

MUSCLES

Several muscles act as dynamic stabilizers of the elbow joint ( Fig. 5 ).
The biceps, brachialis, and triceps compress the joint and stabilize the articulation; however, a posterior vector of forces contributes to posterior subluxation of the elbow when the coronoid and/or radial head are deficient.
The flexor pronator muscles arise from the medial epicondyle and provide dynamic valgus stability.
The common extensor muscles arise from the lateral epicondyle and provide dynamic varus stability.

FIGURE 5

Positioning

For lateral surgery, patients can be placed in the supine position with the arm over the chest supported by a rolled drape to allow the elbow to flex to 90° ( Fig. 6A ).
• Alternatively, an articulated arm positioner can be used to stabilize the arm.
For medial surgery, patients can be placed in the lateral decubitus position with the aid of an elbow positioner ( Fig. 6B ).

FIGURE 6

Exposures


PITFALLS

• Lack of a second assistant when using the supine position.
• Failure to protract the scapula.
• Armholder placed in the antecubital fossa when the patient is in the lateral position.
• A stiff shoulder limits medial and lateral exposure with an arm table or with the patient in the lateral decubitus position.


Equipment

• A sterile tourniquet will allow more proximal incision length and can be removed if more exposure is required.
• A padded armholder placed under the anterior surface of the humerus in the lateral decubitus position is needed to stabilize the arm during surgery.
• A beanbag or alternative positioning braces are needed when performing surgery in the lateral decubitus position.

SKIN INCISION

Choice of skin incision(s) location is controversial; it depends on the fracture/instability pattern, soft tissue injury, and surgeon preference.
Options are medial, lateral, and posterior skin incisions.
A posterior skin incision minimizes injury to the cutaneous nerves and allows both lateral and medial deep exposures if needed; however, larger skin flaps are required.

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