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Proximal Humerus Fx ORIF

Planning

B

Preoperative Plan

1

Radiographic templating

  • template fracture with instrumentation

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

3

Description of potential complications and steps to avoid them

C

Room Preparation

1

Surgical Instrumentation

  • larger Weber clamp
  • low profile precontoured locking plate
  • K wires
  • Steinmann pins
  • Cobb or periosteal elevator

2

Room setup and Equipment

  • standard operating table in the beach chair position
  • fluoroscopy

3

Patient Positioning

  • rotate the table 90 degrees so that the injured shoulder is opposite the anesthesia team

Technique

D

Extended Deltopectoral Approach

1

Identify and mark the deltopectoral groove

  • make a 10-15 cm incision following the line of the deltopectoral groove
  • in obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable

2

Identify the deltopectoral fascia

  • the interval can be found by identifying the cephalic vein

3

Develop the interval

  • retract the cephalic vein medially or laterally
  • retract the deltoid laterally and the pectoralis medially
E

Deep Dissection

1

Mobilize the subdeltoid space

  • take caution to avoid the terminal branches of the axillary nerve
  • identify the position of the axillary nerve via the tug test
  • abduct the arm to the relax the deltoid
  • place a Brown retractor

2

Expose the proximal humerus

  • identify and retract the short head of the biceps and the coracobrachialis medially
  • identify the rotator interval
  • incise the rotator interval from the humeral head to the glenoid
  • place several nonabsorbable heavy braided sutures in the rotator cuff at the bone tendon junctionto allow for mobilization of the humeral head
F

Fracture Reduction

1

Identify fracture pattern

  • reduce fracture using the appropriate reduction maneuver
  • for unimpacted fractures use the parachute technique
  • for impacted fractures use square tip elevator for reduction
G

Provisional Fixation

1

Place Steinmann pins

  • place pins just posterior to the biceps tendon

2

Place tension sutures

  • apply traction to the sutures then tie to the pins
  • this allows for the reduction to be assessed fluoroscopically in multiple planes
H

Reduction Assessment

1

Assess the position of the humeral head, shaft and tuberosities

  • get AP external rotation view
  • the shaft of the humerus should be under the humeral head
  • the greater tuberosity should be 5 to 10 mm below the top of the head
  • the articular surface should point towards the upper portion of the glenoid

2

Assess rotation

  • use the course of the biceps tuberosity to assess the rotation of the reduction
I

Definitive Fixation

1

Apply precontoured plate

  • place the plate lateral to the bicipital groove

2

Assess placement

  • use the external rotation AP view to assess position
  • if the plate is positioned to high, it will cause impingement
  • if it is placed to low, the screw trajectory will be suboptimal

3

Place screws

  • drill through the outer cortex only
  • insert depth gauge to measure length
  • place screws
  • place nonlocked shaft screw to secure the plate to the bone
  • humeral shaft screws are placed in a bicortical fashion
  • place humeral head screws in a unicortical fashion

4

Remove provisional pin and tension sutures

5

Tie sutures

  • place sutures from the cuff tendons through any open holes in the plate
  • use smooth holes to minimize the risk of suture abrasion
J

Wound Closure

1

Irrigation

  • copiously irrigate wound

2

Deep closure

  • use 0-vicryl for fascia

3

Superficial closure

  • use 2-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin

4

Immobilization

  • place in sling

Patient Care

K

Preoperative H & P

1

Perform basic history and physical exam

  • identify medical co-morbidities that might impact surgical treatment

2

Ensure all studies are required to proceed with surgical intervention

  • radiographs
  • AP view
  • make sure the is well centered with the arm in external rotation
  • this identifies the position of the greater tuberosity in relation to the humeral head
  • axillary view
  • assess for humeral head dislocation
  • CT scan
  • 2D scans
  • useful for determining the amount of bone loss and subsequent need for bone grafting
  • 3D scan
  • useful for understanding the geometry of complex fracture patterns
  • used to determine if greater or lesser tuberosity is attached to the humeral head in three or four part fractures

3

Perform operative consent

  • describe complications of surgery including
  • inadequate reduction
  • residual varus deformity
  • screw penetration
  • infection
  • nonunion
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • order AP and lateral views to assess placement of implants
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • inpatient physical therapy

2

Appropriate medical management and medical consultation

3

Discharges patient appropriately

  • outpatient pt
  • pain meds
  • schedule follow up appointment in 2 weeks
M

Intermediate Evaluation and Management

1

Performs focused history and physical

  • concomitant and associated orthopaedic injuries
  • perform neurovascular exam

2

Orders and interprets required diagnostic studies

3

Reduce fracture is necessary

4

Knowledge of surgical indications

5

Post operative management

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • start supine active assisted range of motion at 6 weeks
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • check radiographs for fracture consolidation
  • discontinue sling
  • start using arm for light daily activities
  • avoid strenuous activity for 6 months
N

Advanced Evaluation and Management

1

Order appropriate imaging studies

2

Provides post-op management and rehabilitation

O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

3

Understand how to avoid and prevent complications

4

Treat simple complications intraoperatively and postoperatively

5

Understand how to avoid /prevent potential complications

 

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