[Blocked from Release] Proximal Humerus Fracture Percutaneous Pin Fixation

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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Template fracture

  • identify fracture pattern

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • flexible intramedullary nail
  • fracture table

2

Room setup and equipment

  • setup OR with standard operating table
  • c-arm brought in from the head of the bed

3

Patient positioning

  • modified beach chair position with the back elevated 30 degrees
  • place a bean bag under the head, neck and upper torso to allow the patient to hang over the chair slightly
  • place a chest pad attached to the table to prevent the patient from being pulled off of the bed when tract is applied to the arm
G

Closed Reduction

1

Reduce the fracture

  • abduct and externally rotate the arm
  • have an assistant stabilize the torso
  • apply traction to the arm for disengagement of the fracture fragments

2

Correct angulation

  • typical angulation that needs to be corrected is varus and apex anterior
  • push down on the proximal end of the shaft to correct angulation
  • maintain abduction to correct the varus
H

Placement of the First Pin

1

Place first pin from distal lateral to proximal medial

  • start the pin perpendicular to the shaft
  • drop the hand to the correct angle
  • it is important that the initial approach down to the bone along the final angle of the pin insertion to avoid possible skin tension problems

2

Advance the pin

  • advance the pin into the head stopping several millimeters below the subchondral bone
I

Placement of the Second Pin

1

Place the second pin

  • placement of the second pin is placed more proximal and anterior than the first pin
  • if the first pin is aimed at the inferior border of the head , the second should be aimed more superior for greater pin divergence across the fracture
J

Fixation Test

1

Perform the advance withdrawal test

  • rotate the shoulder and the tips of the should appear to approach the joint then withdraw with continued rotation
  • if the pins appear to long, they should be pulled back
K

Wound Closure

1

Place soft dressings over the pin sites

Postoperative Patient Care
 

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