Preoperative Patient Care A Intermediate Evaluation and Management 1 Performs focused history and physical history mechanism of injury premorbid level of function history of malignancy occupation and hand dominance concomitant and associated orthopaedic injuries perform neurovascular exam physical exam inspection swelling soft tissue injury ecchymosis deformity 2 Orders and interprets required diagnostic studies 3 Knowledge of surgical indications 4 Post operative management postop: 2-3 week postoperative visit wound check diagnose and management of early complications postop: ~ 6 week postoperative visit diagnosis and management of late complications check radiographs for healing of the tuberosities discontinue sling start using arm for light daily activities avoid strenuous activity for 6 months 3 month postoperative visit start strength training with rubber bands B Advanced Evaluation and Management 1 Order appropriate imaging studies 2 Provides post-op management and rehabilitation C Preoperative H & P 1 Perform basic history and physical exam check neurovascular status 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 fluorocopy 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 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 infection nonunion Operative Techniques E 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 F 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 G 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 identify and protect the axillary and the musculocutaneous nerves H Mobilize the Tuberosities 1 Identify the biceps tendon identify the long head of the biceps as it courses through the bicipital groove this tendon should course towards the rotator interval this tendon is a landmark that is used when re-establishing the relationship between the greater and lesser tuberosities 2 Mobilize the tuberosities release the rotator interval and coracohumeral ligament 3 Tag the rotator cuff insertions place heavy nonabsorbable traction sutures through the rotator cuff insertions on the tuberosities 2 to 3 sutures should be placed through the subscapularis and 3 to 4 sutures should be placed through the supraspinatus 4 Retract the tuberosities retract the tuberosities onto their muscular insertions 5 Remove the humeral head and fracture fragments use articular surface to trial the humeral head replacement I Humeral Shaft Preparation 1 Prepare the humeral canal remove hematoma and loose endosteal bone fragments from the shaft 2 Ream the canal use axial reamers without power 3 Place the trial implant place the implant with the lateral fin slightly posterior to the bicipital groove the implant should be placed in 20 degrees of retroversion the medial aspect of the trial head should be at the height of the medial calcar J Determination of Humeral Retroversion and Prosthetic Height 1 Determine retroversion using one of two methods externally rotate the humerus to 30 degrees from the sagittal plane of the body with the humeral head component facing straight medially position the lateral fin of the prosthesis about 8 mm posterior to the biceps groove 2 Determine height of the prosthesis check tension of the soft tissues ensure that the tension of the rotator cuff, deltoid and long head of the biceps is appropriate if the prosthesis is placed to low, deltoid function is compromised and there is no room for reattachment of the tuberosities the top of the prosthesis should be 5.6 cm proximal to the insertion of the pectoralis major K Trial Reduction 1 Assess the position of the humeral head, shaft and tuberosities place drill holes in the proximal humerus medial and lateral to the bicipital groove place Dacron suture through the holes for fixation of the tuberosities to the shaft the greater tuberosity should be 5 to 10 mm below the top of the head 2 Perform a trialed reduction fit the mobilized tuberosities below the head of the modular prosthesis assess glenohumeral stability place towel clips to hold the tuberosities when assessing the implant fluoroscopically the humeral head should not subluxate more than 25 to 30% of the glenoid height inferiorly L Final Implant Placement 1 Cement humeral component place the plate laterally place a cement restrictor to prevent extravasation of the cement distally 2 Place autograft place autograft in the spaces between the tuberosities, prosthesis and shaft 3 Place the final head implant impact the head onto the stem run wire medially to the prosthesis and through the subscapularis insertion 4 Tie sutures tie sutures beginning with the tuberosity to shaft reapproximation then the tuberosity to tuberosity closure using the previously placed suture limbs place a cerclage wire circumerferentially around the greater tuberosity and through the supraspinatus insertion N 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 Postoperative Patient Care O 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 Appropriate medical management and medical consultation 2 Discharges patient appropriately outpatient pt pain meds schedule follow up appointment in 2 weeks R 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
A Intermediate Evaluation and Management 1 Performs focused history and physical history mechanism of injury premorbid level of function history of malignancy occupation and hand dominance concomitant and associated orthopaedic injuries perform neurovascular exam physical exam inspection swelling soft tissue injury ecchymosis deformity 2 Orders and interprets required diagnostic studies 3 Knowledge of surgical indications 4 Post operative management postop: 2-3 week postoperative visit wound check diagnose and management of early complications postop: ~ 6 week postoperative visit diagnosis and management of late complications check radiographs for healing of the tuberosities discontinue sling start using arm for light daily activities avoid strenuous activity for 6 months 3 month postoperative visit start strength training with rubber bands B Advanced Evaluation and Management 1 Order appropriate imaging studies 2 Provides post-op management and rehabilitation C Preoperative H & P 1 Perform basic history and physical exam check neurovascular status 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 fluorocopy 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 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 infection nonunion
E 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 F 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 G 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 identify and protect the axillary and the musculocutaneous nerves H Mobilize the Tuberosities 1 Identify the biceps tendon identify the long head of the biceps as it courses through the bicipital groove this tendon should course towards the rotator interval this tendon is a landmark that is used when re-establishing the relationship between the greater and lesser tuberosities 2 Mobilize the tuberosities release the rotator interval and coracohumeral ligament 3 Tag the rotator cuff insertions place heavy nonabsorbable traction sutures through the rotator cuff insertions on the tuberosities 2 to 3 sutures should be placed through the subscapularis and 3 to 4 sutures should be placed through the supraspinatus 4 Retract the tuberosities retract the tuberosities onto their muscular insertions 5 Remove the humeral head and fracture fragments use articular surface to trial the humeral head replacement I Humeral Shaft Preparation 1 Prepare the humeral canal remove hematoma and loose endosteal bone fragments from the shaft 2 Ream the canal use axial reamers without power 3 Place the trial implant place the implant with the lateral fin slightly posterior to the bicipital groove the implant should be placed in 20 degrees of retroversion the medial aspect of the trial head should be at the height of the medial calcar J Determination of Humeral Retroversion and Prosthetic Height 1 Determine retroversion using one of two methods externally rotate the humerus to 30 degrees from the sagittal plane of the body with the humeral head component facing straight medially position the lateral fin of the prosthesis about 8 mm posterior to the biceps groove 2 Determine height of the prosthesis check tension of the soft tissues ensure that the tension of the rotator cuff, deltoid and long head of the biceps is appropriate if the prosthesis is placed to low, deltoid function is compromised and there is no room for reattachment of the tuberosities the top of the prosthesis should be 5.6 cm proximal to the insertion of the pectoralis major K Trial Reduction 1 Assess the position of the humeral head, shaft and tuberosities place drill holes in the proximal humerus medial and lateral to the bicipital groove place Dacron suture through the holes for fixation of the tuberosities to the shaft the greater tuberosity should be 5 to 10 mm below the top of the head 2 Perform a trialed reduction fit the mobilized tuberosities below the head of the modular prosthesis assess glenohumeral stability place towel clips to hold the tuberosities when assessing the implant fluoroscopically the humeral head should not subluxate more than 25 to 30% of the glenoid height inferiorly L Final Implant Placement 1 Cement humeral component place the plate laterally place a cement restrictor to prevent extravasation of the cement distally 2 Place autograft place autograft in the spaces between the tuberosities, prosthesis and shaft 3 Place the final head implant impact the head onto the stem run wire medially to the prosthesis and through the subscapularis insertion 4 Tie sutures tie sutures beginning with the tuberosity to shaft reapproximation then the tuberosity to tuberosity closure using the previously placed suture limbs place a cerclage wire circumerferentially around the greater tuberosity and through the supraspinatus insertion N 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
O 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 Appropriate medical management and medical consultation 2 Discharges patient appropriately outpatient pt pain meds schedule follow up appointment in 2 weeks R 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