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Proximal Humerus Fracture Hemiarthroplasty

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

 

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