Proximal Humerus Fractures Pathway Updated: 10/4/2016
CPT Codes: 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

Shoulder Hemiarthroplasty for Proximal Humerus Fracture

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Preoperative Patient Care
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
 

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