A 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<br /> start supine active assisted range of motion at 6 weeks postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> discontinue sling start using arm for light daily activities avoid strenuous activity for 6 months 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 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
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 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 H 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 I 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 J 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 K 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 L 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 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 2 Appropriate medical management and medical consultation 3 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 5 Understand how to avoid /prevent potential complications