Percutaneous pins, ORIF offer benefits as proximal humerus fracture treatments

Selecting the ideal treatment depends on the patient’s bone condition and the surgeon’s knowledge of various management techniques.

The ideal treatment for proximal humerus fractures can vary from patient to patient, depending on whether a surgeon prefers to use both percutaneous pins or open reduction and internal fixation, as well as the patient’s bone condition. Still, surgeons should be prepared to change methods perioperatively if their initial choice doesn't work.

Gerald R. Williams Jr., MD, who uses both percutaneous pins and open reduction and internal fixation (ORIF), offered some standard guidelines detailing when each option is best at Orthopedics Today New York 2006, A Comprehensive CME Course.

“From my perspective, closed reduction with percutaneous pins is good for young patients with good bone, no medial comminution that will usually represent a 2-part surgical neck fracture or a valgus impacted 4-part fracture, and every now and then we’ll [apply the technique to] a minimally displaced 3-part or 2-part greater tuberosity fracture,” he said.

Indications for open reduction internal fixation (ORIF) include poor bone quality, too much comminution, unattainable closed reduction and, most of the time, a 2-part greater or lesser tuberosity fracture, Williams reported.

Getting good intraoperative X-rays is one of the most important steps to managing proximal humerus fractures.

“X-rays really help intraoperatively [because] these fragments we're working on are all covered with soft tissue that we can't remove. It’s amazing how good [a case] can look in the operating room to your own two eyes but how bad it can look on X-ray, so an intraoperative X-ray is a must for all fracture management,” he said.

Possible complications with percutaneous pins include early pin loosening, avascular necrosis and postop stiffness. Williams also stressed that if surgeons are going to use percutaneous pins, the pins must be cut below the skin.

“If you use the pins around the shoulder ... and if they start moving, take them out so they don't migrate,” he said. “Second, if they come out of the skin, remove them immediately. Don't just put the patient on oral antibiotics and hope it goes away.”

The most important thing when performing ORIF is to know multiple techniques, he said. Surgeons can use blade plates, locking plates, intramedullary rods or sutures in ORIF. Williams prefers to use locking plates, but has seen surgeons use intramedullary rods most often in general use.

For more information:
Williams GR. Proximal humerus fractures - percutaneous pinning vs. ORIF. Presented at the Orthopedics Today New York 2006, A Comprehensive CME Course. Nov. 11-12, 2006. New York.