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ORIF helps achieve stability of displaced multipart proximal humerus fractures
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Surgical intervention is an option for displaced Neer two-, three-, and four-part fractures in younger active patients and internal fixation with plates has gained increased popularity with the advent of the locking technology. Locked plate technologies have resulted in successful outcomes and biomechanically improved fixation compared to other fixation techniques due to the more ridged fixation in compromised bone. The locked plate functions more like a lever beam and for failure to occur, the entire construct must give way.
Operative treatment can be challenging due to suboptimal bone quality and the naturally deforming forces of the surrounding musculature. The supraspinatus, infraspinatus and teres minor cause posterior and superior displacement of the greater tuberosity. The subscapularis causes medial displacement of the lesser tuberosity and internal rotation of the head in most three-part fractures. The pectoralis major and deltoid cause anterior and superior displacement of the shaft which often results in varus deformity especially in displaced two-part fractures (Figure 1). Heavy sutures can reliably augment tuberosity fixation in patients with poor quality bone to counterbalance the deforming forces of the rotator cuff.
This article describes the operative technique for displaced two-, three- and four-part proximal humerus fractures with suture augmentation. Heavy sutures can assist in fracture fragment manipulation and aids in tuberosity reconstruction. Patient selection is critical for good outcomes after internal fixation. In patients older than 70 years with significant comminution or a history of prior rotator cuff disease arthroplasty may be a better solution if the preferred treatment is surgical.
Patient positioning
Adequate fluoroscopic imaging is crucial to the procedure and an unobstructed view must be verified prior to draping. A standard table is rotated 180° so the patient’s head is now on the foot of the table over the radiolucent foot plate (Figure 2). The patient’s head and torso are elevated approximately 30° with the head supported on a jelly doughnut, taped into place, and torso pulled to the edge of the table. The table is turned 90° to allow the C-arm to be positioned parallel to the patient at the head of the bed. The C-arm is rotated over the top to obtain a direct anteroposterior (AP) view. Once adequate imaging is confirmed, the C-arm can be pulled straight back so as not to interfere with prepping. Once draped, the C-arm can be slipped toward anesthesia between rounds of imaging.
Source: Mark A. Mighell, MD
Approach
A standard deltopectoral approach is utilized. A padded Mayo stand is used to help support the arm in slight abduction, both avoiding the need for an extra assistant and minimizing the tension on the deltoid. The cephalic vein is taken medially with the pectoralis muscle to avoid inadvertent injury during retraction of the deltoid. The Browne deltoid retractor is placed once the subdeltoid space is established. The clavipectoral fascia should be released and the subcoracoid space should be developed. A self-retaining retractor used beneath the conjoined tendon should be avoided due to risk of musculocutaneous neuropraxia. Hematoma can often obscure obvious landmarks, so the biceps tendon is identified deep to the pectoralis tendon where it can easily be palpated to serve as a reference. If the biceps tendon is injured or entrapped in the fracture site, we perform a tenodesis to the upper border of the pectoralis major tendon.
Fracture preparation and reduction
The fracture hematoma and bursal tissue is debrided and the tuberosities are mobilized if these are separate fragments. A primary fracture line usually lies just posterior to the bicipital groove and can be opened to gain access to the head fragment. Heavy composite sutures or tapes are placed at the bone-tendon interface of each tuberosity in a locking Krackow-type fashion, routinely one in the subscapularis followed by at least one in both the supraspinatus and infraspinatus. The anterior stitches are placed first to allow for rotational control and these allow the surgeon to manipulate the fragments to facilitate placement of more posterior sutures.
Anatomic reduction of the head segment is done next with either derotation from an attached lesser tuberosity or utilizing a Key or Cobb elevator to elevate the head. This reduction may be held by placing a K-wire through the head segment into the glenoid (Figure 3). If a large metaphyseal void is encountered due to extensive comminution, a structural bone graft is used. For small voids, corticocancellous bone graft can be used as an alternative. The shaft is then reduced to the proximal segment and the head is provisionally pinned to the shaft to maintain the overall reduction. The bicipital groove can aid in gauging rotation. Placing the pin medial to the bicipital groove in the distal to proximal direction avoids a trajectory toward the brachial plexus and axillary artery and keeps the wire out of the way during plate placement. The tuberosities are then reduced using the traction sutures. If a greater tuberosity segment is present, it also can be pinned by passing a K-wire from the posterolateral edge of the acromion with capture of the tuberosity and fixation into the humeral shaft.
Plate application
The fracture must be anatomically reduced prior to application of the locked plate. Design features that are particularly important are as follows:
- low profile to reduce the risk of overhead impingement on the acromion;
- divergent proximal locking screw options to reduce the risk of pullout and improve head fixation; and
- presence of multiple suture eyelets that facilitate rotator cuff/tuberosity suture attachment to the plate.
The plate is positioned just lateral to the bicipital groove, typically 1 cm to 3 cm distal to the top of the humeral head. A non-locked screw is placed inferiorly in the oblong hole for initial shaft fixation and to allow later distalization of the plate as the tendency is for the plate to initially be placed too high.
A central K-wire is then passed through the plate and into the head to confirm position. Proximal threaded-head screws are then sequentially placed. We prefer to only drill the outer cortex and subsequently place the depth gauge under fluoroscopy to minimize the chances of perforating the articular surface. For younger patients with better bone stock, it may be necessary to use a drill. Superior screws are left shorter, as these are at greater risk for late penetration and may be less important in holding fixation than the more inferior calcar screws, which are aimed toward the stronger inferior posteromedial bone. Once all head screws are placed, the remaining shaft screws are drilled and at least three shaft screws are used (Figures 4 and 5).
Tuberosity fixation
Secure tuberosity fixation is paramount because the deforming forces of the rotator cuff must be neutralized to avoid subsequent displacement and construct failure. The pull of the rotator cuff is counterbalanced by using the previously placed heavy sutures that were placed at the bone-tendon interface to secure the sutures to the plate. Plates that require sutures be passed prior to plate application are less desirable to use than designs that incorporate eyelets or “cleats” that allow for suture passage after the plate is placed and secured (Figure 6). When stable plate fixation has been achieved and the sutures are secured, the patient’s arm is rotated to assure fracture stability. Final fluoroscopic imaging is then obtained. Orthogonal views are reviewed intraoperatively to assure all screws are the appropriate length and none of these are intra-articular.
Postoperative management
Patients are placed in a shoulder immobilizer for 4 weeks and limited to wrist and elbow range of motion only. Formal physical therapy is initiated at 4 to 6 weeks with active range of motion beginning at 8 weeks and strengthening at 12 weeks postoperatively. Follow-up radiographs are obtained at 2, 6, 12 and 24 weeks, and annually for at least 2 years. It is important to monitor patients for hardware complications and late development of avascular necrosis.
- References:
- Badman B, et al. J Shoulder Elbow Surg. 2011;doi:10.1016/j.jse.2010.08.030.
- Duralde XA, et al. J Shoulder Elbow Surg. 2010;doi:10.1016/j.jse.2009.08.008.
- Hepp P, et al. Clin Orthop Relat Res. 2003; doi:10.1097/01.blo.0000092968.12414.a8.
- Ockert B, et al. J Trauma. 2010;doi:10.1097/TA.0b013e3181c9b8a7.
- Padegimas EM, et al. J Shoulder Elbow Surg. 2017doi:10.1016/j.jse.2017.05.003.
- Rose PS, et al. J Shoulder Elbow Surg. 2007;doi:10.1016/j.jse.2006.06.006.
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- For more information:
- Kaitlyn N. Christmas, BS, can be reached at Foundation for Orthopaedic Research and Education, Clinical Research, 13020 Telecom Pkwy. N., Tampa, FL 33637; email: kchristmas@foreonline.org.
- Adam J. Lorenzetti, MD, can be reached at Countryside Orthopaedics, Shoulder & Elbow Service, 19465 Deerfield Ave., Suite 405, Leesburg, VA 20176; email: adam.lorenzetti@gmail.com.
- Mark A. Mighell, MD, can be reached at Florida Orthopaedic Institute, Shoulder Service, 13020 Telecom Pkwy. N., Tampa, FL 33637; email: mmighell@floridaortho.com.
Disclosures: Mighell reports he receives royalties from, is on the speakers bureau of, is a paid consultant for and receives research support from DJO Global; is a paid consultant for, receives research support from and is on the speakers bureau for Stryker; and receives royalties from NewClip Technics. Christmas and Lorenzetti report no relevant financial disclosures.