How to Treat Proximal Humeral Fractures: Pearls to Successful - - PowerPoint PPT Presentation

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Nov 30, 2022 261 likes •508 views

How to Treat Proximal Humeral Fractures: Pearls to Successful Management Brad Parsons, MD Associate Professor and Residency Director Chief, Shoulder Service Icahn School of Medicine at Mount Sinai Conflict of Interest Consultant:

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How to Treat Proximal Humeral Fractures: Pearls to Successful Management

Brad Parsons, MD Associate Professor and Residency Director Chief, Shoulder Service Icahn School of Medicine at Mount Sinai

SLIDE 2

Conflict of Interest

Consultant:

– Arthrex, Inc

SLIDE 3

Spectrum of Challenges

Historically many managed nonoperatively

– “Acceptable outcomes”

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Patient Selection

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Patient Factors

Majority of patients older

– Osteoporotic fracture

Comminution
Challenging ORIF
Historically nonop or Hemi
Weightbearing arms

– Not always “low demand”

Preserve independence?

SLIDE 8

Case 1: 77 y/o female, LHD

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X-Rays Provide the Bulk of Information

APER Outlet Axillary

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CT Can Be Helpful Too

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Beware the Varus Fx

Varus is a problem

– Calcar Comminution – Unstable – Often progresses – Highest rate of hardware failure and cutout

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Valgus Impacted Fracture

Doesn’t fit well into a

classification system

– Lower AVN rate – Special consideration for treatment

– Jakob et al. JBJS. 73B. 1991

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Understanding the Deforming Forces

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Don’t Forget About Version

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Which Fx’s Do I Non-op?

Preserved relationships:

– Preserved head-tuberosity relationship – Minimal varus (tuberosity) – Valgus tolerated better – No block to rotation (version)

Nondominant > dominant
Pt education of outcome

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Surgical Indications/Options

Displaced Fx’s in Active Patients

– Distorted Anatomy

Tub-Head
Head Inclination
Version
Options:

– Fixation

Percutaneous Tx
ORIF with locked plate

– Arthroplasty

Hemi vs. Reverse

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Indications for ORIF

Most Fractures

– 2, 3 and 4-parts – Varus Fx’s – Valgus Impacted

Too late for pinning
Osteoporotic Fxs
Comminution

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Classic Arthroplasty Fx Indications

4 Part Fx-Dislocation
Head Split
Elderly 4-Part/ Some 3-

Part

Some Chronic Situations

– Nonunion – Malunion

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When Do I Do a Hemi?

Younger, unreconstructable (e.g. head split)
Older but good tuberosities (not

comminuted)

Good protoplasm
Physiologic demands

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Indications for Reverse

Elderly patient (> 75)
Poor tuberosity bone

– Comminuted – Osteopenic

Preexisting cuff tear?
Preexisting OA/DJD
Poor protoplasm for

tuberosity healing

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Goal of Surgery: Restore Relationships

Anatomic is Best

– Not always possible – Elderly comminuted fxs

Restore Calcar Integrity

– Bone Contact Key

Tuberosity Relationships

– Restore Inclination – Restore Version

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Conclusions

Most Fx’s can be non-op
Close monitoring:

– Especially varus fx’s

Tuberosity malposition poorly tolerated
Most surgical indications is ORIF
Reverse >> Hemi

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