IM Nailing of 3-4 Part Proximal Humerus Fractures Christopher - - PowerPoint PPT Presentation

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im nailing of 3 4 part proximal humerus fractures
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IM Nailing of 3-4 Part Proximal Humerus Fractures Christopher - - PowerPoint PPT Presentation

Oct 01, 2022 237 likes •846 views

IM Nailing of 3-4 Part Proximal Humerus Fractures Christopher Chuinard MD, MPH Traverse City, MI Disclosures Shoulder Innovations Royalties Consultant Rotation Medical Consultant Research Support Speaker DJO Consultant WMT Patent

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IM Nailing of 3-4 Part Proximal Humerus Fractures

Christopher Chuinard MD, MPH Traverse City, MI

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Disclosures

Shoulder Innovations Royalties Consultant Rotation Medical Consultant Research Support Speaker DJO Consultant WMT Patent Royalties Consultant Research Support

  • Boileau/Hatzidakis

– Royalties for Nail

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What’s Wrong with Treatment of Proximal Humeral Fx?

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Perc Pinning: 62 yo smoker

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Its doable, but hard

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Secondary Surgery

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Plating for 3 & 4 Part Fx

Humeral Head Based Fixation = No or Poor Tuberosity Fixation

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Issues of Plating

Screws parallel to the fracture plane

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AO Biomechanics

  • Screws must be perpendicular to the fx line

(not parallel)…

Screws Parallel to Fx line do not fix tuberosities (AO) Perpendicular Screw Placement

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Issues of Plating

Blood Supply Disruption = Increased Risk of AVN

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3 & 4-Part Fractures

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3 & 4-Part Fractures High Complication Rate

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What’s w rong w ith Current IM Nail Design?

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Too Long & Too Big Not centered in diaphysis

= Malunion

Proximal Bend

= Cuff Tear = Nonunion

Current IM Nails Design

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Issues of Current IM Nail Designs

Humeral Head-based Fixation

No Locking Mechanism

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.

GT GT LT

Humeral Head based fixation

Current IM Nails Design

 Tuberosity migration !

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Do NOT fix the GT !!!...

GT

Current IM Nails

(= Humeral Head screw patterns)

GT Tuberosity Migration = 3 tendons Tear = Shoulder Pseudoparalysis

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Errors of Past Nail Designs

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HH necrosis? GT migration?

3 & 4-Part Fractures

  • r

What is the worst complication for patients?...

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Hemi is the ultimate AVN

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Sadly, Many Hemi’s are Losers

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What’s New w ith Aequalis IM Nail Design?

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New Aequalis Nailing Concept

Head-only Fixation Tuberosity Fixation w/Head Support

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New Aequalis Nailing Concept

Tuberosity Oriented Screw Pattern = Perpendicular to Fx Line

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New Aequalis Nailing Concept

Tuberosity fixation w/Locking Screws Straight, Short, Small Nail

No violation of supraspinatus tendon

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New Aequalis Nailing Concept

Screw Locks in Nail Diaphyseal Centering

Divergence of 0°: Amplitude of motion > 4 mm Divergence of 5°: Amplitude of motion 2,5 mm Divergence of 20°: Amplitude of motion 0,5mm

Proximal screws captured inside the Nail

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I don’t always use a nail, but when I do, it’s an Aequalis

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Percutaneous Approach

Posterior (Neviaser) Portal Anterior Portal

  • P. Boileau

= Varus displacement = Valgus displacement

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Anterior / AC joint

For Translated/valgus deformity (Neviaser portal) for Varus deformity

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3 & 4-PART FRACTURES

Open Superolateral approach

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3 & 4-Part Fractures

Superolateral Approach++

Courtesy : Dr Cuny

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3 & 4-Part Fractures

  • Horizontal Traction of RC Muscles

2 1 4 3

  • Vertical Fracture is POST to the Groove

GT LT

  • P. Boileau
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3 & 4-Part Fractures

Reduction

Lift-up humeral head ‘‘close the book’’ Diaphysis Derotation

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Temporary pining may be needed

3 & 4-Part Fractures

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4-Part Valgus Fracture

GT LT No screws in humeral head needed

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No Humeral Head Fixation Needed

…to get a good result!

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4 Part Fracture Dislocation

12 Months Post-Op

4-Part Fracture Dislocation

Female 27 yo

Courtesy : Dr A. Hatzidakis

calcar screw (head support)

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Take-Home Messages

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IM Locked Nail

Biological advantages Biomechanical advantages

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3 & 4-part Fractures

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Brace in IR IR of diaphysis Brace in NR NR of diaphysis

Whatever the fracture…

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Conclusion: IM Nail

… w ithout the draw backs and complications of either technique!

Benefits of Pinning

(minimal soft-tissue dissection)

& Benefits of Plating

(Locking Technology)

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Hatz 4Part Fx Aequalis IMNCase

Pre-Intra-PostOp XR’s 10/17/10

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Preoperative Radiograph Review

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1st Intraoperative AP View with Traction

Calcar reduces, indicating intact medial periosteal hinge

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AP View after “Head Lift” and Tuberosity “Pull-Down” Near anatomic reduction

  • Humeral head lifted with

Cobb/Periosteal elevator

  • Suture or dental pick placed

in greater tuberosity to pull traction laterally

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Greater Tuberosity Humeral Head Reduction Held with 2.5mm terminally threaded Steinmann Pin

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Placing Guide Pin (For Nail) Insertion

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Nail Insertion Over Guide Pin

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Outlet View

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1st Greater Tuberosity Screw Placed: Fixes tuberosity and supports anteromedial humeral head

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Second Greater Tuberosity Screw

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Final Intraoperative XR’s

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One Week Postoperative Radiographs

Shaft comminution Lesser tuberosity Greater tuberosity

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One Week Postoperative Radiographs

Note early controlled impaction at distal screw, humeral head and greater tuberosity fracture sites

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New Aequalis Nailing Concept

  • Nail: Straight, Small, Short
  • Tuberosity-based Fixation
  • Locked Screws
  • Benefits of minimal tissue

disruption

– Percutaneous approach option – Preserves blood supply – Avoids the complications of plating and traditional nail designs

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Thank You!!!

cchuinard@hotmail.com