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Master Techniques in Orthopaedic Surgery®

Fractures

Third Edition

Master Techniques in Orthopaedic Surgery® Fractures Third Edition

MASTER

TECHNIQUES

IN

ORTHOPAEDIC

SURGERY ®

Editor-in-Chief Bernard F. Morrey, MD

Founding Editor Roby C. Thompson Jr, MD

Volume Editors Surgical Exposures Bernard F. Morrey, MD Matthew C. Morrey, MD

The Hand James Strickland, MD Thomas Graham, MD

The Wrist Richard H. Gelberman, MD

The Elbow Bernard F. Morrey, MD

The Shoulder Edward V. Craig, MD

The Spine David S. Bradford, MD Thomas L. Zdeblick, MD

The Hip Robert L. Barrack, MD

Reconstructive Knee Surgery Douglas W. Jackson, MD

Knee Arthroplasty Paul Lotke, MD Jess H. Lonner, MD

The Foot & Ankle Harold B. Kitaoka, MD

Fractures Donald A. Wiss, MD

Pediatrics Vernon T. Tolo, MD David L. Skaggs, MD

Soft Tissue Surgery Steven L. Moran, MD William P. Cooney III, MD

Sports Medicine Freddie H. Fu, MD

Orthopaedic Oncology and Complex Reconstruction Franklin H. Sim, MD Peter F.M. Choong, MD Kristy L. Weber, MD

H. Fu, MD Orthopaedic Oncology and Complex Reconstruction Franklin H. Sim, MD Peter F.M. Choong, MD

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employees are not covered by the above-mentioned copyright. Printed in China Library of Congress

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Library of Congress Cataloging-in-Publication Data Fractures / editor, Donald A. Wiss. — 3rd ed. p. ; cm. — (Master techniques in orthopaedic surgery) Includes bibliographical references and index. ISBN 978-1-4511-0814-9 I. Wiss, Donald A. II. Series: Master techniques in orthopaedic surgery. [DNLM: 1. Fractures, Bone—surgery. 2. Fracture Fixation, Internal— methods. WE 185]

617.1’5—dc23

2012007461

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.

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10 9 8 7 6 5 4 3 2 1

To My Beloved Mother Dorothy Zuckerman Wiss Who Passed Away As This Book Was Going To Press A lasting bond, a quiet trust, a feeling like no other. A gratitude that fills the heart, A son’s love for his mother.

Contents

Contributors

Series Preface

Preface

Acknowledgments

PART I UPPER EXTREMITY

CHAPTER 1

Clavicle Fractures: Open Reduction and Internal Fixation Donald A. Wiss

CHAPTER 2

Scapula Fractures: Open Reduction Internal Fixation Peter A. Cole and Babar Shafiq

CHAPTER 3

Proximal Humeral Fractures: Open Reduction Internal Fixation John T. Gorczyca

CHAPTER 4

Proximal Humerus Fractures: Hemiarthroplasty William H. Paterson and Sumant G. Krishnan

CHAPTER 5

Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Pascal Boileau, Adam P. Rumian, and Xavier Ohl

CHAPTER 6

Humeral Shaft Fractures: Open Reduction Internal Fixation Bruce H. Ziran and Navid M. Ziran

CHAPTER 7

Humeral Shaft Fractures: Intramedullary Nailing James C. Krieg

CHAPTER 8

Distal Humerus Fractures: Open Reduction Internal Fixation Daphne M. Beingessner and David P. Barei

CHAPTER 9

Intra-Articular Fractures of the Distal Humerus: Total Elbow Arthroplasty Elaine Mau and Michael D. McKee

CHAPTER 10

Olecranon Fractures: Open Reduction and Internal Fixation James A. Goulet and Kagan Ozer

CHAPTER 11

Radial Head Fractures: Open Reduction and Internal Fixation David Ring

CHAPTER 12

Forearm Fractures: Open Reduction Internal Fixation Steven J. Morgan

CHAPTER 13

Distal Radius Fractures: External Fixation Neil J. White and Melvin P. Rosenwasser

CHAPTER 14

Distal Radius Fractures: Open Reduction Internal Fixation Andrea S. Bauer and Jesse B. Jupiter

PART II LOWER EXTREMITY

CHAPTER 15

Femoral Neck Fractures: Open Reduction Internal Fixation Dean G. Lorich, Lionel E. Lazaro, and Sreevathsa Boraiah

CHAPTER 16

Femoral Neck Fractures: Hemiarthroplasty and Total Hip Arthroplasty Ross Leighton

CHAPTER 17

Intertrochanteric Hip Fractures: The Sliding Hip Screw Kenneth A. Egol

CHAPTER 18

Intertrochanteric Hip Fractures: Intramedullary Hip Screws Michael R. Baumgaertner and Thomas Fishler

CHAPTER 19

Intertrochanteric Hip Fractures: Arthroplasty George J. Haidukewych and Benjamin Service

CHAPTER 20

Subtrochanteric Femur Fractures: Plate Fixation Michael J. Beltran and Cory A. Collinge

CHAPTER 21

Subtrochanteric Femur Fractures: Intramedullary Nailing Clifford B. Jones

CHAPTER 22

Femur Fractures: Antegrade Intramedullary Nailing Christopher G. Finkemeier, Rafael Neiman, and Frederick Tonnos

CHAPTER 23

Femoral Shaft Fractures: Retrograde Nailing Robert F. Ostrum

CHAPTER 24

Distal Femur Fractures: Open Reduction and Internal Fixation Brett D. Crist and Mark A. Lee

CHAPTER 25

Patella Fractures: Open Reduction Internal Fixation Matthew R. Camuso

CHAPTER 26

Knee Dislocations James P. Stannard

CHAPTER 27

Tibial Plateau Fractures: Open Reduction Internal Fixation J. Tracy Watson

CHAPTER 28

Extra-Articular Proximal Tibial Fractures: Submuscular Locked Plating Mark A. Lee and Brad Yoo

CHAPTER 29

Tibial Shaft Fractures: Intramedullary Nailing Daniel S. Horwitz and Erik Noble Kubiak

CHAPTER 30

Tibial Shaft Fractures: Taylor Spatial Frame J. Charles Taylor

CHAPTER 31

Tibial Pilon Fractures: Staged Internal Fixation David P. Barei and Daphne M. Beingessner

CHAPTER 32

Tibial Pilon Fractures: Tensioned Wire Circular Fixation James J. Hutson Jr.

CHAPTER 33

Ankle Fractures Rena L. Stewart and Jason A. Lowe

CHAPTER 34

Talus Fractures: Open Reduction Internal Fixation Paul T. Fortin and Patrick J. Wiater

CHAPTER 35

Calcaneal Fractures: Open Reduction Internal Fixation Michael P. Clare and Roy W. Sanders

CHAPTER 36

Tarsometatarsal Lisfranc Injuries: Evaluation and Management Bruce J. Sangeorzan, Kyle F. Chun, Stephen K. Benirschke, and Benjamin W. Stevens

CHAPTER 37

Pelvic Fractures: External Fixation Enes M. Kanlic and Amr A. Abdelgawad

CHAPTER 38

Diastasis of the Symphysis Pubis: Open Reduction Internal Fixation David C. Templeman and Matthew D. Karam

CHAPTER 39

Posterior Pelvic-Ring Disruptions: Iliosacral Screws Milton L. Chip Routt Jr

CHAPTER 40

Sacral Fractures Jodi Siegel and Paul Tornetta III

CHAPTER 41

Acetabular Fractures: The Kocher-Langenbeck Approach Berton R. Moed

CHAPTER 42

Acetabular Fractures: Ilioinguinal Approach Joel M. Matta, Mark C. Reilly, and Hamid R. Redjal

CHAPTER 43

Acetabular Fractures: Extended Iliofemoral Approach David L. Helfet, Milan K. Sen, Craig S. Bartlett, Nicholas Sama, and Arthur L. Malkani

CHAPTER 44

Surgical Dislocation of the Hip for Fractures of the Femoral Head Milan K. Sen and David L. Helfet

CHAPTER 45

Periprosthetic Fractures: Evaluation and Management Guy D. Paiement

CHAPTER 46

Soft-Tissue Coverage: Gastrocnemius and Soleus Rotational Muscle Flaps Randy Sherman and Wai-Yee Li

Index

CHAPTER 46 Soft-Tissue Coverage: Gastrocnemius and Soleus Rotational Muscle Flaps Randy Sherman and Wai-Yee Li Index

Contributors

Amr A. Abdelgawad, M.D.

Assistant Professor Department of Orthopaedic Surgery and Rehabilitation Texas Tech University Health Sciences Center in El Paso El Paso, Texas

David P. Barei, M.D., F.R.C.S.C.

Associate Professor Department of Orthopaedic Surgery University of Washington Orthopaedic Traumatology Harborview Medical Center Seattle, Washington

Craig S. Bartlett III, M.D.

Associate Professor of Orthopaedics Medical Director of Orthopaedic Trauma The University of Vermont Burlington, Vermont

Andrea S. Bauer, M.D.

Orthopaedic Surgeon Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, Massachusetts

Michael R. Baumgaertner, M.D.

Professor Department of Orthopaedics and Rehabilitation Yale University School of Medicine Chief, Orthopaedic Trauma Service Yale—New Haven Hospital New Haven, Connecticut

Daphne M. Beingessner, B.Math, B.Sc, M.Sc, M.D., F.R.C.S.C.

Associate Professor Department of Orthopaedics University of Washington Orthopaedic Traumatology Harborview Medical Center Seattle, Washington

Michael J. Beltran, M.D.

Chief Resident Orthopaedic Surgery San Antonio Military Medical Center San Antonio, Texas

Stephen K. Benirschke, M.D.

Professor Department of Orthopaedics University of Washington Harborview Medical Center Seattle, Washington

Pascal Boileau, M.D.

Head Department of Orthopaedics Department of Orthopaedics and Sports Traumatology

University of Nice-Sophia-Antipolis Nice, France

Sreevathsa Boraiah, M.D.

Westchester Medical Center Valhalla, New York

Matthew R. Camuso, M.D.

Orthopaedic Trauma and Fracture Care Maine Medical Center Portland, Maine

Kyle F. Chun, M.D.

Resident Department of Orthopaedics and Sports Medicine University of Washington Harborview Medical Center Seattle, Washington

Michael P. Clare, M.D.

Director of Fellowship Education Foot and Ankle Fellowship Florida Orthopaedic Institute Tampa, Florida

Peter A. Cole, M.D.

Chief of Orthopaedic Surgery Regions Hospital Professor University of Minnesota St. Paul, Minnesota

Cory A. Collinge, M.D.

Director of Orthopaedic Trauma

Harris Methodist Fort Worth Hospital Clinical Staff John Peter Smith Hospital Fort Worth, Texas

Brett D. Crist, M.D., F.A.C.S.

Associate Professor Co-Director, Orthopaedic Trauma Service Co-Director, Orthopaedic Trauma Fellowship Associate Director, Joint Preservation Service Department of Orthopaedic Surgery University of Missouri Columbia, Missouri

Kenneth A. Egol, M.D.

Professor and Vice Chairman Department of Orthopaedic Surgery NYU Hospital for Joint Diseases Langone Medical Center New York, New York

Christopher G. Finkemeier, M.D., M.B.A.

Co-director Orthopaedic Trauma Surgeons of Northern California Granite Bay, California

Thomas Fishler, M.D.

Instructor Department of Orthopaedics and Rehabilitation Yale University School of Medicine New Haven, Connecticut

Paul T. Fortin, M.D.

Associate Professor

Oakland University School of Medicine William Beaumont Hospital Royal Oak, Michigan

John T. Gorczyca, M.D.

Professor Chief, Division of Orthopaedic Trauma Department of Orthopaedics and Rehabilitation University of Rochester Medical Center Rochester, New York

James A. Goulet, M.D.

Professor of Orthopaedic Surgery The University of Michigan Medical School The University of Michigan Health System Ann Arbor, Michigan

George J. Haidukewych, M.D.

Professor of Orthopaedic Surgery University of Central Florida Academic Chairman and Chief Orthopaedic Trauma and Adult Reconstruction Orlando Health Orlando, Florida

David L. Helfet, M.D.

Professor of Orthopaedic Surgery Weill Medical College of Cornell University Director, Orthopaedic Trauma Service Hospital for Special Surgery/New York-Presbyterian Hospital New York, New York

Daniel S. Horwitz, M.D.

Chief, Orthopaedic Trauma

Geisinger Health Systems Danville, Pennsylvania

James J. Hutson Jr., M.D.

Orthopaedic Surgeon Orthopaedic Trauma Department of Orthopaedics and Rehabilitation University of Miami Miami, Florida

Clifford B. Jones, M.D.

Clinical Professor Michigan State University Orthopaedic Associates of Michigan Grand Rapids, Michigan

Jesse B. Jupiter, M.D.

Hansjorg Wyss/AO Professor Harvard Medical School Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts

Enes M. Kanlic, M.D., F.A.C.S.

Professor Department of Orthopaedic Surgery and Rehabilitation Texas Tech University Health Sciences Center in El Paso El Paso, Texas

Matthew D. Karam, M.D.

Clinical Assistant Professor Department of Orthopaedics and Rehabilitation University of Iowa Hospitals and Clinics Iowa City, Iowa

James C. Krieg, M.D.

Associate Professor Department of Orthopaedics and Sports Medicine University of Washington Harborview Medical Center Seattle, Washington

Sumant G. Krishnan, M.D.

Director Shoulder Fellowship Baylor University Medical Center Attending Orthopaedic Surgeon Shoulder Service The Carrell Clinic Dallas, Texas

Erik Noble Kubiak, M.D.

Assistant Professor Department of Orthopaedics University of Utah Salt Lake City, Utah

Lionel E. Lazaro, M.D.

Orthopaedic Surgeon Orthopaedic Trauma Service Weill Medical College of Cornell University Hospital for Special Surgery and New York-Presbyterian Hospital New York, New York

Mark A. Lee, M.D.

Associate Professor Department of Orthopaedic Surgery Director Orthopaedic Trauma Fellowship

University of California, Davis Sacramento, California

Ross Leighton, M.D.

Professor of Surgery QEII Health Sciences Centre Dalhousie University Halifax, Nova Scotia, Canada

Wai-Yee Li, M.D., Ph.D.

Plastic Surgical Resident University of Southern California Los Angeles, California

Dean G. Lorich, M.D.

Chief Department of Orthopaedics at New York-Presbyterian Associate Director Orthopaedic Trauma Service at Hospital for Special Surgery Associate Professor of Orthopaedic Surgery Weill Cornell Medical Center New York, New York

Jason A. Lowe, M.D.

Assistant Professor Orthopaedic Trauma Surgery Director Fragility Fracture Program Department of Orthopaedic Surgery University of Alabama at Birmingham Birmingham, Alabama

Arthur L. Malkani, M.D.

Orthopaedic Trauma Surgeon

Chief of Adult Reconstruction Service Professor of Orthopaedic Surgery Department of Orthopaedics University of Louisville School of Medicine Department of Orthopaedic Surgery The University of Louisville Louisville, Kentucky

Joel M. Matta, M.D.

Founder and Director Hip and Pelvis Institute at St. John’s Health Center Santa Monica, California

Elaine Mau, M.D., M.Sc.

Resident Division of Orthopaedic Surgery University of Toronto St. Michael’s Hospital Toronto, Ontario, Canada

Michael D. McKee, M.D. F.R.C.S. (C)

Professor of Orthopaedic Surgery Division of Orthopaedic Surgery University of Toronto St. Michael’s Hospital Toronto, Ontario, Canada

Berton R. Moed, M.D.

Professor and Chairman Department of Orthopaedic Surgery Saint Louis University School of Medicine Saint Louis, Missouri

Steven J. Morgan, M.D.

Mountain Orthopaedic Trauma Surgeons Swedish Medical Center Englewood, Colorado

Rafael Neiman, M.D.

Co-director Orthopaedic Trauma Surgeons of Northern California Roseville, California

Xavier Ohl, M.D.

Orthopaedic Surgeon Department of Orthopaedics and Sports Traumatology L’Archet 2 Hospital Nice, France

Robert F. Ostrum, M.D.

Director of Orthopaedic Trauma Cooper University Hospital Professor Department of Surgery Cooper Medical School of Rowan University Camden, New Jersey

Kagan Ozer, M.D.

Clinical Associate Professor of Orthopaedic Surgery The University of Michigan Medical School The University of Michigan Health System Ann Arbor, Michigan

Guy D. Paiement, M.D.

Residency Director for Orthopaedic Surgery Cedars-Sinai Medical Center Los Angeles, California

William H. Paterson, M.D.

Orthopaedic Surgeon Shoulder Service The Carrell Clinic Dallas, Texas

Hamid R. Redjal, M.D.

Fellow Hip and Pelvis Institute St. John’s Medical Center Santa Monica, California

Mark C. Reilly, M.D.

Assistant Professor of Orthopaedics Co-Chief, Orthopaedic Trauma Service University of Medicine & Dentistry of New Jersey New Jersey Medical School Newark, New Jersey

David Ring, M.D.

Associate Professor of Orthopaedic Surgery Harvard Medical School Director of Research Hand and Upper Extremity Service Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts

Melvin P. Rosenwasser, M.D.

Robert E. Carroll Professor of Orthopaedic Surgery Columbia University College of Physicians and Surgeons Director, Orthopaedic Trauma Service New YorkPresbyterian Hospital Director, Hand and Microvascular Service

New York-Presbyterian Hospital New York, New York

Milton L. Chip Routt Jr., M.D.

Professor of Orthopaedic Surgery University of Washington Harborview Medical Center Seattle, Washington

Adam P. Rumian, M.D., F.R.C.S.(Tr&Orth)

Consultant Orthopaedic Surgeon Department of Trauma and Orthopaedics East and North Hertfordshire NHS Trust Hertfordshire, England

Nicholas Sama, M.D.

Orthopaedic Trauma Surgeon Center for Bone & Joint Surgery of the Palm Beaches Royal Palm Beach, Florida Hospital for Special Surgery New York, New York

Roy W. Sanders, M.D.

Chief, Department of Orthopaedics Tampa General Hospital Director, Orthopaedic Trauma Services Florida Orthopaedic Institute Clinical Professor of Orthopaedic Surgery University of South Florida Tampa, Florida

Bruce J. Sangeorzan, M.D.

Professor University of Washington

Harborview Medical Center Seattle, Washington

Milan K. Sen, M.D., F.R.C.S.C.

Chief Orthopaedic Trauma Service Department of Orthopaedic Surgery The University of Texas Health Science Center at Houston Houston, Texas

Benjamin Service, M.D.

Orthopaedic Resident

Orlando Health

Orlando, Florida

Babar Shafiq, M.D.

Director of Orthopaedic Trauma Howard University Hospital Washington, District of Columbia

Randy Sherman, M.D.

Vice Chair Department of Surgery Cedars Sinai Medical Center Los Angeles, California

Jodi Siegel, M.D.

Assistant Professor Department of Orthopaedics University of Massachusetts Medical School UMass Memorial Medical Center Worcester, Massachusetts

James P. Stannard, M.D.

J. Vernon LuckSr. Distinguished Professor & Chairman Department of Orthopaedic Surgery University of Missouri Columbia, Missouri

Benjamin W. Stevens, M.D.

Springfield Clinic Springfield, Illinois

Rena L. Stewart, M.D., F.R.C.S.(C)

Associate Professor, Orthopaedic Surgery Chief, Section of Orthopaedic Trauma Division of Orthopaedics Department of Surgery University of Alabama at Birmingham Birmingham, Alabama

J. Charles Taylor, M.D.

Orthopaedic Surgeon Specialty Orthopaedics, P.C. Memphis, Tennessee

David C. Templeman, M.D.

Associate Professor of Orthopaedic Surgery University of Minnesota Department of Orthopaedic Surgery Hennepin County Medical Center Minneapolis, Minnesota

Frederick Tonnos, D.O.

Assistant Clinical Professor Michigan State University East Lansing, Michigan

Sutter Rosevale Medical Center Roseville, California Mercy San Juan Medical Center Carmichael, California

Paul Tornetta III, M.D.

Professor and Vice Chairman Department of Orthopaedic Surgery Director of Orthopaedic Trauma Boston, Massachusetts

J. Tracy Watson, M.D.

Professor of Orthopaedic Surgery Chief, Orthopaedic Traumatology Department of Orthopaedic Surgery St. Louis University School of Medicine Saint Louis, Missouri

Neil J. White, M.D., F.R.C.S.(C)

Fellow, Hand and Microvascular Service New York-Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, New York

Patrick J. Wiater, M.D.

Attending Orthopaedic Surgeon Department of Orthopaedic Surgery William Beaumont Hospital Beverly Hills, Michigan

Donald A. Wiss, M.D.

Director of Orthopaedic Trauma Cedars-Sinai Medical Center Los Angeles, California

Brad Yoo, M.D.

Assistant Professor Department of Orthopaedic Surgery University of California, Davis Sacramento, California

Bruce H. Ziran, M.D.

Director, Orthopaedic Trauma Orthopaedic Surgery Residency Program Atlanta Medical Center Atlanta, Georgia

Navid M. Ziran, M.D.

Orthopaedic Surgeon Department of Orthopaedic Surgery Santa Clara Valley Medical Center San Jose, California

Series Preface

Since its inception in 1994, the Master Techniques in Orthopaedic Surgery series has become the gold standard for both physicians in training and experienced surgeons. Its exceptional success may be traced to the leadership of the original series editor, Roby Thompson, whose clarity of thought and focused vision sought “to provide direct, detailed access to techniques preferred by orthopaedic surgeons who are recognized by their colleagues as ‘masters’in their specialty,” as he stated in his series preface. It is personally very rewarding to hear testimonials from both residents and practicing orthopaedic surgeons on the value of these volumes to their training and practice. A key element of the success of the series is its format. The effectiveness of the format is reflected by the fact that it is now being replicated by others. An essential feature is the standardized presentation of information replete with tips and pearls shared by experts with years of experience. Abundant color photographs and drawings guide the reader through the procedures step-by-step. The second key to the success of the Master Techniques series rests in the reputation and experience of our volume editors. The editors are truly dedicated “masters” with a commitment to share their rich experience through these texts. We feel a great debt of gratitude to them and a real responsibility to maintain and enhance the reputation of the Master Techniques series that has developed over the years. We are proud of the progress made in formulating the third edition volumes and are particularly pleased with the expanded content of this series. Six new volumes will soon be available covering topics that are exciting and relevant to a broad cross section of our profession. While we are in the process of carefully expanding Master Techniques topics and editors, we are committed to the now-classic format. The first of the new volumes is Relevant Surgical Exposures, which I have had the honor of editing. The second new volume is Essential Procedures in

Pediatrics. Subsequent new topics to be introduced are Soft Tissue Reconstruction, Management of Peripheral Nerve Dysfunction, Advanced Reconstructive Techniques in the Joint, Sports Medicine, and Orthopaedic Oncology and Complex Reconstruction. The full library thus will consist of 16 useful and relevant titles. I am pleased to have accepted the position of series editor, feeling so strongly about the value of this series to educate the orthopaedic surgeon in the full array of expert surgical procedures. The true worth of this endeavor will continue to be measured by the ever-increasing success and critical acceptance of the series. I remain indebted to Dr. Thompson for his inaugural vision and leadership, as well as to the Master Techniques volume editors and numerous contributors who have been true to the series style and vision. As I indicated in the preface to the second edition of The Hip volume, the words of William Mayo are especially relevant to characterize the ultimate goal of this endeavor: “The best interest of the patient is the only interest to be considered.” We are confident that the information in the expanded Master Techniques offers the surgeon an opportunity to realize the patient-centric view of our surgical practice.

Bernard F. Morrey, MD

offers the surgeon an opportunity to realize the patient-centric view of our surgical practice. Bernard F.

Preface

American medicine remains in the midst of a profound and wrenching transformation. The government, the insurance industry, Wall Street, and patients have demanded improved medical care at lower cost. Better medicine (orthopaedics) occurs when doctors practice medicine consistently on the basis of the best scientific evidence available, set up systems to measure performance, analyze results and outcomes, and make this information widely available to patients and the public. Reduced costs have been achieved partly through a wholesale shift to health maintenance organizations, capitation, and managed care. Trauma is a complex problem where initial decisions often dramatically determine the ultimate outcome. Death, deformity, and medicolegal entanglements may follow vacillation and error. When treatment is approached with confidence, planning, and technical skill, the associated mortality rate, preventable complications, permanent damage, and economic loss may be significantly reduced. Uncertainty, inactivity, and inappropriate intervention by physicians are all detrimental to patient care. Certain traditional concepts and fixation techniques need to be abandoned and new approaches learned. This text attempts to address society’s mandate to our profession: better orthopaedics at reduced cost. It provides both residents and practitioners with surgical approaches to 46 common but often problematic fractures that, when correctly done, have proven to be safe and effective. It is my hope that the third edition of this textbook remains a valuable fixture in the catalog of literature on fracture management.

Donald A. Wiss, M.D.

Acknowledgments

The modern scientific world is drowning in information. We have more data than we can possibly use or absorb in our professional lifetimes. There is an avalanche of scientific journals, books, videos, and CME courses competing for our attention. The Internet has allowed anyone with a computer to search the World Wide Web for virtually any topic in any field including orthopaedics and fracture care. So why another textbook about fractures? First, the tremendous success of the two previous editions of this text is strong testimony to the fact that students, house-staff, and practicing orthopaedic surgeons still desire a highly organized, informative, and readable textbookto guide treatment of patients with difficult fractures. Second, our specialty continues to relentlessly change in terms of imaging modalities, reduction techniques, and fixation devices. Thus a third edition was undertaken to fill these perceived needs. My role as Editor is to extract meaning from reams of data, yet remain selectively and self-consciously blind knowing what to ignore, what is extraneous, and what is critical to improve our knowledge base. I could not have devoted 30 years of my life to the study of fractures and nonunions without a passion for this problem and the lessons they offer patient care. I have spent thousands of hours reading, studying, attending courses, reviewing cases, analyzing data, and of course operating, trying to understand fracture management. No sane person would devote such labor, let alone so much of one’s life to the pursuit of questions that did not touch one’s heart and soul while stimulating the mind. The third edition of Master Techniques in Orthopaedic Surgery: Fractures was 2 years in the making. Anyone undertaking such a work will incur debts of gratitude to a number of people who worked on the project with considerable commitment and little public recognition. I am enormously grateful to my wife Deborah for her unwavering support and love while working on this project often in the evenings and weekends “stealing” our precious family time.

In a textbook on surgical techniques, the illustrations and artwork take on primary significance. I am particularly appreciative of the masterful work of the book’s medical illustrator, Bernie Kida. His knowledge of musculoskeletal anatomy, beautiful illustrations, and experience provided a crucial visual correlation with the text, often allowing a near operating room experience. I would like to acknowledge and extend my gratitude to Pamela Swan, my Practice coordinator of 20 plus years. She assisted me with the manuscript preparation for virtually every chapter in the book during the inevitable revision process. This book would have been considerably more difficult without her editorial and organizational talents. Special thanks are due to Eileen Wolfberg, the contact person between the authors, myself, and publisher. For the record, Eileen has worked with me on all three editions of the Master Techniques in Orthopaedic Surgery: Fracture text. Her 30 years of experience in the publishing field and previous professional relationships with many of the contributors to the bookmade for an unbelievably smooth transition. Eileen, I could not have done this book without you! The contributions of Elise Paxson, Robert Hurley, Brian Brown, and the entire publishing team at Wolters-Kluwer were crucial to the success of this project. I am particularly indebted to Robert Hurley who “adjusted the budget” to make this such a beautiful book. Finally, my heartfelt thanks and appreciation to the each of the contributing authors who answered the “bell” once again with yet another academic request for their precious time. Their willingness to share their considerable expertise and to explain the details and nuances of fracture care will unequivocally benefit orthopaedic surgeons everywhere who treat patients with musculoskeletal trauma.

Donald A. Wiss, M.D. Editor

PART I

UPPER EXTREMITY

PART I UPPER EXTREMITY

1 Clavicle Fractures: Open Reduction and Internal Fixation

Donald A. Wiss

INTRODUCTION

Clavicle fractures are common injuries and account for approximately 35% to 40% of fractures in the shoulder region. Most occur in the midshaft, and the majority are treated nonoperatively. Nonsurgical management of this injury was based on historic, retrospective, surgeon, or radiographic studies that equated union with success. These early studies concluded that the residual shoulder deformity was primarily cosmetic and that shoulder and upper limb function were satisfactory. In the past 15 years, there has been a paradigm shift in the evaluation and treatment of clavicle fractures because contemporary studies have reported that nonoperative treatment of widely displaced fractures in adults is associated with persistent anatomical deformity, residual shoulder pain and weakness, and subtle neurologic impairment. Furthermore, recent randomized clinical trials comparing nonoperative with surgical treatment of widely displaced clavicle fractures in adults have shown a 15% rate of nonunion and symptomatic malunion, respectively, in nonoperatively treated patients. These newer studies also used patient-oriented limb-specific outcome measures such as the Constant, Dash, or ASES scores and demonstrated statistically significant improvement in validated patient outcome measures following internal fixation. These studies lend support for the use of internal fixation in selected patients with widely displaced clavicle fractures in adults to decrease the incidence of nonunion and malunion. Surgery has proven to be safe and effective with the most common complication being prominent hardware necessitating removal.

Most classification schemes for clavicle fractures divide them into three basic categories. Group I are middle third fractures, Group II are lateral third fractures, and Group III are medial fractures. Neer et al. further subdivided Group II fractures into three distinct subgroups based on associated soft-tissue and ligamentous injuries. In type I injuries, the coracoclavicular ligaments remain intact; in type II injuries, this ligamentous complex is disrupted allowing superior displacement of the lateral fragment; and type III injuries that involve the articular surface of the acromial-clavicular joint. Several epidemiological studies show that approximately 80% of all clavicle fractures occur in the middle one-third, 15% in the lateral third, and only 5% occur medially. The AO/OTA classification of clavicle fractures is seen in Figure 1.1.

FIGURE 1.1 AO/OTA classification of clavicle fractures. ANATOMY A thorough knowledge of the osseous, soft-tissue,

FIGURE 1.1 AO/OTA classification of clavicle fractures.

ANATOMY

A thorough knowledge of the osseous, soft-tissue, and neurovascular

anatomy of the shoulder is important if surgery is planned. The clavicle is an

S-shaped bone and has an anterior convex to concave curvature when

viewed from medial to lateral. The lateral end of the clavicle flattens while

the medial end remains cylindrical. The midportion is densely cortical with

a short and narrow medullary canal particularly in young adults (Fig. 1.2). Laterally, the clavicle is anchored to the scapula by the relatively weak acromioclavicular ligaments and the more robust coracoclavicular ligaments (conoid and trapezoid). Medially, the clavicle articulates with the sternum and is supported by the thick and strong sternoclavicular, costoclavicular, and interclavicular ligaments. Although the clavicle is predominately a subcutaneous structure, the deltoid muscle arises from the

anterior-inferior portion of the lateral clavicle while the trapezius muscle arises posterior and superior in its midportion. Several other upper limb muscles take all or part of their origin from the clavicle including the subclavius, sternocleidomastoid, and pectoralis major (Fig. 1.3).

sternocleidomastoid, and pectoralis major (Fig. 1.3 ). FIGURE 1.2 The clavicle viewed from above. Note the

FIGURE 1.2 The clavicle viewed from above. Note the S-shaped anatomy of the bone.

FIGURE 1.3 Frontal view of the clavicle and associated soft-tissue structures. From a mechanical point

FIGURE 1.3 Frontal view of the clavicle and associated soft-tissue structures.

From a mechanical point of view, the clavicle functions as a strut between the shoulder girdle and the thorax, and it suspends the upper limb from the chest wall. The clavicle also provides significant protection to the subclavian vessels and the brachial plexus that lie in close proximity (Fig. 1.4).

FIGURE 1.4 Cross section of the anterior chest wall showing the relationship of the subclavian

FIGURE 1.4 Cross section of the anterior chest wall showing the relationship of the subclavian vessels to the clavicle.

INDICATIONS

AND

CONTRAINDICATIONS

FOR

SURGERY

Most clavicle fractures in adults are managed nonoperatively. Nonsurgical treatment is indicated when fracture displacement is <12 to 15 mm, angulation is <10 degrees, and translation is less than a bone diameter. Treatment consists of support for the upper extremity in a sling, shoulder immobilizer, or figure-of-eight _​clavicle strap to relieve pain. In adolescents, teens, and young adults, a figure-of-eight sling is simple and well tolerated. In adults, a sling or shoulder immobilizer is usually preferred. These treatment methods will not “reduce” a clavicle fracture; rather, they are intended to support the upper limb during the healing process. Within 2 to 3 weeks, most patients are able to remove their sling for simple activities of

daily living, bathing, and hygiene. Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. External support is discontinued when the patient has minimal pain and x-rays show progressive healing. Return to activities is dictated by local symptoms. Most patients can return to full activities by 12 weeks if the fracture is healed. Until the turn of this century, the indications for internal fixation of clavicle fractures were very limited. Most major orthopedic textbooks supported surgery for open fractures, those with vascular compromise or progressive neurologic deficits, as well as in patients with scapulothoracic dissociation, or displaced pathologic fractures. Not surprisingly, these conditions represent a small minority of clavicle fractures seen in clinical practice. Current indications for clavicular surgery, based on recent randomized clinical trials, support the use of internal fixation in adults when there is shortening, displacement, or translation >15 to 20 mm (Fig. 1.5). Other strong indications for clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus, displaced group 2 type 2 lateral clavicle fractures, and symptomatic nonunion (Fig. 1.6).

clavicle fractures, and symptomatic nonunion (Fig. 1.6 ). FIGURE 1.5 X-ray of the clavicle showing a

FIGURE 1.5 X-ray of the clavicle showing a widely displaced fracture following a dirt bike accident. This is a strong indication for internal fixation.

FIGURE 1.6 Radiograph of the clavicle showing a displaced Group II Type II distal clavicle

FIGURE 1.6 Radiograph of the clavicle showing a displaced Group II Type II distal clavicle fracture. This fracture pattern has a high incidence of delayed union and nonunion and is another indication for surgery.

PREOPERATIVE EVALUATION

History and Physical Examination

Most clavicle fractures occur following a fall onto the upper extremity or by direct trauma to the shoulder region. Due to pain and inability to comfortably move the extremity, most patients are seen in an emergency room shortly after injury. In patients with clavicle fractures that occur following high-energy trauma such as motor vehicle, motorcycle, or a fall from a height, a full trauma workup is essential. As with all injured patients, a detailed history and thorough physical exam are necessary to accurately diagnose and treat the patient. Substantial trauma to the shoulder girdle can be associated with injuries to anatomically adjacent structures such as the head, cervical spine, chest wall, ribs, and lungs. In these patients, advanced imaging studies and consultation with other medical or surgical specialists may be required. Most patients with clavicle fractures complain of shoulder or clavicle pain that is exacerbated by movement. Physical examination reveals swelling,

tenderness along the clavicle, fracture crepitus, and deformity in displaced fractures. Ecchymosis in the supraclavicular infraclavicular or chest wall often takes 12 to 36 hours to develop (Fig. 1.7). In isolated shaft fractures, active range of shoulder motion is reduced while gentle passive motion is uncomfortable but usually tolerated. With displaced fractures, a clinical deformity is often obvious. The proximal fragment usually displaces upward and may tent the skin. The shoulder girdle is shortened and droops downward and forward. When viewed from the back, the scapula appears prominent or “winged.” Due to the close proximity of the clavicle to the subclavian vessels and brachial plexus, a careful neurologic and vascular examination must be performed and documented.

FIGURE 1.7 Clinical appearance of the shoulder and chest wall following a motorcycle accident that

FIGURE 1.7 Clinical appearance of the shoulder and chest wall following a motorcycle accident that fractured the clavicle.

Imaging Studies

A simple AP and oblique x-ray of the clavicle will confirm the diagnosis of fracture in the vast majority of cases. To obtain an accurate evaluation of the fragment position, two projections of the clavicle are typically obtained:

anterior-posterior view and a (25 to 45 degrees) cephalic tilt view. The AP view should include the upper third of the humerus, the shoulder girdle, and

the upper lung fields, so that other fractures or a pneumothorax can be identified. In the AP view, the proximal fragment is typically displaced superiorly and posteriorly, while the distal fragment is inferior, shortened, and internally rotated. The cephalic tilt view brings the clavicle and acromial-clavicular joint away from the overlying bony anatomy. CT and MRI scans may be useful in sternoclavicular fractures and dislocations but are rarely necessary for diaphyseal fractures.

Treatment Paradigm

Most clavicle fractures in adults are managed nonoperatively. Nonsurgical treatment is indicated when fracture displacement is <12 to 15 mm, angulation is under 10 degrees, and translation is less than a bone diameter. Treatment consists of support for the upper extremity in a sling, shoulder immobilizer, or figure-of-eight clavicle strap to relieve pain. In adolescents, teens, and young adults, a figure-of-eight sling is simple and well tolerated. In adults, a sling or shoulder immobilizer is usually preferred. These treatment methods will not “reduce” a clavicle fracture; rather, they are intended to support the upper limb during the healing process. Within 2 to 3 weeks, most patients are able to remove their sling for simple activities of daily living, bathing, and hygiene. Serial radiographs usually show some callus by 3 weeks and substantial healing by 6 to 8 weeks. External support is discontinued when the patient has minimal pain and x-rays show progressive healing. Return to activities is dictated by local symptoms. Most patients can return to full activities by 12 weeks if the fracture is healed. Until the turn of this century, the indications for internal fixation of clavicle fractures were very limited. Most major orthopedic textbooks supported surgery for open fractures, those with vascular compromise or progressive neurologic deficits, as well as in patients with scapulothoracic dissociation, or displaced pathologic fractures. Not surprisingly, these conditions represent a small minority of clavicle fractures seen in clinical practice. Current indications for clavicular surgery, based on recent randomized clinical trials, support the use of internal fixation in adults when there is shortening, displacement, or translation <15 to 20 mm. Other strong indications for clavicular surgery include complex ipsilateral injuries to the scapula or proximal humerus, displaced group 2 type 2 lateral clavicle fractures, and symptomatic nonunion.

Timing of Surgery

Whereas open clavicle fractures, and those with neurovascular compromise require immediate treatment, the vast majority of closed displaced fractures that require surgery can be done electively during the first week after injury. Patients with other injuries that require early surgery and who remain hemodynamically stable may benefit from early internal fixation. However, in most seriously injured patients with a displaced clavicle fracture, internal fixation should be delayed until the patient’s condition has been optimized.

Surgical Tactic

There are two methods of internal fixation for clavicle fractures:

intramedullary nailing and plate osteosynthesis. The rationale for intramedullary nailing is the relative ease of the procedure with minimal soft-tissue stripping leading to high rates of union and favorable functional outcomes. However, the S-shape curve in the clavicle, its small medullary canal, and the presence of fracture comminution limit its use. By far, the most common method of treatment for displaced clavicle fractures in adults is plate fixation. With this method of treatment, stable internal fixation with restoration of length, rotation, and alignment can be achieved allowing early range of shoulder motion and rehabilitation of the upper limb. Furthermore, recent advances in internal fixation using locking plate designs may also improve results. Most manufacturers now make contoured clavicle-specific plates, which further improve reduction and fixation (Fig. 1.8).

Most manufacturers now make contoured clavicle-specific plates, which further improve reduction and fixation (Fig. 1.8 ).

FIGURE 1.8 Synthes (Paoli, PA) precontoured clavicle plates.

SURGICAL TECHNIQUE

Setup, Positioning, Prep, and Drape

Before the patient is brought into the surgical suite, the operating table is rotated 180 degrees so that the patient’s head is at the foot of the table. This provides more space to accommodate the C-arm image intensifier, which is brought in from the opposite side of the table. Due to significant swelling and skeletal distortion, regional anesthesia is not recommended. Surgery is routinely done utilizing general anesthesia with an endotracheal tube or a laryngeal mask airway, which is taped to the patient on the side opposite the fracture. In my experience, surgery is greatly facilitated by the use of a Mayfield neurosurgical headrest (Fig. 1.9). The patient and the headrest are positioned on the operating table with the affected side close to the table’s edge. The Mayfield headrest allows the patient’s head and neckto be slightly extended and rotated to the nonoperative side giving better access to the clavicle particularly in the medial one-third. The patient’s head is further secured to the Mayfield headrest by circumferentially wrapping it with a large Kerlix roll. The ipsilateral arm rests on a standard arm board, which is adducted or rotated parallel to the OR table (Fig. 1.10). The head (foot) of the table is then elevated 15 to 20 degrees. The C-arm image intensifier is brought in to ensure that the clavicle will be well visualized during the procedure (Fig. 1.11). Because the metal supports in most operating room tables partially obscure the field of view, it is often necessary to tilt or rotate the C-arm a few degrees to achieve satisfactory images. Prior to the surgical prep, the upper chest wall and clavicular regions can be shaved if necessary. The entire clavicle, shoulder, neck, chest wall, and upper extremity are prepped and draped. The image intensifier must be sterilely draped and isolated as well. The sterile surgical field should encompass the entire upper extremity including the clavicle and the ipsilateral acromial- clavicular and sternoclavicular joints (Fig. 1.12). At this point in time, a surgical “time-out” is called, and all members of the surgical, nursing, and anesthesia teams must concur with the patient’s name, medical record number, and correct side and site of surgery, before the procedure begins.

Unless there are specific cardiopulmonary contraindications, the anesthesiologist is asked to maintain the patient’s systolic blood pressure below 100 mm Hg. This small but helpful step can reduce blood loss during the case since a tourniquet is not employed.

loss during the case since a tourniquet is not employed. FIGURE 1.9 Internal fixation and imaging

FIGURE 1.9 Internal fixation and imaging are facilitated with the use of a Mayfield headrest.

FIGURE 1.10 Patient positioning for clavicle surgery.

FIGURE 1.10 Patient positioning for clavicle surgery.

FIGURE 1.11 The C-arm is brought into the operative field from the opposite side of

FIGURE 1.11 The C-arm is brought into the operative field from the opposite side of the

table.

table. FIGURE 1.12 The patient is prepped and draped. Surgery With a sterile marking pen, the

FIGURE 1.12 The patient is prepped and draped.

Surgery

With a sterile marking pen, the superior and inferior borders of the proximal and distal fragments of the clavicle are marked on the skin, and an appropriate length incision is centered over the fracture site (Fig. 1.13). In large, obese, or very swollen patients, the clavicle may be difficult to palpate. In these cases, the C-arm image intensifier can be used to localize the fracture site for the skin incision. A transverse incision is made parallel to the clavicle and deepened through a subcutaneous tissues. Meticulous hemostasis is obtained with electrocautery. Several sensory clavicular nerves cross the surgical field longitudinally. When possible, these nerves should be preserved as they provide sensation to the infraclavicular portion of the chest wall. In many cases, however, one or more of these nerves need to be divided to facilitate exposure and fixation. Patients should be

counseled that some numbness on the chest wall may occur after surgery.

some numbness on the chest wall may occur after surgery. FIGURE 1.13 The surgical incision is

FIGURE 1.13 The surgical incision is marked with a sterile marking pen.

The proximal clavicular fragment is exposed first (Fig. 1.14). It is usually quite prominent, subcutaneous, and is relatively straight forward. At the fracture site, the soft tissues and thin periosteum are elevated several millimeters to expose the bone end. There is a relatively avascular plane between the deltoid anteriorly and trapezius posteriorly that can be developed down to bone. The soft tissues should only be elevated to accommodate the plate medially.

FIGURE 1.14 The proximal fracture fragment is exposed first.

FIGURE 1.14 The proximal fracture fragment is exposed first.

The fracture site is now exposed, and the provisional hematoma is evacuated and copiously irrigated. The distal fragment is visualized at the fracture site and is typically shortened and displaced downward and forward beneath the proximal fragment. To better expose the distal fragment, a small Hohman retractor or serrated reduction clamp is placed just distal to the fracture site, which elevates the bone into the wound for careful subperiosteal dissection. In patients with comminuted fracture patterns, reduction and fixation of one or more butterfly fragments may be necessary to achieve stable fracture fixation. In my experience, cortical fragments measuring 15 to 20 mm in size usually need to be incorporated into the fixation construct. Care should be taken to preserve the soft-tissue attachments to these fragments in order to avoid disruption of their blood supply. In many patients, there is a large anterior butterfly fragment containing fibers of the deltoid muscle. Depending on the fracture geometry, this fragment should be reduced and temporarily fixed to either the proximal or distal main fragment with K- wires or a small pointed reduction clamp (Fig. 1.15A). Because these fragment(s) are relatively small, 2.4-mm or more commonly, 2.7-mm interfragmentary cortical screws are used for definitive fixation (Fig. 1.15B). Comminution that is too small or not critical for mechanical stability are removed if they are devoid of soft tissues and retained as “bone graft” if there are meaningful soft-tissue attachments. Other large butterfly fragments are similarly reduced and fixed.

FIGURE 1.15 Reduction and internal fixation of a large butterfly fragment.

Using small-reduction forceps on the main proximal and distal fracture fragments, the fracture is reduced by distraction and translation. In simple noncomminuted transverse or short oblique fractures, reduction with restoration of cortical continuity often produces sufficient stability to allow removal or repositioning of the reduction clamps to apply the plate. With stable fracture patterns, compression of the fracture through the plate is desirable. In more unstable fracture patterns, a neutralization or spanning plate is preferred. In highly comminuted clavicle fractures, bridging plates that restore length, alignment, and rotation, while preserving the soft-tissue attachments, remain the treatment of choice (Fig. 1.16).

FIGURE 1.16 Internal fixation at the completion of the procedure.

Implants

There are two distinct schools of thought regarding plate placement. The

plate can be placed either anteriorly or superiorly because biomechanical

testing has not demonstrated an optimal position. Proponents of the anterior

plate argue that it is safer, since the screws are directed from anterior to

posterior, thereby avoiding the lung and the neurovascular structures. Furthermore, it reduces the number of patients who may require

symptomatic hardware removal. On the other hand, anterior plating requires additional dissection of the deltoid muscle, particularly distally, and it is more difficult to fit the plate on the thin anterior surface of the distal fragment. With anterior plating, the insertion angle for screws in the plate

may be difficult to achieve in large patients or women with generous

breasts. Alternatively, surgeons who favor superior plating cite easier surgery and fixation with possibly improved biomechanics. The disadvantages with this technique are a greater riskto the important adjacent structures when drilling and the higher incidence of symptomatic hardware. Regardless of the plate position, a plate of adequate strength is required. One-third of tubular plates and minifragment plates as “stand-alone”

implants are rarely indicated in adults. Most studies support the use of thicker

small fragment plate with 3.5-mm screws (Fig. 1.17). In young patients with

excellent bone, nonlocking cortical screws are usually adequate. In older patients with compromised bone stock, or in any fracture with a short proximal or distal segments, locking screws unequivocally improve strength

of fixation. A minimum of three screws (six cortices) should be placed in the major proximal and distal fracture fragments (Fig. 1.18). Frequently, one or

more

screw holes in the plate are left empty at the level of the fracture.

With

fractures involving the distal one-fourth of the clavicle, special

precontoured periarticular clavicle plates may be helpful. These implants

have

a flared or enlarged lateral end to the plate and accept four to six 2.7-

mm

locking screws. However, due to the wide variation in clavicular

morphology, these plates do not always fit well. For most middle third fractures, I prefer to contour a straight pelvic reconstruction plate that allows me to precisely match the patient’s anatomy (Fig. 1.19). Invariably this

requires a double bend to accommodate the S-shape of the clavicle and slight twist in the plate. However, many surgeons favor the precontoured plates for diaphyseal fractures. Prior to closure, intraoperative fluoroscopy is used to assess the quality of the reduction as well as to ensure screws are of appropriate length.

FIGURE 1.17 Synthes (Paoli, PA) 3.5-mm plate used for clavicle fracture fixation.

FIGURE 1.17 Synthes (Paoli, PA) 3.5-mm plate used for clavicle fracture fixation.

FIGURE 1.18 Postoperative x-ray demonstrating stable internal fixation. FIGURE 1.19 A self-contoured pelvic locking

FIGURE 1.18 Postoperative x-ray demonstrating stable internal fixation.

Postoperative x-ray demonstrating stable internal fixation. FIGURE 1.19 A self-contoured pelvic locking plate. In

FIGURE 1.19 A self-contoured pelvic locking plate.

In comminuted fractures when there are small residuals defects around the fracture site, 5 cc of demineralized bone matrix putty is packed around the fracture site to augment healing. The wounds are copiously irrigated and closed in layers. The deep soft-tissue closure should cover the plate. Drains

are not routinely utilized. In all patients, a careful subcuticular plastic closure is done. A firm pressure dressing is applied, and the affected arm is placed into a sling.

Postoperative Management In healthy patients with uncomplicated surgery whose pain is minimal or moderate can be sent home on the day of surgery. In older patients, and those with complex fracture patterns, prolonged surgery, severe pain, or medical comorbidities are admitted to the hospital overnight and discharged on post-op day 1. Hospitalized patients receive two postoperative doses of an intravenous cephalosporin antibiotic (when there is no allergy). Except for the rare open fracture, no additional intravenous or oral antibiotics are administered. Virtually all patients require strong oral analgesics for the first week or two following surgery. Patients are seen in the out-patient clinic approximately 7 to 9 days after their surgery. Sutures are removed, and a radiograph of the clavicle is obtained and reviewed with the patient. The surgical incision is generally left open, and patients are allowed to bathe or shower and get the incision wet. When stable internal fixation has been achieved, patients are allowed to remove their sling for activities of daily living such as eating, grooming, and dressing. Most patients usually wear a sling for 2 to 4 weeks and then discard it. Physical therapy is not routinely employed as the glenohumeral joint is not affected, and most patients are moving their shoulder within the first 2 to 3 weeks. Patients with “office jobs” are allowed to return to work within 2 or 3 weeks flowing surgery. On the other hand, return to work for patients with physically demanding jobs must be delayed a minimum of 6 to 8 weeks and often up to 12 weeks. After the first postoperative visit, patients are followed at monthly intervals until the fracture has healed radiographically, which can range from 8 to 16 weeks. Patients are allowed to return to noncontact sports such as walking, jogging, and cycling at 6 weeks. Participation in more vigorous sports such as soccer, tennis, and baseball is delayed until 10 weeks postoperatively. Return to football, rugby, judo, hockey, etc. should be delayed until the fracture is unequivocally united but not earlier than 12 weeks. All patients are asked to return 1 year after surgery for a discussion regarding the need for plate removal. Hardware removal is recommended for adolescents, teens, and young adults. However, in all other patients, the plate is only removed if there are strong clinical symptoms such as pain,

prominence, or cosmetic issues. In my experience, approximately one-third of patients eventually have their plate removed.

Complications NEUROVASCULAR COMPLICATIONS Complications following internal fixation of clavicle fractures are uncommon. Because of the close proximity of the lung, the subclavian vessels, and brachial plexus, they are vulnerable to iatrogenic injury. Nevertheless, with careful and meticulous surgery, injury to these important structures is rare. The use of a sharp drill bit reduces drill time and the amount of pressure needed to advance the drill bit, thereby decreasing the likelihood of sudden penetration of the far cortex. The danger to the lung and vessels is greatest in the medial one-third of the clavicle necessitating increased vigilance. Placing a small Hohman retractor along the inferior surface of the clavicle opposite, the hole in the plate to be drilled is both practical and reassuring. Several orthopedic companies manufacture drills that have an oscillating mode in addition to the standard forward and reverse, which minimize sudden “plunging” beyond the far cortex. Injury to the lung leading to a pneumothorax or bleeding from a puncture in a major vessel can be extremely difficult to control and may be life threatening. Prevention is the best treatment.

INFECTION As with any surgical procedure, infection can develop following internal fixation. Infections in the first 2 to 3 weeks after surgery are treated with aggressive surgical irrigation and débridement, culture-specific intravenous antibiotics, and retention of hardware if stable fixation has been achieved. In patients with chronic infections and those presenting late usually require hardware removal as well as thorough operative débridement and long-term antibiotics (Fig. 1.20).

FIGURE 1.20 Clinical photo showing infection after internal fixation. MALUNION AND NONUNION Malunion following internal

FIGURE 1.20 Clinical photo showing infection after internal fixation.

MALUNION AND NONUNION Malunion following internal fixation of acute clavicle fractures is rare. It is usually the result of technical errors or fixation failure. On the other hand, nonunion after clavicular plating using modern techniques and implants for internal fixation occurs in approximately 5% of patients. A nonunion is present when there are no progressive signs of healing on radiographs taken between 3 and 5 months following surgery (Fig. 1.21). Both local and systemic factors may contribute to the development of a nonunion. Local factors that have been associated with fractures that fail to unite include excessive soft-tissue stripping, poor reductions, and inadequate fixation. In adults, one-third tubular plates, 2.7-mm implants, or lag screws alone should not be used. They have been associated with high rates of loss of reduction and fixation failures. Systemic factors that may contribute to the development of a nonunion include smoking, poor nutrition, diabetes, corticosteroids, and chronic systemic disease.

FIGURE 1.21 Nonunion with hardware failure after unsuccessful internal fixation of a clavicle. HARDWARE PROMINENCE

FIGURE 1.21 Nonunion with hardware failure after unsuccessful internal fixation of a clavicle.

HARDWARE PROMINENCE By far, the most “complication” following plate osteosynthesis of a clavicle fracture is late-symptomatic hardware removal. Due to the relatively scant soft tissues around the clavicle, internal fixation devices may be prominent particularly after the initial posttraumatic swelling resolves. Plate prominence can be minimized but not entirely eliminated by a careful closure of the deep soft tissues over the plate following the index procedure. When symptomatic, the plate can be safely removed after 1 year. Earlier plate removal has been associated with a small incidence of refracture.

Outcomes and Results In the past 15 years, numerous studies have reported improved radiographic and functional outcomes following internal fixation of displaced clavicle fractures in adults when compared to nonoperative treatment. Hill, McGuire, and Crosby were amongst the first group of investigators to report that closed treatment of displaced middle third clavicle fractures was associated with poor results. They reported that 16 of 52 (31%) patients treated nonoperatively had an unsatisfactory result based on a questionnaire that they developed (not statistically validated). Poor results were associated with brachial plexus symptoms, cosmetic deformity, limb weakness, and nonunion in 15% of patients.

Robinson et al. in a work entitled “Estimating the Risk of Non-Union

Following Non-Operative Treatment of A Clavicle Fracture” reviewed 868 patients treated at a single institution. While the nonunion rate for the entire group was only 6.2%, the nonunion rate more than tripled to 21% in a subgroup of patients with widely displaced fractures. Zlowodzki et al. in a systematic review of 2,144 clavicle fractures published in the literature up to 2005 found that a nonunion developed in 15.1% of fractures after nonoperative treatment, while the nonunion rate after internal fixation was only 2.2%. In a randomized control trial comparing nonoperative versus plate fixation of displaced clavicle fractures, the Canadien Orthopedic Trauma Society reported the results of treatment in 132 patients. There were less nonunions and malunions as well as better Constant and Dash scores in

the operative group.

In a nonrandomized prospective single surgeon study, 106 patients with a displaced clavicle fracture were treated by the author with plate osteosynthesis between 2000 and 2008. One hundred three patients were

followed for an average of 12 months (range, 5 to 43). Indications for surgery were 100% displaced clavicle fractures with shortening, translation,

or displacement >15 mm. These were 74 males and 29 females with an

average age of 34 years (range, 14 to 73). The mechanism of injury

included falls in 18 patients, motor vehicle accidents in 22, motorcycle accidents in 32, and sports injuries in 31 patients. 88 (85%) of the fractures were in the middle one-third, 14 (14%) were in the lateral one-third, and 1 (1%) was in the medial one-third. All were closed injuries. Treatment consisted of conventional plate osteosynthesis in 15 patients and locking plates in 82 patients. Alternative fixation techniques were utilized in six patients with extremely distal clavicle fractures. Ninety-eight of the 103 patients (95%) healed primarily following the index procedure at an average

of 13.5 weeks (range, 6 to 28). Of the five patients who did not heal

primarily, four healed following revision surgery, while one patient failed to unite. Patient outcomes were evaluated using the DASH score, a validated patient-oriented outcome measure for assessing upper extremity disability.

A zero score indicates a “perfect” extremity while a score of 100 means

completely disabled. The mean DASH score in this series was 16 (range, 3

to 58). Complications included one broken plate, seven reconstruction plates

with minor deformation, and eight patients with some loss of shoulder motion. There were no infections. The most frequent complication was

symptomatic hardware necessitating removal in 35 patients (34%). In conclusion, this study supports the use of internal fixation of widely displaced clavicle fractures in adults. The method is both safe and effective.

RECOMMENDED READING

Canadian Orthopaedic Trauma Society. Non-operative treatment campared with plate fixation of displaced mid-shaft clavicular fractures. J Bone Joint Surg Am 2007;89:1–10. Collinge C, Devinney S, Herscovici D, et al. Anterior-inferior plate fixation of middle-third fracture and nonunions of the clavicle. J Orthop Trauma

2006;20:680–686.

Celestre P, Roberston C, Mahar A, et al. Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability? J Orthop Trauma 2008;22:241–247. Duncan SFM, Sperling JW, Steinmann S. Infection after clavicle fractures. Clin Orthop 2005;439:74–78. Hill JM, McGuire MH, Crosby L. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br

1997;79:537–541.

Huang JI, Toogood P, Chen MR, et al. Clavicular anatomy and applicability of precontoured plates. J Bone Joint Surg Am 2007;89-A:2260–2265. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg

2007;15:239–248.

McKee MD, Pederson EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35–40. McKee MD, Wild LM, Schemitsch EH. Mid-shaft mal-unions of the clavicle. J Bone Joint Surg Am 2003;85:790–797. Robinson CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86:1359–1365.

Smekal V, Irenberger A, Struve P, et al. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures —a randomized, controlled, clinical trial. J Orthop Trauma 2009;23:106–

112.

Zlowodzki M, Zelle BA, Cole PA, et al. Treatment of mid-shaft clavicle

fractures:

2005;19:504–508.

Systemic

review

of

2144

fractures. J

Orthop

Trauma

2 Scapula Fractures: Open Reduction Internal Fixation

Peter A. Cole and Babar Shafiq

INTRODUCTION

Scapula fractures are uncommon injuries. A recent epidemiological study from Edinburgh showed that only 52 of 6,986 (0.7%) fractures seen at their fracture clinic involved the scapula (1). It is estimated that scapula fractures account for only 3% to 5% of all fractures about the shoulder girdle, with most occurring in the clavicle or proximal humerus (25). The robust muscular envelope, the mobility of the scapula on the thoracic cage, its oblique orientation to the chest wall, and the surrounding bones, which are more vulnerable to fracture, protect the scapula making fracture of this bone infrequent. In the past 25 years, several studies have documented poor results following nonoperative management of displaced scapular fractures (618). With the development of modern techniques in internal fixation, surgeons began repairing selected scapula fractures utilizing the AO principles of restoration of articular reduction, alignment, and stable internal fixation leading to a renewed interest in the operative management of both displaced intra-articular and extra-articular scapular fractures (6,1018). The surgical treatment of these fractures continues to evolve as our knowledge of shoulder anatomy, surgical approaches, and implants has improved. There is no universally accepted classification for scapula fractures. In 1984, Hardegger et al. (7) published a series of 37 operatively treated scapula fractures and introduced a classification scheme that bears his name. Additionally, Ada and Miller ( 19) proposed a comprehensive classification that was anatomically defined. Mayo et al. (20) modified

Ideberg’s classification for intra-articular fractures (21,22), based on

radiographs and operative findings of 27 intra-articular glenoid fractures. This classification is also helpful in directing surgical decision making, as it takes into account associated scapular body and process fractures, which frequently occur in association with glenoid fractures (Fig. 2.1). The Orthopaedic Trauma Association (OTA) classification system is an alphanumeric system that classifies both intra- and extra-articular fractures (Fig. 2.2). Its main weakness is that it does not correlate fracture patterns or combinations of injuries with real fractures. Scapula fractures have also been mapped from 3D reconstructions to better illustrate the true nature of fracture patterns and could serve as a basis for a comprehensive classification scheme (Fig. 2.3). The main value of three dimensional mapping, however, is to serve as a useful roadmap for surgical planning and

a greater understanding of the muscular force vectors acting on the scapula

(16).

of the muscular force vectors acting on the scapula ( 16 ). FIGURE 2.1 This image

FIGURE 2.1

This image depicts the Ideberg Classification as modified by Mayo et al. It is

a classification specific for intra-articular glenoid fractures and accounts for commonly associated fractures of the body and processes and is helpful in determining surgical approach.

FIGURE 2.2 This figure is the AO/OTA classification for scapula fractures as modified in 2007. Though it provides a systematic way of classifying scapula fractures, it has not been developed by correlating identified patterns of injury or combined injuries. (Adapted from Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1–S133.)

FIGURE 2.3 This illustration shows maps of fractures about the glenoid with three common anatomical zones of involvement in scapular fractures that required surgical treatment. These include (A) the lateral border just inferior to the glenoid, (B) the spinoglenoid notch between the base of the acromion and the superior aspect of the glenoid fossa, and (C) the glenoid cavity with the fracture tracking medially into the body of the scapula. (From Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of scapular fractures with three- dimensional computed tomography. J Bone Joint Surg Am 2009;91(9):2222– 2228 [Fig 4] with permission.)

INDICATIONS AND CONTRAINDICATIONS

Open reduction and internal fixation of intra-articular glenoid fractures is indicated when there is more than 4 mm of articular step-off and more than 20% of the glenoid is involved (2,7,20,21,2325). However, the literature varies considerably with other authors advocating surgery for articular step- off ranging from 2 to 10 mm (20,2528). The decision for surgery as well as the amount or degree of articular step-off, gap, and percentage of joint involvement should be correlated with the patient’s job, age, activity level, physiologic status, and hand dominance (Fig. 2.4A,B).

FIGURE 2.4 A: A 3D-CT image of the right scapula rotated to represent the scapula

FIGURE 2.4 A: A 3D-CT image of the right scapula rotated to represent the scapula on its axis (scapular “Y” view). The image demonstrates significant glenoid fracture displacement and comminution between the major cephalad and caudad fragments. B: A 2D-CT axial image of a displaced intra-articular glenoid fracture that extends coronally dividing the glenoid into anterior and posterior fragments.

The surgical indications for displaced extra-articular scapula fractures are controversial because there are no randomized controlled studies comparing operative versus nonoperative treatment. Relative indications for internal fixation of extra-articular scapular fractures include the following:

Lateral border offset (sometimes referred to as medialization) >20 mm on an anteroposterior (AP; Grashey) view x-ray of the shoulder

offset (sometimes referred to as medialization) >20 mm on an anteroposterior (AP; Grashey) view x-ray of

(Fig. 2.5A,B)

Angular deformity >45 degrees as seen on a scapular Y radiograph of the shoulder (Fig. 2.6A , B ) 2.6A,B)

Lateral border offset >15 mm plus angular deformity >30 degreeson a scapular Y radiograph of the shoulder (Fig. 2.6A , B ) Glenopolar angle (GPA)

Glenopolar angle (GPA) <22 degrees as measured on a true AP Grashey view radiograph of the shoulder (Fig. 2.7A , B ) 2.7A,B)

Displaced double lesions of the superior shoulder suspensory complex (SSSC)AP Grashey view radiograph of the shoulder (Fig. 2.7A , B ) • Both the clavicle

• Both the clavicle and scapula fractures are displaced >10 mm (Fig.

2.8A,B)

• Complete acromioclavicular dislocation and scapula fracture displaced >10 mm

dislocation and scapula fracture displaced >10 mm FIGURE 2.5 A, B: 3D-CT (P/A view) and True

FIGURE 2.5 A, B: 3D-CT (P/A view) and True A/P (Grashey) radiograph of left shoulder demonstrating Lateral Border Offset (sometimes referred to as medialization). Note that the displacement is measured from “A” the anatomic location of the lateral border (inferior and medial to the glenoid) to the tip of the displaced distal fragment “B.” (Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic Measurement Technique for Extra- articular Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371–3378,

with permission.)

with permission.) FIGURE 2.6 A, B: Scapular “Y” radiograph and 3D-CT rotated to “Y” view demonstrating

FIGURE 2.6 A, B: Scapular “Y” radiograph and 3D-CT rotated to “Y” view demonstrating angular deformity. (Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic Measurement Technique for Extra-articular Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371–3378, with permission.)

FIGURE 2.7 A, B: 3D-CT (P/A view with acromion subtracted) and True A/P (Grashey) radiograph

FIGURE 2.7 A, B: 3D-CT (P/A view with acromion subtracted) and True A/P (Grashey) radiograph of right shoulder demonstrating GPA. On the Grashey view, measured from inferior glenoid rim to superior glenoid rim to most distal point of scapula inferior angle. (Anavian J, Conflitti JM, Khanna G, et al. A Reliable Radiographic Measurement Technique for Extra-articular Scapular Fractures. Clin Orthop Relat Res 2011;469(12):3371–3378, with permission.)

FIGURE 2.8 A, B: 3D-CT and AP shoulder demonstrate double lesion to the SSSC (clavicle

FIGURE 2.8 A, B: 3D-CT and AP shoulder demonstrate double lesion to the SSSC (clavicle fracture and scapula neckfracture).

We also advocate operative management of displaced scapular fractures in patients with complex ipsilateral upper extremity injuries particularly in younger highly active patients, when two or more of the above criteria are met (Fig. 2.9).

FIGURE 2.9 Authors’ preferred algorithm for the management of scapula fractures.

FIGURE 2.9 Authors’ preferred algorithm for the management of scapula fractures.

Contraindications to scapula surgery include extra-articular scapular fractures that are displaced <15 mm and angulated <25 degrees because the outcomes of nonoperative treatment for even moderately displaced scapula fractures are uniformly good (34,8,2932). Active mobility of the elbow and wrist is encouraged immediately, but a sling and rest are indicated for 10 to 14 days. Scapula fractures heal rapidly due to the rich blood supply in the shoulder girdle. Active range of motion can be started by 4 weeks and advanced quickly. Resistive exercises are begun by 8 weeks and restrictions lifted as symptoms allow by 12 weeks. The term superior shoulder suspensory complex is the osseoligamentous relationship between the three scapula processes, described by Goss in 1993 (33). Goss theorized that if there were two disruptions in this “ring,” made up by the acromion, coracoid, and glenoid, as well as their capsule-ligamentous connections, then the glenohumeral joint would be “floating,” a condition that describes discontinuity between the axial and appendicular skeleton (Fig. 2.10). Though this theory has been challenged by some authors (3436), Goss recommended surgery if two such disruptions occur simultaneously. We agree with Edwards et al. ( 34) and Ramos et al. (36) that surgery is not indicated when each component of the double displacement is stable and minimally displaced.

FIGURE 2.10 This illustration depicts the SSSC, which is an osseoligamentous ring made up of

FIGURE 2.10 This illustration depicts the SSSC, which is an osseoligamentous ring made up of the structures along the dotted line. Goss theorized that if two structures in the ring were disrupted, then a “floating shoulder” lesion would be present, implying that there would be no osseous or ligamentous continuity between the axial skeleton and the forequarter. Figure 2.8 shows 3D-CT and AP radiographs of this lesion.

Isolated fractures of the acromion or coracoid process are uncommon. Fractures of the acromion process or spine usually occur as a result of a direct blow to the superior shoulder region, whereas coracoid process fractures result from violent traction injuries through the biceps and coracobrachialis. While indications for operative management of these fractures have not been established, we use several criteria to aid in determining the need for surgery. If either an acromion or coracoid fracture is displaced more that 10 mm, or there is an ipsilateral scapula fracture or multiple disruption of the SSSC, then open reduction and internal fixation is warranted (19,3741). When the acromion is displaced more than 5 mm, a supraspinatus outlet view should be obtained and evaluated for acromial depression, which may contribute to an impingement syndrome, much like a

type III “hooked” acromion, and occasionally warrant internal fixation. Outcomes following acromion and coracoid process fixation are good with high rates of union (13,4041). Anavian et al. reported the results of operative management of 14 coracoid and 13 acromion fractures treated operatively. Most were treated with interfragmentary screw fixation and in selective cases with suture fixation. Supplemental mini or small fragment plate fixation was used for coracoid fractures that extended into the glenoid fossa or acromial spine. Similarly, 2.4- or 2.7-mm reconstruction plates were used when fixation of acromion fractures extending into the scapular neckor base. Distal acromion fractures were treated with a tension band or a mini fragment locking plate on the superior surface or along the anterior or posterior acromial edge. Postoperatively, patients were treated with passive- and active-assisted range of motion for the first month, progressing to resistance exercises after 2 months and full, unrestricted activity by 3 months. All patients were pain free at rest and with upper extremity activities at the time of final follow-up (mean 11 months, range 2 to 42 months). Mean DASH score for those patients with functional assessments was 7 (0 to 26), better than that of the uninjured population normative baseline DASH score 10. The only complications in this series were soft- tissue irritation requiring hardware removal in two patients and removal of ectopic bone in one patient (14).

PREOPERATIVE PLANNING

History

Fractures of the scapula occur as the result of blunt trauma with strong of forces applied to the shoulder. Partial articular fractures, usually involving the anterior glenoid, are commonly associated with anterior shoulder dislocations. These fractures are often referred to as bony Bankart lesions (42) and may be characterized by anterior shoulder instability. If shoulder instability is present with subluxation of the humeral head on radiographic examination, or clinical examination, then operative intervention, given an appropriate surgical candidate, is recommended. Surgery is usually necessary when there is involvement of more than 20% of the articular surface. A second type of scapula fracture involves the glenoid neckand body with

or without articular involvement, and this pattern most commonly occurs following high-energy trauma. Associated injuries occur in up to 90% of patients in this group, and a thorough physical examination is necessary to avoid overlooking serious concomitant injuries (2,21,37). In the seriously injured patient, scapular fractures are often overlooked leading to delays in treatment. It is a common misconception that scapulothoracic dissociation occurs following high-energy blunt trauma, but this is not the case as this devastating injury results from a violent traction force to the upper extremity.

Physical Examination

The physical examination must be thorough and complete as associated injuries are common particularly to the spine, cranium, and thorax. When possible, the shoulder and upper extremity should be examined with the patient sitting or standing to give good access to the posterior forequarter, which is difficult when the patient is supine in bed or on a gurney. Medial and caudal displacement of the shoulder may be obvious producing marked asymmetry, particularly if the patient is upright. Medialization may or may not be apparent on the initial radiographic studies, but once the patient is upright and attempts to move the extremity, the shoulder medializes as the scapula rotates forward over the thorax. In some patients with scapula and multiple rib fractures, the chest wall fails to support the scapula and contributes to deformity (Fig. 2.11). Patients with highly displaced scapula fractures, particularly when associated with multiple ribs or a clavicle fracture, are unable to forward elevate or externally rotate their shoulders, even a few weeks after injury.

FIGURE 2.11 Clinical examination of a patient with a displaced scapula fracture. Appreciate the dramatic

FIGURE 2.11 Clinical examination of a patient with a displaced scapula fracture. Appreciate the dramatic depression and medialization of the forequarter. It is important to assess medialization clinically, and later, postinjury, rather than on a supine injury radiograph or CT scan.

Skin integrity should be assessed as abrasions are common after the typical mechanism of a direct blow to the shoulder. If surgery is indicated, it should be delayed until there is skin re-epithelialization around 7 to 14 days, after injury (Fig. 2.12). Ipsilateral, concomitant, neurovascular injuries are common and require a very careful assessment of the brachial plexus and peripheral pulses. Brachial plexus injury occurs in over 10% of patients with scapula fractures (5,30). Axillary nerve sensation should be documented; however, motor function to the deltoid is frequently impossible to determine with displaced fractures. The suprascapular nerve is vulnerable and commonly injured in association with fractures that extend into the spinoglenoid notch at the base of the acromion, so-called true scapula neck variants (18) (Fig. 2.13A). Based upon a review of 96 surgically treated scapula fractures, the senior author identified 14 cases of suprascapular nerve injury almost exclusively associated with these fracture patterns. Consequently, we recommend electrodiagnostic studies (electromyography and nerve conduction studies—EMG/NCS) be performed in patients with

fractures involving the suprascapular and/or spinoglenoid notch. These studies are of little diagnostic value immediately after injury and should be performed at least 2 weeks after injury when fibrillations and positive sharp waves may be present indicating denervation (axonotmesis and neurotmesis) (43,44). Every effort should be made to identify injury early and before surgical intervention, when possible (45).

and before surgical intervention, when possible ( 45 ). FIGURE 2.12 Note the scarring that resulted

FIGURE 2.12 Note the scarring that resulted from abrasions that occurred at the time of impact of the patient’s shoulder following a bicycle crash. Surgery was delayed until the skin re-epithelialized in order to decrease the chance of infection.

FIGURE 2.13 A. 3D-CT illustrating a “true scapula neck” fracture that extends through the spinoglenoid

FIGURE 2.13 A. 3D-CT illustrating a “true scapula neck” fracture that extends through the spinoglenoid notch. This fracture pattern is often associated with suprascapular nerve injury. B. Intraoperative photo illustrating the lacerated suprascapular nerve and its proximity to the glenoid fragment. C. Intraoperative postreduction and fixation. The glenoid fragment is off of the suprascapular nerve. A 4-0 Prolene stitch was utilized to tackthe lacerated nerve to an adjacent nerve branch and muscle.

Radiographic Studies

Because high-energy scapula fractures often present in an emergent setting in patients with concomitant chest injuries, a chest x-ray and computed tomography (CT) scans are routinely acquired during the trauma evaluation. If a scapula fracture is identified on the screening chest x-ray, dedicated scapular radiographs should be obtained. These include an AP shoulder,

scapula Y, and axillary views. Due to pain, the axillary view is often difficult to obtain. One simple technique we have found helpful is to have the patient hold an IV pole that is slowly abducted to 30 degrees. Another method is to forward elevate the patient’s arm 15 degrees while the x-ray gantry is directed toward the axilla from a caudal position next to the patient’s hip. The AP x-ray of the scapula should be taken 35 degrees off the sagittal plane to correspond with the same angular position of the scapula on the thorax, the so-called Grashey view. The orthogonal scapular Y view is 90 degrees to the AP view. If there is an intra-articular glenoid fracture detected on any x-ray view, then a 2D-CT scan with 1- to 2-mm axial cuts plus coronal and sagittal reformation are helpful for the definition of articular displacement, comminution, and fracture extension (Fig. 2.14). If there is more than 1 cm of fracture displacement at the scapular neck on any view, an AP radiograph of the opposite shoulder is helpful to better define the fracture displacement. It is not uncommon to be misled on the AP view of the injured shoulder because the glenoid may be angulated through the lateral border fracture, eliminating the normal glenohumeral joint (clear space) on a technically correct radiograph. In these circumstances, a 3D CT scan can be very helpful to assess the degree of angular deformity, as well as glenoid displacement (see Figs. 2.52.8). Anavian et al. (15) described techniques to measure medialization, angulation, GPA, and translation of scapula fractures and have established the clear superiority of CT scans over plain x-rays for this purpose.

FIGURE 2.14 2D-CT with 1-mm cuts shows the comminution at the glenoid articular surface. 2D

FIGURE 2.14 2D-CT with 1-mm cuts shows the comminution at the glenoid articular surface. 2D and 3D reformats may miss this detail due to volume averaging. Obtaining an axial 2D-CT in addition to sagittal and coronal reformats is important when intra-articular fractures are present. A. Axial cuts depicting anterior glenoid comminution. B. Semicoronal cuts depicting anterior and inferior comminution.

SURGERY

The scapula is part of the suspensory mechanism of the shoulder that attaches the upper extremity to the axial skeleton through the clavicle. Eighteen muscles originate or insert on the scapula, which provides a stable

base for glenohumeral mobility. The goal of the surgery is to restore the relationship of the axial and appendicular skeleton as well as length, alignment, rotation, and anatomic reduction of articular surfaces to allow early range of shoulder motion and rehabilitation. The majority of scapula fractures that require internal fixation can be approached through an anterior deltopectoral or posterior Judet approaches. Additional approaches have been described for atypical fracture patterns. In an effort to limit incisions and reduce potential surgical morbidity, we also use a minimally invasive posterior approach for select cases (10). Isolated anterior glenoid fractures, as well as associated transverse fracture extending through the glenoid and into the base of the coracoid (Mayo type II fracture), are best treated through a deltopectoral approach. In most other fractures involving the scapula including the scapular neck or body fracture with or without glenoid involvement are done through a posterior approach. Combined anterior and posterior approaches are rarely necessary. They are indicated with concomitant anterior articular fractures combined with scapula neck and body variants or when there is a highly displaced coracoid and comminuted glenoid in addition to a scapular body or neckfracture. Lastly, the clavicle or acromioclavicular joint may require its own approach to address these injuries. Although clavicle fractures will be discussed in another chapter, it is important to point out that they can be approached when the patient is either in the beach chair or in the lateral decubitus position. From the posterior perspective, the scapula is a triangular flat bone, with a thin translucent body, surrounded by borders that are well developed and thick and serve as points for muscular origins and insertions. The lateral border of the scapula sweeps up from the inferior angle, forming the thickest condensation of bone that ends in the neck of the glenoid process. The scapular borders and the glenoid neckprovide the thickest and strongest bone for reduction and fixation with plates and screws. From the anterior perspective, the coracoid process is a curved osseous projection off the anterior glenoid neck and serves as the origin for the short head of the biceps, pectoralis minor, and coracobrachialis. The glenoid process, beneath the acromion, contains the pear-shaped glenoid fossa, which is approximately 40 mm in a superior-inferior direction and 30 mm in an anterior-posterior direction in its lower half in adults (46).

SURGICAL APPROACHES

Posterior Approach

Surgery is performed under general or regional blockanesthesia. The patient is positioned in the lateral decubitus position, “flopping” slightly forward beneath a well-padded axillary roll. Bumps should be positioned on an arm board to support the affected extremity. Prefabricated upper extremity positioners are very helpful to support the affected extremity (Fig. 2.15). The entire forequarter is widely prepped and draped to allow for unrestricted motion of the shoulder. The bony landmarks around the shoulder are palpated and marked with a sterile pen. The prominent posterolateral portion of the acromion is palpated and traced medially to the superomedial angle of the scapula and turns distally along the vertebral border. “Shucking” the scapula with one hand, as if to protract and retract the shoulder to create scapula-thoracic excursion, allows the surgeon to better feel the bony landmarks in large or muscular patients.

FIGURE 2.15 This image demonstrates positioning of the patient when performing a posterior approach to

FIGURE 2.15 This image demonstrates positioning of the patient when performing a posterior approach to the scapula. Soft (BoneFoam) positioning wedges allow for a supportive working surface, while protecting the downside arm. The

body, positioned on a beanbag, should be allowed to fall forward. The entire

arm should be prepped free to allow for manipulation and motion of the glenohumeral joint during the procedure.

A Judet posterior incision is made 1 cm below the acromion spine and 1

cm

lateral to the vertebral border. This allows for lateral retraction of the

flap

with adequate coverage of the implants (Fig. 2.16).

with adequate coverage of the implants (Fig. 2.16 ). FIGURE 2.16 This image depicts a Judet

FIGURE 2.16

This image depicts a Judet posterior incision. It is planned along these

landmarks: 1 cm caudal to the acromion spine and 1 cm lateral to the vertebral border.

The incision is developed onto the bony ridge of the acromial spine, splitting the interval between the trapezius and deltoid insertions. The incision curves distally at an acute angle just under 90 degrees around the

superomedial angle and down the vertebral border. For access to the lateral border of the scapula, the incision must be extended to allow for mobilization of the infraspinatus. Properly executed, the fascial incision along the acromial spine and medial border should provide a cuff of tissue that can be sutured backto its bony origin at the end of the procedure (Fig. 2.17).

its bony origin at the end of the procedure (Fig. 2.17 ). FIGURE 2.17 A. This

FIGURE 2.17 A. This image shows the posterior Judet approach with the development of a flap from the acromial spine and vertebral borders. This extensile exposure allows full visualization of the entire infraspinatus fossa (the posterior scapula) from the vertebral border to the lateral border. The surgeon’s fingers are reflecting the entire flap en mass, and a Cobb elevator is used to dissect the flap off the flat posterior scapular surface. This approach is best reserved for cases that surgery is delayed more than 10 days or for cases that are severely comminuted with several displaced fracture lines exiting multiple scapular borders. It cannot be used when the intra-articular inspection is required. B. Image of same patient in Figure 2.18A after flap elevation and retraction. This patient has a fracture characterized by separation of the glenoid neckfrom the lateral border up into the spinoglenoid notch. There is extension of another fracture line into the scapular body, which is apparent in this image. What is not apparent is the severe lateral border offset and anteversion of the glenoid articular surface. Note the location and vulnerability of the suprascapular neurovascular bundle exiting from just below the acromion before it enters the infraspinatus muscle.

Based on the preoperative plan, the degree of exposure depends on the need for limited or complete exposure of the posterior scapula. Working through limited intermuscular windows is favored to limit dissection and can be used to access fracture intervals at the lateral border, acromial spine, and vertebral border (Fig. 2.18). Alternatively, an extensile exposure can be performed by elevating all of the muscles from the infraspinatus fossa exposing the entire posterior scapula. The flap can be elevated laterally as far as the lateral scapular border and allows exposure to the glenoid neck. While the extensile approach exposes the entire posterior surface of the scapular body, the entire subscapularis muscular sleeve on the anterior surface of the scapula is preserved, maintaining the blood supply to the scapular body (Fig. 2.17B). Therefore, the extensile approach is biologically respectful, with almost a 100% union rate. An extensile approach that elevates the deltoid, infraspinatus, and teres minor in a single flap is usually reserved for fractures that are over 10 days old or for complex patterns with four or more exit points around the ring of the scapular perimeter. This extensile exposure allows the surgeon adequate control of the fracture at multiple points to allow mobilization and reduction of the fracture. It will not allow for exposure of the articular surface of the glenoid due to the large flap, which cannot be retracted sufficiently lateral for joint exposure. For adequate intra-articular exposure, an intermuscular dissection is necessary over the posterior glenohumeral joint.

FIGURE 2.18 Using the technique of accessing intermuscular windows, the most important window is between

FIGURE 2.18 Using the technique of accessing intermuscular windows, the most important window is between the infraspinatus and teres minor to access the lateral border of the scapula and scapula neck. A–C illustrate development of this interval as well as mobilization of the infraspinatus from the scapular spine for additional exposure of the scapular body.

If limited intermuscular windows are utilized, the Judet fasciocutaneous flap is elevated, and tactically created intermuscular intervals around the scapular perimeter are used to access specific fracture locations (Fig. 2.18). The intermuscle plane at the spine of the scapula is between the trapezius and the deltoid. By subperiosteal dissection, the inferior margin of the spine is uncovered to expose the rotator cuff muscles. The deltoid is elevated off

the muscular origin of the infraspinatus and tagged through its fascial cuff for reattachment to bone through tunnels at the conclusion of the case. We have found that mobilization and careful retraction of the deltoid allow the surgeon to work anteriorly at the lateral border and scapula neck without taking down the deltoid. This technique is more tedious, but spares taking down the deltoid and the need for reattachment and postoperative immobilization. At the vertebral border of the scapula, the intermuscular interval is between the infraspinatus and the rhomboids (Fig. 2.19). However, the most important window is between the infraspinatus and teres minor to gain access to the lateral border of the scapula and scapular neck. Furthermore, the glenohumeral joint can be exposed to treat intra-articular fractures. Knowledge of the correct intermuscular intervals is crucial to avoid denervation of the infraspinatus, axillary nerve, or posterior humeral circumflex vessels. Once this interval is developed, the lateral border of the scapula can be exposed, allowing restoration of glenoid version and lateral border offset (Fig. 2.18). If the glenoid articular surface must be visualized, a transverse capsulotomy is made allowing a retractor to be placed on the anterior edge of the glenoid to retract the humeral head (Fig. 2.20). During the arthrotomy, the capsule should be incised just distal to the labrum and is localized with an 18-gauge needle.

FIGURE 2.19 Limited intermuscular window technique vertebral (medial) border.

FIGURE 2.19 Limited intermuscular window technique vertebral (medial) border.

FIGURE 2.20 This image depicts an extensile posterior approach with extension superiorly over the acromion

FIGURE 2.20 This image depicts an extensile posterior approach with extension superiorly over the acromion with exposure of the acromioclavicular joint to address an associated fracture of the acromion. There is also an intra-articular glenoid fracture for which a capsulotomy has been performed to allow access to the glenohumeral joint.

The lateral border can be reduced using small-pointed bone reduction clamps, small (4 mm) external fixation pins as joy sticks, or a plate (Figs. 2.21 and 2.22). Large reduction tenaculums are difficult to apply because of interference with the large muscular flap. In these cases, small external fixation pins in the proximal and distal fragments can be secured in proper

orientation with a small external fixator bar and clamps to line up the lateral border for subsequent plating (Fig. 2.23). Alternatively, a 2.7-mm dynamic compression plate straddling the lateral border of the scapula can be used to reduce the fracture (as well as definitive fixation) since it is applied without the need for contouring. If the reduction is not stable, a provisional 2.0-mm plate and screws placed slightly more medial can be used to provisionally hold the lateral border aligned. Occasionally, a larger clamp can be placed at the medial extent of the fracture at the scapula spinal or vertebral borders to help decrease stress on the lateral border to improve the reduction.

stress on the lateral border to improve the reduction. FIGURE 2.21 Lateral border reduction with Shantz

FIGURE 2.21 Lateral border reduction with Shantz pins and clamp.

FIGURE 2.22 This image depicts a scapula fracture treated 2 weeks after injury with

FIGURE 2.22 This image depicts a scapula fracture treated 2 weeks after injury with

multiple fractures through the “ring” of the scapula periphery. A Judet extensile approach was used and multiple pointed bone tenaculums are applied at the periphery wherever there is a fracture exit point with displacement. The 2.7 reconstruction plate is applied to the vertebral border of the scapula body extending to the scapular spine.

border of the scapula body extending to the scapular spine. FIGURE 2.23 This image depicts lateral

FIGURE 2.23 This image depicts lateral border reduction accomplished with an external fixator applied to 4.0-mm Schanz pins placed in the proximal (cephalad) and distal (caudad) segments. The 2.7-mm locking plate is applied to the thick bone along the margin of the lateral border.

In our experience, 2.7-mm plates are well suited for the scapular borders

and are of adequate strength to resist breakage. These plates are lower profile than 3.5 plates, are easier to contour, and offer a greater number of screws per centimeter. A 2.7-mm dynamic compression plate is used on the lateral border where stresses are greatest, whereas 2.7-mm reconstruction plates are used for the scapular spine and vertebral borders of the scapula, making plate contouring around the base of the spine and the vertebral border easier. Two pediatric Kocher clamps are useful for bending and twisting the plates. We favor longer plates and more screws for added stress distribution since each screw is only 8 to 10 mm for the vertebral border. The use of locked small and minifragment plates allows shorter plates given the better screw purchase over shorter working lengths. In the case of a posterior glenoid fracture with intra-articular or neck involvement where there is minimal displacement or involvement of the scapular spine or vertebral border, a direct posterior approach can be employed. In these cases, reduction and fixation can be accomplished solely through the interval between infraspinatus and teres minor. If greater exposure to the glenoid fossa or superior glenoid is desired, an infraspinatus tenotomy can be performed leaving a centimeter of cuff insertion at the greater tuberosity for repair. This allows the slender musculotendinous portion of the infraspinatus to be retracted off the superior glenoid region for better access to the glenohumeral joint. This maneuver is particularly helpful in large muscular patients and can be used in conjunction with an extensile approach in which the whole infraspinatus and teres minor are elevated. It is repaired with strong nonabsorbable sutures and requires protection from active external rotation for 6 weeks postoperatively. Before wound closure, it is important that any adhesions or shoulder stiffness be released by manipulation of the shoulder prior to waking the patient, especially in patients whose surgery has been more than 2 weeks postinjury. We routinely use a suction drain under the flap and reattach the rotator cuff with strong nonabsorbable suture through several drill holes at the scapular spine and vertebral border to improve fixation. We prefer an absorbable subcuticular suture for the skin closure.

A Minimally Invasive Posterior Approach

Approximately three quarters of scapular fractures treated operatively are done through a posterior approach (47). We have recently utilized a

minimally invasive surgical technique with limited muscular dissection that permits open reduction and internal fixation of selected scapula body and neck fractures (10). The use of small incisions distant from the fracture site to introduce implants and apply fixation is a well-accepted technique in the management of long bone fractures. We have applied this concept to fixation of the scapula. Because the scapula is a triangular (ring-type) bone with predictable fracture exit points, incisions are made at each fracture end, allowing the majority of the scapular body to remain unexposed (Fig. 2.24A,B). This approach allows for direct reduction of the fracture at its margins without violating soft-tissue attachments along the majority of the fracture across the scapular body.

FIGURE 2.24 A: Represents small incisions placed directly over the medial and lateral

FIGURE 2.24 A: Represents small incisions placed directly over the medial and lateral

borders of the scapula at the fracture ends. These windows are often adequate for affecting reduction and plate application at these two common sites of displacement. (Adapted from Gauger EM, Cole PA. Surgical Technique: A Minimally Invasive Approach to Scapula Neckand Body Fractures. Clin Orthop Relat Res 2011;469(12):3390–3399.) B: Deeper exposure through these limited windows, retractor, and clamp placement, as well as plate positioning.

Positioning is the same as for the previously described posterior approaches. Limited incisions are made as necessary depending on the fracture pattern, usually placed laterally over the glenoid neck and lateral border and also medially where the fracture exits at the spine or vertebral border (Fig. 2.24A,B). Through the lateral incision, the dissection is developed to the fascia overlying the inferomedial margin of the deltoid. The deltoid is retracted cephalad with a wide retractor, exposing the fascia overlying the external rotators. The fascia is opened, exposing the teres minor and infraspinatus. The muscular interval between these muscles is developed bluntly, exposing the fracture site as it exits the lateral scapular border. Care must be taken to avoid injury to the axillary nerve and posterior circumflex humeral artery as they pass through the quadrilateral space, distal to the infraspinatus muscle. Additionally, the infraspinatus is carefully retracted superiorly to avoid injury to the suprascapular nerve as it exits at the spinoglenoid notch (48) (Fig. 2.25).

FIGURE 2.25 A, B: Intraoperative photos showing minimally invasive limited incisions, deeper exposure, clamp, and

FIGURE 2.25 A, B: Intraoperative photos showing minimally invasive limited incisions, deeper exposure, clamp, and plate application. One can clearly see the division between the deltoid and infraspinatus muscles. What is more difficult to discern is the interval between the infraspinatus and teres minor. Once this important interval has been identified and developed, retractors can be placed to expose the lateral scapula border.

Through the medial incision, at the base of the scapula spine at its medial border, dissection is developed to the fascia and then directly down to bone. Subperiosteal dissection is then extended along the vertebral border distally as needed to expose the medial border fracture line for reduction and plate application. These two small windows are usually adequate for reduction and plate application at the two most common sites of displacement, the lateral and medial scapular borders. Once the lateral and medial incisions have been made and the fracture exposed, a small external fixation pin (with small T-handled chuck) is placed in the cephalad fragment (glenoid neck),

and second external fixation pin is inserted into the caudal fragment (distal lateral border). The external fixation pins are used as “joy-sticks” to reduce the fracture. Small-pointed bone reduction forceps may be used laterally and medially to maintain reduction. The clamp may be applied through small pilot holes on either side of the fracture. The external fixation pins and pilot holes must be strategically placed to avoid interference with plate placement (Figs. 2.24B, 2.25, and 2.26).

with plate placement (Figs. 2.24B , 2.25 , and 2.26 ). FIGURE 2.26 Postoperative AP radiograph

FIGURE 2.26 Postoperative AP radiograph of patient in Figure 2.25.

Because longer plates are not feasible through these small windows, we recommend the use of 2.7-mm locking plates. A 2.7-mm reconstruction plate is contoured to the medial border, and a 2.7-mm dynamic compression plate is used for the straight lateral border. The fascia is closed with number 0 or 1 absorbable braided suture and the subcutaneous tissue with 2-0 absorbable braided suture. The skin is closed with running 3-0 absorbable subcuticular suture. Suction drains are not necessary.

Special Circumstances: Posterior Approach

Associated Spine Injuries  Cervical and thoracic spine injuries are associated with scapular fractures in over 20% of cases. Often times, the orthopedic surgeon must coordinate patient care with a spine surgeon prior to positioning and induction of anesthesia. Intraoperative positioning must be carefully executed. It is desirable to have the spinal injury surgically stabilized first to insure protection of the spinal cord, if indicated. However, if the spine injury is managed nonoperatively, intraoperative in-line traction with skeletal tongs is preferred. Caliper or tong traction is easier to work around than a cervical collar, with regard to both safety and draping.

Suprascapular Nerve Injury Suprascapular nerve injuries are commonly seen following high-energy displaced scapular fractures. An electromyogram and NCS should be obtained before surgery in patients who present more than 2 weeks after injury. Most injuries are contusions or neurapraxia. Lacerations to the suprascapular nerve occasionally occur in patients where the fracture extends into the spinoglenoid or suprascapular notches. The nerve should be visualized and protected at the base of the acromion during the posterior approach in these fracture patterns. If a laceration is discovered, then repairing the lacerated nerve end or branches to the infraspinatus is useful and can promote some recovery of function. Suturing with a 6-0 nonabsorbable monofilament suture is recommended.

Anterior Surgical Approach

The patient is placed in a beach chair position with an arm board attached to support the extremity. A small towel roll is placed under the ipsilateral shoulder to help bring it forward. An x-ray cassette is positioned behind the shoulder during the setup so an intraoperative film can be obtained obviating the need for intraoperative fluoroscopy (Fig. 2.27). A classic anterior deltopectoral incision is made, and the cephalic vein is identified and retracted laterally. The interval between the deltoid and pectoralis major is developed down to the clavi-pectoral fascia, which is opened exposing the coracobrachialis and subscapularis. The upper and lower borders of the subscapularis tendon are identified as they insert into the lesser tuberosity. At the inferior margin of the subscapularis, muscles are the transversely

running inferior humeral circumflex vessels, which should be ligated. With the humerus in a neutral position, the subscapularis tendon is sharply released 1 cm from its insertion on the lesser tuberosity leaving a cuff of tendon for later repair. Frequently adherent to the underlying joint capsule, the subscapularis should be carefully separated from the underlying capsule for later closure in distinct layers. Stay sutures are placed on each side of the subscapularis muscle to facilitate closure as well as to prevent medial retraction. The joint capsule is incised longitudinally a few millimeters from the glenoid rim giving access to the glenohumeral joint. Following irrigation of the joint, the glenoid fracture is identified and reduced (Fig. 2.28A).

glenoid fracture is identified and reduced (Fig. 2.28A ). FIGURE 2.27 Photo of a patient in

FIGURE 2.27 Photo of a patient in the beach chair position. The patient is positioned with an x-ray plate behind the shoulder to allow for an intraoperative radiograph. Because this exposure allows excellent visualization of the anterior glenoid, intraoperative fluoroscopy is rarely necessary. We also routinely place a towel roll under the ipsilateral shoulder to improve shoulder extension and

facilitate exposure. This patient has a clavicle malunion with clavicle displacement and deformity.

clavicle malunion with clavicle displacement and deformity. FIGURE 2.28 A: Anterior, deltopectoral approach. The

FIGURE 2.28

A: Anterior, deltopectoral approach. The subscapularis has been incised 1

cm from its insertion on the lesser tuberosity, tagged with heavy stay

sutures, and retracted medially. The joint capsule has been separated from

the undersurface of the subscapularis, tagged with stay sutures, and retracted

laterally. B: With the subscapularis and joint capsule retracted, excellent

exposure and visualization of the glenoid and anteroinferior glenoid fragment

is obtained.

Reduction can be obtained using a dental pick or small elevator and provisionally fixed with Kirschner wires (Fig. 2.28B). Fluoroscopy is not needed because the articular fracture reduction is directly visualized. Depending on the size of the fragment or the degree of comminution, fixation is achieved with mini or small fragment screws. When comminuted,

a mini buttress plate is placed on the anteroinferior edge of the glenoid. Layered closure of the capsule and subscapularis is done.

In cases where additional visualization is necessary due to a large or comminuted anterior glenoid rim that will require a buttress plate, a coracoid osteotomy can be helpful to increase exposure. The coracoid is predrilled

with a 2.5-mm drill bit and completed with an osteotome or micro-oscillating

saw. Once released, the conjoined tendon and coracoid are reflected distally

and medially, which gives excellent exposure of the anterior glenoid and

scapular neck. Because the musculocutaneous nerve penetrates the coracobrachialis approximately 5 to 6 cm from the tip of the coracoid, it is important to protect the musculocutaneous nerve during retraction (49). At

closure, the near cortex of the coracoid should be overdrilled with a 3.5-mm bit improve interfragmentary compression with a 3.5-mm cortical screw (Fig. 2.29).

compression with a 3.5-mm cortical screw (Fig. 2.29 ). FIGURE 2.29 A,B. Coracoid osteotomy. Postoperative AP

FIGURE 2.29 A,B. Coracoid osteotomy. Postoperative AP and axillary lateral radiographs showing anterior glenoid fixation and the coracoid osteotomy repaired with a 3.5-mm screw and washer placed with a lag technique.

Postoperative Management

Rehabilitation following internal fixation of scapular fractures is based on the concept that stable internal fixation of the fracture allows early passive range of shoulder motion. We often use a regional anesthetic block with an indwelling interscalene catheter for the first 48 to 72 hours postoperatively to allow early range of motion. Passive range of shoulder motion is started on the first or second postoperative day under the direction of a physical or occupational therapist. Active-assisted range of motion is advanced as the patient’s pain subsides. The goal during the first 4 weeks after surgery is to regain and maintain shoulder motion rather than strength training. Lifting and carrying with the affected shoulder is delayed at least 4 weeks and often longer. Following hospital discharge, patients continue therapy as well as a home exercise program using pulleys and supine-assisted motion with push- pull sticks. Ipsilateral elbow, wrist, and hand exercises including 3- to 5-

pound weights (on a supported elbow) are encouraged to prevent muscular atrophy and promote edema reduction.

Postoperative Protocol

A sling or shoulder immobilizer is worn for comfortatrophy and promote edema reduction. Postoperative Protocol The drain is removed when output is <15 mL

The drain is removed when output is <15 mL per 8-hour shiftProtocol A sling or shoulder immobilizer is worn for comfort Passive- and active-assisted range of shoulder

drain is removed when output is <15 mL per 8-hour shift Passive- and active-assisted range of

Passive-

and

active-assisted

range

of

shoulder

motion

postoperative day 1 or 2

starts

on

Hand, wrist, and elbow exercises (3 to 5 pounds) begin during the first weekrange of shoulder motion postoperative day 1 or 2 starts on Shoulder strengthening exercises are started

Shoulder strengthening exercises are started at 4 weeks postoperativelyelbow exercises (3 to 5 pounds) begin during the first week Advance the strengthening program at

Advance the strengthening program at 8 weeksexercises are started at 4 weeks postoperatively Remove all restrictions at 12 weeks postoperatively if the

Remove all restrictions at 12 weeks postoperatively if the fracture has healedpostoperatively Advance the strengthening program at 8 weeks Follow-Up   Patients are followed in the clinic

Follow-Up  Patients are followed in the clinic at 2, 6, and 12 weeks postoperatively and an AP, scapula Y, and axillary radiographs are obtained. We recommend follow-up at 6 months and at 1 year with a single AP x-ray to document radiographic and functional outcomes. Patients with associated injuries may warrant longer follow-up, especially those with a brachial plexopathy. At the 6-week follow-up visit, shoulder strengthening exercises with weights are begun and advanced as the patient’s symptoms permit. If the patient has persistent loss of shoulder motion, a manipulation under anesthesia should be considered. This is more common in patients who have a brachial plexus injury, head trauma, cervical spine injuries, or complex- associated fractures of the ipsilateral extremity.

OUTCOMES

Mayo et al. (20), in a series of intra-articular glenoid fractures, documented 82% good or excellent results in 27 patients evaluated clinically and radiographically at 43 months postoperatively. Schandelmaier et al. ( 28), in 2002, reported the results of 22 displaced intra-articular glenoid fractures treated operatively with screw and plate fixation. Surgery was undertaken if the intra-articular displacement was >5 mm. With a mean follow-up of 10

years, they found good, durable functional results based on the Constant and Murley score in 18 of 22 patients. The operative shoulders had overall results of 94% (for strength, pain, ROM, and function) as compared to the uninjured side. Four complications were reported, including one superficial and one deep infection, one patient had shoulder stiffness, and one patient developed subacromial impingement. In another series of 33 intra-articular glenoid fractures, Anavian et al. reported the functional outcomes including DASH score, strength, and range of motion following internal fixation. This single surgeon series was notable in that 23 of 33 fractures were Mayo/Ideberg type IV or V, with 13 patients having a peripheral nerve or brachial plexus injury and 30 patients having ipsilateral injuries. At follow-up of 25 months, 91% of the patients had a DASH score of 10.8, and average ranges of motion were not significantly different from the contralateral extremity. Although there were mild deficits in strength, 24 patients had no pain whatsoever, and 90% of patients returned to preinjury workand recreational activity (12). Scapula neck fractures should be treated operatively if significant displacement or angulation leads to deformity with functional imbalance of the parascapular musculature. Ada and Miller (19) recommended internal fixation when the glenoid is displaced medially more than 9 mm or there was more than 40 degrees of angular displacement. This recommendation was based on a follow-up of 16 patients with scapular fractures treated nonoperatively, of whom 50% had pain, 40% had exertional weakness, and 20% had decreased motion at a minimum of 15 months’ follow-up. Eight patients in this same study were treated operatively, and all achieved a painless range of motion. Hardegger et al. (7) achieved 79% good or excellent results in a series of 37 patients with scapular fractures treated operatively, although only five cases were “severely displaced or unstable” scapula neck fractures, although these were not analyzed separately. Nordqvist and Petersson (50) analyzed 68 scapula fractures at a mean 14- year follow-up and found that 50% of nonoperated patients that healed with residual deformity had significant shoulder symptoms. Armstrong and Van Der Spuy (8) noted that 6 of 11 patients with displaced scapula neck fractures had residual stiffness at 6 months. Herrera et al., in 2009, reported on the results of 22 patients with scapula fractures treated whose operative management was delayed >3 weeks from injury. In all cases, surgery was delayed due to late referral or the presence

of concomitant injuries that precluded early operative intervention. Despite these challenges, the authors reported marked improvement in radiographic alignment with surgery as well as maintenance of reduction at follow up. Patients were followed for a mean of 26.4 months (12 to 72). Radiographic and functional outcomes were obtained for 16 patients, and DASH scores were collected for 14 patients. Patients had an overall DASH score of 14 (0 to 41) as compared to a mean DASH of 10.1 in the normal population, and Short Form 36 (SF-36) scores were comparable to the normal population in all measured parameters. The authors demonstrated that radiographic and functional outcomes were satisfactory even when surgical treatment was delayed (13). Recently, the senior author (PAC) reported the results of reconstruction of scapular malunions in five patients treated at a mean of 15 months after injury. All patients were initially treated nonoperatively and presented with debilitating pain, weakness, and were unable to return to work. Four of five patients had associated injury to the chest wall and two had ipsilateral clavicle fractures resulting in a “floating shoulder” or double disruption to the SSSC. All patients underwent osteotomy and reconstruction, followed by early rehabilitation. Radiographic measurements, range of motion, strength testing, DASH, and SF-36 questionnaires were performed preoperatively and postoperatively with a mean follow-up of 39 months (18 to 101 months). All patients were pain free with regard to the shoulder, and all were united radiographically. Mean DASH scores improved from 39 (27 to 58) to 10 (0 to 35). Mean ROM and strength improved in all six measures and were significantly different from the contralateral, uninjured extremity in only external rotation strength. There were no complications, and four of the five patients returned to their previous occupation and recreational activities. One patient was unable to return to work as a truck driver and attributed this to a lower backcondition related to spine fractures (17). Herscovici et al. (51) reported on internal fixation of seven clavicle fractures in patients with ipsilateral scapula neck fractures. In this series, all patients achieved excellent functional results with no deformity at 48.5- month follow-up. Two other patients in this series treated nonoperatively had significant shoulder drooping and decreased range of motion. Others have advocated internal fixation of just the clavicle as well for restoration of length and sufficient stability (52). Leung et al. (53) treated 15 such patients with internal fixation of both the fractures and reported good or excellent

results in 14 patients 25 months after surgery. Ramos et al. (36), on the other hand, reviewed 16 patients with ipsilateral clavicle and scapula neck fractures treated conservatively. Ninety-two percent had good or excellent results at 7.5-year follow-up. A significant shortcoming of the three former studies is that none documented the degree of displacement of the scapula neck fracture, and in the latter, the radiologic outcome was noted to be good in all but one, suggesting minimal original displacement. In a recent retrospective study by Edwards et al. (34), the outcome of nonoperative treatment of ipsilateral clavicle and scapula fractures was assessed at a mean 28-month follow-up. Nineteen of twenty healed uneventfully, with excellent range of motion and function, but only 2 of 20 scapula fractures and 8 of 20 clavicle fractures were displaced more than 1 cm.

COMPLICATIONS

While stable, minimally displaced fractures usually result in good outcomes, patients with displaced unstable fractures often have residual pain and decrease range of motion. Missed or delayed diagnosis of a displaced fracture or nerve injury may result in malunion or nonunion, which may cause deformity, dyskinesis, or weakness, leading to pain, glenohumeral instability, crepitance, rotator cuff dysfunction, and glenohumeral degenerative joint disease (5456). Fortunately, the rate of risk in ORIF for scapula fractures is quite low in the published literature. Peripheral nerve injury inclusive of suprascapular, axillary, and musculocutaneous nerves all have injury potential given their proximity to surgical approaches; however, the published incidence is rare, partly due to the difficulty of determining whether neurologic injury is due to the injury. Scapula fracture patterns involving the suprascapular and spinoglenoid notches are associated with an increased risk of suprascapular nerve injury. The surgeon must command a thorough anatomical knowledge of the danger zones to avoid insulting surgical forces. The greatest risk is for suprascapular nerve injury during a posterior approach, given the excessive infraspinatus elevation that occurs from gaining exposure to the lateral border and glenoid neck. Wijdicks et al. (18) described danger zones for the suprascapular nerve and circumflex scapular artery based on dissection of 24 cadaveric specimens. Risks of iatrogenic nerve injury during anterior

exposures can be reduced by limiting retraction of the coracobrachialis

where the musculocutaneous nerve traverses approximately 6 cm inferior to

the coracoid.

A well-reported complication is shoulder stiffness. This may be particularly true for patients who have been mobilized for excessive periods

either before or after surgery. Our policy is to manipulate the shoulder after fixation and while the patient is still asleep to release all intrinsic and extrinsic contractures. This is salient when the patient’s surgery is delayed. Patients with cognitive delay, head injury, multiple extremity injuries are all vulnerable to stiffness, and occasionally if a patient is not progressing rapidly toward normal motion by 6 weeks postoperatively, a manipulation under anesthesia should be arranged. To this procedure, we always add an intra- articular steroid injection to prevent reoccurrence of scar tissue after intra- articular fractures. It is rare that patients need this formal procedure, but is effective at giving them a “kickstart” when indicated. There is a low rate of implant failure associated with ORIF of scapulas with plates and screws, and reported malunion rates are almost nonexistent. Lantry et al. (47) reported a failure rate of 3.6% in their systemic review of operatively treated scapula fractures. Our strategy to prevent hardware failure includes the use of either locking plates or long plates with conventional screws to mitigate pullout and also provide stability to the whole scapular perimeter with the use of vertebral border and scapula spine plates when fractures. This approach reduces stress on any single implant and was associated with a 100% union rate in a recent cohort of 84 patients by our group (11). Due to the robust blood supply to the shoulder, both infection and nonunion should be rare occurrences if principles are followed, and the complications that tend to occur are treatable, assisting the surgeon and patient greatly with

the decision to weigh the risks and benefits of operative management.

ILLUSTRATIVE CASE FOR TECHNIQUE

A 22-year-old male was involved in a truck rollover accident and was

ejected from the vehicle. He was initially diagnosed with multiple bilateral rib fractures, bilateral pneumothorax, sternal fracture, complex spine fractures, acromioclavicular dislocation, renal injury, as well as a traumatic brain injury. The patient required an exploratory laparotomy and internal

fixation of his spine fractures. He was subsequently transferred to our hospital for additional care. Physical examination at 5 weeks postinjury revealed that the left shoulder was significantly depressed with diminished sensation in axillary nerve, and there was a profound loss of left shoulder of motion due to stiffness and pain. An AP radiograph of the shoulder showed a displaced glenoid neck fracture with a dislocated acromioclavicular joint. In addition, there was significant angulation on the scapular Y view with 100% translation (Figs. 2.30 and 2.31). Due to the degree of displacement, a CT with 3D reconstructions was obtained for more accurate measurements and preoperative planning.

FIGURE 2.30 A–C: AP, scapular-Y, and axillary views of the left shoulder. There is a

FIGURE 2.30 A–C: AP, scapular-Y, and axillary views of the left shoulder. There is a displaced glenoid neckfracture with a decreased GPA on the AP view. Also seen on this view is a dislocated acromioclavicular joint. Hundred percent displacement of the scapular body is seen on the Y view.

FIGURE 2.31 Panoramic view of both clavicles demonstrating marked displacement of the acromioclavicular joint. The

FIGURE 2.31 Panoramic view of both clavicles demonstrating marked displacement of the acromioclavicular joint. The malrotated position of the glenoid is clearly visible when compared to the contralateral shoulder in this image.

The CT scan revealed:

Lateral Border Offset: 38 mm Angular Deformity: 45 degrees Glenopolar Angle: 18 degrees

The fracture pattern was atypical in that there was a large segmental component of the lateral border. The indications for surgery included a double disruption of the SSSC. Although there is no literature on glenoid version to suggest operative indications, the anteversion measured 32 degrees (Figs. 2.32 and 2.33). An EMG was performed preoperatively because of sensory changes noted and verified the presence of a complete axillary mononeuropathy. The suprascapular nerve was not tested due to patient intolerance of the exam.

FIGURE 2.32 A: 3D CT scan oriented in scapular Y position demonstrates angular deformity of

FIGURE 2.32 A: 3D CT scan oriented in scapular Y position demonstrates angular deformity of 45 degrees. B: 3D CT scan oriented in PA view demonstrates medial-lateral displacement of the glenoid fragment (orange dashed line) and lateral border (green dashed line) relative to the scapular body (blue

dashed line). C: 2D axial CT image depicting 32 degrees of glenoid anteversion relative to scapular body.

32 degrees of glenoid anteversion relative to scapular body. FIGURE 2.33 A: 3D CT scan oriented

FIGURE 2.33 A: 3D CT scan oriented in PA view. B: 3D CT with images manipulated such that the lateral border is reduced to its normal, anatomic location (note that the lateral border is straight from the glenoid neckto the inferior angle of the scapula). With the lateral border reduced, one can appreciate the true lateral border offset (38 mm) of the glenoid relative to the anatomic position of the lateral border. C: 3D CT with glenoid and lateral border reduced anatomically. The glenoid relative to the lateral border, increased GPA, restored glenoid retroversion and repositioning of the acromion more vertically, decreasing the potential for rotator cuff impingement.

An extensile posterior Judet approach with elevation of the infraspinatus and teres flap was performed because the fracture was 6 weeks old and required osteoclasis to mobilize the four major fragments. Furthermore, multiple exit points of the fracture along the scapula perimeter were needed for reduction and fixation. Longer plates were necessary for stable fixation of the segmental fracture at the lateral border, glenoid neck, and scapula spine (Fig. 2.34).

FIGURE 2.34 Intraoperative photographs. Judet Flap. A: Marked displacement of the lateral border with angulation.

FIGURE 2.34 Intraoperative photographs. Judet Flap. A: Marked displacement of the lateral border with angulation. B: There is a bone void after the fracture has been disimpacted, reduced, and fixed in an anatomic position. C: Callus removed at the time of exposure is used as bone graft before placing a drain and repairing the Judet flap.

The patient was placed in the lateral decubitus position, leaning forward. During flap elevation, care was taken to protect the neurovascular bundle. The callus was removed from the fracture site so that the reduction could be visualized. External fixation pin joysticks (with T-handled chucks) were used in the glenoid neck and lateral border to achieve fracture reduction. A provisional reduction was obtained with clamps at all borders including the lateral border at two locations. A 10-hole 2.7-mm locking plate was placed on the lateral border, and a 16-hole 2.7-mm recon plate was contoured to extend along the scapular spine, the superior angle, and down the medial border. These long plates were favored over multiple small plates to create a stronger construct. A second plate was placed along the lateral border to reinforce this area, which was under significant deforming force post reduction. The callus was used as bone graft. The acromioclavicular joint was reduced and stabilized through a second incision using a tightrope technique (Arthrex, Naples, Florida) (Fig. 2.35). Physical therapy was begun for full active and passive range-of-motion exercises.

FIGURE 2.35 A–C: Postoperative AP, scapular Y, and axillary radiographs showing restoration of anatomic positioning

FIGURE 2.35 A–C: Postoperative AP, scapular Y, and axillary radiographs showing restoration of anatomic positioning of the scapula and AC joint.

At 6 months, the patient had significant improvement in both range of motion and strength. His range being essentially equal and 60% strength compared to his opposite shoulder. His DASH score was 22 at this visit, and we were optimistic for a full return in shoulder function in spite of his severe constellation of injuries. Radiographs revealed a healed fracture.

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3 Proximal Humeral Fractures: Open Reduction Internal Fixation

John T. Gorczyca

INTRODUCTION

Fractures of the proximal humerus are common injuries and comprise approximately 4% of fractures seen in clinical practice. They are the third most common extremity fracture in the elderly after the hip and distal radius. The majority of these fractures are the result of lower-energy injuries in older patients, which occur following a ground-level fall. Fortunately, most fractures are minimally displaced and are best treated nonoperatively. However, with higher-energy mechanisms such as motor vehicle collisions, athletic injuries, or falls from a height, the fracture is commonly multifragmentary, displaced or unstable, and surgery is often indicated. Displaced proximal humeral fractures can present complex technical challenges, especially in elderly patients with compromised bone. Over the past decade, there has been a dramatic increase in the number of patients with proximal humerus fractures treated surgically. This is due to an aging population who are living longer and have an increased expectation of improved shoulder outcome as well as significant improvement in the implants used to treat these fractures. Traditionally, hemiarthroplasty was the most common procedure in the geriatric patient with a displaced three- or four-part proximal humeral fracture. However, this procedure is associated with unpredictable outcomes even in the hands of experienced shoulder surgeons. With the recent development and widespread availability of periarticular locking plates for the proximal humerus, there has been a renewed interest in internal fixation as an alternative treatment. While the early reports with locked plating were promising, the technique is not a

panacea and numerous problems have been described. The most common classification of proximal humeral fractures was described by Neer (Fig. 3.1). Although inter- and intraobserver reliability of this classification system is imperfect, its popularity stems from its relative simplicity and its utility in guiding treatment.

FIGURE 3.1 The Neer classification of proximal humeral fractures.

INDICATIONS

AND

CONTRAINDICATIONS

FOR

SURGERY

Regardless of the method of treatment, the great majority of proximal humerus fractures will heal. Nonoperative treatment is indicated for all nondisplaced and most minimally displaced fractures in virtually all age groups. Following injury, fracture healing takes 6 to 10 weeks, but functional recovery of shoulder motion and strength takes much longer, and even fully compliant and motivated patients may fail to regain preinjury levels of function and activity. Surgery is indicated for most patients with significantly displaced three- and four-part fractures and dislocations of the proximal humerus. The nonoperative management of widely displaced fractures often leads to symptomatic malunion, with painful loss of shoulder motion frequently due to impingement, muscle weakness, and rotator cuff pathology. The goal of surgery is to restore the head shaft relationship and tuberosities with stable fixation to allow early range of shoulder motion. This permits many patients to lift their arm above their shoulder for activities of daily living. In many patients, the inability to perform this task may compromise a geriatric patient’s ability to live independently. However, many elderly and frail patients with multiple medical comorbidities should be treated nonoperatively accepting some loss of function. Likewise, preexisting neuropathy or stroke that compromises the expectation for functional benefit after surgery are strong indications for nonoperative treatment. Less common indications for surgery include bilateral fractures, ipsilateral upper extremity injury (“floating elbow” or “floating shoulder”), open fractures, fracture dislocations, polytrauma, and fractures with associated vascular injury. Displaced fractures in adult patients should be reduced and stabilized. More than 40 years ago, Neer recommended surgery for fractures of the proximal humerus with displacement of the head or either of the tuberosities by 1 cm, or angulation >45 degrees, which we still follow today. Isolated fractures of the greater tuberosity should be reduced and stabilized when displacement is >5 mm in any direction.

Not all proximal humeral fractures that require surgery are amenable to internal fixation. Strong indications for hemiarthroplasty include head- splitting fractures (with the exception of some young patients with healthy bone) anatomic neck fractures, and displaced three- and four-part fractures in patients with either comminution or osteoporosis that would not support internal fixation. Preexisting chronic rotator cuff deficiency with arthropathy is better treated nonoperatively or with shoulder arthroplasty.

PREOPERATIVE PLANNING

History and Physical Examination

Seriously injured patients should undergo initial evaluation according to Advanced Trauma Life Support (ATLS) protocols to ensure a thorough evaluation and to prevent missed injuries. In the multiply injured patient with a shoulder fracture, injuries to the head, neck, chest wall, and upper extremity commonly occur. Proximal humeral fractures that occur in elderly patients following lower energy falls may be associated with injuries to the head, face, or wrist. When possible, a careful history may reveal substantial medical comorbidities such as hypertension, coronary artery disease, or diabetes. The patient’s medication record should be scrutinized with particular reference to anticoagulation medication. Other important factors include hand dominance, occupation, and living status, which may play an important role in decision making. All patients should have a complete physical examination. The extremity should be examined for swelling, ecchymosis, peripheral pulses, and neurologic impairment. Any questions regarding the vascular integrity warrant further evaluation, with an ankle-brachial index, Doppler evaluation, or angiography. If any abnormality is identified, vascular surgical consultation should be obtained. A thorough neurologic examination of the entire upper extremity must be performed and documented. Evaluation of the axillary nerve can be difficult in a swollen painful shoulder, but should be tested by asking the patient to contract the deltoid muscle whenever possible. Range of motion of the shoulder is typically limited due to pain. It is also important to evaluate the elbow, forearm, wrist, and hand performed in order to avoid missing a more distal injury.

Radiographic Evaluation

The proximal humerus consists of four parts: The humeral head, the greater and lesser tuberosities, and the humeral shaft (Fig. 3.2). In order to optimally visualize these four parts, all patients with a shoulder injury should have an anteroposterior view, a transscapular lateral (“Y”) view, and an axillary lateral view (Fig. 3.3AC). The axillary lateral, while challenging to obtain in the trauma setting, often provides crucial information. It is frequently the best view to rule out a coronal plane head-splitting fracture, a glenoid rim fracture, as well as a glenohumeral joint subluxation or dislocation. It is important to remember that if the x-ray beam is not orthogonal to the axis of the humeral shaft (which is often the case), then any measurement of fracture angulation will be exaggerated. Thus, the transscapular lateral radiograph provides a better view for accurately measuring fracture angulation. In patients with complex fracture patterns, a computed tomographic (CT) scan can be helpful to evaluate fragment size and displacement and can reveal nondisplaced fracture lines (Fig. 3.4 A,B). The thickness of the humeral head seen on the CT scan should be carefully assessed when considering internal fixation. If the head is too small or thin, stable fixation may not be achieved and cut out of the screws is more likely. In addition to the axial, sagittal, and coronal reconstructions, 3D imaging provides detailed topographic views which may allow a clearer appreciation of the fracture geometry (Fig. 3.4C). In some cases, the scapula can be “subtracted” giving even more information about the fracture morphology. Based on the physical exam, x-rays of the cervical spine, clavicle, ribs, elbow, or forearm may be indicated.

FIGURE 3.2 The pathoanatomy of proximal humeral fractures.

FIGURE 3.2 The pathoanatomy of proximal humeral fractures.

FIGURE 3.3 A . Anterior-posterior view. B. Trans-scapula lateral view. C. Axillary lateral view.

FIGURE 3.3 A. Anterior-posterior view. B. Trans-scapula lateral view. C. Axillary lateral view.

FIGURE 3.4 A . The CT scan allows determination of the “thickness” of the humeral

FIGURE 3.4 A. The CT scan allows determination of the “thickness” of the humeral head available for fixation. B. Axial CT cut of a valgus impacted fracture demonstrates displacement of the greater and lesser tuberosities. C. A 3D CT image of a complex proximal humerus fracture.

Timing of Surgery

The majority of displaced proximal humerus fractures can be managed in a semielective fashion without compromising the quality of the outcome. A patient with an isolated closed, proximal humeral fracture seen in the emergency room can be discharged to home or to a suitable location if the pain is controlled and their social circumstances permit. These patients are seen in the office or clinic several days later and scheduled for surgery if indicated. On the other hand, if the pain is poorly controlled, the social circumstances are not optimal, or the patient has other injuries, patients are typically admitted to the hospital for earlier surgery. Fortunately, there are relatively few indications for emergent surgery. However, an open fracture, a fracture with a vascular injury, an irreducible fracture with impending skin compromise, or an irreducible fracture dislocation require immediate intervention. In these cases, surgery should be performed as soon as an operating room becomes available and a surgical team can be assembled.

Surgical Tactic

The most important step in preoperative planning is for the surgeon to carefully evaluate the x-rays and CT scan and answer two questions. First, does this fracture require surgery, and second, what is the optimal implant if surgery is required. Despite good preoperative planning, there is a small group of patients where the final decision between internal fixation and arthroplasty cannot be made until the time of surgery. If any doubt exists, the patient should be consented for both types of surgery, and the equipment and implants must be in the operating room at the beginning of the case. Surgery can be performed with the patient in either the beach chair position or supine on a flat-top radiolucent table. There are advantages and disadvantages with each technique. In the supine position, the patient should be positioned at the edge of the table with the arm supported on a hand board or a Mayo stand to allow shoulder abduction. Properly positioned, this setup will not interfere with the use of the C-arm. The patient’s head is supported on a gel “donut” or a rolled-up stockinet, and the patient’s eyes should be protected during the case (Fig. 3.5).

FIGURE 3.5 Intraoperative setup for open reduction and internal fixation of a proximal humerus fracture

FIGURE 3.5 Intraoperative setup for open reduction and internal fixation of a proximal humerus fracture with the patient in the supine position. The patient’s head is supported on a gel “donut” and the patient’s eyes are protected with plastic shields.

Prior to prepping and draping, the C-arm should be moved into position to ensure high quality anteroposterior and axillary lateral images can be obtained (Fig. 3.6AD). In most operating rooms, this is easiest if the surgical table is rotated 90 degrees. I prefer the C-arm to come in from the cranial side, slightly oblique to allow visualization of the entire humeral head and the edge of the glenoid when an axillary lateral view is obtained. It is wise to rehearse these moves so that the radiology technician can change from an AP to an axillary lateral views easily without the need to move the arm or shoulder. The spot for the C-arm is marked with tape on the floor in order to re-create the intraoperative position of the fluoroscopy unit during surgery (Fig. 3.7).

FIGURE 3.6 A. The patient is positioned with the involved shoulder at the edge of
FIGURE 3.6 A. The patient is positioned with the involved shoulder at the edge of

FIGURE 3.6 A. The patient is positioned with the involved shoulder at the edge of the table and the arm supported in approximately 60 degrees of abduction with a Mayo stand. B. An AP fluoroscopic x-ray is obtained. C. The C-arm is rotated to obtain an axillary lateral view with abduction and mild traction. D. An axillary lateral must show the entire head and the glenoid.

FIGURE 3.7 The position of the C-arm base is marked on the floor with tape.

FIGURE 3.7

The position of the C-arm base is marked on the floor with tape.

Surgery

Surgery is most commonly performed under general anesthesia, which

allows optimum control of the patient’s blood pressure and muscle paralysis. Regional nerve blocks are most useful for postoperative pain control. A helpful technique is to position and tape the endotracheal tube on the

side

opposite the fracture. Maintaining the mean arterial pressure close to 70

mm

Hg helps minimize bleeding, and muscle paralysis or relaxation is

helpful to lessen the forces required for muscle retraction and fracture reduction. A cepholsoporin antibiotic is given for prophylaxis within 1 hour of surgery. A Foley catheter, arterial line, central venous pressure (CVP) monitoring, or Swan-Ganz catheters are used when the patient’s medical comorbidities or physiologic status dictates. The entire upper extremity, shoulder, chest wall, and neck are prepped

and draped in the usual orthopedic fashion. A surgical time-out is called, and all members of the surgical, nursing, and anesthesia teams must agree on the patient’s name, medical record number, and correct side and site of surgery.

Techniques—Isolated Greater Tuberosity Fractures

The patient is positioned, prepped, and draped as outlined above. For isolated greater tuberosity fractures, I prefer a deltoid-splitting approach rather than

a deltopectoral incision. The challenge is to reduce and stabilize the fracture through a small incision that must not extend more than 5 cm distal to the

acromion to avoid injury to the axillary nerve. For most greater tuberosity fractures, I do not identify the axillary nerve rather proceed in a stepwise fashion to reduce and stabilize the greater tuberosity through the deltoid split. The skin incision, and the deltoid muscle split, start proximally at the anterior-lateral edge of the acromion and extend straight distally for 5 cm. The muscle is split through a relatively avascular plane in the deltoid raphe.

A loose suture can be placed through the deltoid muscle fibers 5 cm distal to

the acromion to prevent further muscle separation with injury to the axillary nerve. Deep to the muscle is the hemorrhagic subdeltoid bursa, which should be evacuated and excised to improve visualization. With internal and external rotation of the shoulder, the fracture lines will be appreciated. The fracture should be mobilized to expose the undersurface of the greater tuberosity and the defect in the proximal humerus. With the shoulder in internal rotation, a no. 2 or no. 5 heavy nonabsorbable suture is passed twice through the supraspinatus tendon at its insertion on the tuberosity capturing bone and tendon. I prefer a no. 5 ethibond suture with a large cutting needle, which can be gradually worked through the hard cortical bone by grasping the needle close to its point and rotating it backand forth like the tip of an awl. In younger patients with hard bone, a small drill bit can be utilized. Due to the posterior and proximal displacement of the greater tuberosity by the retracted supraspinatus and infraspinatus muscles, the first suture is often placed too far anteriorly. If this is the case, the first suture is used to pull the greater tuberosity anteriorly and distally in order to place two additional sutures in a better position. After this, the first suture can be removed. A curette is used to remove clotted blood and debris from the cancellous underside of the greater tuberosity.

The greater tuberosity sutures are gradually pulled to reduce the greater tuberosity into the defect in the proximal humerus. Two drill holes are made approximately 1 cm anterior and distal to the defect along the vector of the sutures used to reduce the greater tuberosity. Following this, the needle end of each suture is passed from within the fracture site out through the drill hole. The sutures are pulled tight is placed on the sutures to remove slack, and the greater tuberosity is held with digital pressure or with a blunt probe and provisionally fixed with one or two K-wires. Ideally, the guide wires for 3.5 or 4.0 mm partially threaded cannulated screws are used, and passed obliquely to engage the medial cortex of the humeral shaft followed by an appropriate length screw (Fig. 3.8AD).

FIGURE 3.8

FIGURE 3.8

A. AP radiographic showing a greater tuberosity fracture dislocation. B. Postreduction radiograph demonstrates reduction of the glenohumeral joint with persistent displacement of the greater tuberosity. C. AP x-rays show anatomic reduction of the tuberosity following internal fixation and tension band suture augmentation. D. Axillary lateral radiograph.

It should be emphasized that in the soft bone of the proximal humerus, both internal fixation and suture augmentation are necessary to prevent early fixation pull-out. The screw(s) ensure anatomic reduction of the tuberosity, but are not strong enough alone to allow physiologic shoulder motion. The sutures provide a more durable fixation of the greater tuberosity and resist tensile forces better. However, suture fixation alone can result in a malunion of the tuberosity if positioned too distally, which can compromise shoulder strength and motion. On the other hand, retraction of the cuff with posterior and proximal displacement of the tuberosity is also a risk when suture repair is performed alone. After placing one or two partially threaded screws across the fracture and into the medial cortex, the suture ends are tightened and tied with a smaller, absorbable suture. In order to prevent loosening of the knot, the two ends of suture above the knot can be tied together. The fracture reduction and screw position is confirmed with fluoroscopy and stability is checked with gentle shoulder motion. Finally, the rotator cuff is inspected for any sign of tear or deficiency. If a supraspinatus or infraspinatus tear is present, it is carefully repaired with nonabsorbable sutures. The deltoid fascia is closed with absorbable suture, the subcutaneous tissues are approximated, and staples or sutures are placed in the skin. After application of a sterile dressing, the arm is placed in a shoulder immobilizer.

Techniques—ORIF of Two- to Four-Part Fractures in Adults

Virtually all displaced two-, three-, and four-part fractures of the proximal humerus that require suture ends are approached through a deltopectoral incision. The incision starts just distal to the coracoid process and extends 12 to 17 cm toward the lateral side of the biceps tendon depending on how much exposure is needed. The cephalic vein is identified, protected, and

retracted. The deltopectoral interval is developed digitally, down to the clavipectoral fascia, which is then incised as far proximally as its confluence with the coracoacromial ligament. The space between the lateral aspect of the proximal humerus and the deltoid is developed by careful blunt dissection, and a Hohman retractor is placed between the two. Abduction of the shoulder to 45 degrees or more facilitates mobilization of the deltoid. Approximately one-third of the anterior deltoid insertion is released on the shaft to improve exposure and space for the plate. In three- and four-part fractures, the greater and lesser tuberosities are identified and tagged with two nonabsorbable sutures passed through each of the tuberosities (i.e., total four sutures) where the cuff inserts into the bone. As described in the description of isolated greater tuberosity fracture repair, the first suture in the greater tuberosity is often used for traction that allows optimal placement of one or two additional sutures for secure fixation. After the tuberosities are secured by the sutures, the sutures can be used to manipulate the tuberosities into a reduced position. Attention is now directed to the head fragment. In the uncommon event that the head fragment is dislocated, it can be reduced using a thin periosteal elevator to lift the head over the edge of the glenoid. Alternatively, one or two 2.0-mm terminally threaded K-wires can be drilled into the head fragment and used as joy sticks to help manipulate and reduce the head fragment. In some cases, the head is impacted on the shaft. In most patients, it should be disimpacted to allow reduction of the tuberosities using an osteotome or a thin periosteal elevator. The fracture line between the impacted humeral head and the metaphysis can usually be recognized visually when the split between the greater and lesser tuberosities is separated with an instrument or lamina spreader. It is important to preserve bone stock on the head fragment by gradually freeing it around the periphery before attempting to reduce it (Fig. 3.9).

FIGURE 3.9

FIGURE 3.9

Reduction of an impacted humeral head fragment. By placing an instrument in the fracture line between the greater and lesser tuberosities, the surgeon first develops a plane between the head and the tuberosities, then gently lifts the head from the metaphysis.

In young patients with dense bone and large tuberosity fragments, the stability of the humeral head usually improves after reduction of the tuberosities. Once the reduction has been verified fluoroscopically, the tuberosities and head fragment are provisionally stabilized with K-wires, which do not interfere with subsequent plate placement. Unfortunately, most patients with displaced proximal humeral fractures are elderly and have soft osteoporotic bone, which invariably has some component of crushing and comminution. In these patients, the ability to maintain an adequate reduction of the humeral head by provisional fixation of the tuberosities alone is very limited. In these cases, the greater tuberosity fragment should be carefully evaluated. If it is small or multifragmentary, its reduction and stabilization should be postponed until after the head and shaft are reduced and stabilized. On the other hand, if the greater tuberosity fragment is large, it should be reduced and provisionally stabilized to the head using multiple K-wires outside the plane of the proposed plate. If the lesser tuberosity is fractured and unstable, it is also reduced and held with K- wires. The humeral shaft, which is typically displaced anteriorly and medially, is then reduced to the head with traction and the aid of a periosteal elevator (Fig. 3.10A,B). The shaft is provisionally stabilized to the head with one or two oblique K-wires directed from anterior-lateral-distal to posterior- medial-proximal (Fig. 3.11A). If the K-wires are able to hold the reduction, fluoroscopy is used to assess the reduction prior to plate placement. The plate is positioned directly laterally so that the anterior edge of the plate is located lateral to the long head of the biceps tendon (Fig. 3.11B).

FIGURE 3.10 A. The humeral head and shaft are reduced with the aid of a

FIGURE 3.10

A. The humeral head and shaft are reduced with the aid of a long thin

periosteal elevator. The elevator is used to lever the shaft posteriorly and

laterally into a reduced position relative to the head. B. Intraoperative fluoroscopic view shows the position of the elevator.

fluoroscopic view shows the position of the elevator. FIGURE 3.11 A. Intraoperative photo shows heavy sutures

FIGURE 3.11

A. Intraoperative photo shows heavy sutures placed in the greater and less

tuberosities and the head and shaft reduced and held with K-wires. B. The plate is placed on the lateral aspect of the proximal humerus and fixed to the

humerus under fluoroscopic control. The tuberosity sutures are tied to the plate.

Unfortunately, due to comminution and poor bone quality, K-wires and

reduction clamps alone will not usually hold the reduction in the poor bone of the humeral head. In this case, the greater and lesser tuberosities are reduced to the humeral head, and the plate is fixed to the proximal fragment

with K-wires through the perimeter of the plate. Fluoroscopy is used to

verify plate position and the overall reduction. The plate is reduced to the

shaft, thereby indirectly reducing the shaft to the head. Care must be taken to

ensure that the superior aspect of the greater tuberosity will end up 8 to 10

mm distal to the superior edge of the humeral head after final plate

positioning. With the plate pushed firmly against the bone, two locking screws are placed through the most proximal holes into the humeral head. Screw position is checked on AP and lateral fluoroscopy. One or two additional locking screws are placed more inferiorly into the humeral head, and the position is again confirmed fluoroscopically. The next step is to fix

the plate to the shaft. The plate is held against the shaft with direct pressure,

and the shaft is pushed proximally toward the head in an attempt to

maximize bony contact and create a load-sharing construct. There is a

tendency for the shaft to displace anteromedially by the pull of the pectoralis major muscle. This deformity should be corrected before the

plate is fixed to the shaft. Typically, one or two nonlocking screws are

placed in the distal fragment to secure the plate against the bone with the

remaining holes filled with 3.5-mm locking screws.

Another scenario commonly encountered is the challenge of restoring the correct angular and rotational relationships between the humeral head, shaft, and the glenoid. This generally occurs when there is significant comminution of surgical neck allowing the head to collapse or rotate into varus or retroversion. The metaphyseal defect will not support the head fragment in its normal alignment or version. This usually requires placement of bone

graft material (allograft, autograft, or substitute) into the metaphyseal void to

buttress the head and provide mechanical support for fracture reduction. Another alternative is to reduce and temporarily pin the humeral head into the glenoid. If the greater tuberosity fragment is large (which is usually not the case in this scenario), it is reduced to the head using traction sutures, and

a plate is positioned laterally, held with K-wires, checked on fluoroscopy,

and fixed to the head and greater tuberosity with two proximal locking screws as described previously. After confirmation of an adequate reduction

and plate position fluoroscopically, two additional locking screws are placed

in the head, and the plate is reduced and fixed to the shaft. If the greater

tuberosity fragment is small or multifragmentary, the plate is positioned and provisionally secured to the head fragment with K-wires. Reduction and plate position are verified fluoroscopically, as poorly placed screws in the humeral head that have to be removed and replaced will further compromise fixation in the osteopenic humeral head. These are typically the fractures with thin head fragments for which arthroplasty is often a treatment option. The head and shaft are reduced and stabilized with screws. Locking screws are placed in any of the remaining holes that will provide purchase into bone. No screw tip should be closer than 5 mm from articular surface. Next, the sutures placed in the tuberosities are used to reduce them to the humeral head, and they are secured to the plate. The sutures can be passed through one or more holes along the periphery of the plate or even as a cerclage around the entire plate. Whatever technique is chosen, it is crucial that the tuberosities are anatomically reduced and securely fixed. The sutures should not be passed through locking holes in the plate if possible, as the threaded edge of the hole may abrade or transect the suture. Some surgeons prefer to pass the sutures through the holes in the plate prior to positioning of the plate, which makes passage of the sutures easier. The disadvantage with this technique is keeping the sutures out of the way during the remainder of the procedure, and the preselected position of the sutures in the plate may not be at the ideal vector for tuberosity reduction or fixation. Following internal fixation, the rotator cuff should be evaluated, and any tears should be repaired with nonabsorbable suture. The wounds are copiously irrigated and meticulous hemostasis obtained with cautery. The wound is closed in layers.

Postoperative Care

The surgical incision is inspected at 48 hours prior to hospital discharge When the wound is clean and dry, pendulum exercises and gentle active range of shoulder motion is initiated. Patients are instructed in six exercises

they can perform at home independently:

1. Clockwise shoulder rotation—performed while leaning forward, starting initially with small rotations, and gradually increasing the size of rotation as comfort improves.

2. shoulder rotation—as above, different direction of

Counterclockwise

rotation.

3. Tight fist—the patient makes a tight fist, and then fully extends all fingers.

4. Thumb to shoulder—the patient flexes the elbow in an attempt to touch the anterior shoulder with the thumb, and then gradually extends the elbow as far as possible, then repeats.

5. Front-assisted lift—the patient uses a 1 inch dia. wooden dowel (broomstick), and, grasping it with both hands spaced 6 inches apart, slowly lifts it forward with the contralateral uninjured arm, while the injured arm follows with minimal active contraction of the deltoid. The arm is lifted (shoulder flexed) to the point of mild discomfort, at which point the arm is gently lowered to the resting position.

6. Side-assisted lift—the same dowel is used, the hands are placed a shoulder’s width apart, and the uninjured arm pushes the dowel to the opposite side, and the contralateral shoulder abducts with minimal active contracture (i.e., active-assisted).

The patient performs 10 repetitions of each exercise and does these exercises three times per day. When not performing exercises or bathing/showering, the patient protects his arm/shoulder in a sling or shoulder immobilizer. Patients are seen for follow-up at 2 weeks and at 6 weeks where AP and axially lateral radiographs of the shoulder are obtained to confirm fracture reduction and to assess fracture healing. At 6 weeks, patients begin independent range of motion exercises with gravity resistance. If at 6 weeks, the patient is unable to forward flex the shoulder to 90 degrees independently, referral to a physical therapist is recommended. At 3 months, the fracture should be healed, and the patient may perform passive stretching and resistive exercises without restriction (Fig. 3.12). Once good shoulder motion has been restored, upper limb strengthening using progressive weights or bands is instituted. Independent passive stretching can be performed by “walking the fingers up the wall” anteriorly and at the side

as well as external rotation using the dowel for terminal stretch. If motion is not adequate, the patient should be referred to a physical therapist for assistance with the passive stretching and resistive strengthening exercises.

FIGURE 3.12 Range of shoulder motion in a 30-year-old male 5 months following internal fixation of a displaced proximal humerus fracture.

Complications

The most common problem after a proximal humerus fracture is shoulder stiffness (Fig. 3.13). It is unusual for a patient to regain normal shoulder motion after internal fixation of a displaced fracture. Fortunately, most patients are able to perform activities of daily living with mild or moderate shoulder stiffness. In order to minimize the risk of more significant shoulder stiffness, the surgeon must achieve stable fracture fixation including the fixation of the tuberosities and initiate early motion. If the patient is unable to perform independent exercises, or is not making progress independently, a physical therapist should be involved in the rehabilitation

FIGURE 3.13 Seven months following internal fixation of a three-part proximal humerus fracture, this 59-year-old

FIGURE 3.13 Seven months following internal fixation of a three-part proximal humerus fracture, this 59-year-old female still has significant loss of forward elevation and shoulder abduction.

Screw cut-out or penetration through the subchondral bone into the glenohumeral joint occurs most commonly in elderly patients, but it occurs in younger patients as well (Fig. 3.14). Methods to minimize this risk are (a) placing screws into the subchondral bone without having drilled the entire screw path, (b) checking the position of the screw tips with multiple fluoroscopic projections, to ensure that the screw tips are at least 5 mm from the subchondral bone, and (c) manually pushing the shaft proximally prior to plate fixation in order to increase bone contact and lessen the tendency for the humeral head to collapse. Some authors recommend the use of a custom fit fibular allograft to mechanically support the humeral head.

FIGURE 3.14 A 61-year-old male referred to our institution for treatment of failed fixation and

FIGURE 3.14

A 61-year-old male referred to our institution for treatment of failed fixation

and screw penetration into the joint.

Many forms of fixation failure can occur after open reduction and internal fixation of proximal humerus fractures. Displacement of the tuberosities can

occur due to failure of the suture or as a result of the suture cutting through the tuberosity and cuff (Fig. 3.15). Proper positioning and placement of the suture at the insertion of the rotator cuff, use of a heavy suture, passage of the suture through smooth holes in the plate (i.e., avoiding locking screw holes), and securing the suture with detailed attention to knot tying will minimize this risk. Fixation failure by plate or screw breakage usually occurs

as a result of fracture nonunion, but may also occur if the patient is not compliant with postoperative activity restrictions.

FIGURE 3.15 Loss of reduction of the greater tuberosity following internal fixation.

Aseptic necrosis may occur after a proximal humerus fracture (Fig. 3.16A,B). In the past, the fear of its occurrence led many surgeons away from open reduction and internal fixation toward nonoperative treatment or arthroplasty for these fractures. There is increasing recognition that when aseptic necrosis occurs, it is not always associated with a poor result. In many cases, patchy aseptic necrosis occurs without head collapse and relatively few symptoms. However, if aseptic necrosis with head collapse occurs and the patient is symptomatic, they may benefit from shoulder arthroplasty. In order to reduce the risk of aseptic necrosis, unnecessary soft-tissue stripping should be avoided. Intraoperative manipulation and reduction of the head and shaft should be performed “from within” the fracture, taking care to use: (a) long periosteal elevators to lever the shaft and head into position; (b) heavy sutures to assist with fracture reduction without elevation of soft tissues; and (c) K-wires for provisional fixation whenever possible.

and (c) K-wires for provisional fixation whenever possible. FIGURE 3.16 AP (A) and lateral (B) radiographs

FIGURE 3.16 AP (A) and lateral (B) radiographs of a patient with avascular necrosis and

collapse of the humeral head following internal fixation of a proximal humerus fracture.

Results/Outcomes

Most studies report that 70% to 75% of patients obtain satisfactory outcomes following locked plating of proximal humeral fractures. The reported 1-year mortality rate is elevated although it returns to the age-expected level after the first year. Although there is a common belief that the results of internal fixation have improved since the advent of locked plate fixation, this has not been clearly established. There are few randomized controlled trials comparing locked plating with nonoperative treatment or other treatment modalities. The use of locked plates to treat proximal humerus fractures has significantly increased in number over the past decade. However, this is a challenging surgical procedure, fraught with potential complications, and the results can be less than satisfactory. Proper and thorough evaluation of the patient and the fracture, preoperative preparation, careful technique, and realistic expectations of surgical results remain essential in order to achieve good results. Nevertheless, it is an important tool in the armamentarium of the fracture surgeon.

RECOMMENDED READING

Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma

2007;21:676–681.

Badman BL, Mighell M. Fixed-angle locked plating of two-, three-, and four- part proximal humerus fractures. J Am Acad Orthop Surg

2008;16(5):294–302.

Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br 1997;79:857–865. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14(3):183–190. Fankhauser F, Schippinger G, Weber K, et al. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop 2005;430:176–

181.

Gardner MJ, Boraiah S, Helfet DL, et al. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22(3):195–200. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma

2007;21(3):185–191.

Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg 2004;12(4):205–212. Hernigou P, Germany W. Unrecognized shoulder joint penetration during fixation of proximal fractures of the humerus. Acta Orthop Scand

2002;72(2):140–143.

Herscovici D, Saunders DT, Johnson MP. Percutaneous fixation of proximal humeral fractures. Clin Orthop 2000;375:97–104. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427–433. Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 1992;74:505–515. Jakob RP, Miniaci A, Anson P, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Am 1991;73:295–298. Kannus P, Palvanen M, Niemi S. Increasing number and incidence of osteoporotic fractures of the proximal humerus in elderly people. Br Med J 1996;313:1051–1052. Koval KJ, Gallagher MA, Marsicano JG, et al. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203–207. Meier RA, Messmer P, Regazzoni P, et al. Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma 2006;20:253–260. Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077–1089. Olsson C, Petersson CJ. Clinical importance of comorbidity in patients with a proximal humerus fracture. Clin Orthop Relat Res 2006;442:93–99. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87–92. Rietveld AB, Daanen HA, Rozing PM, et al. The lever arm in glenohumeral

abduction after hemiarthroplasty. J Bone Joint Surg Br 1988;70:561–565. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am

2003;85:1647–1655.

Rowkles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus: an anatomic study. J Bone Joint Surg Am 2001;83(11):1695–

1699.

Soete PJ, Clayson PE, Costenoble VH. Transitory percutaneous pinning in

fractures of the proximal humerus. J Shoulder Elbow Surg 1999;8:569–

573.

Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg 1984;100:249–259. Sudkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009;91:1320–1328. Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84:1919–1925. Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury 1998;29:349–352.

4

Proximal Humerus Fractures:

Hemiarthroplasty

William H. Paterson and Sumant G. Krishnan

INTRODUCTION

Proximal humeral fractures are common injuries representing 4% to 5% of

all fractures in clinical practice, but they account for nearly half of all

shoulder girdle injuries (1). After the hip and distal radius, fractures of the proximal humerus are the third most common fracture in the elderly, with a strong female predominance (2). In this age group, mechanical ground-level falls are the most common cause of fragility fractures of proximal humerus, and there is a strong correlation with the presence of osteoporosis. Early evaluation and management of these injuries is important in optimizing treatment and functional outcomes. There are a bewildering number of treatment alternatives for managing proximal humeral fractures. Nevertheless, there is universal agreement that nondisplaced and minimally displaced fractures are best managed nonoperatively. Percutaneous fixation, plate osteosynthesis, intramedullary nailing, and arthroplasty are the most common methods of treatment for displaced and unstable fractures in adults.

A recent Cochrane database review of interventions for treating proximal

humeral fractures in adults showed that no single method of treatment was

preferable (3). This may be due to the limited number of patients stratified

to individual techniques as well as the wide variety of injury patterns and

treatments. Arthroplasty is most commonly advocated for the primary treatment of displaced three- and four-part fractures in osteoporotic bone in the elderly. However, it is technically demanding, and numerous studies have documented unpredictable outcomes (4). Notwithstanding, recent advances

in surgical technique and prosthetic designs have led to more successful outcomes (59). Improved outcomes have been documented when soft- tissue dissection is minimized and there is restoration of the “gothic arch” and anatomic reconstruction of the tuberosities (5).

INDICATIONS AND CONTRAINDICATIONS

Age, bone quality, fracture pattern, and timing of surgery are important factors that influence the surgical procedure, implant selection, and the functional and radiographic outcome. Utilizing these specific variables, we have devised an “evidence-based” treatment algorithm (Table 4.1) (10).

TABLE 4.1 Factors Affecting Treatment Choice
TABLE 4.1 Factors Affecting Treatment Choice

Age

One of the most important considerations in selecting a method of treatment in proximal humeral fractures is the chronological and physiologic age of the patient. Most female patients when they reach the sixth decade of life have some degree of osteoporosis, and many have impaired neuromuscular control as well. These factors may compromise osteosynthesis by increasing the risk of fixation failure, postoperative fracture displacement, nonunion, and/or avascular necrosis (11). Fractures in patients aged 65 years or less appear to be more amenable to humeral head preservation techniques.

Bone Quality

Similar to age, a patient’s bone quality can affect the success of humeral head preserving fixation techniques. Despite improved fixation strength in osteoporotic bone afforded by locking plate technology, complications

continue to be higher in these patients after open reduction and internal fixation (12).

Fracture Pattern

Hertel et al. (13) investigating perfusion of the humeral head after an intracapsular fracture was able to prospectively correlate radiographic fracture morphology with intraoperative humeral head vascularity. Radiographic criteria predictive of humeral head ischemia included a posteromedial metaphyseal fragment extending <8 mm below the articular surface and disruption of the medial hinge defined as displacement of the humeral shaft>2 mm. When these two preoperative radiographic findings were present in conjunction with an anatomic neck fracture, there was a 97% positive predictive value for humeral head ischemia. Even when the humeral head is vascular and amenable to preservation, the ability to maintain adequate fracture stability is necessary for successful fracture healing. The medial calcar of the humerus must be intact or restored at the time of surgery for a “stable” reduction. Comminution in this region increases the riskof a varus fracture reduction.

Timing of Surgery

The delay between injury and definitive surgery is the final variable that may affect functional outcomes following surgical management of proximal humeral fractures. For example, a fracture amenable to percutaneous fixation techniques may become impossible to reduce closed and pin percutaneously after 7 to 10 days or when early callus forms that prevents closed reduction. It is also clear that the outcomes following early arthroplasty for proximal humeral fractures are significantly improved compared to arthroplasty more than 4 weeks after injury (14). We believe that optimal surgical timing for shoulder fracture arthroplasty is 6 to 14 days after injury to allow for partial resolution of the soft-tissue swelling (assuming no acute neurovascular injury or other situation necessitating an earlier intervention) (15). Very rarely, glenohumeral arthritis may preexist in a patient with a displaced proximal humerus fracture. If the degenerative changes are mild or moderate, conventional hemiarthroplasty is still indicated. If end-stage glenoid arthrosis is present, a total shoulder arthroplasty with insertion of a

glenoid component should be strongly considered. As experience with reverse shoulder arthroplasty increases, the indications for utilizing this prosthesis in the initial treatment of proximal humerus fractures have become better defined. We typically use a reversed prosthesis when the patient is older than 75 years, when the greater or lesser tuberosity cannot be reconstructed, or the patient has ipsilateral lower extremity fractures that require crutches or a walker. In the infrequent situation in which a patient with a proximal humerus fracture has a concomitant irreparable rotator cuff tear or cuff tear arthropathy, a reversed prosthesis should be considered. Contraindications to shoulder fracture arthroplasty are typically related to severe medical comorbidities that prevent surgical management in general. Nonoperative treatment may be a better treatment alternative for geriatric patients with complex medical comorbidities, extremely low functional demands, and minimal pain at the time of presentation. Other contraindications for arthroplasty are a history of infection, severe contracture of the shoulder girdle, open epiphysis, or fractures amenable to other fixation techniques.

PREOPERATIVE PLANNING

Clinical Evaluation

Marked edema and ecchymosis, which can extend down the arm and into the chest, are often seen in patients with proximal humeral fractures. Many elderly patients with these injuries are on anticoagulation therapy. Evaluation for concomitant injuries or associated medical conditions is important in these elderly patients. A cardiac or neurologic event may be the predisposing cause of the fall. Most of these patients require a careful medical evaluation by an appropriate specialist particularly if surgery is contemplated. Subtle neurologic injury occurs in a large number of patients with proximal humeral fractures (15). Utilizing electromyography, Visser et al. (15) documented neuropraxia of the axillary and/or suprascapular nerves in 50% of patients. Clinical appreciation and documentation of this finding is important for both prognostic evaluation and preoperative counseling, as eventual recovery may take up to 12 to 18 months after surgery (6). These may be very difficult to identify clinically in a patient with a painful swollen

shoulder following fracture.

Radiographic Evaluation

Radiographs should include anteroposterior, scapular “Y,” and/or axillary views. As part of our protocol, we obtain full-length scaled radiographs of both humeri using a ruler of defined length for preoperative planning (Fig. 4.1). If plain radiographs do not allow a clear understanding of the fracture morphology, a computed tomography scan with three-dimensional reconstructions may be a helpful.

FIGURE 4.1 A scaled ruler is placed on the patient’s arm during the radiograph to

FIGURE 4.1 A scaled ruler is placed on the patient’s arm during the radiograph to calculate magnification.

Neer’s classic four-part description of proximal humerus fractures has endured by virtue of its simplicity. Despite this, interobserver reliability and intraobserver reproducibility have been reported to be only poor to fair (16). A “comprehensive binary” description of these fractures based upon Codman’s original concept of fracture planes has also been described (Fig.

4.2) (13). In this classification, there are 12 possible fracture patterns: 6 patterns resulting in 2 fracture fragments, 5 patterns resulting in 3 fracture fragments, and 1 pattern resulting in 4 fracture fragments. In the original study by Hertel et al., ischemia was observed only in types 2, 7, 8, 9, 10, and 12. This system has demonstrated improved interobserver reliability as well as better intraobserver reproducibility.

reliability as well as better intraobserver reproducibility. FIGURE 4.2 Hertel’s binary (LEGO) proximal humerus

FIGURE 4.2 Hertel’s binary (LEGO) proximal humerus fracture description system. HH, humeral head; GT, greater tuberosity; LT, lesser tuberosity. (Modified from Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427–433.)

Restoring the “Gothic Arch”

Anatomic restoration of humeral height, correct prosthetic version, and tuberosity reconstruction play critical roles in determining functional outcome (5). Many studies have shown that poor functional results correlate

closely with prosthesis and/or tuberosity malposition. Boileau et al. (4) described the “unhappy triad,” in which the prosthesis is cemented “proud” and retroverted and the greater tuberosity has been positioned too low. This combination is associated with persistent pain and stiffness and poor function. Careful attention to the restoration of the proximal humeral anatomy is crucial in obtaining good results following shoulder fracture arthroplasty. We use the term “gothic arch” to describe the architectural anatomy of the proximal shoulder girdle as seen on an anteroposterior radiograph (5). The arch is formed by tracing a line along the medial border of the proximal humeral calcar to the articular surface and joining this with a line along the lateral border of the scapula to the articular surface. The result is a classical “vaulted” or “gothic” arch shape seen in medieval period architecture (Fig. 4.3). This simple concept allows for a highly reproducible surgical technique for restoration of proper humeral height, which improves the potential for anatomic tuberosity reconstruction.

FIGURE 4.3

FIGURE 4.3

The “gothic arch” of the normal shoulder is formed by (1) a line drawn along the medial humeral shaft and calcar and (2) a line drawn along the lateral scapular border, which intersect at (3) the inferior articular margin. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

Using the scaled preoperative radiographs, we first measure the entire length of the intact contralateral humerus from a line perpendicular to the medial epicondyle to the top of the humeral head (N) (Fig. 4.4A). On the injured side, the length of the fractured humerus (F) (Fig. 4.4B) is determined by measuring from a line perpendicular to the medial epicondyle to the fracture line at the humeral metadiaphysis. Humeral height for the prosthesis that must be restored (H) is calculated by subtracting F from N (Fig. 4.4C). In addition, we measure the length of the greater tuberosity fragment (G) (Fig. 4.4D), which should be within 5 mm of H to ensure that humeral prosthetic height will allow for anatomic tuberosity reconstruction. These steps are vital and cannot be overlooked. Full-length scaled radiographs of both humeri can even be done in the operating room immediately prior to surgery, using digital radiography with markers for precise preoperative measurements.

FIGURE 4.4 A . Length of normal humerus (N) is the distance along the humeral

FIGURE 4.4 A. Length of normal humerus (N) is the distance along the humeral shaft from a line perpendicular to the medial epicondyle to the top of the humeral head, corrected for magnification. B. Length of fracture (F) is the distance along the humeral shaft from a line perpendicular to the medial epicondyle to the fracture line at the humeral metadiaphysis, corrected for magnification. C. The amount of humeral height to be restored (H) is the value of N minus F. D. Greater tuberosity length (G) should be within 5 mm

of humeral head height (H). (A through D reprinted with permission from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg

2005;6(2):57–66.)

As a final check, the preoperative value G is compared with the length of the greater tuberosity fragment measured intraoperatively (Fig. 4.5). This is important because the greater tuberosity should be positioned 3 to 5 mm below the prosthetic head.

should be positioned 3 to 5 mm below the prosthetic head. FIGURE 4.5 Intraoperative measurement of

FIGURE 4.5 Intraoperative measurement of greater tuberosity should be within 5 mm of humeral head height (H). (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

SURGICAL TECHNIQUE

General hypotensive anesthesia, without the use of a regional nerve block, is preferred. The patient is positioned supine on the operating room table in a modified beach-chair position using a bean bag for scapula support (Fig. 4.6). The head of the table is elevated 20 to 30 degrees. If desired, the table may now be turned 90 degrees to allow for a C-arm to be brought in directly

perpendicular to the patient. A sterile articulated arm holder is utilized (McConnell Arm Holder, McConnell Orthopedic Manufacturing Company, Greenville, TX). The extremity, shoulder, chest wall, and neck are prepped and draped with the affected arm free.

and neck are prepped and draped with the affected arm free. FIGURE 4.6 Modification of the

FIGURE 4.6 Modification of the beach-chair position.

If there is no contraindication, appropriate preoperative and perioperative intravenous antibiotics are administered (cephalosporin or vancomycin) for a 24-hour total duration. A 5- to 7.5-cm deltopectoral approach is used. The incision is placed in the deltopectoral interval and starts at the medial tip of the coracoid paralleling the path of the cephalic vein (Fig. 4.7). A mobile soft-tissue window will allow the procedure to be performed through a relatively small incision. Prior to making the incision, the skin and subcutaneous tissue are infiltrated with 0.25% bupivicaine with epinephrine. The cephalic vein is retracted medially with a small strip of the deltoid. By blunt dissection, the deltopectoral interval is developed down to the clavipectoral fascia. Small Hohmann retractors are placed under the deltoid proximally and over the coracoacromial ligament. A self-retaining retractor

is then placed beneath the deltoid and conjoint tendon (Fig. 4.8). The biceps tendon is identified in the intertubercular groove, tagged, and divided at its insertion for later tenodesis. Typically, the fracture line can be located with an elevator or osteotome between the tuberosities, just posterior to the bicipital groove. The greater tuberosity is identified and mobilized. Four nonabsorbable horizontal mattress nonabsorbable sutures (No. 5 Ethibond, Ethicon, a Johnson and Johnson Company, New Brunswick, NJ) are placed separately in the greater tuberosity at the bone-tendon junction (two in the infraspinatus and two in the teres minor). Similarly, the lesser tuberosity is identified and mobilized. Two nonabsorbable sutures are placed around the lesser tuberosity at the subscapularis bone-tendon junction (Fig. 4.9). The tuberosities are gently retracted to gain access to the humeral head. Dissecting scissors are used to divide the rotator cuff in line with the tuberosity fracture plane. The head fragment is carefully removed and measured with a caliper. If the humeral head measurement is intermediate between sizes, the smaller size should be selected. The humeral head is saved and used to procure three structural cancellous bone grafts, which will be placed into and around the humeral component (Fig. 4.10). Loose bony fragments are removed from around the glenoid, and the joint is copiously irrigated and inspected for signs of damage or arthrosis.

FIGURE 4.7 Modified deltopectoral incision. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al.

FIGURE 4.7 Modified deltopectoral incision. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

FIGURE 4.8 Retractor placement. ( 1 ) Over the coracoacromial ligament, ( 2 ) on

FIGURE 4.8 Retractor placement. (1) Over the coracoacromial ligament, (2) on top of the acromion, (3) self-retaining retractor placed under the deltoid and conjoint tendon.

FIGURE 4.9 Four separate heavy nonabsorbable sutures are placed at the greater tuberosity bone-tendon junction.

FIGURE 4.9 Four separate heavy nonabsorbable sutures are placed at the greater tuberosity bone-tendon junction. Two temporary stay sutures are placed at the lesser tuberosity bone-tendon junction.

FIGURE 4.10 This osteotome is included in the prosthetic instrumentation set and is used to

FIGURE 4.10 This osteotome is included in the prosthetic instrumentation set and is used to fashion structural bone graft from the humeral head.

The humeral shaft is mobilized and delivered into the wound. The medullary canal is prepared by hand using cylindrical reamers and fracture-specific trial implants of increasing diameter (Aequalis Fracture Prosthesis, Tornier, St. Ismier, France) until the appropriate trial implant and head size are determined. The smallest reamer that demonstrates cortical contact is chosen, and since we recommend a cemented stem, we do not attempt to “ream up” to a larger implant stem diameter. If desired, a trial stem and head may now be placed into the humerus. Fracture jigs are available to allow for stable trial implant height and retroversion during a trial reduction. If a trial reduction feels too loose or tight, one must reassess whether the anatomy has been properly restored using the “gothic arch” technique as described below. If the medial calcar is fractured, it is provisionally stabilized using cerclage wire or heavy suture fixation with the

last broach used in the medullary canal (Fig. 4.11).

FIGURE 4.11 A fractured medial calcar is stabilized using cerclage wire or heavy suture fixation.

FIGURE 4.11 A fractured medial calcar is stabilized using cerclage wire or heavy suture fixation.

The next step is to restore the proximal humeral “gothic arch” anatomy. Unlike other described techniques, we do not reference the reconstruction using the lateral humeral metadiaphysis. The appropriate diameter fracture- specific prosthetic stem is opened, and the preselected size trial head is placed on the definitive implant with the eccentric head offset rotated into the most lateral position (Fig. 4.12). We systematically place the humeral head offset in this most lateral position as this decreases the amount of “medial overhang” of the humeral head and increases the lateral room under the prosthetic head for bone graft and anatomic positioning of the greater tuberosity.

FIGURE 4.12 Appropriate prosthetic humeral head placement is in the most laterally offset position. Using

FIGURE 4.12 Appropriate prosthetic humeral head placement is in the most laterally offset position.

Using the preoperative radiographic calculations as previously described, a mark corresponding to length H is placed on the prosthetic implant by measuring from the top of the trial humeral head (see Fig. 4.4D). During provisional placement of the prosthesis inside the medullary canal, the mark should be visible at the fracture line of the humeral shaft. The line of the

“gothic arch” (medial calcar of the humerus up to the inferior margin of the anatomical neck down the lateral scapular border) should be unbroken (Fig. 4.13). This is confirmed visually and by using an instrument such as a freer elevator to trace a smooth line from the top of the prosthetic humeral head inferiorly to the medial calcar. Appropriate retroversion of the prosthesis is confirmed by rotating the forearm to a neutral position and facing the prosthetic humeral head toward the glenoid (Fig. 4.14). This step ensures that the patient’s own retroversion is restored and is approximately 20 degrees relative to the transepicondylar axis of the elbow.

degrees relative to the transepicondylar axis of the elbow. FIGURE 4.13 With the prosthesis placed inside

FIGURE 4.13 With the prosthesis placed inside the medullary canal, the “gothic arch” is unbroken. Restoration of humeral head height is confirmed with the ruler. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

FIGURE 4.14 Appropriate version is determined by rotating the prosthetic humeral head to face the

FIGURE 4.14 Appropriate version is determined by rotating the prosthetic humeral head to face the glenoid with the forearm in neutral rotation at the patient’s side.

The greater tuberosity is measured and noted to be within 5 mm of the

measured humeral head height (H) (Fig. 4.5). The “gothic arch” anatomy of the proximal humerus is consistently recreated intraoperatively using this method. If there is any concern, intraoperative fluoroscopy can be utilized to confirm restoration of the gothic arch with the prosthetic stem and head. If the arch is not “restored,” then either

1. Prosthetic height may be incorrect (it is usually too high)

2. Medial calcar is fractured and has not yet been restored

3. Head size is either too large or has not been rotated into the most lateral offset position (Fig. 4.12)

Once the arch has been established, the implant is removed, and two drill holes are placed in the proximal humeral shaft on either side of the bicipital groove. Two heavy nonabsorbable sutures (No. 5 Ethibond, Ethicon, a Johnson and Johnson Company, New Brunswick, NJ) are placed in a horizontal mattress fashion through these holes to be used as “tension band” sutures during the final tuberosity fixation (Fig. 4.15). A cement restrictor is placed 2 cm distal to the distal tip of the prosthesis. Taking care to ensure that the previous “gothic arch” anatomy is restored (Fig. 4.16), the prosthetic stem is cemented into the canal in slight valgus using third-generation cementation technique. The humeral canal is thoroughly irrigated, and a small diameter suction tube is placed into the canal to vent blood during cementation. The cement is mixed using a vacuum centrifugation device and injected into the humeral canal using a large syringe. Gentle pressurization of the cement is performed using a separate wet glove, adding a small amount of cement each time. The vent tube is removed during the third (final) pressurization. One to two centimeters of proximal cement is removed from the intramedullary canal to allow for placement of bone graft. Final tightening of the wire or suture used to fix the medial calcar fracture (if present) is performed. The final head of predetermined size is gently impacted into the appropriate position. Three structural cancellous bone graft wedges (obtained from the humeral head) are then placed as follows: (a) in the “window” of the fracture-specific prosthesis; (b) under the greater tuberosity at the “lateral” fin of the prosthesis; and (c) under the anteromedial edge of the prosthetic head between the head and neck of the implant (Fig. 4.17).

FIGURE 4.15 Two heavy nonabsorbable sutures are placed through drill holes on either side of

FIGURE 4.15 Two heavy nonabsorbable sutures are placed through drill holes on either side of the intertubercular groove.

FIGURE 4.16 Restoration of the “gothic arch” with the final prosthesis in place. (Reprinted from

FIGURE 4.16 Restoration of the “gothic arch” with the final prosthesis in place. (Reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

FIGURE 4.17 Three structural cancellous bone graft wedges are then placed: (a) in the “window” of the fracture-specific prosthesis; (b) under the greater tuberosity at the “lateral” fin of the prosthesis; and (c) under the anteromedial edge of the prosthetic head between the head and neckof the implant.

With the humeral prosthesis reduced into the glenoid, tuberosity osteosynthesis is now performed. The medial limbs of the sutures previously placed at the greater tuberosity bone-tendon junction are passed around the prosthetic neck (Fig. 4.18). With the greater tuberosity in a reduced position, two of these sutures are tied over the structural bone graft (Fig. 4.19). The remaining two greater tuberosity sutures (medial limbs) are placed through the subscapularis bone-tendon junction from posterior to anterior and tied down while the lesser tuberosity is held reduced (Fig. 4.20). Sutures previously placed through drill holes in the humeral shaft are then used to create a vertical “tension band.” One suture is placed from anterior to posterior through the subscapularis tendon, rotator interval, supraspinatus, and superior infraspinatus tendons (anterosuperior cuff). The other is passed from posterior to anterior through the teres minor and infraspinatus, superior supraspinatus, and leading edge of subscapularis tendons (posterosuperior cuff) (Fig. 4.21).

FIGURE 4.18 Medial limbs of sutures previously placed at the greater tuberosity bone- tendon junction

FIGURE 4.18 Medial limbs of sutures previously placed at the greater tuberosity bone- tendon junction are passed around the prosthetic neck.

FIGURE 4.19 Two sutures previously placed at the greater tuberosity bone-tendon junction tied down around

FIGURE 4.19 Two sutures previously placed at the greater tuberosity bone-tendon junction tied down around the prosthesis.

FIGURE 4.20 The two remaining sutures previously placed at the greater tuberosity bone- tendon junction

FIGURE 4.20 The two remaining sutures previously placed at the greater tuberosity bone- tendon junction are placed through the lesser tuberosity bone-tendon junction and tied down.

FIGURE 4.21 Sutures placed through drill holes in the humeral shaft ( gray, light blue

FIGURE 4.21 Sutures placed through drill holes in the humeral shaft (gray, light blue) are used for vertical “tension band” fixation. Additional simple sutures are used to reinforce rotator interval closure (purple).

The biceps is tenodesed within the bicipital groove or rotator interval to soft tissue (Fig. 4.22). The shoulder is taken through a full range of motion, to ensure there is no motion of the tuberosity fragments. Passive intraoperative range of motion should be at least 160 degrees of elevation, 40 degrees of external rotation at side, 60 degrees of external rotation in 90-degree abducted position, and 70 degrees of internal rotation in a 90-degree abducted position. Closure of the wound is performed. Postoperative x-rays should demonstrate anatomic reconstruction of the proximal humerus (Fig.

4.23).

demonstrate anatomic reconstruction of the proximal humerus (Fig. 4.23 ). FIGURE 4.22 Soft-tissue biceps tenodesis.

FIGURE 4.22 Soft-tissue biceps tenodesis.

FIGURE 4.23 A . Four-part proximal humeral fracture with broken “gothic arch.” B . Restoration

FIGURE 4.23 A. Four-part proximal humeral fracture with broken “gothic arch.” B. Restoration of the “gothic arch” and tuberosity anatomy. C. Two years after surgery. (A and B reprinted from Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic

Arch.” Tech Shoulder Elbow Surg 2005;6(2):57–66, with permission.)

POSTOPERATIVE MANAGEMENT

Patients are placed into a Smart Sling orthosis (Innovation Sports/Ossur, Foothill Ranch, CA) for 6 weeks (Fig. 4.24). Passive motion with the patient supine is begun the day after surgery. Passive supine limits of 90 degrees of forward flexion and 30 degrees of external rotation are maintained for the first 4 postoperative weeks. During weeks 5 to 6, passive supine forward flexion is full, and external rotation is maintained at 30 degrees. At 7 weeks after surgery, active motion is allowed, and resistance exercises begin 10 weeks postoperatively.

and resistance exercises begin 10 weeks postoperatively. FIGURE 4.24 The Smart Sling orthosis. COMPLICATIONS Many

FIGURE 4.24 The Smart Sling orthosis.

COMPLICATIONS

Many complications can be avoided by proper patient selection, meticulous

attention to detail, and careful surgical technique.

1. Component Malposition. A prosthesis placed too high can over tension the superior rotator cuff, resulting in pain and limited elevation. Incorrect prosthetic height or version also makes initial anatomic reduction of the tuberosities difficult and will increase the risk of later tuberosity displacement and/or nonunion (6). This can be avoided by following the criteria for restoring the “gothic arch” anatomy of the proximal humerus as described.

2. Tuberosity Malposition. Even when the implant is placed correctly, fixing the tuberosities in a nonanatomic position can result in a poor outcome. The proximal greater tuberosity should be 3 to 5 mm below the top of the prosthetic head. Placing the greater tuberosity too low will have a similar effect to placing the prosthesis too proud. An intraoperative AP radiograph should be obtained if there is any question about the adequacy of reduction.

3. Failure of Tuberosity Fixation. A key technical point is passing the sutures used in tuberosity fixation around the prosthetic neck. This provides superior stability by compressing the tuberosity to the prosthetic neck

(10).

4. Stiffness. In an effort to reduce the risk of early tuberosity migration, the surgeon may be concerned about starting early postoperative shoulder motion. However, the excellent initial fixation afforded by this technique allows for early protected motion as described. Other causes of stiffness include pain as the result of poor prosthesis or tuberosity position or patient inability to participate in a structured therapy program.

5 . Other. Less common complications include infection, intraoperative humeral fracture, heterotopic ossification, nerve injury, complex regional pain syndrome, prosthetic loosening, rotator cuff failure, and glenoid arthritis.

RESULTS/OUTCOMES

We performed a retrospective review of 170 consecutive patients treated by

a single surgeon (SGK) with this technique of proximal humeral

hemiarthroplasty and tuberosity osteosynthesis between 2001 and 2006 (6). The mean age was 72 years and follow-up was 24 to 56 months. Between

September 2001 and March 2004, 58 standard humeral prosthetic stems (STD) were implanted. From April 2004 through May 2006, 112 fracture- specific prosthetic stems (FX) were used. Differences between groups in age, mean time to surgery, and visual analog pain scores were not significant. The mean ASES score was higher in the FX group (72 vs. 55, p < 0.0001), and mean goniometric active elevation was better in the FX group (129.8 vs. 95.4, p < 0.0001). Overall, 127/170 (75%) greater tuberosities healed to the humeral shaft. Tuberosity healing was noted to be 89/112 (79%) in the FX group and 38/58 (66%) in the STD group (p = 0.03). The FX group had a higher percentage of patients 77/112 (69%) with active elevation >120 degrees when compared to the STD group 28/58 (48%), this was significant (p = 0.007). These results appear to support improved outcomes associated with the fracture-specific stem compared to the standard stem.

REFERENCES

1. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle

injuries in an urban population. J Shoulder Elbow Surg 1995;4(2):107–

112.

2. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87–92.

3. Handoll HHG, Ollivere BJ. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2010;12: Art. No.:

CD000434. DOI: 10.1002/14651858.CD000434.pub2

4. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg

2002;11(5):401–412.

5. Krishnan SG, Pennington WZ, Burkhead WZ, et al. Shoulder arthroplasty for fracture: restoration of the “Gothic Arch”. Tech Shoulder Elbow Surg

2005;6(2):57–66.

6. Krishnan SG. Shoulder arthroplasty for fractures of the proximal humerus: where are we in 2010? AAOS Instructional Course Lectures, New Orleans, March 2010.

7. Castricini R, De Benedetto M, Pirani P, et al. Shoulder hemiarthroplasty for fractures of the proximal humerus. Musculoskelet Surg April 19,

2011 [Epub ahead of print].

8. Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop Traumatol Surg Res 2010;96(6):683–694. 9. Esen E, Dogramaci Y, Gultekin S, et al. Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients. Injury

2009;40(12):1336–1341.

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Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons;

2008.

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12. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009;91(6):1320–1328.

13. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13(4):427–433.

14. Sperling JW, Cuomo F, Hill JD, et al. The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results. In: Marsh JL, Duwelius PJ, eds. Instructional course lectures. Vol. 56. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:45–

57.

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1993;75(12):1745–1750.

5 Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures

Pascal Boileau, Adam P. Rumian, and Xavier Ohl

INTRODUCTION

Although Neer reported favorable results following hemiarthroplasty for proximal humeral fractures in 1951, a large number of subsequent studies have been unable to duplicate his functional and radiological outcomes. In fact, most reports of shoulder hemiarthroplasty for fractures of the proximal humerus in the United States document a high incidence of shoulder pain and stiffness (1,2). Many authors have documented that the results of hemiarthroplasty are closely related to the accuracy of reduction and healing of the tuberosities, particularly the greater tuberosity (3). If the greater tuberosity heals in a malunited position or migrates because of fixation failure, a poor outcome is predictable. The critical role of the greater tuberosity is explained by the fact that three of the four rotator cuff muscles insert directly onto it: the supraspinatus, infraspinatus, and teres minor. If the greater tuberosity does not heal properly, then the function of these muscles will be compromised, leading to shoulder dysfunction. Furthermore, malunion or nonunion of the tuberosity can lead to bony impingement with decreased range of shoulder motion, pain, and stiffness. In reverse shoulder arthroplasty (RSA), the center of rotation of the shoulder joint is medialized and the humerus is lowered, resulting in an increased lever arm with improved function of the deltoid for abduction. The prosthesis is designed to compensate for deficiencies of the rotator cuff, particularly the supraspinatus (4). A RSA is a semiconstrained prosthesis, and insufficiency of the greater or lesser tuberosity will not cause instability of a properly positioned prosthesis. This makes it an attractive option for

arthroplasty in fracture cases where successful reconstruction and osteosynthesis of the proximal humerus and tuberosities are problematic. However, its use should be restricted to more elderly patients (i.e., over 70 years of age) as long-term results with this implant are not available, and preliminary studies report deterioration of function after a few years (5). Although RSA can compensate for cuff deficiency as described above, the surgical goal should include reduction, fixation, and healing of the greater tuberosity to preserve the external rotation function of the shoulder whenever possible (6).

INDICATIONS AND CONTRAINDICATIONS

RSA for fracture is reserved for comminuted osteoporotic fractures in elderly patients that are unsuitable for osteosynthesis or conventional hemiarthroplasty. These include four-part fractures and fracture dislocations of the proximal humerus, head-splitting fractures, some three-part fracture dislocations, and three-part fractures without valgus impaction of the humeral head (7,8). Factors that would favor the use of a RSA rather than hemiarthroplasty include age over 70 years, severe osteopenic bone or metabolic bone disease, marked comminution of the fracture, preexisting rotator cuff disease, inflammatory arthritis, heavy smoking, and the use of systemic steroid medication. Contraindications to RSA include age under 70 years, active infection, a complete axillary nerve deficit, inadequate glenoid bone stock to support a glenoid implant, and inability or unwillingness of the patient to comply with postoperative rehabilatation. RSA for fractures is a technically demanding procedure and should not be performed by inexperienced surgeons without specialized training.

PREOPERATIVE PLANNING

Preoperative planning is essential to obtain a successful outcome after RSA for fracture and to prevent avoidable complications. A detailed history should be obtained, and a careful physical examination should be performed. The motor and sensory function of the axillary nerve must be accurately assessed because a significant number of patients with proximal humeral fractures have subtle injuries to the nerve. While neurological dysfunction tends to recover slowly, it may delay recovery and

rehabilitation. This is especially important since RSA relies on the deltoid muscle to be the prime driver of shoulder movement. In our opinion, RSA should not be performed in a patient with a complete axillary nerve palsy. Radiographic evaluation should include anteroposterior (AP), scapular Y, and axillary lateral views as well as a CT scan to classify the fracture, and determine fracture displacement and evaluate the status of the tuberosities. The CT also allows some evaluation of the rotator cuff as to the degree of fatty infiltration and muscular atrophy as well as the ability to assess the glenoid bone stockto support a glenoid component (9). We believe that the ideal timing of surgery is at 3 to 7 days after injury, which avoids operating through acutely injured and edematous soft tissues and lessens the risk of wound complications. Surgery after a delay of more than 3 weeks becomes technically difficult due to fracture callus that results in difficulty mobilizing the tuberosity fragments and requires a more extensive soft-tissue dissection. Preoperative radiographic planning is very important if successful outcome is to be consistently achieved. The normal anatomical landmarks that are used as reference points to position the humeral prosthesis are displaced or compromised as a result of the fracture. Correct positioning of the humeral prosthesis, especially in terms of vertical height, is crucial as implanting the prosthesis too deep or too proud in the humeral canal can lead to a poor result (10). In our opinion, it is not acceptable to rely on “eyeballing” the height of the prosthesis at the time of surgery as this leads to unpredictable, unreproducible, and often unacceptable results. Scaled AP radiographs of both humeri should be obtained. The length of the normal humerus is measured along the prosthetic axis as shown in Figure 5.1. On the fractured side, the length of the remaining distal humeral shaft fragment is measured from the lateral edge of the fracture (Fig. 5.1). The difference between these two measurements, adjusted for the magnification factor, gives the distance above the lateral edge of the distal humeral shaft fragment that the top of the prosthesis needs to be implanted to achieve the correct humeral length.