The standard surgical approach for internal fixation of proximal humerus fractures is the interval between the deltoid and pectoral muscles proximally. The thorax should be situated as close to the edge of the table as possible to allow free access to and mobilization of the shoulder. Whatever the type of prosthesis, implantation for proximal humerus fracture is a. It then coursed distally along the external margin of the humerus and remained posterior to the lateral intermuscular septum until it emerged from the. Complications may include injury to an artery or nerve, and compartment syndrome the cause of a humerus fracture is usually physical trauma such as a fall. The proximal humerus is often regarded as consisting of four parts, which assists in understanding function and, more specially, describes the essential parts in reconstruction after fracture or in joint replacement. A deltopectoral approach, passing outside of the cephalic vein, is recommended. Nov 17, 2019 a proximal humerus fracture is a common injury to the shoulder. The proximal humerus receives its blood supply from branches of the axillary artery while anterior and posterior humeral circumflex arteries originate distal to the anatomic neck and travel proximally to supply the humeral head. Step 1 surgical approach the patient is placed in the beachchair position.
Like hip fractures, proximal humerus fractures are a major cause of morbidity in the elderly population. In fact, in patients older than 65, proximal humerus fractures are the third most common broken bone after hip fractures and wrist. Anatomical landmarks for the anterior deltopectoral approach are. Proximal humerus and lateral 23 of clavicle and upper scapula, including relationship of the humeral head to the glenoid cavity. However infusion flow rate in the proximal humerus. Conclusion with the right patient selection, the just discussed posterior approach for the proximal humeral diaphysis exposure is a worthwhile and rewarding procedure. The distance between the proximal edge of the fossa. A lateral approach to the distal humerus following. Mar 17, 2016 plate fixation is the gold standard for diaphyseal fracture management, and the anterolateral approach is widely used by reconstructive surgeons. This process is experimental and the keywords may be updated as the learning algorithm improves. The upper or proximal extremity of the humerus consists of the bones large rounded head joined to the body by a constricted portion called the neck, and two eminences, the greater and lesser tubercles. The deltopectoral approach for reverse shoulder arthroplasty. Proximal humerus fractures are rare in paediatric traumatology. According to the anatomic characteristics of the proximal humerus.
The proximal humeral physis contributes approximately 80% of the growth of the humerus. Unstable proximal humerus orthopaedic medical group of. Proximal humerus fractures evaluation and management lynn. The ao classification of proximal humeral fractures, along with the neer classification, is one of the most frequently used systems for classifying proximal humeral fractures the ao classification divides proximal humeral fractures into three groups, a, b and c, each with subgroups, and places more emphasis on the blood supply to the articular surface 1,2. Advantage of minimally invasive lateral approach relative to. The accuracy of the diagnosis of many shoulder disorders visually without quantitative shape analysis is limited, motivating a clinical need for some ancillary method to access the proximal biceps. The minimally invasive lateral approach is the optimal alternative for the. Proximal humerus plating system is designed to minimize the risk of some of the complications commonly associated. Article information, pdf download for the deltoid lift. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated.
Especially common in elderly individuals due to osteoporosis, proximal humerus fractures are among the most common broken bones in the shoulder. The anterolateral approach to the proximal humerus for. The axillary nerve can be palpated at the lower margin of the incision. Surgical treatment of three and fourpart proximal humeral fractures. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3 and 4part proximal humeral fractures. By 3 weeks, active assisted rangeof motion and pendulum exercises may be initiated under the supervision of a physical therapist. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. Jan 12, 2014 surgical approaches to distal humerus fractures dr. Bring the fractured proximal humeral shaft into the wound by removing the bolster and extending the arm in slight adduction. The deltopectoral approach is a welldescribed and commonly utilized surgical approach to the glenohumeral joint and proximal humerus for both shoulder arthroplasty and fracture fixation 12 3. Surgical approaches to distal humerus fractures dr. Proximal humerus site for anesthesia full text view. For complex and unstable fractures locking proximal humerus plate.
A conservative estimate is that proximal humerus fractures account for approximately 5% of all fractures. Proximal humerus, threepart fracture, fourpart fracture, surgical treatment, orif. Surgical treatment of osteochondroma of the proximal. Shoulder arthroplasty for acute proximal humerus fracture em. An anterosuperior approach for proximal humeral fractures.
Department of orthopaedics, acg medical college, chennai, india author for correspondence abstract the posterior aspect of the proximal region of humeral diaphysis can be exposed through the longitudinal. From june 2004 to january 2009, 12 patients 8 men, 4 women. Fractures of the proximal humerus represent about 5% of all fractures, being the third most common fracture among elderly patients. T1 how to transition to percutaneous pinning for proximal humerus fractures. Oct 11, 2019 a conservative estimate is that proximal humerus fractures account for approximately 5% of all fractures. This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses.
To avoid damaging the axillary nerve, do not split. In the swedish fracture register sfr fractures of all types are registered by the attending physician, often a junior doctor. The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. Biomechanical analysis of proximal humerus plate for spatial subchondral support a thesis submitted to the university of manchester for the degree of doctor of philosophy in the faculty of science and engineering 2017 ali jabran school of mechanical, aerospace and civil engineering. To evaluate the outcomes of treating patients with proximal and middle onethird humeral fractures treated with lateral distal tibial helical plate. Unstable proximal humerus rehab protocol active finger, hand, wrist, and elbow exercises are encouraged. All proximal humerus fractures classified as 11a, 11b12 b3, and 11c12 c3. The outcomes of proximal humerus fractures with medial. Routine trauma projection of the shoulder that is used to visualize fractures or dislocations of the proximal humerus and scapula and is an excellent projection to demonstrate the coracoid process and scapular spine in profile. In this age group most injuries are related to low injury falls. The skin incision starts from the coracoid process and is slightly convex toward the medial side, extending distally as far as the insertion of the deltoid muscle on the lateral humeral. These fractures occur primarily in older patients, many of whom are osteoporotic. Approach the standard surgical approach for internal fixation of proximal humerus fractures is the interval between the deltoid and pectoral muscles proximally. The location and alignment of the platehumerus construction was confirmed using both the anteroposterior and.
Approximately 75% of these fractures undergo a conservative treatment resulting in. Proximal humerus plating system is designed to provide intraoperative flexibility and efficiency to the surgical team. This video demonstrates in detail a novel technique for nonbridging external fixation of the proximal humerus. Treatment of proximal humeral fractures acta chirurgiae. Fracture of the proximal humerus is a common orthopaedic injury and is likely to increase in incidence. Learn about the humerus deltopectoral approach, an online 3dvideobased course, accredited by the royal college of surgeons of england. The proximal end of the plate was fixed temporarily at the anterolateral side of the greater tuberosity using a kirschner wire, and the distal end was fixed with a screw. For complex and unstable fractures locking proximal. However, the outcomes of humeral shaft fracture fixation using a medial approach are rarely reported.
Biomechanical analysis of proximal humerus plate for. Metaphyseal fractures account for about 70% of cases and epiphyseal separation for the remaining 30%. Michael j gardner orif of the proximal humerus through an anterolateral acromial approach. The full text of this article is available in pdf format. Working around a spiraling radial nerve at the posterior midshaft requires either a transmuscular dissection or a tricepsavoiding paramuscular technique. Over 250,000 doctors use vumedi to improve patient care and grow their practice. The video details pearls in planning and techniques. Proximal humerus plating system takes full advantage of the principle of spatial subchondral support, which was successfully used in its predecessors, the s3 proximal humerus plating system and the dvr anatomic volar plating system. Proximal humerus bone fractures overview verywell health. Indication the anterior deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the abkrdaje approach. A minimally invasive approach for plate fixation of the. Proximal humerus fracture is often seen in elderly population 1 and postmenopausal female.
Keywords surgical approaches, proximal humeral fractures, orthopedic tumors, proximal humerus, deltoid lift. Deltopectoral vs deltoid split approach for proximal humerus. Finally, among all pathological fractures, 40% involve the proximal humerus. Outcomes for surgical management for proximal humerus nonunion have been reported, with failure rates ranging from 9% to 20%4,8,10 an optimal surgical approach would provide adequate exposure of the fracture fragments and relevant anatomy while preserving the tissue viability with minimal dissection to achieve higher rates of union. Fractures of the proximal humerus represent about 45 % of all fractures and are the third most common fractures in the elderly. Validity of humerus fracture classification in the swedish. Nonsurgical management is appropriate for the majority of young children with proximal humeral fractures. Severely displaced proximal humeral fractures can lead to significant vascular injury.
If the anterior fragment consists of the lesser tuberosity, the bicipital groove and the anterior part of the greater tuberosity, it is strongly recommended to use a supraspinatus split in line of the. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. Fractures of the proximal humerus commonly affect elderly patients. A deltopectoral approach allows adequate view of the anterior. Bicipital root and proximal tendon disorders are an important symptom generator in the shoulder. The ability to correctly classify fractures is of importance for choosing the appropriate treatment and for providing appropriate data for research and quality registers. How to transition to percutaneous pinning for proximal.
For the majority of fractures, a modified aoota classification is used. More videos of surgical techniques of the shoulder can be found. Relevance thumbs up comments views newest oldest 15. Partially release the deltoid insertion anteriorly, if necessary, and retract laterally to access the proximal humerus. The fracture is also observed in children mostly following fall and young adults following direct impact, which results in fracture. Proximal humerus fracture classifications shoulderdoc. An alternate proximal humerus io insertion technique has been developed to meet the needs of anesthesia patient positioning that uses a slightly more distal insertion site and a superior angle of insertion. Advantage of minimally invasive lateral approach relative to conventional.
Proximal humerus fracture is quite a common injury among elderly population who. Overall, following hemiarthroplasty for fracture the shoulder was pain free or. Humerus the long head of the biceps tendon and the lesser tuberosity are retracted anteromedially while the greater tuberosity is retracted posteriorly. The deltopectoral approach for reverse shoulder arthroplasty made through the subscapularis tendon if present and capsule 1 cm medial to its insertion on the proximal humerus if the subscapularis tissue quality is adequate for mobilization for repair and if passive external rotation preoperatively is equal to or greater than 20 figure 5. Proximal humerus plating system is designed to provide intraoperative flexibility and. Using a modification of this approach, we describe its use in a group of patients requiring either internal fixation or hemiarthroplasty for proximal humeral fracture and the effect of this approach on the postoperative function on the axillary nerve and deltoid muscle. As such, there is extensive remodeling potential in fractures in younger, skeletally immature patients. Proximal humerus fractures includes everything the orthopedic surgeon needs to know.
This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a. Theses fractures are increasingly common in the over 60s age group. Biomechanical analysis of proximal humerus plate for spatial. Rotator cuff anterior approach proximal humerus deltoid muscle cephalic vein these keywords were added by machine and not by the authors. A proximal humerus fracture is a break in the arm bone near the shoulder, or a broken shoulder. There are relatively few studies examining the treatment of nonunions of the proximal third of the humerus and the ideal treatment and surgical approach remains unclear. Learn about the distal humerus lateral approach, an online 3dvideobased course, accredited by the royal college of surgeons of england. The deltopectoral approach is commonly used for surgical treatment of proximal humerus fractures.
Medial approach to treat humeral midshaft fractures. A humerus fracture is a break of the humerus bone in the upper arm. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder. The other tumours responsible for pathological phfs are aneurysmal bone cyst, nonossifying fibroma, fibrous dysplasia, and bone malignancies such as osteosarcoma 2. The development and anatomy of the proximal humerus explain the various fracture types, displacements, and potential complications. This chapter describes the bony structures of the proximal humerus. Fixation of complex proximal humeral fractures in elderly. If a breathing technique cannot be used for the transthoracic lateral projection of the proximal humerus the exposure should be made using.
Minimally invasive percutaneous osteosynthesis for. Proximal humerus fracture is considered to be the third most. Nonbridging external fixation for proximal humerus fractures. Proximal fractures are classified into one of four types of fractures based on the displacement of the greater tubercle, the lesser tubercle, the surgical neck, and the anatomical neck, which are the four parts of the proximal humerus, with fracture displacement being defined as at least one centimeter of separation or an angulation greater. Surgical exposures of the humerus the neurovascular and muscular anatomy about the humerus precludes the use of a truly safe fully extensile approach. A rarely used posterior surgical approach to the upper posterior part of humerus sathis kumar g. The mean patient age was sd, 4 years, and the median followup was 11 months range, 1 to 78 mo. Humerus is a typical long bone present in the arm that articulates proximally with the scapula and distally with the bones of the forearm, namely, radius and ulna.
An anatomic study of the cephalic vein in the deltopectoral shoulder approach. Deltoidsplit or deltopectoral approaches for the treatment. A total of 318 patients with proximal humeral fractures were treated with orif using either the locking proximal humerus plate lphp or proximal humeral internal locking system philos. There may be a decreased ability to move the arm and the person may present holding their elbow. However, accessing the lateral aspect of the proximal humerus using this approach requires extensive soft tissue dissection and retraction, as it is an indirect approach to the plating zone. Nonunions of proximal humerus fractures can be disabling as a result of pain, deformity and instability, and are often found in geriatric patients with poor bone quality. External rotation is evident by greater tubercle visualized in full profile on the lateral aspect of humerus. Extended deltopectoral approach to the humeral shaft and many more surgical approaches described step by step with text and illustrations.
Retract the cephalic vein laterally and the pectoralis major medially. Its upper surface is rounded and marked by three flat impressions. Simple regression formulae relative to proximal and distal segments right and left humerus right humerus. Unicameral bone cyst is the leading cause, as this lesion develops in the proximal humerus in 51% of cases. The guest edited thematic issues are published free of charge. This is a retrospective case series of 31 pediatric patients with proximal humeral oce treated with surgical excision. Approach a deltopectoral or transdeltoid approach is recommended. Proximal humerus fractures pediatric orthopaedic society.
Proximal humerus fractures in children and adolescents. A posterior surgical approach to proximal part of the. Plate fixation is the gold standard for diaphyseal fracture management, and the anterolateral approach is widely used by reconstructive surgeons. Extended deltopectoral approach to the humeral shaft. The head caput humeri, is nearly hemispherical in form. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1 complication rate. Estimation of total length of humerus from its proximal and distal segments 94 int j res med. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to. The distance between the most distal point of the fossa olecrani and trochlea humeri ef, h5. Delay of motion has deleterious effects on shoulder range of motion, pain, and function. The proximal humeral locking plate seems to be an adequate device for the fixation of displaced proximal humerus fractures as 83% of our study population had goodmoderate functional. Its proximal end consists of the head, greater tubercle and lesser tubercle. Minimally invasive plate osteosynthesis of proximal humerus fractures via an anterolateral delta split approach.
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