I.

INTRODUCTION

A fractureof the upper (proximal) end of the humerus, the long bone of the upper arm, is a frequent type of shoulder fracture. The humerus is a relatively thick bone with a large, round, smooth head that articulates at its upper end (proximally) with the shoulder blade (scapula) to form the shoulder joint and articulates at its lower end (distally) with the elbow. The shoulder joint consists of the hemispherical "ball" of the humeral head, the concave "socket" of the glenoid cavity of the scapula, and a group of 4 muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that form the rotator cuff. The most common mechanism of injury in a proximal humerus fracture istrauma to the arm or shoulder, such as occurs with a fall onto an outstretched hand. Fractures of the proximal humerus usually involve the humeral shaft, surgical neck, or the sites of muscle attachment (greater or lesser tuberosities). Fractured bones may remain in alignment (nondisplaced fracture) or fragments may separate and become misaligned (displaced fracture). The majority of proximal humerus fractures are nondisplaced and may be treated nonsurgically. Displaced fractures most commonly involve the surgical neck of the humerus. The degree of fracture displacement is dependent upon the direction of pull of the muscles that attach to the tuberosities. Greater tuberosity fractures account for 15% of proximal humerus fractures, and are associated with anterior shoulder dislocations one-third of the time (Norris). Incidence and Prevalence: Proximal humerus fractures account for 5% of all fractures (Frankle). Incidence increases with age. Proximal humerus fracture is a major cause of morbidity in individuals age 65 and older (Frankle). A study entitled New Clinical Practice Guideline for Treating Common Elbow Fractures in Children that states the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors has recently approved and released an evidence-based clinical practice guideline (CPG) on "The Treatment of Supracondylar Humerus Fractures." Andrew Howard, MD, pediatric orthopaedic surgeon, medical director of the Trauma Program at the University of Toronto Hospital for Sick Children and the chair of the AAOS Work Group responsible for this CPG, said that surgeons see many of these types of fractures, particularly in children ages 5 to 9 (2011).

II.

THE SURGICAL PROCEDURE a. Description of the procedure

Reduction and preliminary fixation

Place rotator cuff sutures Subscapularis and supraspinatus tendon Begin by inserting sutures into the subscapularis tendon (1) and the supraspinatus tendon (2). Place these sutures just superficial to the tendons bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities.

Infraspinatus tendon Next, place a suture into the infraspinatus tendon insertion (3). This can be demanding, and may be easier with traction on the previously placed sutures, or with properly placed retractors.

Variations depending on the approach chosen Inserting sutures into the infraspinatus tendon is easier with a lateral approach. A) shows a deltopectoral approach and B) an anterolateral (transdeltoid) approach.

Use of stay sutures Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.

Insert a preliminary traction suture into the visible part of the posterior rotator cuff

and pull it anteriorly. This will expose the proper location for a suture in the infraspinatus tendon insertion. Then the initial traction suture is removed. Pearl: larger needles A stout sharp needle facilitates placing a suture through the tendon insertion.

Pearl: use of retractors Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.

Similarly, a so-called delta retractor may improve deltoid retraction.

Pitfall: use of forceps or clamps in osteoporotic bone Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone. This should be avoided by using sutures as handles for manipulation and reduction.

Reduce the humeral head Correct the valgus impaction by elevating the lateral aspect of the humeral head. The required force may vary according to the degree of impaction. Various techniques can be used to lift the humeral head such as: A) Digital pressure B) Use of a blunt periosteal elevator (as illustrated)

C) Leverage. A varus force can be applied to the humeral shaft. This can be achieved by using a fulcrum (eg, the surgeons fist, as shown, or a roll of towels) in the axilla.

D) Combination of direct manipulation and leverage.

E) If the fragments are jammed together, disimpaction with a bone punch may be required.

Pearl: incising the periosteum Exposure and reduction of the humeral head may be aided by dividing any soft-tissue

connections between the tuberosities and extending this incision proximally between the fibers of the supraspinatus tendon.

Note: If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). This is because the typical intertuberosity fracture line of a fourpart fracture is actually lateral to the bicipital groove, and thus through the greater tuberosity.

Fix the humeral head temporarily Quite often, the initial humeral head reduction is sufficiently stable that preliminary fixation is not required. Nevertheless, it might still be advantageous to secure the humeral head using 2 or 3 K-wires. Make sure that they are anterior enough to avoid interfering with the plate application. Note: In the following illustrated procedure, K-wires are used. If the greater tuberosity is comminuted, additional smaller K-wires may be needed to fix separated fragments.

Reduce the tuberosities If the humeral head is properly reduced and the correct inclination of the humeral head is achieved, the tuberosities can now easily be positioned underneath the humeral head. Pull the sutures between the subscapularis and the infraspinatus tendons horizontally

and tie them together.

Confirm reduction After preliminary fixation check the reduction visually and by image intensification. Visual control There should be no gap or step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly against the shaft fragment.

Radiographic confirmation The AP x-ray should show the correct relationship between the humeral head and the tuberosities. Superolaterally, the humeral head and the greater tuberosity should be flush without a step-off or gap. In particular, make sure that the greater tuberosity is not above the humeral head.

Confirm the inclination of the humeral head. The centrum collum diaphyseal angle (CCD) is illustrated. It is the angle between the axis of the humeral diaphysis, and the axis of the humeral neck, best identified as a perpendicular to the base of the humeral head. The CCD should be approximately 135. Valgus displacement of the humeral head must be corrected so there is enough room laterally for the tuberosities to be reduced.

This intraoperative x-ray shows an unacceptable step-off.

Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive retroversion of the humeral head. This view might also reveal malpositioned tuberosities.

In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and not the patients arm when obtaining the axial/lateral.

Pearl: reduction of tuberosities under humeral head Anatomical reduction requires proper approximation of the tuberosities underneath the humeral head. Secure this by tightening the horizontal sutures between the subscapularis and infraspinatus tendons (lesser and greater tuberosities).

Pitfall: insufficient reduction of humeral head A common mistake in reduction of the humeral head is insufficient elevation of the humeral head laterally, in relation to the humeral shaft. This keeps the tuberosities from fitting properly under the humeral head. As shown, the humeral head may remain below the top of the tuberosities. Proper reduction may be aided by incising the periosteum and supraspinatus tendon.

Pearl: osteoporotic bone In osteoporotic bone, stability may be increased by accepting some medial impaction of the humeral head.