Humerus fracture

operative treatment include

displaced two-part surgical neck fractures, displaced (>5 mm)
greater tuberosity fractures, displaced three-part fractures,
and displaced four-part fractures in young patients. The type
of fixation (transosseous suture fixation, percutaneous
pinning, intramedullary nailing, or plate fixation) used
depends on the patient’s age, activity level, and bone quality;
the fracture type and associated fractures; and the surgeon’s
technical ability
classification
• The most commonly used classification system for proximal
humeral fractures is that of Neer
Two-part greater tuberosity fractures

• Usually these fractures are stabilized with transosseous

sutures or occasionally
with screws in larger fragments. The rotator interval also
must be repaired
 Two-part surgical neck fractures
• Closed reduction and percutaneous pinning have been reported to be successful
in fractures that are reducible and are not comminuted

• rigid intramedullary
nailing our preferred technique

• Widely displaced fractures, fractures with comminution, and irreducible

fractures are stabilized with a locked-plate
Three-part proximal humeral fractures

• elderly patients with

osteopenic bone may require hemiarthroplasty

• most of these fractures locking plate fixation is the preferred

procedure
Four-part proximal humeral fractures

• Rigid fixation with locking

plates currently is our procedure of choice for four-part
proximal humeral fractures in young, active patients

• Hemiarthroplasty is a viable option in elderly patients with low

functional demands.
 Implant and technique
INTRAMEDULLARY NAILING OF A
PROXIMAL HUMERAL FRACTURE
• Position the patient on a radiolucent table with the thorax
“bumped” 30 to 40 degrees

• Make an incision diagonally from the anterolateral corner of the acromion, splitting
the deltoid in line with its fibers in the raphe between the anterior and middle
thirds of the deltoid .To protect the axillary nerve, avoid splitting the deltoid more
than 5 cm distal to the acromion

• Under direct observation, incise the rotator cuff in line with its fibers
 • Use a threaded pin as a “joystick” in the posterior humeral
head to derotate the head into a reduced position
• Place the initial guidewire posterior to the biceps tendon
and advance it under fluoroscopic guidance into the
appropriate position as shown on anteroposterior and
lateral views

• Use the reduction device to reduce the fracture and pass

the bead-tipped guidewire. With sequentially larger reamers
, ream the humerus to the predetermined diameter, usually
1.0 to 1.5mm larger than the nail diameter
• When reaming is completed, pass the nail down the
humeral canal, avoiding distraction of the fracture ensure
that the nail is below the articular surface
of the humeral head.
 • OPEN REDUCTION AND INTERNAL
FIXATION OF PROXIMAL HUMERAL
FRACTURES
• ANTEROLATERAL ACROMIAL
APPROACH FOR INTERNAL FIXATION
OF PROXIMAL HUMERAL FRACTURE
• Position the patient on a radiolucent table with a beanbag
“bump” holding the shoulder and thorax 30 to 40
degrees off the table
• Make a 10-cm skin incision from the palpable anterolateral edge of the acromion
distally in line with the fibers
of the deltoid
• Identify the deltoid fascia and anterior deltoid raphe
between the anterior middle heads of the deltoid (Fig.
57-35A) and split the raphe in line with its fibers for several
centimeters
• do not split it distally more
than 5 cm from its origin to avoid damage to the axillary
nerve
 FRACTURES OF THE HUMERAL SHAFT
• Plate osteosynthesis remains the gold standard of fixation for
humeral shaft fractures