9 Proximal Humerus Open Reduction and Internal Fixation

10.1055/b-0040-174132

9 Proximal Humerus Open Reduction and Internal Fixation

Joseph J. King and Matthew R. Patrick

Summary

Open reduction and internal fixation of proximal humerus fractures is a viable treatment option in certain cases with good bone stock and significant fracture displacement. Adequate fracture reduction and sufficient fixation is paramount to achieving a good outcome. If bone quality is insufficient, augmentation with calcar screws, calcium phosphate cement, or bone graft are practical options to assist in bony union and to prevent failure of fixation. Several tips and tricks are available to help the surgeon achieve fracture reduction and adequate fixation as well as to prevent hardware prominence and fixation failure.

9.1 Setup (Critical for Success of the Procedure)

Lazy beach chair position is preferred.

Easier to get XR compared to formal beach chair position (▶Fig. 9.1a, b).
Slide patient so that the head is on the lateral aspect of the table and at the very top of the table.
- May need posterior access for percutaneous fixation.
- Improves visualization under fluoroscopy.
Use padded Mayo stand or hydraulic limb positioner for the arm.
Bed turned 90 degrees from anesthesia.
Fluoroscopy machine should be at the head of the bed.
Prior to prepping patient, confirm ability to obtain adequate fluoroscopic images.
Alternate position. Supine on a radiolucent flat top table
- May be best for poly-trauma patients who cannot tolerate or are not allowed to position in a beach chair position.
- Slide patient to the edge of table
  
  Use plexiglas or radiolucent arm holder to support arm from shoulder to elbow.
- Position best suited for anterolateral (deltoid-splitting approach).

**Fig. 9.1 (a)** Preoperative anterior-posterior XR of the proximal humerus showing a displaced proximal humerus fracture with lateral displacement of the shaft. Medial calcar comminution is noted. **(b)** Preoperative axillary lateral XR of the proximal humerus showing fracture comminution and a reduced glenohumeral joint.

9.2 Approach

Deltopectoral approach is preferred.
- Extensile approach
- Excellent exposure, but may have some difficulty in visualizing the posterior greater tuberosity.
- Minimal risk of axillary nerve injury
- Can be extended into the anterolateral approach to the humeral shaft if needed (i.e., longer plate needed if there is a subsequent complication).
Alternative approach—anterolateral deltoid-splitting approach
- Plate placement and screw trajectory are easy.
- Axillary and/or radial nerve injury risk
- Good visualization of entire greater tuberosity, but limited exposure of lesser tuberosity
- Limits injury or disruption of soft-tissue/vascular supply along the calcar and medial humerus.
- Non-extensile

9.3 Exposure

Identify all visible fracture lines and debride soft tissues at the edges of the fracture fragments.
Release any adhesions superficial to the rotator cuff in the subacromial space and/or tuberosities.
Avoid significant deep medial dissection (medial to bicipital groove) to preserve arterial supply.
Make room for the plate distally.
- Deltopectoral approach. May need to release the anterior deltoid insertion.
- Anterolateral deltoid-splitting approach. May need to release part of the lateral deltoid insertion.
For deltoid-splitting approach
- Identify the axillary nerve within the deltoid muscle fibers and avoid injury to it.
- Axillary nerve is typically 5–7 cm distal to the lateral acromion within the deltoid muscle.