Humerus proximal: extraarticular fracture—11-A3

10.1055/b-0034-87613

Humerus proximal: extraarticular fracture—11-A3

Reto Babst

Case description

A 90-year-old woman stumbled on stairs and fell from her standing height onto her right shoulder. It was an isolated injury and the fracture was closed. The patient lived independently but had mild medical comorbidity.

Indication for MIPO

Upon examination, the patient was found to have local swelling, pain, and an inability to move the shoulder. It was decided that operative treatment would allow for early functional aftertreatment. Due to the fracture morphology—a two-part pattern and medical comorbidity consisting of well-adjusted hypertension, a MIPO procedure was chosen.

a–b Preoperative AP (a) and lateral (b) x-rays.

Preoperative planning

A hand-drawn or computer-generated preoperative plan is recommended including the approach, the reduction techniques, and the selected implant. If adequate reduction is not obtained through a minimally invasive approach, a plan B should always be thought out in advance ( Fig 12.3-2 ).

Preoperative plan. 1 Stay sutures rotator cuff. 2 Plate insertion with aiming device. 3 Temporary proximal fixation with K-wire. 4 Plate alignment and temporary fixation with drill bit. 5 LHS for definitive proximal fixation. 6 Cortex screw to reduce the plate against the shaft. 7 LHS for definitive fixation. 8 Replace drill bit with LHS. 9 Add two proximal LHSs.

Operating room setup

Anesthesia

General or regional anesthesia may be used, depending on the patient‘s condition. A supraaxillary regional anesthesia will help to control postoperative pain even when using a general anesthesia.

Patient and image intensifier positioning

A beach-chair position is preferred for the MIPO approach to facilitate indirect reduction either by gravity or slight traction.

The image intensifier is positioned at the head of the patient, enabling AP visualization of the fracture ( Fig 12.3-3a ). Internal rotation of the flexed arm allows an axial view to be obtained.

The arm is draped free to allow free mobility of the shoulder and elbow ( Fig 12.3-3b ). Flexion of the elbow to 90° in slight internal rotation helps to restore axial alignment in fractures with metaphyseal extensions.

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