Humerus, proximal: proximal humeral shaft fracture with extension into the humeral head—12-B2.1
Case description
A 75-year-old obese man fell from his standing height onto his left shoulder as a result of a cardiac syncope. He suffered from multiple medical comorbidities and was a heavy smoker. The patient was independent and lived at home.
Indication for MIPO
The patient had local swelling with a hematoma and pain localized to the left proximal humerus. He was unable to move his arm due to severe pain. The patient‘s level of compliance was moderate. He suffered from chronic obstructive pulmonary disease due to nicotine abuse. It was decided that operative treatment would allow for easier postoperative rehabilitation regarding both mobilizing his shoulder and arm and allowing treatment of his pulmonary disease. A MIPO approach was chosen to limit the operative trauma bearing in mind his severe comorbidities. Conservative treatment was not considered.
Preoperative planning
A hand-drawn or computer-generated preoperative plan is always recommended. The plan should include the approach, reduction techniques, and implant selection ( Fig 12.4-2 ). If adequate reduction is not achieved through a limited approach, a plan B should always be considered.
Operating room setup
Anesthesia
General or regional anesthesia may be used, depending on the patient‘s condition. A supraaxillary regional anesthetic will help control postoperative pain even when a general anesthetic is used, as with this patient.
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 12.4-3a ). 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. Flexion of the elbow to 90° in slight internal rotation helps to restore axial alignment in fractures with metaphyseal extensions. Preoperative planning of plate length allows the position of the incisions to be marked on the skin ( Fig 12.4-3b ). The plate is slightly bent and twisted so the distal part of the plate lies on the anterior aspect of the bone away from the laterally running radial nerve ( Fig 12.4-3c ).
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