Proximal Humerus Fractures

Matthew D. Milewski, MD

CLOSED REDUCTION, PERCUTANEOUS PINNING

Positioning

Either
- Supine on a radiolucent table with interscapula bump or
- Beach-chair modified position as noted in Chapter 2
Preprep/draping fluoroscopic exam (Figure 3-2) for:
- feasibility of reduction
- need for fixation to maintain reduction
- adequate positioning to perform reduction and pinning (particularly important if in the beach-chair position)
Extend operative area above shoulder to ipsilateral head for freedom of movement during reduction, pinning, and fluoroscopy imaging (the anesthesia position is often useful, in which the head is slightly turned toward the contralateral shoulder)
Anesthesia on opposite, unaffected side of head
- Christmas tree protection and constraint to head during reduction
Entire arm and shoulder girdle prepped and draped using U-drapes from neck, across chest, and back to scapula (Figure 3-3).
Set up here is key, extra time in precision is invaluable later
Padded Mayo stand is often useful for arm support (alternatively, a mechanized arm holder such as the Trimano (Arthrex) or Spider (Smith & Nephew) can be used.) (Figure 3-4)

Figure 3-1 ▪ OR set up in modified beach chair for closed reduction pinning or open reduction proximal humerus fracture.

Reduction and Pinning Technique

Reduce fracture
- The distal fragment is adducted and internally rotated by the pectoralis major, latissimus dorsi, and teres major insertions.
- The proximal fragment is abducted—externally rotated by the supraspinatus, infraspinatus, and teres minor.
- Longitudinal traction with abduction, forward flexion, and external rotation brings the distal fragment and arm to the proximal fragment.
- Rarely is this stable after reduction except when the fracture, which is button-holed out through the periosteum, reduces back inside the periosteum, thus providing stability
- If unstable with bringing the arm back to the side, rereduce and pin

Pinning (Figure 3-3)

This is much harder than you think
Align the desired oblique angle of pin direction distal to proximal K-wires on skin (Figure 3-4).
Use fluoroscopy to check path on AP view and mark skin (Figure 3-5).
Make skin stab wound a bit more distal, so that the wire enters bone at the desired spot for pin placement. The distal distance for the skin incision is dependent on the patient’s habitus and arm size (Figure 3-6).
Blunt dissection down to bone is necessary before again checking the pin path on fluoroscopy (Figure 3-7). A slightly larger skin incision and wider deep dissection will allow increased mobility to adjust for the starting point.

Figure 3-2 ▪ A and B, Orthogonal views for fluoroscopic visualization of pinning of proximal humerus fracture.
Use power drill a bit larger than the chosen smooth pin to enter the cortex
- This gives degrees of freedom of motion for proper pin placement
Run the first pin into humeral head but do not penetrate into the joint
- Gently move shoulder to make sure the pin location is as planned.

Place second pin mostly parallel with slight divergence if possible (Figure 3-8)

Figure 3-3 ▪ Entire upper limb and shoulder girdle prepped and draped for surgery.

Figure 3-4 ▪ Pneumatic air holder, fluoroscopy for AP view with pins in place.

Figure 3-5 ▪ A, Using smooth wire and fluoroscopy to outline first pin trajectory for fixation. B, Closer view of first pin skin marking and now using pin to outline trajectory of second pin.

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