8/10/2019 Proximal Humerus Fracture Orif

1/2

PROXIMAL HUMERUS

-

Supine with Cardiac board extension for arm

-

Draw sheet rolled, placed between scapulae

-

Make sure anesthesia tapes the ET tube to the opposite side, have them move all of their chest

leads away from prep area-

Bring patient to the edge of the table, rotate 90 deg

-

Drape with 1015 coming from top-down, from hairline to nipple to midline

-

Prep the entire hand in

-

Down sheet over body, sticky blues, splints, stocking to elbow and large coban.

-

Ioban around edges of splits, with thicker over armpit

-

C-arm to come in from head of patient

-

Mark landmarksant/post clavicle, AC joint, Acromion, soft V of Nevasier, coracoid process

-

Draw incision from sup edge of coracoid, extending 10-15cm distally toward lateral condyle of

elbow, when held in neutral positionfeel for DP groove, center incision over this.

-

Make incision SUPERFICIAL just through the dermis, then use tonsil to begin dissecting withassistant using bovie.

-

Use self-retainers from above and below in early stages to put tension on soft tissue. Bovie

down to look for fat stripe/cephalic v.

-

Once you identify the interval and the vein, can take it either medial or laterallateral is

generally preferred because it has many perforators to the deltoid

-

Use debakeysto grab any perforators to coagulate

-

Pick a side, and develop the plane with the tonsil

-

Once developed, use your finger to define the sub-deltoid spaceyou want to get all the way

around the humeral head to the CA ligament and inferior to the deltoid insertion.

-

Place the deltoid retractormake sure the patient is RELAXED-

May release part of the proximal deltoid insertion if needed, as well as superior aspect of the

Pec Majorleave 5-10mm of insertion cuff to repair at end of case

-

Can make incision in clavipectoral fascia, just lateral to conjoined tendon, place Covell retractor

under this and under deltoiddont want to pull too hard on conjoined tendon (Msk nerve)

-

Identify bursa on top of rotator cuff and remove with rongeur/boveremove superior aspect to

the rolled border of the CA ligaementobviously DO NOT go deep to get the cuff, better to

leave some bursa

-

Use #5 Ticron sutures to grab most posterior aspect of rotator cuff (Infra)take as big of bites

as possible from leading edge to medial aspect, then take bite to insertion edge again, forming a

U (3mm apart), then cut needle and use hemostat

-

Place 4 sutures through cuff to enable you to mobilize the cuff/GT fx

-

Identify the long head biceps tendon (LHBT) insertiondont grab this or CA ligament with your

cuff sutures

-

Clean fracture sites and mobilize, irrigate (use pituitary, dental pick, K-rongeur)

-

Reduce using small Weber clamps

-

Hold in place using 2-0 K-wires (fluoro reduction)

8/10/2019 Proximal Humerus Fracture Orif

2/2

-

Fit plate to fracture, should be approx. 5mm inf to RC and lateral to LHBT

-

Hold plate in place using .016 k-wirebe careful b/c you can fit .02 k-wire through plate hole,

but will get stuck!

-

Hold plate on with K-wire and get fluoro to look at A/P, Lat position of plate, reduction

-

Start with non-locking shaft screw in mid-plate (2.5mm gold drill) approx. 30mm

-

Then put in locking guide to put in calcar/kickstand screw first

-

When drilling, make sure you are co-linear and use bouncing techniquegoal is to go through

cancenllous head to the subchondral bone and then STOP. DO NOT GO THROUGH

SUBCHONDRAL BONEbetter to be short, really difficult to measure and easy to penetrate.

-

Make sure to take more fluoro then you probably need to check screw length (airball)

-

Eaiser to put in screws with IR and then check AP/Grashey view for screw length, but need to

fluoro to check b/c round head.

-

Fill all locking holes in head

-

Place 2-3 non-locking holes in shaft, may need to place 1-2 locking

-

USE FLUORO TO CHECK SCREW LENGTHS

-

Once happy with screw lengths, irrigate and get final AP/Lat shots

-

Use free needle to pass Ticron sutures through superior holes to tie down the RC

-

Use #2 Ethibond to repair Pec Major if you released earlier (Dont grab LHBT)

-

Close D-P interval with 0-Vicryl to close over cephalic vein

-

Irrigate

-

2-0 Victryl to subdermal layer

-

Staples v. 3-0 monocril

-

Use ultrasling for post-op immobilization

-

Post-op XRMake sure you fluoro for screw length!