The humeral head can usually be reduced by externally rotation the arm and gentle pushing and rotating the head into its anatomic position. Reduce that fragments into anatomic position.Confirm that the head fragment is not split or impacted and the cartilage is intact. Gently identify the humeral head fragment, being careful to avoid any neurovascular injury.Generally splinting the rotator interval between the tuberosities provides adequate exposure to the proximal humerus. The greater tuberosity and supraspinatus are lateral. The lesser tuberosity and subacapularis tendon are medial to the long head tendon. The key to identifying the various components is the long head of the biceps tendon. Identify the long head of the biceps tendon and ensure that it is preserved thoughtout the case.Ensure the anterior humeral circumflex vessels are protected and preserved.Release upper 1/3 of pectoralis tendon if needed for exposure.Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial ligament.Preserve cephalic vein by ligating any branches to deltoid and taking the cephalic vein and its surrounding tissues medially.Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic vein.).Deltopectoral incision from just medial to AC joint to just lateral to the proximal edge of the biceps muscle belly.Have a well-padded height adjustable Mayo stand or shoulder positioner available to hold the arm during the case. Prep and drape in standard sterile fashion.Examination under anesthesia of affected shoulder.Pre-operative antibiotics, +/- interscalene block.Must ensure calcar reduction and strongly consider calcar screw placement.Stryker SPS proximal humeral locking plate.Hand Innovations S3 plate Stryker Numelock II plate.Arthex Humeral SuturePlate: plate has easily usable suture holes, but is not side specific.If there are concerns about the patients bone quality, or fracture pattern a hemiarthroplasty prosthesis should be available and the patient should be consented for both ORIF and hemiarthroplasty.Consider augmenting with calcium phosphate cement (Synthes Norian SRS) (Kwon BK, JBJS 2002 84A:951).Consider getting xrays of normal side to aid in pre-op planning.Develop preoperative plan based on pre-operative radiographs using AO technique.Proximal Humerus ORIF Pre-op Planning / Case Card Proximal Humerus Fracture Hemiarthroplasty 23616.Head split or short articular fragment.No clear evidence for ORIF in patients >65yrs old.) Relatively young active patients with good bone density.High energey 3-, 4-part proximal humerus fractures.Lesser tuberosity fractures are pulled medially. If greater tuberosity is fractured it is pulled superiorly and posteriorly by the suprspinatus and infraspinatus. Supraspinatus abducts the head fragment in two part fractures. Deforming forces: Pectoralis major pulls the shaft medially, anteriorly and internally rotates.Most common site of injury to the axillary artery is in the third part(named in relation to the pec minor) of the artery at the origin of the anterior and posterior humeral circumflex arteries.The humeral head is retroveted an average of 30 degrees. The neck-shaft inclination angle averages 145 degrees. Normal distance from the greater tuberosity to the superior protion of the articular surface of the humeral head = 7-8mm (Iannotti JP, JBJS 1992 74A:491), (Takase K, JSES 2002 11:557). Mean distance between the pectoralis major tendon and the top of the humeral articular surface is 5.6cm (Murachaovsky J, JSES 2006 15:675). If both indicate ischmia the positive predictive value of ischemia for an anatomic neck fx is 97%.
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