锁骨骨折的固定盘治疗经验分享

1、Fixation of Proximal Humerus Fractures with Locking PlatesNeer Classification Based on Parts Shaft Head Greater and lesser tuberosity Part = 1 cm displacement OR 45 degrees angulationAO/ASIF Classification Based on likelihood of vascular injury Type A: Unifocal, intact vascular supply Type B: Bifoca

2、l, possible injury to blood supply Type C: Articular fx involving anatomic neck, Osteonecrosis most likely in this groupMost Proximal Humeral Fractures Can Be Treated Without Surgery Stable fracture Non displaced or minimally displaced two-part and three-part fractures Sling Shoulder immobilizer Ear

3、ly ROMIndications for Locking Plates for Proximal Humerus Fractures Three and four part salvageable fractures Valgus impacted for four part Three part fractures in varus Elderly, osteoporotic Very proximal (Mighell: two part anatomic neck fractures in the patient younger than 40 years) Two part surg

4、ical neck fx with 30of varus is relative indication for fixed angle to avoid tuberosity impingementSurgical approach DP approach AL acromial approachVascular Supply Ascending branch of anterior humeral circumflexVascular Implications of Minimally Invasive Plating of Proximal Humerus FracturesGardner

5、 et al. JOT October, 2006In DP approach AHCA is directly in the surgical fieldVascular Implications of Minimally Invasive Plating of Proximal Humerus FracturesGardner et al. JOT October, 2006Note only small terminal motor branches of the axillary nerve are directly lateralVascular Implications of Mi

6、nimally Invasive Plating of Proximal Humerus FracturesGardner et al. JOT October, 2006 AVN rates up to 16% for 3-4 part fractures vs 9% for minimally invasive Locking plate studies show AVN rates 4-13% DP approach large dissection and muscle retraction DP is an indirect approach to plating zone 6 ca

7、daveric specimens AL acromial approach 10 cm incision from AL acromion Raphe b/w anterior and middle heads split 6 cm typically found axillary nerve found 3 hole Synthes locking proximal humerus plate Latex polymer injected into axillary artery Findings: No vessels exposed that penetrate head Avoid

8、AHCA in the groove “bare spot” hypovacular zone found on GT Anterior raphe incision is colinear with the “bare spot in all specimensPlate to anterior vessel 4 mmPlate to posterior vessel 7mmAverage width 30 mmVascular Implications of Minimally Invasive Plating of Proximal Humerus FracturesGardner et

9、 al. JOT October, 2006 Advantages of AL approach Direct approach to GT Avoids blood supply Allows conversion to hemiarthroplasty21 y/o MVA open fxThe Importance of Medial Support in Locked Plating of Proximal Humerus FracturesGardner et al. JOT March 2007 What factors influence the maintenance of fr

10、acture reduction after locked plating of proximal humerus fractures?Role of medial column supportThe Importance of Medial Support in Locked Plating of Proximal Humerus FracturesGardner et al. JOT March 2007 35 patients 3 part and 4 part fx or 2 part with 100% displacement or varus and medial comminu

11、tion RTC sutures thru plate 5 locking screws to head/ non-locked “humeral head height” relative to plate measured at 3 and 6 monthsHUMERAL HEAD HEIGHTThe Importance of Medial Support in Locked Plating of Proximal Humerus FracturesGardner et al. JOT March 2007Adequate medial support(+MS): Medial pill

12、ar not comminuted and reduced Shaft medialized and impacted into head Oblique locking screw into inferomedial head within 5mm subchondral boneThe Importance of Medial Support in Locked Plating of Proximal Humerus FracturesGardner et al. JOT March 2007 Regardless of the reduction achieved 1 or severa

13、l inferomedial screws important w/ medial comminution or medial malreduction No relation with age, sex, cement augmentation, fracture typeMedial pillar not comminuted and reduced3.5 months7 months2 monthsAnalysis and Efficacy and Failure in Proximal Humerus Fractures Treated With Locking PlatesAgude

14、lo et al Nov/Dec JOT 2007 Multi center (5) over nealy 5 years Approaches varied (DP and AL) Implants varied 136 pts with follow up Varus malreduction defined as head-shaft angle of 120 degreesAnalysis and Efficacy and Failure in Proximal Humerus Fractures Treated With Locking PlatesAgudelo et al Nov

15、/Dec JOT 2007Statistically significant association b/w loss of fixation and varus malreduction (120) 30.4% when head shaft angle 120 11% when head shaft angle 120Endosteal Implants Assist in indirect reduction of medial cloumn Provide mechanical support for medial column and humeral head Fibular allograft of 6cm Inserted thru lateral fx into shaft Push screw thru plate Incorporates in 6 12 weeks 5 years 42 patients over 42 fx 3 radiographic failures 7.1429% vs 36% Any takers for a follow up study?The Geisinger ExperienceInsert Graft Between Tuberosities at this StepAlternative Use