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FixationofProximalHumerusFractureswithLockingPlatesNeerClassificationBasedonPartsShaftHeadGreaterandlessertuberosityPart=1cmdisplacementOR45degreesangulationAO/ASIFClassificationBasedonlikelihoodofvascularinjuryTypeA:Unifocal,intactvascularsupplyTypeB:Bifocal,possibleinjurytobloodsupplyTypeC:Articularfxinvolvinganatomicneck,OsteonecrosismostlikelyinthisgroupMostProximalHumeralFracturesCanBeTreatedWithoutSurgeryStablefractureNondisplacedorminimallydisplacedtwo-partandthree-partfracturesSlingShoulderimmobilizerEarlyROMIndicationsforLockingPlatesforProximalHumerusFracturesThreeandfourpartsalvageablefracturesValgusimpactedforfourpartThreepartfracturesinvarusElderly,osteoporoticVeryproximal(Mighell:twopartanatomicneckfracturesinthepatientyoungerthan40years)Twopartsurgicalneckfxwith>30°ofvarusisrelativeindicationforfixedangletoavoidtuberosityimpingementSurgicalapproachDPapproachALacromialapproachVascularSupplyAscendingbranchofanteriorhumeralcircumflexVascularImplicationsofMinimallyInvasivePlatingofProximalHumerusFractures

Gardneretal.JOTOctober,2006InDPapproachAHCAisdirectlyinthesurgicalfieldVascularImplicationsofMinimallyInvasivePlatingofProximalHumerusFractures

Gardneretal.JOTOctober,2006NoteonlysmallterminalmotorbranchesoftheaxillarynervearedirectlylateralVascularImplicationsofMinimallyInvasivePlatingofProximalHumerusFractures

Gardneretal.JOTOctober,2006AVNratesupto16%for3-4partfracturesvs9%forminimallyinvasiveLockingplatestudiesshowAVNrates4-13%DPapproachlargedissectionandmuscleretractionDPisanindirectapproachtoplatingzone6cadavericspecimensALacromialapproach 10cmincisionfromALacromionRapheb/wanteriorandmiddleheadssplit6cmtypicallyfoundaxillarynervefound3holeSyntheslockingproximalhumerusplateLatexpolymerinjectedintoaxillaryartery Findings:NovesselsexposedthatpenetrateheadAvoidAHCAinthegroove“barespot”hypovacularzonefoundonGTAnteriorrapheincisioniscolinearwiththe“barespot’inallspecimensPlatetoanteriorvessel4mmPlatetoposteriorvessel7mmAveragewidth30mmVascularImplicationsofMinimallyInvasivePlatingofProximalHumerusFractures

Gardneretal.JOTOctober,2006AdvantagesofALapproachDirectapproachtoGTAvoidsbloodsupplyAllowsconversiontohemiarthroplasty21y/oMVAopenfxTheImportanceofMedialSupportinLockedPlatingofProximalHumerusFractures

Gardneretal.JOTMarch2007

Whatfactorsinfluencethemaintenanceoffracturereductionafterlockedplatingofproximalhumerusfractures?RoleofmedialcolumnsupportTheImportanceofMedialSupportinLockedPlatingofProximalHumerusFractures

Gardneretal.JOTMarch200735patients3partand4partfxor2partwith100%displacementorvarusandmedialcomminutionRTCsuturesthruplate5lockingscrewstohead/non-locked“humeralheadheight”relativetoplatemeasuredat3and6monthsHUMERALHEADHEIGHTTheImportanceofMedialSupportinLockedPlatingofProximalHumerusFractures

Gardneretal.JOTMarch2007Adequatemedialsupport(+MS):MedialpillarnotcomminutedandreducedShaftmedializedandimpactedintoheadObliquelockingscrewintoinferomedialheadwithin5mmsubchondralboneTheImportanceofMedialSupportinLockedPlatingofProximalHumerusFractures

Gardneretal.JOTMarch2007Regardlessofthereductionachieved1orseveralinferomedialscrewsimportantw/medialcomminutionormedialmalreductionNorelationwithage,sex,cementaugmentation,fracturetypeMedialpillarnotcomminutedandreduced3.5months7months2monthsAnalysisandEfficacyandFailureinProximalHumerusFracturesTreatedWithLockingPlates

AgudeloetalNov/DecJOT2007Multicenter(5)overnealy5yearsApproachesvaried(DPandAL)Implantsvaried136ptswithfollowupVarusmalreductiondefinedashead-shaftangleof<120degreesAnalysisandEfficacyandFailureinProximalHumerusFracturesTreatedWithLockingPlates

AgudeloetalNov/DecJOT2007Statisticallysignificantassociationb/wlossoffixationandvarusmalreduction(<120°)30.4%whenhead–shaftangle<120°

11%whenhead–shaftangle≥120°EndostealImplantsAssistinindirectreductionofmedialcloumnProvidemechanicalsupportformedialcolumnandhumeralheadFibularallograftof6cmInsertedthrulateralfxintoshaftPushscrewthruplateIncorporatesin6–12weeks5years42patientsover42fx3radiographicfailures7.1429%vs36%Anytakersforafollowupstudy?TheGeisingerExperienceInsertGraftBetweenTuberositiesatthisStepAlternativeUseofAllograftConclusionsPositionsoyoucangetimagesthendrapeKnowbothapproachesAvoid

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