肱骨近端骨折.ppt

ProximalHumerusFractures Dislocations History Demographics Bimodal young highenergy elderly lowenergy osteoporosis 45 ofallhumerusfx elderlyfemales4 1overmales77 ofallprox hum fracturesfemale Consequences AssociatedInjuries DisabilitiesoftenunderestimatedLossofmotionLossofreductionAVNheterotopicboneAssociatedInjuriesrotatorcuffnerve axillary brachialplexus vascularscapula clavicle Anatomy AppearanceofOssificationCentersepiphysis4moGr Tub 3yrL Tub 5yrPhysealscarclosure20 22yrs ProximalHumeralRetroversion 35 40degreesrelativetoepicondylaraxis BloodSupply Axillaryarteryant humeralcircumflex ascendingbranch arcuateartery isthemajorbloodsupplytothearticularsurfacepost humeralcircumflex Arcua Arcuate afeeffe Nerves BrachialPlexusaxillarysuprascapularmusculocutaneous RotatorCuffMuscles SupraspinatousInfraspinatousSubscapularisTeresMinorDeltoidPectoralisLongheadbiceps Classification Neer 4part 2partAN anatomicneck SN surgicalneck 3partSN GT LT4partSN GT LT headsplits articularimpressionsfx dislocations AOtypeA2partextracapsulartypeB3partpartiallyintracapsulartypeCvascularisolationofhead4partintracapsular Classification Neer2partSN AN GT LT3partSN GTorLTAN GTorLT4partneck bothtuberosities dislocationNeer sdefinitionofdisplacement 1cmor 45degrees RadiographicWorkUp TraumaSeriestruescapularAPaxillary headdefects displacementoftuberositiesYortransscapularOthermodifiedaxillaryAPinint andext rotation CTScanarticularfracturesimpressionheadsplitglenoidfracturesassesstuberositydisplacementforoperativedecisionmaking RadiographicWorkUpScapularAP Axillary Yview CTScan Treatment Considerationsforclosedtreatmentpatientagedisplacementsurgicalnecktuberositiesarticularsurfacefunctionaldemandarmdominanceabilitytosalvagewithanarthroplastylaterifneeded Methodsofclosedtreatmentslingslingandswathhangingcastabductionpillow FracturestoConsiderforClosedTreatment Minimallydisplaced2partfx s orpositionalreductionofsignificantdisplacement GTfracturesshouldbe 5mm Minimallydisplaced3 and4 partfractures FracturestoConsiderforORIF DisplacedGTfx 5mm LTfxwithinvolvementofarticularsurfaceDisplacedorunstablesurgicalneckfxDisplacedanatomicneckfxinyoungpt Displaced reconstructible3 and4 partfractures FracturestoConsiderHemiarthroplasty Young Middleagenonreconstructablearticularsurface severeheadsplit orextrudedanatomicneckElderlymany4partssomesevere3partsmost3 4partfracturedislocationsmostheadsplits CurrentTechniquesofORIF PercutaneousPins Jaberg H 1992 Suture K wire tensionbandtechnique Cornell C H 1994 Darder A 1993 Hawkins J R 1987 Neer C S 1970 FlexibleIMnails Lee C K 1981 Robinson C M 1993 Wesley M S 1977 ButtressPlates Esser R D 1994 Kristiansen B 1986 Paavolainen P 1983 Savoie F H 1989 SelectedLockedRigidIMnailsBladePlateFixation Weber1984 Sehr Szabo1988 Jupiter Scheid1999 ProximalHumeralLockingPlates SurgicalApproachesDeltopectoralDeltoidSplittingPosteriorPercutaneous Fracture FixationSN LT 3part 4part surgeonchoiceGT SomeSNifusingIMfixationscapula glenoid occasionalposteriorarticularfractureFx samenabletopinningornailing PercutaneousPinning Technique beachchairposition closedmanipulation oscillatingdrill terminalthreadpins atleastbidirectionalpins seeJabergH 1992 cutpinsbeneathskin slingandswath followcloselyAssociatedProblems nerveinjury axillary pinloosening migration noearlymotionBestUse limited2or3partwhenothertechniquesnotfavorable Migration SutureorK wire TensionBand Technique beachchairposition deltoidsplittingordeltopectoralapproach kwireandsuturerepairoftuberositieswithtensionband sutureorwire tometaphysisAssociatedProblems cuffconstriction limitedheadfixationtoshaft wiremigrationBestUse GT LT GT LT tuberositieswithundispl SN FlexibleNails Technique beachchairposition deltoidsplittingapproach lateraltuberosityorcuffsplittinginsertion maycombinewithtensionbandsutureAssociatedProblems limitedheadfixation migrationintosubachromialspace cuffviolationBestuse 2partSNNewerplatesandnailsmorefavorable LockedRigidNailsforProximalHumerus enhancedproximalfixationwithtwistedbladesormultiplescrews ButtressPlating Technique sittingorsupine deltopectoralapproach lateraltobiceptsgroovetominimizevasculardamageAssociatedproblems poorheadfixation largedissection iatrogenicvasculardamage impingementBestuse low2partSN largeGT rarelyusedtechniqueduetoimpingementandpoorheadfixationNewerlockingplatesnowfavorable BladePlateTechnique Technique beachchairpositon deltopectoralapproach metaphysealslotlateraltobic groove minimalsofttissuestrippingAssociatedProblems learningcurve penetrationofhumeralheadinosteoporoticboneAdvantages noimpingementinhighangleblade superiorheadfixationtoothertechniques easilycombinedwithsuturefixationoftuberosities PROXIMALHUMERALLOCKINGPLATE PROXIMALHUMERALPLATE PROXIMALHUMERAL Hemiarthroplasty Technique beachchairposition deltopectoralapproach retaintuberosityfragmentswithcuffattachments combinesuturerepairoftuberosities bonegraftfromheadifneededAssociatedProblems unpredictableresultsfromfunctionstandpoint stillrequiresbonyhealing oftuberosities Bestuse elderly3 4part headsplits disvascularAN Results SN closedtreatmenthasyielded60 90 satisfactoryresultsGT 50 100 poorresultswithdisplaced 5 1cm fracturestreatedclosed GoodresultswithORIF 3Part closedtreatment min displacementornonoperativeelderlypt yieldsunpredictableresults 15 70 satisfactory ORIFwithgoodreduction 60 80 goodtoexcellentresults 4Part poorresultswithclosedtreatment Hemiarthroplastygivessatisfactorypainresultswithsomewhatunpredictablefunctionalresults ORIFinyoungerpatienthaveyielded 50 satisfactoryresults HigherAVNinORIFHeadSplit IfCTSshowssegmentattachedtoLTthenORIF IfseverefragmentationofarticularsurfacethenHemi Complications MisdiagnosisdegreeofGTdisplacementmissedpost Dislocationmassiverot cuffavulsionwithhighenergydislocation Suspectwhensevereswellingheadsplit doubleshadow bestseenonaxillaryv orCTS Complications NonunionInyoung treatlikeanacutefractureifheadviable Considerhemiarthroplastyinelderlyorosteoporotic Complications AVNSignificantincidencein3and4partfractures HigherwhentreatedwithORIF Unlikehip incidencedoesnotcorrelatedirectlywithsymptoms Canbeminimizedwithdecreasedsofttissuestrippingandnoencroachmentofcircumflex arcuateart AdhesiveCapsulitisalmostuniversalbutminimizedwithearlymotioncontrolledP T manipulationunderanesthesiaoccasionalarthroscopicrelease ShoulderDislocations Classifiedby DirectionEtiologyInvoluntaryvsvoluntary AnteriorShoulderDislocation MostcommonUpto20 40 neurologicinjury axillary brachialplexus Axillaryx rayorCTtoassessforheadimpactionorHillSachslesionMaybeassociatedwithgreatertuberosityfracture PosteriorShoulderDislocation AssociatedwithseizuresorelectricalshockCommonlymissedonX rayHighincidenceofassociatedlessertuberosityfracture Exampleofaposteriordislocation ShoulderDislocations Etiology TraumaticUsuallyunidirectionalAtraumaticOftenassociatedwithmultidirectionalinstability psychiatricproblemsifvoluntary ShoulderDislocations Pathoanatomy Stretching TearingofcapsuleUsuallyoffglenoidOccasionallyoffhumerus HAGLlesion Labraldamage Bankart lesionreferstoavulsionofanterior inferiorlabrumoffglenoidrim Maybeassociatedwithglenoidrimfracture bonybankart HumeralHeadimpressionfracture Hill SachsLesion ShoulderDislocations RotatorCuffTear The posteriormechanism ofshoulderinstability coinedbyDr EdCraig ClinOrthop190 1984 CommoninolderpatientsBewareofinabilitytoliftthearminanolderpatientfollowingadislocation ShoulderDislocations Evaluation Inspection notefullnessofanteriorchest prominenceofacromionNotepositionofarmandrestrictedmotionDocumentdetailedneurovascularexam Deltoidatrophy6monthsaftershoulderdislocation ShoulderDislocations Imaging X rays shouldertraumaseries CTifuncertain Specialviews StrykernotchviewimagesHill SachslesionWestPointviewimagesanterior inferiorglenoidCTscan bestifconcernedaboutassociatedfractureMRI bestforevaluatingassociatedsoft tissuepathology Tornanteriorlabrum ShoulderDislocations Treatment ImmediatereductionManytechniquesAdequatesedationControlscapulaImmobilizationControversialre positionandduration 19patientsstudieswithMRIEffectofarmpositionondegreeofcoaptationofBankartlesiondocumentedformultiplepositionsConclusion Immobilizationinexternalrotationprovidedthebestreductionoftheanteriorlabrum Positionofimmobilizationafterdislocationoftheglenohumeraljoint Astudy