Instructional Course Lecture   |    
Nonprosthetic Management of Proximal Humeral Fractures
Joseph P. Iannotti, MDPhD; Matthew L. Ramsey, MD; Gerald R. Williams, MD; Jon J.P. Warner, MD
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An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Joseph P. Iannotti, MD, PhD
Department of Orthopaedic Surgery A-41, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address: iannotj@ccf.org

Matthew L. Ramsey, MD
Gerald R. Williams, MD
Presbyterian Hospital, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA 19104

Jon J.P. Warner, MD
Harvard Shoulder Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 275 Cambridge Street, Fourth Floor, Boston, MA 02114

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2004 in Instructional Course Lectures, Volume 53. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Aug 01;85(8):1578-1593
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Most proximal humeral fractures are not sufficiently displaced or angulated to require surgical management. It is estimated that 20% of all proximal humeral fractures should be treated surgically 1 , and humeral head replacement is the preferred method of treatment for many of those fractures. An indication for hemiarthroplasty is the classic four-part fracture or four-part fracture-dislocation, particularly when the articular segment of the humeral head is separated from the tuberosities and the humeral shaft, because of the expected high risk of osteonecrosis. Other indications for hemiarthroplasty are fragmentation of the articular surface and severe osteoporosis. On the other hand, reduction and internal fixation can be accomplished for displaced fractures associated with an intact humeral head with good-quality bone. The indications for open or closed reduction and internal fixation are related to the fracture pattern, the quality of the bone, the status of the rotator cuff, and the age and activity level of the patient. The goal of reduction and fixation of a proximal humeral fracture is to obtain nearly anatomic reduction and stable fixation to allow an early range of motion 2 . Recently, there has been an emphasis on the use of less invasive open procedures for reduction and fixation, thereby minimizing periarticular scarring and decreasing the risk of vascular insult to the articular humeral head segment from the surgical exposure 3-5 .
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Joseph P. Iannotti
    Posted on October 21, 2003
    Dr. Iannotti responds to Dr. McGrory
    Cleveland Clinic

    I agree with your comments and recommendations. I believe that figure 13, rather than the line art drawing, correctly reflects your recommendation to place the starting position of the pins more distally.

    James E. McGrory
    Posted on October 15, 2003
    Non Prosthetic Management of Proximal Humerus Fractures
    Texas Arthroscopic Surgical Clinic, P. A.

    I read with interest the Instructional Course Lecture by Iannotti, et al on nonprosthetic management of proximal humerus fractures. The review was comprehensive and well-organized, and is a valuable resource for the practicing orthopaedic surgeon.

    I would call the authors and your readers attention, however, to a study that attempted to define the risk of injury to neurovascular structures about the shoulder during percutaneous pin fixation of the proximal humerus(1). While the authors of the Instructional Course Lecture correctly recommend spreading the soft tissues with a clamp or hemostat to lessen the risk of injury to the axillary nerve, it should be remembered that the nerve may still be injured by blind spreading with the hemostat itself, or from being tethered around a pin after it is placed. Furthermore, the main trunk of the axillary nerve and posterior humeral circumflex artery, that lie immediately inferior to the humeral head medially, cannot be protected in this manner.

    A preferable approach is to attempt to avoid these structures entirely using slight alterations in pin placement. Moving the starting point for lateral pins more distally, and avoiding overpenetration of the the medial cortex within 2 centimeters of the inferior aspect of the humeral head, will lessen the risk of injury to the anterior branch and main trunk of the axillary nerve, based on data obtained from our cadaveric dissections. If lateral pins must be placed more proximally, a more generous incision and careful exposure of the humeral shaft under direct visualization will minimize the risk of direct trauma to the anterior branch of the axillary nerve.

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