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Selected Instructional Course Lecture   |    
Avoiding Complications in the Treatment of Humeral Fractures
Jeffrey O. Anglen, MD1; Michael T. Archdeacon, MD, MSE2; Lisa K. Cannada, MD3; Dolfi HerscoviciJr., DO4
1 Department of Orthopaedics, Indiana University School of Medicine, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202-5111. E-mail address: janglen@iupui.edu
2 Department of Orthopaedics, University of Cincinnati Medical Center, P.O. Box 670212, 231 Albert Sabin Way, ML 0212, Cincinnati, OH 45267
3 5323 Harry Hines Boulevard, Dallas, TX 75390
4 Florida Orthopaedic Institute, 13020 Telecom Parkway North, Temple Terrace, FL 33673
View Disclosures and Other Information
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 February 2009 in Instructional Course Lectures, Volume 58. 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).
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Stryker Orthopaedics) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1580-1589
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Look for this and other related articles in Instructional Course Lectures, Volume 58, which will be published by the American Academy of Orthopaedic Surgeons in February 2009:"Prevention of Complications in Proximal Femur Fractures," by Michael T. Archdeacon, MD, MSE, Lisa K. Cannada, MD, Dolfi Herscovici Jr., DO, Robert F. Ostrum, MD, and Jeffrey O. Anglen, MDMost humeral fractures heal uneventfully, but a variety of complications can occur after both surgical and nonoperative treatment. Three of the most common complications encountered are nonunion of a humeral shaft fracture, loss of fixation of a proximal humeral fracture, and radial nerve palsy. This lecture will focus on these three relatively common complications and will discuss their etiology, risk factors, prevention, detection, and treatment.
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    Accreditation Statement
    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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    Andy C Karich
    Posted on September 06, 2008
    A Technical Suggestion for Fixation of Proximal Fracture of the Humerus
    St Jude Medical Center, Fullerton, CA

    To the Editor:

    I want to share a technical pearl that I do not think is universally known regarding fixation of proximal humerus fractures. While tension band fixation (suture through cuff and plate) is an obvious necessity for displaced tuberosity fractures in the treatment of 3 and 4 part proximal humerus fractures, I also have found it to be a helpful component of the fixation construct for surgical neck fractures and for the unfractured tuberosity in 3-part fractures (that which is still attatched to the humeral head.)

    Failure of fixation of surgical neck fractures with locking plate and screw fixation alone tends to occur in varus due to the pull of the rotator cuff. The simple addition of tension band suture fixation is very effective in conjuction with locking plate and screw fixation to prevent this varus displacement. I have used this technique at least 20 times with no fixation failure (2 failed at > 8 months due to avascular necrosis in 4 part fractures).

    Technically, after the approach and fracture exposure, I place a #2 fiberwire suture into the subscapularis, supraspinatus, and infraspinatus as a first step. These sutures may be used as a reduction aide as they afford control of the proximal fragment. Once the fracture is reduced (the hard part), the plate is applied and screws inserted. The sutures are then passed through the holes in the plate and tied as the final step in fixation. Alternatively, the sutures can be passed through the holes in the plate just before plate application, but they should be tensioned and tied after completion of metallic fixation. This additional fixation affords a tension band augmentation circumferentially. I recommend this technique for the fixation of virtually all proximal humerus fractures.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

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