Gardner 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 413%
• DP approach large dissection and muscle retraction
• Stable fracture • Non displaced or
minimally displaced two-part and threepart fractures • Sling • Shoulder immobilizer • Early ROM
Indications for Locking Plates for Proximal Humerus Fractures
• DP is an indirect approach cadaveric specimens
• AL acromial approach
• 10 cm incision from AL acromion
• Raphe b/w anterior and middle heads split
fractures in the patient younger than 40 years) • Two part surgical neck fx with >30°of varus is
relative indication for fixed angle to avoid tuberosity impingement
• 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
Gardner et al. JOT October, 2006
In DP approach AHCA is directly in the surgical field
Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures
• 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
Fixation of Proximal Humerus Fractures with Locking Plates
Neer Classification
• Based on Parts
– Shaft – Head – Greater and lesser
tuberosity
• Part = 1 cm displacement OR 45 degrees angulation
Average width 30 mm
Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures
Gardner et al. JOT October, 2006
• Advantages of AL approach • Direct approach to GT • Avoids blood supply • Allows conversion to hemiarthroplasty
AO/ASIF Classification
• Based on likelihood of vascular injury
– Type A: Unifocal, intact vascular supply
– Type B: Bifocal, possible injury to blood supply
Surgical approach
• DP approach • AL acromial approach
Vascular Supply
• Ascending branch of anterior humeral circumflex
Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures
– Type C: Articular fx involving anatomic neck,
• Osteonecrosis most likely in this group
Most Proximal Humeral Fractures Can Be Treated Without Surgery
• Avoid AHCA in the groove
• “bare spot” hypovacular zone found on GT
• Anterior raphe incision is colinear with the “bare spot’ in all specimens
Plate to anterior vessel 4 mm Plate to posterior vessel 7mm
Gardner et al. JOT October, 2006
Note only small terminal motor branches of the axillary nerve are directly lateral
Vascular Implications of Minimally Invasive Plating of Proximal Humerus Fractures