Introduction The percutaneous approach to proximal humeral fixation emphasizes minimum dissection with the goal of preserving vascularity of the articular segments and thereby decreasing the risk of osteonecrosis.
Step 1: Preoperative Planning Perform preoperative imaging to assess fracture displacement and comminution in order to confirm that percutaneous treatment is appropriate.
Step 2: Closed Fracture Reduction Attempt closed fracture reduction prior to incision.
Step 3: Surgical Approach for Humeral Head and Shaft Reduction Obtain anatomic humeral head reduction, insert terminally threaded pins, and check pin placement fluoroscopically.
Step 4: Tuberosity Fracture Reduction and Fixation of the Tuberosity Fragments Fix the tuberosity fracture(s).
Step 5: Wound Closure Cut the pins below the skin and irrigate and close the wounds.
Step 6: Postoperative Rehabilitation Begin passive shoulder motion after pin removal, and initiate active motion at six weeks after pin removal.
Results The results of this technique in twenty-seven patients with an average age of 58.8 years (range, forty-two to seventy-six years) at the time of injury were reported previously6.
Pitfalls & Challenges
The percutaneous approach to proximal humeral fixation emphasizes minimum dissection with the goal of preserving vascularity of the articular segments and thereby decreasing the risk of osteonecrosis.
Proximal humeral fractures vary with regard to pattern, degree of comminution, and patient factors such as age, bone quality, and activity level. These fractures have been treated with interfragmentary suture fixation, percutaneous pinning, plate fixation, intramedullary nailing, hemiarthroplasty, and reverse total shoulder arthroplasty. With any humeral-head-preserving technique, nonunion, malunion, and osteonecrosis are important postoperative concerns.
Previous studies have suggested that percutaneous fixation may decrease the risk of osteonecrosis in patients who have sustained a proximal humeral fracture. The prevalence of osteonecrosis after percutaneous pinning has been reported to be 4% to 16%1, which is lower than the …
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