EASIER WAY OF TREATING THESE CASES

1. Fracture Proximal Humerus
K-Wire Fixation And External
Fixation.
JAYANT SHARMA
M.S., DNB.,MNAMS.
Web :www.drjayantsharma@gmail.com

2. Fracture Proximal Humerus
• 4-5% of all cases.
• Third most common
beyond 65 years age.
• Aim of management is
Early Mobilization.

3. Classification
• A) A.O. Classification:
Based on severity of injury
and AVN
• 1. Type A: No vascular
isolation of articular
segment is detected.
• 2. Type B: Partial vascular
isolation of articular
segment
• 3. Type C: Total vascular
isolation of articular
segment

4. • Codman noted that
the fractures follow
Epiphyseal Plates.
Four possible sites
are Lesser tuberosity,
Greater tuberosity,
head and Shaft.

5. • Management of these fractures continues to
be a controversial subject.
• Various options are:
• Non operative.
• ORIF.
• External fixation.
• Tension band fixation.
• Arthroplasty

6. Disadvantages Of Various Methods
• A. Non Operative:
• Failure to obtain early mobilization which
results in:
• Higher rate of Shoulder Stiffness
• Pain and
• Malunion.

7. • B. Internal fixation:
• Difficulty in achieving
rigid fixation in cancellous
bone
• As cortical bone is very
thin shell and weak
purchase of screw results
in pull out.
• Intra op bleeding.
• Increased Risk of AVN.
• Adhesions post
operatively, reduce ROM
due to excessive
dissection. Normal head thickness 19mm

10. Disadvantage of Arthroplasty
• Stiffness
• Scarring
• Hardware problems
• Tuberosity malposition
• Functional score are same as Ex. Fix (Norris
et.al.1995). Only 53% had ability to use arm above
shoulder.

11. Advantages of Minimally Invasive
Techniques And External fixator
• Avoids dissection of Deltoid, Rotator Cuff and
biceps due to use of small pin diameter.
• Lower incidence of AVN(Ascending branch of
Anterior circumflex Humeral artery is not
disturbed).
• Minimal blood loss.
• Less scarring of scapulo humeral interface.

12. • Eliminates another Surgery for Hardware
removal.
• Faster rehabilitation.
• Effective in polytrauma, as can be done in
Supine position.
• Some authors have reported good to
excellent results in Osteoporotic fractures

13. • Resch H et.al, JBJS (Br) 1997,
• In 3 or 4 part fracture 90 % good to excellent
results.
• AVN incidence was 1%
• Chen CY, Journal of Trauma 1998,
• 2 or 3 part fracture showed 85%good results .
• Calvo et.al Journal of Shoulder and Elbow2007,
• Excellent to good results in 2 and 4 part fractures
was 85% with percutaneous pinning and external
fixation, with early mobilization.
• AVN incidence was 2%.

14. Complications
• 1. Non union
• 2. Superficial infection
• 3. Deep infection
• 4. Bicipital tendinitis
• 5 Reflex sympathetic dystrophy
• 6. Loss of reduction.

15. IMPORTANT RED FLAG.
• Circumflex humeral
artery branch of
Axillary artery.
• This proximal branch
runs through the
Bicipital groove.

16. Operative Steps.
• GA/ Brachial block
• Supine position with a sand bag to
elevate shoulder.
• Structures at risk:
• a. Axillary nerve
• b. Posterior humeral circumflex artery
• c. Anterior branch of Axillary Artery.
• d. Cephalic vein.
• e. Biceps tendon.
• f. Musculocutaneous nerve.

18. Operative contd...
• 2.5mm Schanz pins/ K
wire at humeral head at
300 to each other in
horizontal plane.
• 1st: In true lateral/
coronal plane
2nd: just lateral to
bicipital groove
3rd: 300 posterior to 1st
one.

19. A displacement of Greater tuberosity superiorly
may cause Impingement.
A displacement posteriorly can cause External
rotation is blocked.

20. • Next 2.5mm pin inserted in
coronal plane in line with 1st
pin, approximately 4cm or 3
finger/ below the 1st pin in
upper third of Humerus.
• 3rd pin placed 2cm below the
above pin laterally.
• Wires are placed from lateral
cortex to medial cortex into
the head upto the
subchondral area

22. Operative contd...
• Now the wires are
joined through Link
joints of JESS and a
curved rod.

23. • A wire can be placed
from the head to bring
down the head as near
to the shaft.

24. Joshi’s External Stabilizing System
• Assembly consists of :
• 1. A simple light modular mini fixator
• 2. Invented by Dr. B. B. Joshi
• 3. Has high safety profile
• 4. Ease of application

25. Joshi’s External Stabilizing System.
• Has an advantage of:
• Fixed angle stability.
• Provides stability even in osteoporotic fractures.
• Early results are encouraging.
• No comparison with plating and
hemiarthroplasty available.

26. COMPONENTS
• A) Link joints:
• 1. Basic clamping unit of
JESS
• 2. Cross holes at different
levels
• 3. One is oval other is
round and perpendicular to
oval hole
• B) Connecting rods:
• Diameter vary from 2-4mm
• Available in various lengths

30. Post op
• Pouch arm sling is applied.
• Pain free ROM, ASAP.
• Pins cleaned with Povidone iodine.
• Patient follow up for 2,4,6 and 8 weeks.
• Removal at 6 or 8 week.
• Then for bimonthly till 1 year.

31. Physiotherapy

36. Nabeil Ebraham’s Technique
• 4 Step technique
• 2 pins of 2.5 mm inserted in Shaft.
• 2 pins of 2.5 mm in Head.
• Head is externally rotated to place Greater
tuberosity pin, avoids Axillary nerve, Posterior
circumflex humeral artery.
• Pins are used as joystick to reduce the
fragments external fixator then applied.
• Additional anterior pins are added for stability.

37. Nabeil Ebraham’s Technique

41. ILIZAROV RING FIXATION
• Cumbersome assembly.
• Needs expertise and
has steep learning
curve.

42. Take Home Message
• Early mobilization and ease of fixation is an
advantage with External fixation devices.
• Elderly Patients and osteoporotic fractures
are well managed with Ex. Fix.
• Avoids need of redo surgery.
• Less expertise needed, Surgeon and Patient
friendly procedure.

43. THANK YOU FOR A
PATIENT LISTENING

44. Constant Scoring System
• Four variables that are used to assess the function of
the shoulder.
• The subjective variables are
• Pain
• Activities of daily living (ADL) (sleep, work,
recreation/sport), which give a total of 35 points
(pain: 15, ADL: 20).
• The objective variables are
• Range of motion
• Strength, which give a total of 65 points (range of
motion: 40, strength: 25

45. • Altogether there are 100 points.
• Constant Score divides the outcome of
patients into four categories, i.e.
• Excellent having a score >85,
• Good having a score between 71 and 85,
• Fair having a score between 61 and 70,
• Poor outcome with a score of 60 or less.