This document discusses the management of proximal humerus fractures through K-wire fixation and external fixation. It describes the classification of these fractures, advantages and disadvantages of various treatment methods, operative technique using external fixation, post-operative care, and outcomes assessments using the Constant Scoring System. The key points are that external fixation allows early mobilization, avoids complications of internal fixation, and can achieve good to excellent results, especially in elderly patients and osteoporotic fractures.

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.