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Humerus External Fixation, Avoiding Neuro vascular injury
- 1. HUMERUS EXTERNAL FIXATION: Avoiding Neurovascular Injury Melesse Gardie, Orthopaedics Resident Duane Anderson, MD Soddo Christian Hospital Soddo, Ethiopia June 2016
- 2. Goals of External fixation of the Humerus • Create the greatest stability possible with 4 pins and one bar if possible • Avoid NV injury in the process • Recreate normal anatomy of the bone, nl length, rotation, angulation • Allow wound care with ease • Allow painless ROM of the shoulder and elbow if possible
- 3. Outline of Presentation 1.Anatomy (Bony and Soft tissues) 2.External Fixation principles as applied to the humerus 3. Techniques to avoid NV injury 4. Case examples
- 4. Ex Fix Goals explained • Pin 1 and 4 should be as far apart as possible and pins 2 and 3 should be as close as possible to create greatest stability • The bulk of the muscles of the humerus are flexors(anterior) and extensors(posterior) of the elbow, the pins should try to avoid entrapping these muscles • The radial nerve is the most important structure at risk • The axillary nerve is at risk proximally
- 5. ANATOMY kkkkkkkkkkkkkkkkk 1. Bony Anatomy: -proximal -Shaft -Distal Humerus Shaft (Upper Border Pec maj insertion to supra condylar ridge is nearly cylinderical prox & triangular distally 3 surfaces separated with 2 borders Radial groove Deltoid Tuberosity Nutrient foramen
- 6. Position of inter tubercular groove, glenoid cavity, prox humers, distal humerus Torsion of Humerus Antero superior view.
- 8. 2. Soft tissue Anatomy
- 13. Vasculature
- 14. Axillary Nerve
- 15. Axillary nerve posterior view
- 16. Radial/axillary nerves posterior view right left • Crosses the intermuscular septum 8-12 cm proximal to the elbow
- 17. Radial Nerve Greatest risk of injury is in the distal third of the humerus TTriangular Interval: Radial Nerve Profonda Brachial Artery Laterel I/M Septum
- 18. Indications for external fixation • Open fractures with or without extensive soft tissue loss • Infected open fractures • Burn patients with fractures • Highly comminuted fractures • Segmental bone loss • Vascular injuries • As an element of salvage procedure in cases of major complications after nailing or plating • As primary treatment in polytrauma patients
- 19. Open fractures • All open fractures do not need External fixation • Low energy open fractures that are relatively stable and need 1 or 2 debridements don’t need an ex fix, plating, or rodding • Higher energy injuries that will require repeated debridement are the biggest indication • Infected open fractures are a major indication
- 20. External Fixation Technique • placement of the pins depends on the location of the fracture • generally a single frame with two pins each proximal and distal to the fracture gives enough stability
- 21. External Fixation Technique • Far distally straight lateral pin placement avoids entrapment of flexors and extensors of the elbow • The radial nerve is at risk • The nerve crosses the intermuscular septum 8- 12 cm from the elbow in the adult patient • The nerve then sits on top of the brachialis and under the radiobrachialis
- 22. Distally • Distally straight lateral pin placement allows avoidance of the radial nerve and entrapment of flexors and extensors of the elbow if careful surgical technique is followed
- 23. External Fixation Technique • Distally straight lateral pin placement allows avoidance of the radial nerve and entrapment of flexors and extensors of the elbow if carefully done
- 24. Dangerous • Skin Incision long enough (>1.5cm) to avoid strain of skin margins after pin placement and to allow easy blunt dissection, distally very careful dissection and retraction and placement of soft tissue protectors are essential in prevention of nerve injury • The more nervous you are the bigger the incision, expose the nerve if you are afraid..
- 25. Safe areas • In safe areas of the humerus small incisions with placement of drills through soft tissue protectors is enough
- 26. Pin placement • Place drill sleeve with trocar in the prepared soft tissue channel position in correct place, predrill both cortices • Pin placement should also be done with sleeves, and feeling of the pin thread itself into the opposite cortex confirms correct insertion depth
- 27. Proximally/Axillary nerve • In an adult the axillary nerve is 7 cm from the acromion • Is is just below the surgical neck • It corresponds to the largest bulk of the deltoid • Go just below this point for most fracture patterns • Make an incision and bluntly dissect down to the bone and place a drill in the soft tissue protector and use as a trocar
- 28. The logical sequence of fixeters • The most proximal and distal pins should be placed first #1, #4 • Then a bar should interconnect them
- 29. Rotation and length! Pin #1, #4 • With the first two pins and the bar get the Rotation and length correct! IMPORTANT! • If you don’t have rotational markers at the fx assume the proximal fragment is in neutral rotation, ie put the forearm straight up in the supine position(the rotator cuff is balanced in neutral rotation
- 30. Pins #2, #3 • Your assistant needs to hold the fx anatomically while the middle pins are placed • I do NOT feel that the pins have to avoid fracture hematoma
- 31. Fine tuning the fx site with the middle pins, #2, #3 • USE the bar/pin clamp as a drill guide while the fx is held anatomically by your assistant
- 32. How to avoid the radial nerve in the middle/distal thirds of the humerus • In some fractures the nerve is visible, this is an obvious advantage • The nerve in the middle- distal third is going from posterior to anterior as it goes distally • Use what you can see to your advantage, if you need to follow its course surgically do so
- 33. How to avoid the radial nerve in the middle third of the humerus • If you know where the nerve is, pull it out of the way • If you know it just went posterior on its way proximally, then go further proximally and direct your pin away from the nerve by directing the angle of the drill anteriorly carefully hold the drill to avoid a plunge posteriorly Distal prox
- 34. Make an incision if you have to to find the nerve! • Injuring the nerve because you want to make a small incision in the middle-distal third of the humerus is NOT wise
- 35. Elbow motion in the hospital
- 36. Shoulder motion in the hospital
- 37. Ex fix and ORIF • Open elbow injuries to allow motion • Spanning the elbow for very unstable open injuries
- 38. Open 3A, fx’s on both sides of the joint
- 39. Limited ORIF on the humerus (major bone loss), spanning ex fix
- 41. Ex fix removed at 3 months • at 4 months a capsulotomy was done to allow elbow motion
- 42. 6 months later
- 43. 6 months post injury
- 44. Gustilo 3 B open fx
- 45. After ex fix and minimal ORIF
- 46. Move it!
- 47. Local Flap and coverage, move!
- 49. A Humerus Ex fix is invaluable!
Editor's Notes
- The surface of the humerus can be also divided into three longitudinal parts; anterolateral, anteromedial, and posterior. Each area is defined by bony ridges that extend from the tuberosities to the supracondylar Region The lateral border runs from the dorsal aspect of the greater tubercle to the lateral epicondyle and separates the anterolateral surface and posterior surface. It is traversed in its center by the radial nerve in its sulcus. It is the site proximally for the insertion of the teres minor and the origin of the lateral head of the triceps brachii and distally for the origin of the brachioradialis and extensor carpi radialis longus, The medial border extends from the lesser tubercle to the medial epicondyle. Proximally, it is the site attachment for the teres major. Around the center is the site for the insertion of the coracobrachialis and just distal is the entrance of the nutrient canal. This canal serves as the entrance for the vascular supply of the humeral shaft, a site of crucial importance for proper healing of any fracture. In general, two-thirds of all humeri have a single nutrient. The mean position of this canal lies distal to the midpoint of the humerus and to the apex of the deltoid insertion. From this position, it spirals proximally and medially to the dorsal surface of the middle third of the shaft. This region should be avoided during any surgical operation Important osseous landmarks of the humeral diaphysis are the deltoid tuberosity (point of insertion of the deltoid muscle) on the anterolateral surface at the junction of the proximal and middle thirds of the diaphysis and the spiral groove in the middle/posterior aspect that contains the radial nerve and the profunda brachii artery
- With the upper limb in the neutral (zero-degree) position<-p.237)the greater tuberosity faces laterally and the lesser tubErosity faces anteriorly. The inter tubercular groove between them transmits the tendon of long head of biceps muscle. The glenoid cavity forms a 30' angle with the Sagittal plane. The shaft of the adult humerus normally exhibiU some degree of torsion, i.e., the proxim~l end of the humerus Is rotated relative to Its distill end. The degree of this tol'$lon c.an be assessed by supertmposlng the axis of the humeral head (from the antl!r of the greater tubero.sity to the centzr of the humeral head) over the eplcol'ldylar aids of the elbow joint. Thls torsion anglto equals apprOldmately 16*1n .-an adult. compared wlttl .-about 60*1n a nt\Worn. The decrease In the tol'$lon angle with body growtfl correlates IMth the change in the position of the scapulae. Thus, while the glenoid cavity in the newborn still faces anteriorly, It Is directed much more laterally In the .-adult (seep. 21 1). A:s the position of the sc.apula dlanges, there Is a compensatory decrease In the torsion angle t» ensure that hand movements will remain within the visual field of the adult.
- The musculature of the humeral shaft provides a natural splinting mechanism and may be a major factor contributing to the success of closed methods for the treatment of most fractures. When an operation is required, all approaches to the humeral shaft have the potential for dangerous outcome due to the extensive .neurovascular structures
- Perfusion of the proximal humerus arises from the axillary artery where it passes between the pectoralis minor and teres major muscles. At this level, the axillary artery gives off the humeral circumflex arteries (Fig. 37-18). The ACHA runs horizontally behind the conjoined tendon over the anterior aspect of the surgical neck of the humerus to anastomose laterally with the PCHA. At the level of the biceps tendon the ACHA gives off a branch that ascends behind the long head of the biceps on the surface of the bicipital groove proximally (Fig. 37-19). Within 5 mm of the articular surface it penetrates the cortical bone, becoming the arcuate artery which provides vascularity to most of the humeral head46,147 (Fig. 37-20). The PCHA arises as a larger branch at the same level as the ACHA at the lower margin of the subscapularis muscle. It travels posteriorly with the axillary nerve giving off several branches that pierce the posteromedial aspect of the proximal humeral metaphysis providing vascularity to the humeral head. The PCHA finally crosses the quadrilateral space winding around the surgical neck and anastomosing anteriorly with the ACHA. While some authors have found the arcuate artery from the anterolateral ascending branch of the ACHA to be the main arterial supply to the humeral head,147 several studies have shown branches from the PCHA to the posteromedial head to be at least equally important The brachial artery provides the main arterial supply to the arm and is the continuation of the axillary artery (Fig. 6.35). It begins at the inferior border of the teres major (Figs. 6.32A and 6.35) and ends in the cubital fossa opposite the neck of the radius where, under cover of the bicipital aponeurosis, it divides into the radial and ulnar arteries (Figs. 6.33B and 6.35). The brachial artery, relatively superficial and palpable throughout its course, lies anterior to the triceps and brachialis. At first it lies medial to the humerus where its pulsations are palpable in the medial bicipital groove (Fig. 6.32B). It then passes anterior to the medial supraepicondylar ridge and trochlea of the humerus (Figs. 6.35 and 6.36). As it passes inferolaterally, the brachial artery accompanies the median nerve, which crosses anterior to the artery (Figs. 6.32A and 6.36). During its course through the arm, the brachial artery gives rise to many unnamed muscular branches and the humeral nutrient artery (Fig. 6.35), which arise from its lateral aspect. The unnamed muscular branches are often omitted from illustrations, but they are evident during dissectionThe main named branches of the brachial artery arising from its medial aspect are the deep artery of the arm and the superior and inferior ulnar collateral arteries. The collateral arteries help form the periarticular arterial anastomoses of the elbow region. Other arteries involved are recurrent branches, sometimes double, from the radial, ulnar, and interosseous arteries, which run superiorly anterior and posterior to the elbow joint. These arteries anastomose with descending articular branches of the deep artery of the arm and the ulnar collateral arteries
- Comes off posterior cord behind the axillary artery, anterior to the subscapularis muscle Travels through the quadrangular space runs here with the posterior circumflex humeral artery and vein Gives off an anterior, posterior, and articular terminal branch Terminal branches anterior branch wraps around the surgical neck of the humerus on the undersurface of the deltoid supplies the anterior deltoid muscle traditional "safe zone" from lateral acromion is 5 cm axillary nerve has been shown to run 3-5 cm from the acromion in 20% of patients damage to nerve with a muscle split here will denervate the anterior deltoid terminates in small cutaneous branches for the anterior/anterolateral skin posterior branch supplies the teres minor and posterior deltoid muscles pierces the deep fascia and terminates as the superior lateral cutaneous nerve of the arm articular branch enters the shoulder joint inferior to the subscapularis Hornblower's test indicates teres minor pathology shoulder placed in 90 degrees of abduction, 90 degrees of external rotation positive if patient falls into internal rotation Quadrangular Space Borders medial: long head of triceps lateral: humeral shaft superior: teres minor inferior: teres major Contents axillary nerve At the level of the proximal humerus, the axillary nerve passes from anterior to posterior, accompanied by the posterior circumflex artery, inferior to the anatomic neck through the quadrilateral space surrounded by teres minor superiorly, the long head of the triceps medially, teres major inferiorly, and the humeral shaft laterally. After giving off the branch to the teres minor, it passes anteriorly on the undersurface of the deltoid at a distance ranging from 2 to 7 cm distal to the acromion.55,133,192 This distance has been found to be inversely proportional to the length of the deltoid.213 It crosses the anterior deltoid raphe between the anterior and middle deltoid in the form of a single terminal branch allowing for preservation of the innervation of the anterior deltoid when the nerve is isolated during the deltoid-splitting approach.133,13
- Posterior wall axilla courses on posterior wall of the axilla (on subscapularis, latissimus dorsi, teres major) 3 Branches in axilla posterior cutaneous nerve of the arm branch to long head of triceps branch to medial head of triceps Triangular interval it then runs thru triangular interval with profunda brachii artery in posterior compartment between long head of triceps and humerus Spiral groove next it courses through the spiral groove between lateral and medial heads of triceps bottom line = Safe zone posteriorly of 10cm distal to lateral acromion& 10 cm proximal to lateral epicondyle branches in spiral groove inferior lateral cutaneous nerve of the arm posterior cutaneous nerve of the forearm branch to lateral head of triceps branch to medial head of triceps and anconeus Lateral intermuscular septa next it passes through the lateral intermuscular septa never less than 7.5 cm above the distal articular surface. runs between brachialis and brachioradialis (anterior to lateral epicondyle) Triangular Interval Borders superior: teres major lateral: lateral head of the triceps or the humerus medial: long head of the triceps Contents profunda brachii artery radial nerve
- Medium External Fixator Humeral Shaft frames: Modular frame for upper extremity use