Shoulder Arthroplasty for Proximal Humerus Fracture

Dr TSE Lung Fung

Department of O&T, Prince of Wales Hospital

The Chinese University of Hong Kong

Arthroplasty in Upper Limb Trauma AADO/HKSSH Conjoint Scientific Meeting 2012

Let’s start with a case……

• Mr. Lee

• M/84

• Good past health

• Retired, lives alone

• ADL independent

• Right handed

The history

• Slipped and fell while getting off bus 7/6/2008

• Landed on out stretched right hand

• Immediate pain over right upper arm

• Failed to move injury arm

• Denied preceding symptoms

• HI with mild bleeding right forehead

At other hospital…

• Admitted to ORT unit

• X ray showed right # neck of humerus, displaced

• P/E showed axillary nerve intact, no distal NV deficit, active finger movement

• Suggested for operation

• Patient strongly requested for DAMA for geographical reasons

2 days later…

• Attended PWH AED 9/6/2008, admitted our unit

• Chief complaint:

– Persistent pain right upper arm near shoulder

– 1st dorsal web space numbness

P/E on arrival

• Significant right shoulder defomity

• Right shoulder swelling +ve

• Max tenderness at proximal humerus

• Decreased ROM of shoulder due to pain

• Motor at elbow / wrist / fingers intact

• Decreased light touch sensation distal to wrist

• Radial pulse not palpable; Doppler signal +ve

• Distal skin pale, but warm, cap refill normal

X rays – shoulder / humerus

CT angiogram

Progress

• EOT done

• Intra-op findings:

– 4-part fracture of right proximal humerus

– Proximal humeral shaft impingement on axillary artery

– Artery still intact

• Partial shoulder replacement done

• Axillary artery released from kinking

• Right radial pulse revert to normal

Post-op X ray

Proximal humeral fracture

• Incidence: 5%

• Etiology: – Fell on out stretched hand

– High energy trauma

• 4 major parts: – Humeral head superior to

anatomical neck

– Lesser tuberosity

– Greater tuberosity

– Shaft of humerus

www.theodora.com/anatomy

PWH Fracture Pattern 2000-2005 Dr LF Tse/ Dr N Tang

0

10

20

30

40

50

60

70

80

90

100

no

.

16-60 61-80 >/=81

Age

prox

shaft

distal

Stable vs Unstable

• Stable – Impacted fracture

• Unstable – Two-part

– Three-part

• Surgical neck + greater / lesser tuberosity

– Four-part

• Anatomical neck + tuberosities

– Fracture dislocation

Possible associated injuries

• Brachial plexus injury (motor + sensory)

• Axillary artery injury

• Mechanism: – Direct injury by sharp bony

fragments / laceration

– Stretching / Bowstringing due to displaced fragment

Posteomedial branch anastomoses with

arcuate artery

Challenge: Geriatric Patients

• Osteopenic Bone • BMD correlates linearly with bone holding for

plates and screws • Bone failure vs implant failure • Complications:

1. Joint stiffness 2. Non-union 3. Mal-union 4.Osteonecrosis 5. Heterotrophic bone formation

Indication for shoulder arthroplasty

• Three parts or four parts fracture and fracture dislocation on very osteoporotic bone

• chronic dislocation with impression # of humeral head > 40% articular surface

• head splitting fracture

• fail ORIF or conservative treatment

• old fracture with humeral head resorbed

A little history

• 1893- French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.

• 1951- Neer I, Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.

• 1974- Neer II Prosthesis. Modified Neer I to conform to a glenoid component.

• Courtesy of Smith & Nephew

Implant

Mono-block Modular

4 sizes, XS, S, M, L

Supine or Beach Chair position

Free the shoudler joint

Arm Support

Head Stabilization

Fluocoscopy – Glenohumeral Joint

Surgical Approach

Deltopectoral Approach

Coracoid

Procedure

ZIMMER® BIGLIANI/ FLATOW® THE COMPLETE SHOULDER SOLUTION

Procedure

ZIMMER® BIGLIANI/ FLATOW® THE COMPLETE SHOULDER SOLUTION

Re-attachment of lesser and greater tuberosities and capsules

Post-op Shoulder immobilizer

Questions…?