Minimally invasive surgery has become increasingly popular in recent years. Proximal humeral fractures can also be treated with MIPO technology. Minimally invasive plate osteosynthesis has been proven to be a safe and effective method.
Anatomical Basis:
The proximal humerus is generally divided into four parts: the humeral head, greater and lesser tuberosities, and the humeral shaft. The supraspinatus, infraspinatus, and teres minor muscles are all attached to the greater tuberosity. The attachment point of the muscle is related to the direction of fracture displacement.
Position of the humeral head relative to the humeral shaft: retroversion angle of about 20°, valgus position of about 130°
The humeral tuberosity is the attachment point of the rotator cuff, so when a fracture occurs, the main bone fragments will have a typical misalignment corresponding to the direction of tension (below).
a: Avulsion fracture of the greater tuberosity. b: Subhumeral head fracture. c: Three-part fracture involving the lesser tuberosity. d: Three-part fracture involving the greater tuberosity
Surgical Technique
1. Body position: beach chair position.
2. Indirect reset technology
The arm is pulled longitudinally. Since the humeral shaft often shifts anteromedially, an additional scroll (a) can be placed in the axilla to assist reduction (black arrow in b). In the case of multi-fragment fractures, slight external rotation of 30° can bring the dorsally displaced fragments closer together. If adequate reduction is not possible, direct open reduction is required. 3. Incision selection
Anterolateral approach (triangular split): A 5 cm long skin incision is made starting from the distal end of the humeral shaft at the tip of the acromion and split along the direction of the deltoid muscle fibers. The subdeltoid bursa is opened and the subacromial space is entered. Pay attention to protecting the axillary nerve.
4. Direct Reset:
Insert a 2.5 mm threaded K-wire just above the greater tuberosity. Use it as a joystick to assist in rotational reduction.
5. Non-absorbable sutures are used to suture the starting point of the rotator cuff and other areas for future use.
6. Place the steel plate:
Using a large periosteal elevator, pass the axillary nerve underneath and separate the deltoid attachment anteriorly, insert the 5-hole angle-stabilizing plate into the prepared channel from proximal to distal: The plate should be placed 2-4 mm dorsal to the bicipital groove to reduce subsequent biceps tendon irritation or anterior humeral circumflex artery injury. 5-8 mm inferior to the tip of the greater tuberosity prevents subsequent impingement. 7. When the plate is in the correct position, screw in the screws one by one to secure it.
Proximal: When inserting the humeral head locking screw, it should be fixed to the center, lower back and upper back of the humeral head as much as possible. Because these areas have higher bone density, better internal fixation strength can be obtained. The humeral head locking screw should be fixed to the subchondral bone, and repeated perspectives from multiple angles are required to exclude the possibility of penetrating the articular surface. Finally, the damaged rotator cuff is repaired. Distal: 3 to 4 locking screws or cortical bone screws are inserted percutaneously at the distal end (one 2.0 cm small incision or several 0.5 cm small incisions can be used).
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Post time: Jul-11-2024