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Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach

Plattenosteosynthese von proximalen Humerusfrakturen über den minimalinvasiven anterolateralen Deltasplit-Zugang

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Abstract

Objective

Minimally invasive plate osteosynthesis of proximal humerus fractures via an anterolateral delta split approach.

Indications

All proximal humerus fractures classified as 11-A1-3, 11-B1-2 (B3), and 11-C1-2 (C3) according to the AO/OTA system.

Contraindications

Head split and closed irreducible dislocation type fractures, fractures with primary neurovascular impairment, and fractures in children with open growth plate.

Surgical technique

Beach chair position. Anterolateral delta split approach. Maintain rotator cuff insertions with nonabsorbable sutures. Reduction and K-wire retention of the tuberosities to the head fragment. Establish a tunnel along the anterolateral aspect of the proximal humerus with a blunt instrument (e.g., elevatorium). Attachment of the rotator cuff sutures to the corresponding plate holes of a 5-hole PHILOS® plate. Insertion of the plate underneath the deltoid muscle along the prepared tunnel. Preliminary fixation of the plate to the humerus head. Distal alignment of the plate and preliminary fixation. Reduction of the fracture onto the plate with a cortical screw in the shaft segment. Definitive plate fixation in the shaft and head segment. The nonabsorbable sutures are then tightened onto the plate.

Postoperative management

Immediate guided active exercise is encouraged. Weight bearing is increased according to radiological signs of consolidation.

Results

In a prospective evaluation from 2003–2006, 29 patients (8 male and 21 female) with a mean age of 64 years (16–91 years) were analyzed. The mean follow-up time was 12 months (6–32 months). The operation was accomplished in 75 min (55–155 min) with an image intensifier time of 160 s (48–807 s). All fractures healed in a timely manner. The median Constant score reached 78 points (28–93 points). In one case (3%), clinical evidence of a lesion of the anterior branch of the axillary nerve was found.

Zusammenfassung

Operationsziel

Stabilisierung von proximalen Humerusfrakturen über einen minimalinvasiven anterolateralen Deltasplit-Zugang.

Indikationen

Proximale Humerusfrakturen entsprechend der AO/OTA-Klassifikation 11-A1-3, 11-B1-2 (B3), 11-C1-2 (C3).

Kontraindikationen

Head-split-Frakturen und geschlossene irreponible Luxationsfrakturen, Frakturen mit primärer Gefäss- und Nervenläsion sowie Frakturen bei offenen Epiphysenfugen.

Operationstechnik

Halbsitzende „beach chair“-Lagerung. Anterolateraler Deltasplit-Zugang. Anschlingen der Tuberkula mit nicht-resorbierbaren Fäden. Reposition und präliminäre K-Draht-Retention der Tuberkula gegenüber der Kopfkalotte. Submuskuläres Tunnelieren des Plattenlagers z. B. mit einem Elevatorium. Einfädeln der Fäden in die entsprechenden peripheren Löcher einer 5-Loch-PHILOS®-Platte und Einschieben der Platte entlang dem präparierten Tunnel unter dem Delta-Muskel. Präliminäre Fixation im Kopfbereich mit einer winkelstabilen Schraube. Ausrichtung der Platte distal und ebenfalls präliminäre Fixation im untersten Plattenloch. Überprüfen und ggf. Korrektur der Achsenstellung im seitlichen Strahlengang. Die Reposition des Humerusschaftes gegen die Platte erfolgt nun mit einer Kortikalisschraube im proximalen Schaft. Definitive Fixation der Platte im Kopf und Schaft. Verknoten der vorgelegten Fäden.

Weiterbehandlung

Sofortige aktiv-assistierte Mobilisation und Belastungssteigerung je nach radiologischer Konsolidation.

Ergebnisse

Von 2003 bis 2006 wurden 29 Patienten (8 Männer, 21 Frauen) mit einem mittleren Alter von 64 Jahren(19–91 Jahre) in einer prospektiven Studie untersucht. Das durchschnittliche Follow-up betrug 12 Monate (6–32 Monate). Die mittlere Operationsdauer lag bei 75 min (55–155 min), die mittlere Durchleuchtungszeit bei 160 s (48–807 s). Alle Frakturen heilten zeitgerecht. Funktionell erreichten die Patienten durchschnittlich einen Constant-Score von 78 Punkten (28–93 Punkte). Ein Patient (3%) wies klinische Anzeichen für einen Ausfall des anterioren Astes des N. axillaris auf.

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Conflict of interest

The corresponding author states the following: no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Authors and Affiliations

  1. General Surgery, Trauma Unit, Kantonsspital Graubünden, Loëstrasse 170, 7000, Chur, Switzerland

    Y.P. Acklin MD & C. Sommer MD

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  1. Y.P. Acklin MD
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  2. C. Sommer MD
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Correspondence to Y.P. Acklin MD.

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Acklin, Y., Sommer, C. Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach. Oper Orthop Traumatol 24, 61–73 (2012). https://doi.org/10.1007/s00064-011-0051-9

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