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Closed Reduction and External Fixation of Proximal Humeral Fractures: Rationale and Surgical Technique

March 01, 2017

Contributors: Marco Assom, MD; Enrico Bellato, MD; Francesco Caranzano, MD; Filippo Castoldi, MD; Roberto Rossi, MD; Davide Blonna, MD; Davide Blonna, MD

2017 HONORABLE MENTION This video describes the rationale and the surgical technique for closed reduction and external fixation of proximal humerus fractures. This surgical technique was developed to capitalize on the advantages of the traditional percutaneous pinning technique (eg, temporary fixation, preservation of the soft tissues, and better cosmesis) and to improve its limitations, particularly weak fixation in osteoporotic bone. The main modifications are the use of long threaded pins and a dedicated external fixator. The first modification allows the pins to purchase good-quality bone not only beneath the articular surface of the humeral head but also in the lateral cortex of the metaphysis. This helps achieve a strong bicortical fixation. The second modification further increases pin stability. The surgical technique has been standardized and divided into five steps. The first step is operating room setup. The patient is placed in the beach-chair position, the fluoroscopy unit is placed on the side of the patient's contralateral shoulder, and the x-ray beam is oriented with the glenoid. The second step is double skin preparation (first with 4% gluconide chlorexidine and then with povidone iodine). The third step is closed reduction of the fracture, which involves two main maneuvers. First, the shoulder is forced into abduction with the scapula stabilized (to reduce varus displacement of the humeral head), and then a posteriorly directed force is applied to the arm (to reduce medial displacement of the humeral shaft and internal rotation of the head). The fourth step is fixation of the fracture with the use of six long-threaded Kirschner wires, which are inserted in a standard manner and stabilized with the external fixator. The last step is postoperative care, which consists of early passive mobilization of the shoulder, pins, wound medication once a week, and pin removal at approximately 40 days postoperatively.

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