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Percutaneous Pinning for Surgical Neck Fracture: Method of Choice—Affirms
Percutaneous Pinning for Surgical Neck Fracture: Method of Choice—Affirms Leesa M. Galatz, MD Percutaneous pinning for proximal humerus fractures is an excellent treatment method in appropriate selected patients. Indications include low energy injuries, valgus impacted proximal humerus fractures, fractures with good bone stock, no medial calcar comminution, and minimal tuberosity comminution. Contraindications include high energy injuries, fractures with comminution at the medial calcar and tuberosities, osteopenia, and unreliable patients. Advantages over open reduction and internal fixation include shorter operating room time, less soft tissue stripping around the fracture, smaller incision and less scarring. While there is a steep learning curve, percutaneous pinning has distinct advantages in selected cases, making it a useful part of the armamentarium for treatment of proximal humerus fractures. Semin Arthro 18:19-22 © 2007 Elsevier Inc. All rights reserved. KEYWORDS shoulder, proximal humerus fracture, treatment, internal fixation
P
ercutaneous pinning is a technically challenging but useful method of treating proximal humerus fractures. There are many options for addressing any given fracture, however, in appropriate fractures, percutaneous pinning offers several distinct advantages. Complete understanding of proximal humerus anatomy is critical to any surgeon to accomplish percutaneous reduction and fixation. The surgeon must be able to interpret three-dimensional anatomy based on twodimensional fluro images. This skill, therefore, requires a certain learning curve. The purpose of this article is to argue the advantages of percutaneous pinning and to briefly outline a safe method of performing the procedure. Function of the shoulder is highly dependent on surrounding soft tissues, namely, the rotator cuff and the deltoid muscles. Surgical approaches to the shoulder offer limited exposure. Full exposure of the tuberosities is limited using the deltopectoral approach and the deltoid splitting approach. Even with good exposure, the surrounding rotator cuff tissues obscure direct view of the joint. Thus, this is one of the few intraarticular fractures that is fixed under indirect visualization even with an open approach. Several factors determine the appropriate approach for a given fracture. There is a biphasic distribution in both age
Washington University School of Medicine, Department of Orthopaedic Surgery, Barnes-Jewish Hospital, St. Louis, MO. Address reprint requests to Leesa M. Galatz, MD, One Barnes Hospital Plaza, 11300 West Pavilion, St. Louis, Missouri 63110. E-mail: galatzl@ wustl.edu
1045-4527/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2006.11.018
and energy of injury of proximal humerus fractures. With regards to age, there is a peak in younger age groups. These fractures generally are a result of high-energy injuries. There is a second peak in later age groups in which these represent fractures of fragility and are low-energy injuries. Another factor is the degree of displacement. The shoulder can generally not tolerate significant displacement of the tuberosities, thus an anatomic reduction is important. Approximately 85% of proximal humerus fractures can be treated nonoperatively.1,2 These are minimally or nondisplaced. Bone quality is another important factor. In younger patients with highenergy injuries, good bone quality is good despite significant displacement. The bone fragments hold hardware well and have good healing potential. In older patients, bone quality is an issue, as the poorer quality bone does not hold hardware well. These fractures are at significant risk for loss of fixation. The final factor important in consideration of proximal humerus fractures is patient demands and expectations. An older, sedentary individual could potentially tolerate some loss of function or overhead elevation compared with a younger person. A younger, higher-demand person expects and requires better return of function. There are several reasons to consider a minimally invasive approach to fracture fixation in the proximal humerus. Overall in orthopedics there is a trend toward minimally invasive treatment of all types of musculoskeletal injuries, and proximal humerus fractures are no exception. Percutaneous pinning is a joint-preserving option. It involves less soft tissue dissection. This is important to protect the vascularity of the 19
L.M. Galatz
20 fracture fragments. Viability of the humeral head fragment is dependent on preservation of the feeding vessels. Techniques that involve a lot of soft tissue dissection often compromise these small feeding vessels, specifically the anterior lateral branch of the anterior humeral circumflex artery,3,4 leading to posttraumatic avascular necrosis. Performing successful percutaneous pinning relies on principles of ligamentotaxis. In lower energy injuries, the soft tissue sleeve that surrounds the proximal humerus including rotator cuff and periosteum is often intact. By reducing the fragments and taking advantage of this intact soft tissue sleeve, one can obtain a stable reduction. Benefits include stable reduction, as well as preserving revascularity and biology of fracture healing. Successful percutaneous pinning takes less operating room time and results in decreased blood loss compared with conventional open techniques. Furthermore, there is decreased scarring with less dissection and thus, potentially less stiffness and easier rehabilitation.
Indications Certain fracture configurations lend themselves to minimally invasive fixation. These fractures are generally lower energy injuries. Lower energy fractures occur leaving the soft tissue sleeve intact. Rotator cuff tears are not as large or as prevalent in these injuries. The periosteal soft tissue sleeve in many fractures remains intact. In particular, valgus-impacted fractures5-7 are the ideal fracture for percutaneous pinning (Fig. 1A and B). The humeral head is impacted in between the greater and the lesser tuberosities. This pattern of impaction leaves the periosteal hinge along the posteromedial aspect of the proximal metaphysis intact. The feeding vessels from the posterior humeral circumflex artery course along this area, maintaining blood supply to the humeral head. Thus, valgusimpacted fractures are far less susceptible to avascular necrosis than other four-part fracture configurations. The reduction6,7 maneuver is simple and the fracture lends itself to a stable reduction after percutaneous pinning. A stable reduction after percutaneous reduction is critical for a successful procedure. Any fracture that is not stable after reduction and pinning should be converted to an open procedure. The pins and screws placed percutaneously offer some stability, however, the fixation is not as rigid as the plate and screw constructs. Fractures amenable to percutaneous pinning should involve minimal to no comminution, especially at the proximal metaphysis. Any comminution along the proximal metaphysis leads to an unstable reduction. This is analogous to putting a golf ball on a broken tee. Percutaneous pins are not rigid enough to maintain appropriate length tension relationship with significant comminution of the proximal shaft. Therefore, these comminuted fractures should be fixed with an open procedure. On the other hand, fractures with minimal comminution, and large, good-quality bone fragments are very amenable to percutaneous fixation. Patient selection is arguably the most important factor in a successful percutaneous pinning procedure.
Contraindications
Figure 1 (A) Valgus-impacted fractures are recognized by the loss of the normal neck–shaft angle of the proximal humerus and lateral displacement of the tuberosities. (B) Valgus-impacted fracture after percutaneous reduction and fixation.
Certain fractures should not be treated with minimally invasive fixation. Fractures that occur as a result of high-energy injuries, for example, are associated with significant disruption of soft tissue periosteum and rotator cuff tears, which make reduction difficult and potentially unstable. These fractures are much more effectively treated with an open procedure. Some level of displacement cannot be reduced percutaneously. Significant displacement at the surgical neck may be reducible if there is no interposing soft tissue. An entrapped biceps tendon may prevent successful reduction. As mentioned above, comminution at the proximal metaphysis is a contraindication to percutaneous pinning. Comminution of the tuberosities, in particular the greater tuberosity, is also a contraindication for percutaneous fixation. In many fractures the greater tuberosity is fragmented into multiple pieces and the portion that actually contains the insertion of the rotator cuff is quite small. These fractures require suture fixation to augment and maintain fracture stability. Tuberosity
Percutaneous pinning for surgical neck fracture: method of choice—affirms fractures amenable to percutaneous fixation comprise large fragments with good bone quality that will hold a screw with a washer. Significant osteopenia is also a contraindication to percutaneous fixation. The humerus must be comprised of sufficient enough bone quality to hold screws and pins. Noncompliant patients should not be treated with percutaneous pinning. There are reports of pin migration and this procedure requires close follow-up. This is not a procedure that should be performed in a patient who may not return for regular follow-up. The pins must be closely monitored for any pin migration during the healing period and ultimately removed.
Technique The patient is positioned either supine or in the 10 to 15° beach chair position. The fluoroscope is usually placed parallel to the patient and brought in from the cephalad direction to leave the space lateral to the shoulder free for reduction and instrumentation. The arm is placed in an arm holder. We do not use an iodine plastic drape over the skin because this can be caught in the pins and introduced into the wound. The surgical neck is reduced first. In a surgical neck fracture, the deforming force is primarily the pectoralis major, which pulls the proximal shaft anterior and medial. To neutralize these forces the arm is flexed and abducted, and a distraction and posterior vector is placed on the proximal shaft to reduce the shaft to the head.8 Reduction is often accomplished with the help of a “reduction portal.” This reduction portal is placed 2 to 3 cm distal to the anterolateral corner of the acromion, 0.5 to 10 cm lateral to the biceps. In a proximal humerus fracture, the line of the fracture between the greater and the lesser tuberosities often occurs about 5 mm posterior to the biceps tendon. Therefore, the reduction portal should be placed at the level of the surgical neck just posterior to the biceps tendon. This location is confirmed under fluoroscopy. A 1- to 2-cm incision is made in the skin and blunt dissection is performed through the deltoid. A blunt-tipped instrument such as a bone tamp or a blunttipped elevator can be placed through the fracture fragments under fluoroscopic guidance under the humeral head and the head can often be levered onto the proximal shaft. Terminally threaded 2.5- or 2.7-mm pins are placed in retrograde fashion from the shaft into the head. Care should be taken to protect surrounding soft tissues. A fracture drill guide or a drill guide used for arthroscopic anchor placement are useful for this purpose. The angle of the pins should allow the pins to go from the shaft into the head without exiting the humeral head posteriorly. This is one of the most common mistakes, because the assessment is done in two dimensions and it is difficult to tell when the pins exit the shaft or head posteriorly on an anteroposterior fluoroscopic view. Two to three pins are placed at different angles of entry. A couple of pins placed parallel to each other act as a single point of fixation. Therefore, differential directions are helpful in maintaining stability of the surgical neck reduction.
21
The tuberosity reduction is performed after the head is stabilized. Through the “reduction portal,” a hook instrument can be applied to the tuberosity to reduce it. The greater tuberosity is reduced by anterior and inferior force. Percutaneous screws are placed through the greater tuberosity, engaging the shaft in the proximal medial cortex. A washer is used, but care should be taken to avoid overtightening these screws, as the washer can fracture the tuberosity with overtightening. The lesser tuberosity can likewise be reduced with a hook instrument, pulling it laterally and placing the screws from the anterior to posterior direction. This screw is placed through a smaller percutaneous incision over the lesser tuberosity. If the greater tuberosity fragment is large enough, two separate screws are recommended. One can be a cancellous screw into the humeral head. The reduction maneuver for a valgus-impacted proximal humerus fracture is different from an otherwise displaced two- or three-part fracture. The head is impacted onto the shaft, resulting in a 90° angle between the long axis of the shaft and the articular surface of the head. Thus, the proximal humerus has lost the normal inclination angle of the head relative to the shaft. This fracture is reduced through the percutaneous reduction portal. A blunttipped instrument is placed through the reduction portal at the level of the surgical neck in between the greater and the lesser tuberosity and the head fragment is impacted superiorly to restore normal angulation. Because the greater and the lesser tuberosities were simply displaced laterally by the impacted head, once the head is reduced, the tuberosities naturally fall into anatomic position and can be fixed with percutaneous screws. The use of 4.5 cannulated screws is recommended, as these screws are available in adequate lengths and the guidewire is substantial enough for use in the proximal humerus. The small percutaneous incisions are closed with interrupted suture. The pins are routinely cut beneath the skin to avoid problems with pin tract infections. The pins are easily removed as an office or simple operating room procedure. The extremity is immobilized in a sling for 2 to 3 weeks. If stability and reduction are maintained, then passive motion exercises can be started at 2 to 3 weeks postoperatively. Pins are removed 4 to 6 weeks postoperatively or sooner if they begin to loosen and migrate.
Conclusion Percutaneous reduction and fixation is an excellent procedure in certain fracture configurations. These include lowerenergy injuries, fractures with minimal comminution with good bone quality, valgus-impacted fractures, and fractures that are stable after percutaneous reduction, in compliant patients. It is contraindicated in high-energy injuries with significant comminution and displacement that cannot be reduced and rendered stable with percutaneous reduction and fixation. Comminution at the proximal metaphysis, in particular, is a contraindication to percutaneous pinning because this results in an unstable reduction. People with poor
22 bone quality and noncompliant patients should also be considered relative contraindications to this technique. Advantages of percutaneous fixation include a shorter procedure, decreased blood loss, improved cosmesis, and lower morbidity. Patient selection is critical for successful percutaneous pinning fixation of proximal humerus fractures.
References 1. Neer CS II: Displaced proximal humeral fractures .II. Treatment of threepart and four-part displacement. J Bone Joint Surg Am 52:1090-1103, 1970 2. Neer CS II: Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 52:1077-1089, 1970
L.M. Galatz 3. Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: an anatomical study. J Bone Joint Surg Am 72:14861494, 1990 4. Laing PG: The arterial supply of the adult humerus. J Bone Joint Surg Am 38A:1105-1116, 1956 5. Resch H, Povacz P, Frohlich R, et al: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 79: 295-300, 1997 6. Jakob RP, Miniaci A, Anson PS, et al: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 72:295-298, 1991 7. Resch H, Beck E, Bayley I: Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg 4:73-80, 1995 8. Jaberg H, Warner JJP, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 74A:508-515, 1992
P
ercutaneous pinning is a technically challenging but useful method of treating proximal humerus fractures. There are many options for addressing any given fracture, however, in appropriate fractures, percutaneous pinning offers several distinct advantages. Complete understanding of proximal humerus anatomy is critical to any surgeon to accomplish percutaneous reduction and fixation. The surgeon must be able to interpret three-dimensional anatomy based on twodimensional fluro images. This skill, therefore, requires a certain learning curve. The purpose of this article is to argue the advantages of percutaneous pinning and to briefly outline a safe method of performing the procedure. Function of the shoulder is highly dependent on surrounding soft tissues, namely, the rotator cuff and the deltoid muscles. Surgical approaches to the shoulder offer limited exposure. Full exposure of the tuberosities is limited using the deltopectoral approach and the deltoid splitting approach. Even with good exposure, the surrounding rotator cuff tissues obscure direct view of the joint. Thus, this is one of the few intraarticular fractures that is fixed under indirect visualization even with an open approach. Several factors determine the appropriate approach for a given fracture. There is a biphasic distribution in both age
Washington University School of Medicine, Department of Orthopaedic Surgery, Barnes-Jewish Hospital, St. Louis, MO. Address reprint requests to Leesa M. Galatz, MD, One Barnes Hospital Plaza, 11300 West Pavilion, St. Louis, Missouri 63110. E-mail: galatzl@ wustl.edu
1045-4527/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2006.11.018
and energy of injury of proximal humerus fractures. With regards to age, there is a peak in younger age groups. These fractures generally are a result of high-energy injuries. There is a second peak in later age groups in which these represent fractures of fragility and are low-energy injuries. Another factor is the degree of displacement. The shoulder can generally not tolerate significant displacement of the tuberosities, thus an anatomic reduction is important. Approximately 85% of proximal humerus fractures can be treated nonoperatively.1,2 These are minimally or nondisplaced. Bone quality is another important factor. In younger patients with highenergy injuries, good bone quality is good despite significant displacement. The bone fragments hold hardware well and have good healing potential. In older patients, bone quality is an issue, as the poorer quality bone does not hold hardware well. These fractures are at significant risk for loss of fixation. The final factor important in consideration of proximal humerus fractures is patient demands and expectations. An older, sedentary individual could potentially tolerate some loss of function or overhead elevation compared with a younger person. A younger, higher-demand person expects and requires better return of function. There are several reasons to consider a minimally invasive approach to fracture fixation in the proximal humerus. Overall in orthopedics there is a trend toward minimally invasive treatment of all types of musculoskeletal injuries, and proximal humerus fractures are no exception. Percutaneous pinning is a joint-preserving option. It involves less soft tissue dissection. This is important to protect the vascularity of the 19
L.M. Galatz
20 fracture fragments. Viability of the humeral head fragment is dependent on preservation of the feeding vessels. Techniques that involve a lot of soft tissue dissection often compromise these small feeding vessels, specifically the anterior lateral branch of the anterior humeral circumflex artery,3,4 leading to posttraumatic avascular necrosis. Performing successful percutaneous pinning relies on principles of ligamentotaxis. In lower energy injuries, the soft tissue sleeve that surrounds the proximal humerus including rotator cuff and periosteum is often intact. By reducing the fragments and taking advantage of this intact soft tissue sleeve, one can obtain a stable reduction. Benefits include stable reduction, as well as preserving revascularity and biology of fracture healing. Successful percutaneous pinning takes less operating room time and results in decreased blood loss compared with conventional open techniques. Furthermore, there is decreased scarring with less dissection and thus, potentially less stiffness and easier rehabilitation.
Indications Certain fracture configurations lend themselves to minimally invasive fixation. These fractures are generally lower energy injuries. Lower energy fractures occur leaving the soft tissue sleeve intact. Rotator cuff tears are not as large or as prevalent in these injuries. The periosteal soft tissue sleeve in many fractures remains intact. In particular, valgus-impacted fractures5-7 are the ideal fracture for percutaneous pinning (Fig. 1A and B). The humeral head is impacted in between the greater and the lesser tuberosities. This pattern of impaction leaves the periosteal hinge along the posteromedial aspect of the proximal metaphysis intact. The feeding vessels from the posterior humeral circumflex artery course along this area, maintaining blood supply to the humeral head. Thus, valgusimpacted fractures are far less susceptible to avascular necrosis than other four-part fracture configurations. The reduction6,7 maneuver is simple and the fracture lends itself to a stable reduction after percutaneous pinning. A stable reduction after percutaneous reduction is critical for a successful procedure. Any fracture that is not stable after reduction and pinning should be converted to an open procedure. The pins and screws placed percutaneously offer some stability, however, the fixation is not as rigid as the plate and screw constructs. Fractures amenable to percutaneous pinning should involve minimal to no comminution, especially at the proximal metaphysis. Any comminution along the proximal metaphysis leads to an unstable reduction. This is analogous to putting a golf ball on a broken tee. Percutaneous pins are not rigid enough to maintain appropriate length tension relationship with significant comminution of the proximal shaft. Therefore, these comminuted fractures should be fixed with an open procedure. On the other hand, fractures with minimal comminution, and large, good-quality bone fragments are very amenable to percutaneous fixation. Patient selection is arguably the most important factor in a successful percutaneous pinning procedure.
Contraindications
Figure 1 (A) Valgus-impacted fractures are recognized by the loss of the normal neck–shaft angle of the proximal humerus and lateral displacement of the tuberosities. (B) Valgus-impacted fracture after percutaneous reduction and fixation.
Certain fractures should not be treated with minimally invasive fixation. Fractures that occur as a result of high-energy injuries, for example, are associated with significant disruption of soft tissue periosteum and rotator cuff tears, which make reduction difficult and potentially unstable. These fractures are much more effectively treated with an open procedure. Some level of displacement cannot be reduced percutaneously. Significant displacement at the surgical neck may be reducible if there is no interposing soft tissue. An entrapped biceps tendon may prevent successful reduction. As mentioned above, comminution at the proximal metaphysis is a contraindication to percutaneous pinning. Comminution of the tuberosities, in particular the greater tuberosity, is also a contraindication for percutaneous fixation. In many fractures the greater tuberosity is fragmented into multiple pieces and the portion that actually contains the insertion of the rotator cuff is quite small. These fractures require suture fixation to augment and maintain fracture stability. Tuberosity
Percutaneous pinning for surgical neck fracture: method of choice—affirms fractures amenable to percutaneous fixation comprise large fragments with good bone quality that will hold a screw with a washer. Significant osteopenia is also a contraindication to percutaneous fixation. The humerus must be comprised of sufficient enough bone quality to hold screws and pins. Noncompliant patients should not be treated with percutaneous pinning. There are reports of pin migration and this procedure requires close follow-up. This is not a procedure that should be performed in a patient who may not return for regular follow-up. The pins must be closely monitored for any pin migration during the healing period and ultimately removed.
Technique The patient is positioned either supine or in the 10 to 15° beach chair position. The fluoroscope is usually placed parallel to the patient and brought in from the cephalad direction to leave the space lateral to the shoulder free for reduction and instrumentation. The arm is placed in an arm holder. We do not use an iodine plastic drape over the skin because this can be caught in the pins and introduced into the wound. The surgical neck is reduced first. In a surgical neck fracture, the deforming force is primarily the pectoralis major, which pulls the proximal shaft anterior and medial. To neutralize these forces the arm is flexed and abducted, and a distraction and posterior vector is placed on the proximal shaft to reduce the shaft to the head.8 Reduction is often accomplished with the help of a “reduction portal.” This reduction portal is placed 2 to 3 cm distal to the anterolateral corner of the acromion, 0.5 to 10 cm lateral to the biceps. In a proximal humerus fracture, the line of the fracture between the greater and the lesser tuberosities often occurs about 5 mm posterior to the biceps tendon. Therefore, the reduction portal should be placed at the level of the surgical neck just posterior to the biceps tendon. This location is confirmed under fluoroscopy. A 1- to 2-cm incision is made in the skin and blunt dissection is performed through the deltoid. A blunt-tipped instrument such as a bone tamp or a blunttipped elevator can be placed through the fracture fragments under fluoroscopic guidance under the humeral head and the head can often be levered onto the proximal shaft. Terminally threaded 2.5- or 2.7-mm pins are placed in retrograde fashion from the shaft into the head. Care should be taken to protect surrounding soft tissues. A fracture drill guide or a drill guide used for arthroscopic anchor placement are useful for this purpose. The angle of the pins should allow the pins to go from the shaft into the head without exiting the humeral head posteriorly. This is one of the most common mistakes, because the assessment is done in two dimensions and it is difficult to tell when the pins exit the shaft or head posteriorly on an anteroposterior fluoroscopic view. Two to three pins are placed at different angles of entry. A couple of pins placed parallel to each other act as a single point of fixation. Therefore, differential directions are helpful in maintaining stability of the surgical neck reduction.
21
The tuberosity reduction is performed after the head is stabilized. Through the “reduction portal,” a hook instrument can be applied to the tuberosity to reduce it. The greater tuberosity is reduced by anterior and inferior force. Percutaneous screws are placed through the greater tuberosity, engaging the shaft in the proximal medial cortex. A washer is used, but care should be taken to avoid overtightening these screws, as the washer can fracture the tuberosity with overtightening. The lesser tuberosity can likewise be reduced with a hook instrument, pulling it laterally and placing the screws from the anterior to posterior direction. This screw is placed through a smaller percutaneous incision over the lesser tuberosity. If the greater tuberosity fragment is large enough, two separate screws are recommended. One can be a cancellous screw into the humeral head. The reduction maneuver for a valgus-impacted proximal humerus fracture is different from an otherwise displaced two- or three-part fracture. The head is impacted onto the shaft, resulting in a 90° angle between the long axis of the shaft and the articular surface of the head. Thus, the proximal humerus has lost the normal inclination angle of the head relative to the shaft. This fracture is reduced through the percutaneous reduction portal. A blunttipped instrument is placed through the reduction portal at the level of the surgical neck in between the greater and the lesser tuberosity and the head fragment is impacted superiorly to restore normal angulation. Because the greater and the lesser tuberosities were simply displaced laterally by the impacted head, once the head is reduced, the tuberosities naturally fall into anatomic position and can be fixed with percutaneous screws. The use of 4.5 cannulated screws is recommended, as these screws are available in adequate lengths and the guidewire is substantial enough for use in the proximal humerus. The small percutaneous incisions are closed with interrupted suture. The pins are routinely cut beneath the skin to avoid problems with pin tract infections. The pins are easily removed as an office or simple operating room procedure. The extremity is immobilized in a sling for 2 to 3 weeks. If stability and reduction are maintained, then passive motion exercises can be started at 2 to 3 weeks postoperatively. Pins are removed 4 to 6 weeks postoperatively or sooner if they begin to loosen and migrate.
Conclusion Percutaneous reduction and fixation is an excellent procedure in certain fracture configurations. These include lowerenergy injuries, fractures with minimal comminution with good bone quality, valgus-impacted fractures, and fractures that are stable after percutaneous reduction, in compliant patients. It is contraindicated in high-energy injuries with significant comminution and displacement that cannot be reduced and rendered stable with percutaneous reduction and fixation. Comminution at the proximal metaphysis, in particular, is a contraindication to percutaneous pinning because this results in an unstable reduction. People with poor
22 bone quality and noncompliant patients should also be considered relative contraindications to this technique. Advantages of percutaneous fixation include a shorter procedure, decreased blood loss, improved cosmesis, and lower morbidity. Patient selection is critical for successful percutaneous pinning fixation of proximal humerus fractures.
References 1. Neer CS II: Displaced proximal humeral fractures .II. Treatment of threepart and four-part displacement. J Bone Joint Surg Am 52:1090-1103, 1970 2. Neer CS II: Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 52:1077-1089, 1970
L.M. Galatz 3. Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: an anatomical study. J Bone Joint Surg Am 72:14861494, 1990 4. Laing PG: The arterial supply of the adult humerus. J Bone Joint Surg Am 38A:1105-1116, 1956 5. Resch H, Povacz P, Frohlich R, et al: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 79: 295-300, 1997 6. Jakob RP, Miniaci A, Anson PS, et al: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 72:295-298, 1991 7. Resch H, Beck E, Bayley I: Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg 4:73-80, 1995 8. Jaberg H, Warner JJP, Jakob RP: Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 74A:508-515, 1992