Open Reduction and Internal Fixation of a Diaphyseal Periprosthetic Humeral Fracture

CHAPTER 1

I'm Mike Weaver. I'm one of theorthopedic trauma surgeons here at the Brighamand Women's Hospital.Today we have a 57-year-old woman who sustained a fall,and she has a distal third humeral shaft fracture.Previously, she had afailed shoulder replacement and so had this revisionto a reverse total shoulder prosthesis.It's hard to see on the x-ray, but there is a cementmantle that goes down - and youcan see the cement restrictor here. So kind ofas expected, you have the stiff construct,and so you have a fracturebelow it. This make things a littlebit tricky. She has a radial nerve palsy.She isn’t tolerating a splinting very well,and she's a little bitlarger body habitus.And so those combination of things are pushing us to fixit for pain control and function.So the plan today is gonna beto do a posterior approach.The approach I use for this is a littlebit different. I don't split the triceps,but it's more of a posterolateralapproach - so a posterior skin incision and then come around.What I'm looking foris the brachial cutaneousnerve, and that's gonna take me to the radial nerve,which is really the key to this case.You know, a lot of peoplehave anxiety operating on the humerusfor the risk of radial nerve palsy, andso I think you want to find it and protect it every single time.So this approach allows you to see theradial nerve very well. We're gonna dissectout the whole thing in the posterior aspect of the armto look for a direct entry,although the vast majority of the time in a situation likethis it’s just a neuropraxia from a bruise.So we'll come around the radialside of the triceps, expose our fracture site.It's a relatively simple fracture pattern,so I'm expecting that we should be able toachieve absolute stability. We're gonna usea couple lag screws and then neutralize with a long plate.Here traditionally in thehumerus, people use large fragment fixation.However, you can use small fragment fixation.And the plate that we're gonna use today is aSynthes product, althoughall of the other companies make these. It's athicker small fragment plate, soeven though you're using 3.5 screws,you're getting a thicker plate, which is gonnagive you a little bit more support for the humerus.That plate comes allthe way down distally, so we’ll getplenty of fixation here. And then proximally, we're eithergonna get screws around thestem, which is pretty small,so hopefully we can get some screws around itthrough the cement mantel. If that fails,we do have the periprosthetic set availableto us, so we can put cerclage cables at the top.Cerclage in the humerus isa little bit tricky, but if you're looking at the radial nerve,that's the thing you’re worried about - and so we should be okay. So,should be all right.

CHAPTER 2

Here, I'll switch with you.

All right so, there you go. So you got midline incision - maybeslightly radial -and now we're just gonna come over hereand look for that little thing.So this is all triceps.So what I want you to do is dissect up here using your Metz.And it'll be right up here.Hold on - let’s just dissect down here a little bit more there.And then switch thiscuz I think this will be a better retractor up high.So the skin incision is posterior, but really,the deep dissection is lateral cuz whatwe're gonna do is protect - preserve the entire triceps.I'll be right with you. I think you've got it here.No, you don't want to get under the muscle - it's more like -what you want to do is get in this plane. So you want toelevate off the triceps.So you want to look.Like this.Because this is the intermuscular septum.So that’s her humerus, or... Yeah. So that’s humerus.Yeah, feel there.See there’s bone now. That's bone there. That’s fractured.This is the radial column of the humerus - all the waydown here - so our plates going to sit all the way down here,coming up.And so you know that the -the triceps inserts along the entire face of thehumerus, but we're gonnapreserve everything else.And you can feel - if you feel with your finger upthere, you can feel the fracture way up there.I need a new glove, Paul.Right side, please.And so there you can start - there’s our - there’s what we'relooking for, right? So...We’re not going through the triceps; we just come around it.So, this is the triceps here when you start,like that. That's triceps, so we're just going around it.That's lateral edge of triceps. And then that justtakes you right down to the bone. Yep.And then you just elevate it off the bone.

All right, so we found that.And we’re at the fracture, but we can't do anything morewithout being proximal.So - but I think we found the nerve, soI think we're okay to let our tourniquet down.So you know ideally, you know -someone that's thinner - you can get the tourniquetup here -do the whole thing without a tourniquet.Her’s - you - I - I figured we’d have tolet it down to get the very proximal exposurecuz it’s - you know, it’s a pretty highfracture to be doing from the back, but...This makes me much happier - you know,we're gonna be looking right at the nerve.Plate will be under it.Yeah, that’s good.I don't care about getting every last bit of skin; I just want itfor the bulk of the bacteria.All right, here you go.So the fracture’s here. We’re gonna need to be upprobably about to there.Skin knife, please? Yes, sir.Thank you.Mike, I will always come up this way to give you stuff.Okay, sounds good.Just so you don’t have to turn and look for me.Nice and straight right above there. Yep. Good.Tourniquet is good for the surgeon, bad for the patient.Got it?So here - see this is - I would just split thatwith your fingers. See that loose areolartissue? So this is what I did down below.See that? It just goes right back.And then we are up on here.See now we’re up on humerus again - way up there.Way up - way, way, way…The hard partis that we got to do both sides of that.That’ll do it.Oh yeah, actually,I like those better don’t I - the wider ones. Thank you.So everytime I put one of these on,I want to be really carefulcuz of that nerve. So we're looking right at the nerve.That's not on the nerve; it’s holding it back.So that's the proximal piece.You can see a split in it that I saw on the -right there -that we're gonna have to deal with -that I saw on thescout film - you know, our C-arm image, but not on theplain film. So that,you know, makes it a little bit more tricky, butlike I said, I think we’re gonna be okay. There’s that.Thank you very much.That’s good. That’s good.That’s good.All right so, you can see this real nicely.So there’s proximal fragment, distal fragment. There’s thefracture - and then right over the fracture,right by that spike of bone.

So let’s get the hematoma. Let meget a Schnidt and pull that little clot out.Yep. Oh beautiful. Now let’s switch sucker tips,and I want you to clean out that fracture. I find theFrazier tip to be the best - best cleaning devicecuz it sucks itand it's like - it's like a curette at the same time. So it's...This is the stuff you want to get out right there.That's the move.There’s a little bit of clotting right here. I guess I’langle at that like this.Good.Good, and now let’s work on that piece.I’m gonna take this, and now I’m under that piece there.So you see here,this is the clot we’ve got to rid of right here.So whenever I'm cleaning a clot in a long bone, I try to workthrough the fracture. You know,so if you look at the bone, it’s still coveredin pink periosteum. You know, we haven't devitalized it.Oh look at that. Oh - makes me feel better.And then let’s work above the nerve there.So go all the way up to the apex.See - I want to see the apexup there. Yep, there it is.Unfortunate.So, do you have a Cobb elevator?Yeah. Can you hold that for me for one second?Small or large? Small, please.All right, so now I just want make a path for our plate.You know, we'renot going to deal with the top of our platefor a little while, but weknow we have to be up there to put a -to put a cable on it.And that’s going to be the hardest part of the case.I think it’d be way up there.Way up there.Oh boy.Okay, here we go.All right, let’s redo it - let’s reduce it. What do you want?Large - or the small fracture reducing forceps, please. Yep.

CHAPTER 3

Let’s see where we are at here.This is gonna be where it’s two-handed.So why don’t you just give it a little pull? Justgive it a little pull first, and thenyou’re gonna key that spike in.Good, and be ultra-mindful of that othertine. See that there?Yeah. You’re right behind - underneath it.Good, that’s it. That’s all you need.Good. One click is all you need.So now what you've done is establish length.Now, let’s look up here.Do you have that Weitlaner back? Yeah.The bigger or the smaller? The bigger of the two, yep.Do you have a Freer?Oh no, it’s just that we have to key it in there.So here, this is the spike. It’s right over here.It’s behind your finger there.I think I got it. No, it’s right there. See that?So release here.Bone.I think that’s a better vector there.I just want to see the apex.The apex is keyed in right there. See that?So we have anatomic reduction ofof that apex.Good. All right, suck in there.Do you think maybe a vector a little more distal?Well I think it’s - can I see the pointed?It’s more A to P.This is - let’s hold that there. I think I’mnot gonna be able to do it from that side of the nerve.I’ll have to do it under the nerve,and I think it’s more of this kind of vector here.

All right, so...What's what?That radiopath -the dot?Stable? Oh yeah, that’ssomething that we didn’t move.X-ray there.Yeah so, we look like we have an anatomic reduction there.X-ray.So that looks good.All right, good. Thank you.Normally, you want to check in two planes.To check a lateral here, youhave to twist the arm,and we don’t have that great of clamps - andwe don’t need to cuz we are looking at it.

Weitlaner.Oh boy.Doing this - just take this down.Yeah. The way to think of this is as if you're doinga olecranon osteotomyon this side. And then you canfollow that same path down all the wayto the ulna if you wanted.I’m on bone there. Good. So then we just need to clear that.Do you have another - the smaller of the Weitlaners?Yep.And the Freer?So here we just need to release a little bit of thatmuscle off the bone. Right there.Good, and then just to show you, that’s the olecranon fossaright there. See that? So we probablyhave to go a touch more distal -cuz this plate, you know,that we are using today goes pretty distal.Kinda aim back towards here.Good. There you go. Good.Good.So there’s the main part of the radial nerve down there.Because this is the - that’s the main radial nerve right there.This is that little nerve.Yeah, so that's the main one right there.Yeah. Oh, we lost that. This clamp’s not holding anything.Hold that.I'm gonna try one clamp in the middle this time.That’s close - less than ideal.Just a little bit up.Can you hold that there? Hold that in with like your sucker.Can I see the Bennett?Can you hold this back for me? Right about like that.That’s better. And there we go.Can I go work on the side? Yeah.I think we're good.So we can see it at thetop, we can see it at the bottom, soI think we’re ready for our lag. Here's anterior apex?Yeah.There's the nerve and then -hiding underneath it is the real nervecuz that's the radial nerve right there.That's good there.Yeah, so I think we're gonna have one herethat's gonna be kindawith your hand flat like this,and then this one's going to be more A to P.

So, you know, every different set has different things,but these are the tworadial column plates that are in the Synthes set.So you can see thatthe top plate here is very thin.This is pretty malleable; you can bendit in your fingers. This is really stout.So even though this takes small fragments screws,the plate itself is a lot more rigid so can support a little bitmore load.So this is our -we're gonna need plate benders as well, but theycan be the ones - in there.

CHAPTER 4

Why don't we - why don’t we drill for the screw?All right, so is that what...So where do you want your first lag screw?I'm going to go through that and then come out.Where’s the Bovie?So start it like this, and then come like that.And you want to push that back in there and come around.I am just going to move this up a micron.There’s the nerve right there.Freer.Freer.So I just wanted to move that tine up a tiny bitbecause, you know, thetip of the fracture is right here,so I think you’d have to be prettyangled right up against that tine.Okay. Go ahead.And I’m heading out like this, right?But I would be a little bit closer to that tine -not so close thatthe head won't go down but a tiny bit closer.Oh my - there you go - just like that.Give her that?And then as you - once you’re starting,I'm gonna drop your hand a little bit like -now stop for a second.There you go.Good. That’s it. Okay, come on out - all right.You can come right out. It’s not going to go anywhere.Good. I want you to stop the drill when it goes through.There have been cases of wrapping up the nervein the drill biton the far side. Here, the nerve shouldn't be there, but…We may countersinkbefore you depth gauge because it changes the length.

Thank you. So,we just use a slightly smaller countersink for a 2.7 screw.A little bit more.Remember your angle looks like that.Good. It's important hold that angle because,if you think about it, the bone that you want to removeis that bone back there.So that when the screw head engages,it's going to be the same shape as the countersink.There we go. So there we -now I'm happy.

Depth gauge.Could be short.24. 24 please.24? Yep.

2-4's here.Get it? Yeah.Will you be doing another? Just - just twist it.I want to be super gentle here.Yes, one more just like that.Angle just a little bit more like that. There you go.It's not going to bite.It's two fingers.It’s more just tapping into the far cortex there.Give that a little bit more.That’s actually down there.

Hold on. That’s - that’s - you got the nerve.You've got the nerve there.Can I get the Freer? Yes sir.So that areolar tissue - you get that under the drilland just going to wrap it right up.So see that stuff right there?So we just need to make sure that’s totally away.Good, and your angle is going to belike that.And then down.Going to be right by the radial nerve.Hope I don’t have to take this one out.There you go.Good. Good. Doesn’t need as much on thisbecause it's not as oblique as the -see that? Your circumferential. That's all you need.Depth gauge.22.Pardon? 22. 22.Good, that's nice. Good, all right. So now we have it reduced.The nerve is out of the way.Right there.All right, now it’s time to put a plate on.All right, so... Freer?That clamp, I think, can stay there.This clamp can come off, butto be honest, it’d be nice to leave it if we can because it's kind ofjust protecting this.So why don’t we see if we can slide it up and up. All right, plate?

CHAPTER 5

That's the one you had chosen - the 10 hole.I think this is the one that’s got to go.So you see it doesn’t fit perfect.That’s because no one is built like the models.Actually, it fits pretty good.Oh - no, it doesn’t. See that?See that rock there? So we have to give it a littlebit of a bend in the middle portionright where the radial nerve is.See that? See that? Yeah.But I like that distally. Why don’t we - can I see - come infor a shot, please.What I want to do is see that I'm happy distally, and ifthat's right where we want it,which I think it is, then we'll bendit up at the top.

Yep. Shot.All right, we're definitely high enough with the plate.And...Where - I don't even see the problem.It’s - it’s under all those clamps.Distally, we’re not going to see it. All right, good.And I don’t want to…X-ray there.X-ray there.X-ray there.Good, so you can see we are distal enough with the plate.So now let’s mark where we’re going to bend it.We’re going to bend it rightabout -just look. See, that’s the bend right at the radial nerve.Yeah. So that’s the radial nerve fold right there.So keep your finger there.Keep your finger - so right there. That’s the hole. Okay.

Plate benders.Give it a contour there.Here you go. Give it a contour.It’s a - you want to bend it that way.I'm going on like this so I want to bend it like...Well, it's gonna sit this way, so you want to bend it down.You want to be out of the way -the other way - the other way.That way, yep.That's it.That sound good or what? Yeah, that sounds good.Can you suck that for me?Right here, please.I’d say we’re halfway there.No one’s humerus is actually straight.It does have a little bit of bow in itin the AP plane. So if you look here -so there’s a narrow and a big.So you got to make it into the opposite, so that one's na- bigand then narrow.That’s towards you - to get a -yep, there you go.You feel it give? A little bit.Yeah, it looks like it - looks like it bent more.You know, it’s a hard - it’s something you feel like -you know, you feel like, oh,it’s no longer being -you know, elastic and deformed - it’s elastic.That’s pretty good. Maybea tiny, tiny, tiny, tiny, tiny, tiny - try a tiny bit more.Nah, it’s like flexing on to it, so it’s fine.All right, good. Locking tower, please.So put a locking tower right up there by my index finger.

We’re going to do 1-6 K-wires now.Okay. Do you want inserts for that? Yes.So this is a technique I use a lot - using locking towers,inserts, K-wiresto hold the plate exactly where I want,and then when I’m happy, I fill it up.It wants to live there. Alright, K-wire.All right.Now these distal ones are unicortical, locking.They’re ending right at the capitulum.Usually, it’s only the distal one or two that are like that.Good.Now, can I see a Freer?So here we got to feel - are we really centered on the bone?It feels pretty damn good.It looks pretty damn good, so why don’t we just try it -see what it looks like?One cortex only. Be gentle.Good, that’s it. Just little bites. All right, good.Alright, come on in.Ohh, right there.All right, so let’s get rid of some of this stuffso we can interpret our X-rays a little better.Shot there.All right, so you can see proximally, we’re a little ulnar,and distally, we’re a little bitradial. So all we have to do is center up the plate some.All right, back out for a second.It feels like that too,so let’s start up here. So we just need to move it towardsyou a tiny bit.Watch out. Come up.Come off, please.All right, come on in. So that sits a little bit better too.Now it’s sitting. Shot there.Yeah, that’s a lot better.So - we’re centered at the top there - I like that - and thendistally, that’s the hardest part.X-ray.X-ray.We have to be even more -ever so slightly moreradial. I think maybe, actually, if we do that, it will be okay.X-ray.This is really annoying.X-ray.Yeah. If we could be just1 or 2 mm more ulnar.Watch out. Come out.I’m going to change it to there, so it gets a new hole.I’m going to move it more my way.Okay.Good.Come on in.All right, so I think that’s going to be good. If we like that -shot there.So we’re centered all the way up,which is really nice, and then justto see that last bit - x-ray.That’s good.And when you actually put the plate on the bone - x-ray.X-ray.It’s sitting right where we want it, so that’s nice. Good.If anything, it looks like we could be more -I think we need to move it more over.So - because I think we are off the bone here a little bit.See that? That’s justgoing to be - we need to move it over. This - I thinkthis clamp was blocking us. All right, sorry - wire driver.Let's take that off.Normally, I hate having that clamp off.You know, I like to have a clampover my fracture.There you go.Real gentle, please.You’re pushing really hard. Be gentle, please.Good.There - now it’s sitting on the bone.Don’t take it too far, please. Yep.

Okay, so I'll just go right here.Now remember, you’re not -just right in the middle - right there.And then just remember you’re not -you’re not centered on the bone. You’re onthe radial side of it. It’s a radial column plate.So you have to aim - you have to aima little over here. Good.Good.Depth gauge.Now I’m thinking to myself, that wasa nice boomp-boomp. You know, so you’repretty centered on the bone,so your angle must have been pretty good.24, please. So what I want is a good two screws distally,two screws proximally.And then we can check an AP and a lateral,and then we'll fill it up. Okay.This one I wouldn’t get all the way super snug - just down.All right, and now let’s work up here.Again, that plate is sitting nice on the bone,so you did a nice job contouring it. Looks perfect. Thanks.Okay.Right at that hole. Yep, parallel to this guide.Here you're centered. Yep.Here you are centered.You’re not going to get a cortex here, I don’t think.Cement or plastic. Keep going.Plastic. Now that’s going to be the far cortex.Good.Depth gauge. Yep.Some of the arthroplasty surgeons really frown on it, butI think drilling through cementgives you the best bite you’ll ever get.24 maybe. It’s off the bone a touch.Ready?There you go.Just get it down.Suck in there.Suck over here.Good.Why don’t you do another non-locker? Yeah...You know, looking at your x-ray - you know, this one hereshould be fine. This one here is fine too.So why don’t you just put this one in because that’s -that’ll be a better bite.I got the screw driver.Can you give us the drill? I’m giving an angle.Right there.Right at the top of the hole, please. Yep, there - like that.Remember your angle over the top like that. There you go.Here you go.Good.Depth gauge.24, please.One thing you want to make sure of is that you're not inthe olecranon fossa, which we’re notbecause we’re looking at it, but you wantto be able to extend your arm.All right. Ready?What was - is that a -what - what screws have we put in so far?Just 24s. All right, awesome.I actually want to take a picture before we put in the nextscrew because I don’t know where we areup here with respect to thestem. And I think we want to do some locking screws,so I wantto figure out if there’s room to get a locking screwin that area. That should be a little bit better.That - yeah, that’s better than this one was.Yep. Shot there.So that is right at the tip.It looks like...X-ray there.The tip of implant is in locking holeright adjacent to where we are. Yeah - okay.So I think what we can do there is - x-ray there.That’s not so hot. x-ray there.X-ray there.Yeah, so I think we can miss the implantwith some screws.You know, it will be close, but I think we can do it.X-ray again.So that would be this way,so that’s going to be missing this side of it.X-ray.X-ray.Or - x-ray there.Well, you can’t miss it with locking screws. X-ray again.Well, you did a good job of centering it.It’s like too centered. Okay, all right.Back out for a second.Alright, I think we're going to have to put one here.A 2-5 drill. Yeah. Yeah. Do you have a Weitlaner first -and then a baby Bennett? Sure. Yep.There - just like that.We don’t need it very far. That’s plenty.Depth gauge.Okay, so those two long screws... Do you need a unicorticalfrom the pericostal to here?No, those are large frag.And I don’t - I don’t believe in thosereducing the stress riser effect anyway.They’re good for periprosthetic femur fracturesbut not so good for these.Hold on, I'll... Let me come out with this.Can I get another Bennett? Yeah.Okay.Top part of the hole. Guide all the way down.Guide all the way down. It’s not down yet.There you go.And then try like that. Yep.Try to be as AP as you can.Yeah, that will work.Good. All right.All right.Make sure you get your angle.There you go.It’s a little bit more towards me. There you go.I don’t think we’re going to use -we may get away without cables, Paul. Sure thing.All right, can you suck in there for me?Hold this for a second. Yes, sir.Can you hold those apart?So this is why it’s so important to meto have your drill guide downbecause, if it’s not down, the head of the screwengages on the side of the platebefore it gets down. Okay. And thenyou got to get past thatto really be down.See, now it’s sitting in the hole.Okay, good. Wire driver.All right, 2-5 drill. Yep.That will work.That will work.There we go.You know, that one we didn’t need to do that for, butsince we have to anyway, I figure...There we go.All the way down with the drill guide.This is going to be pretty close to an AP.It's going to be like that.Cement. That’s fine. That’s cement.And that’s good. Yep.You can feel a difference -pinching that as you go through there.Thank you.All right, that’s tight. All right.All right, do you want to call that good, proximally?Can I see that screwdriver back?You know - I want to do one more. The reason isthere was that non-displaced crack here.So those two screws are really kind of -a little bit compromised. Okay.We only have two screws really above that.So why don't we -why don’t we just do another here?A couple of non-locking screwsis not going to break the bank.That time you’re skidding across the implant, you hear that?Titanium is even better bite than...Here you go.We’re going to switch to non - or to locking here.Okay, thank you.So it gets harder, then easier, thenharder again. Yeah, that’s the -a lot of people leave those screws loose, and that’sa big - you can’t do that. All right.So let’s pick our pattern.Out of convention, I always like the last hole filled.And this is going to be like a kind of funny angle.It’s is going to be like that.So extending into the capitulum - like that.Okay. And then, probably that one.2-8.2-7. 2-72-8. 2-8.So then we’ll go 1, 2, 3, and that way we’ll have five oneither side.This will be bicortical.Do you have a wire driver?You can drill that one. This will be unicortical.Should I drill?That's fine.Do you have a wire driver? Yeah, and then we’ll justdrill them all, and we’ll be done drilling. Sure.Can we get a gram of vanco powder?Yeah, I don’t think we need a drain because it’s pretty dry.This is the scary thing to me.See, that’s not even the nerve - like, right? That’s just...That’s the one where... That’s the brachial cutaneous nerve,and then you see it’s hiding there.This is the time when I would saywe don't need to use a cable.This is a 2-6 coming next. That’s correct.We’re going to take our pictures, and unless something looksreally screwy, we’re done.So one of the thingsI always document in the operative reportis the location of the nerve. So in this -and I - you know, usually, I try not to put a screwhead under it.So here I’ll document it as under the - you know,under the - it’s between themost proximal lag screwand the most distal plate screw. Really, it’s under that.You know,when the - when the muscle folds back,it’s right over that screw.And why - why do you do that?In case you have to take it out? Because you want - if you’re the one who has totake it out, you want to know where it is. Taking theseplates out is one of the hardest things.The distal part here is prominent.I would consider even cutting the plateinstead of risking the nerve. I think,you know, dissecting out the nerve - you know, it’s -it would be cool to getthe whole plate out, but I think -you know, if it was botheringher, I would just cut the end of the plate off because that wayyou don’t have to worry about it.All right, so we got end of plate -can I see that screwdriver?Yep.Excellent.All right.So this is a really satisfying surgery because,like, these people are miserable, and when theywake up, they’re still miserable -but a few days later, they’re notmiserable -you know, because their arm works.All right.Come on in.

Right there. Shot-sky.Shot.X-ray there.So there’s our plate. I like where it sits distally.Can you make that straight up and down for us? X-ray there.Can you now flip it upside down?Like upside down or... Shot there.X-ray there.X-ray there.And now, x-ray there.X-ray there.So you can see we are square up there,so that looks really good. X-ray.X-ray.X-ray.X-ray.X-ray.X-ray.X-ray.X-ray. That’s the cement restrictor.X-ray.X-ray there.And now go over the top.No - actually, let me try this. X-ray there.X-ray.Here you can see -you know, that there is a slight bow to the humerus,but we have ananatomic reduction. So that looks really good.All right, thank you. Save that. Yep.So this -this is the brachial cutaneous nerve.All right? So we found that at the intermuscularseptum and traced that back to the radial nerveright here. And so the radialnerve is a little bit hard to see, and I don't want to fullydissect it out because I don't want to devitalize it, butunderneath this youcan see there's the radial nerve. It starts up hereand courses downand then down all the way.So we have a nice view of it all the way from downdistally away from thehumerus, through the spiral groove,over the plate, and then back now up here, proximally.All right. Nice work.

CHAPTER 6

Get her done.Alright, we'll take the stuff. Magic powder, please. Yes, sir.And the nice thing is that this is atrue internervous point - I mean, we didn't disrupt any muscle.So this - the people love this.Well, I shouldn't say love it, but they -you know, they recover pretty quickly from this.They tolerate it.You know, I would much rather have someonelarger this way than larger this way.All right, so...A 20-year-old dude who spends too much timeat Gold's Gym is harder than this.With a body mass index of negative 3 or whatever it is.Okay.

CHAPTER 7

The surgical treatment of humerus fracturesis a little bit contentious. Up until themid-to-late 80s, the vast majority of these were treatednon-operatively, and still, a lot ofpeople use functional bracing as theirprimary mode of treating humerus fractures. And in fact,most of the patients that I see, I try to recommendnon-operative managementbefore deciding to fix it. In this particular case, thepatient was obese, and she had a -a functional problem. She - with her lower extremity.She had ataxia from gentamicin toxicity years ago,and so she really needs her -her upper extremities. So given the -the pain control issues that she hadand difficulty with bracing, she elected to have this fixed.The other kind ofthing that's evolved overtime is thethinning of the radial nerve. So shehad a radial nerve palsy.There was a time when people used radial nervepalsy as an indication for surgery. However, now,I think that's - that'spretty much irrelevant except in the case of an open fracture.The big indication for me is an open fracture,so all open fractures I'm going to treat operatively.I think if you're thereand you're debriding it,then you should stabilize it at the same time.Pathologic fractures, again, are a time whenfixing the humerus makes more sense. And thenthe other big indication for me is polytrauma.So a lot of times peoplehave other extremity injuries, they need to use their arm -and especially in a young,fit person with good bone quality,you're going to let them be full weight-bearing afterfixing your humerus,and so it allows them to get up and walk, so...So poly trauma, open fractures, andpathologic fractures are my three main indications.So similar to other extremity things, really,you know, we're looking for function. The bigissue is going to be radial nerve.So she had a radial nerve palsy to begin with,and so the recovery of the radial nerve is really going toaffect how she does.Otherwise, we're looking for, you know, motion of theshoulder and the elbow joint, which -you know, I think fixing it gives you anadvantage because you're going to start moving it early.But then again, you have to deal with the -the problems of surgery, scar tissue, and things like that.The techniques that we used are pretty standard, right? It's -you know, absolute stability - so lag screw fixation and aneutralization plate. The particular plate that we used todayI really like, and likewe talked about during the surgery,there a lot of different companies that makethis same style of plate.And it's essentially a small fragment plate, using smallfragment screws, but it's much thicker.So it has the thickness of a large fragmentplate. So in the humerus,you want a little bit extra support and astandard small fragment plate -probably not strong enough - whereas a plate likethis I think gives you that extra support.Treating humeral shaft fracture surgically isextremely rewarding to patientsif you don't get a radial nerve palsy.I think that's why we don't do it more often - is this big fearof the radial nerve. You know,patients that have humeral shaft fractures acutelyare miserable. It's very hard to deal with the brace,it's very painful, it'shard to get around - and surgery fixes that,so they feel immediately better. Soit's really rewarding on that side, butyou do have to accept this riskof a radial nerve palsy. And although most of themget better, some of them don't.And so that would be the big worry.So I think with this technique and when you're treatingperiarticular fractures in general,you know, there - you can get into trouble if yourely too much on your hardware. So,you know, all the implantcompanies have done a fantastic job ofdesigning periarticular plates that fit the averageperson, but no one's average.And so like you saw in this case, you know,we're able to get a really nice reductionand use the lag screws tofix it. If we put the plate on withoutfurther contouring it, it would havejust ripped that reduction apart, right? Becausethe humerus wasn't perfectly straight -there was a little bit of a bow to it. And so I think -just like in any other periarticular situation,if you take your timeand really make sure things fit -sometimes it takes a little work to contourthe plates - it ends up working a little bit better.As far as platinghumeral fractures, I think really the -you know, there have been a lot ofadvances with variable angle plates and screws,so I think the implant technology ispretty good.I do think there's some work that can be done though forperiprosthetic fractures.So this fracture was a little bit unique in thatthere was a stem above it,and, you know, really, we have three options.One is putting screws through thecement mantle, and in this case that worked out pretty well,but sometimes you can't do that.If you can't do that, you're left with shortlocking screws orcerclage cables - both of which arekind of cumbersome to use. The short locking screwsare easy to put in,but they don't really work very well. They'repretty weak, and the cerclage cables - particularly aroundthe humerus - are very challenging and,you know, fraught with risk. So I think,you know, fixation around periprosthetic fracturesin both the humerus and also the lower extremity are -are something we need to work on.Postoperatively, I just use a sling. So the patientwakes up in an ACE wrap. They are in a sling.They come out of it right away for motion.And I typically limit a geriatric patient to5 or 10 pounds, and then younger patients haveno restrictions. And that's just simply amatter of bone quality,and I'm worried a little bit about the fixation.As far as the radial nerve is concerned,I put people in acock-up wrist splint. And then they work withoccupational therapy to maintain theirmotion, and we expect that it should get better.If there's no improvement at 3 months,we'll get an EMG, but there'sreally no indication to do itbefore that. We saw the radial nerve. We know it's intact.It's just a matter of it waking up.