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Upper limb Trauma- Proximal humeral fractures MisFRCS(Tr&Orth)herNone of this is going to be new….. So many resources!! Previous terms talks on bridge/panopto- previous shoulder term has debates and presentations on the literature FRCS mentor talks- Mr Kang Cambridge orthopaedics/Youtube- Mr Van Rensburgs library of knowledgeWhat’s the problem? NOT ALL PROXIMAL HUMERAL FRACTURES ARE THE SAME!THE LITERA TURE Neer Classification introduced in 1970!Profher ‘justified’ treatment choices in 2015 (for some)! Hertel used his lego to Profher 2 aiming 2004ict head ischaemia in choices for others!tThe Anatomy Subscapularis insertion Supraspinatous insertion Blood supply: Posterior humeral circumflex artery provides 64% of the blood supply to the humeral head. Hettrich et al, JBJS Am 2010 Deltoid/ Pec insertionPoor prognostic factors Medial calcar <8mm Medial hinge disrupted >2mm Anatomical neck # (represents articular fragment depth <1.5cm)The reality VSImaging Need 2 views: you might be surprisedImaging Get a CT if you’re not sure or to help your surgical planning/decision makingWho, What, When? WHO Every patient is different: 1. Ma.hDo they need their upper limbs to mobilise (ie pelvic/femoral/ankle fractures) 2. Pre-morbid function, comorbidities 3. Shoulder function 4. Expectation managementWhat to do….WHAT? Fracture pattern- Head viability- Predictors of ischaemia: Hertel ● Loss of medial hinge ● Metaphyseal head extension <8mm of calcar Bone quality- Mean cortical thickness; Tingert 2003 <4mm risk of lA+B+C+Dfixation 4WHAT? The ‘Hallam’ rules of surgery: 1. Fracture dislocation 2. Articular fragment displacement- ie pointing the wrong way 3. Medialisation of shaftFIX Proximal humeral locking plate improves varus instability Interlocking cross screw fixation for articular raftingREPLACE Hemiarthroplasty: Reverse shoulder replacement: Indications: 3 or 4 part fractures, heIndications: 3 or 4 part fractures, head split, poor Requirement: Intact cuff, adequate bonebone quality, cuff failure usually younger and higher demandCase 1: 57 year old female Fall in shower PMHx: ETOH xs SHx: Right hand dominant Smoker1. How will you assess the patient? 2. What’s your surgical plan? Now what??1. Can you talk through the deltopectoral approach to the shoulder? 2. Can you describe the intervals and triangles of the shoulder?Case 2: 49 year old female Fall from bike PMHx: Hypertension SHx: RHD Hairdresser Plan? 1. What factors will influence your choice of management? 2. What options are there for fixation?