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An Introductory Surgical Anatomy Case Series: Upper Limb Surgery Tiam Sahraie and Caity Ellis University of Edinburgh SSC5 Orthopaedics ProjectLearning Outcomes • Enhance Understanding of Upper Limb Anatomy • Identify Important Surgical Landmarks of the Upper Limb • Discuss Upper Limb Fracture and Injuries • Recall Fracture Demographics and Mechanisms of Injury • Revision of important UKMLA Orthopaedic Presentations • Provide an Introduction to real surgical procedures through images • Inspire Future Orthopaedic Surgeons!Introduction – Prevalence and Importance • Proximal humerus fractures account for 5-6%of allfractures 1 • Common in the 65+ due to low-energy trauma (e.g., falls) • Also seen in younger patients due to high-energy trauma (e.g., motor vehicle accidents, sports injuries) 1. Court-Brown CM, Caesar B. Epidemiologyof adultfractures: A review. Injury. 2006;37(8):691–697. 10.1016/j.injury.2006.04.130Introduction – Impact on Quality of Life • Elderly patients: May lead to immobility, pneumonia, or long-term care needs • Functional outcomes: Can be affected depending on fracture type and treatmentAnatomy Recap – Key Structures of the Proximal Humerus • Humeral Head • Surgical Neck • Greater Tuberosity (2) • Lesser Tuberosity (3) • Humeral Shaft • Greater Tuberosity: Supraspinatus, infraspinatus, and Anatomy Recap – teres minor muscles. • Lesser Tuberosity: Subscapularis muscle. Rotator Cuff and Tuberosities • Displacement of tuberosities can lead to rotator cuff dysfunction and shoulder instability. Image Credit: https://teachmeanatomy.info/upper-limb/muscles/shoulder/intrinsic/ Anatomy Recap – Axillary Nerve and Vascular Structures • Axillary nerve (10): Riskof injury in fractures near the surgical neck. • Brachial artery: Risk in high- energy fractures • Cephalic vein:Mobilised during surgery Image Credit: NettersAnatomy Recap – Axillary Nerve and Vascular Structures Axillary nerve (10):Risk of injury in fractures near the surgicalneck. Brachial artery: Risk in high- energy fractures Cephalic vein (4): Mobilised during surgery Image Credit: NettersMechanism of Injury – Low Energy Trauma Falls (elderly): Impaction fractures, minimal displacement • • Co-morbid: Osteoporosis, low bone mineral density • Typically: FOOSH • Lifetime risk of 13% in women 50+ 1 1. Walter N, Szymski D, Kurtz SM, et al. Proximal humerus fractures - epidemiology, comparison of registry data. Bone Joint Res. 2023;12(2):103-112. doi:10.1302/2046-3758.122.BJR-2022-0275.R1sed on MedicareMechanism of Injury – High Energy Trauma greater displacement.nts, sports injuries: Comminution, multi-part fractures with •Typically, younger patients.Clinical Presentation – History •Mechanism of injury (e.g., fall, trauma). •Prior shoulder injuries. •Comorbidities (e.g., osteoporosis). Medications (e.g., steroids) •Clinical Presentation – Examination •Pain, swelling, and tenderness. •Limited/reduced range of motion. •Crepitus may be presentwhilst mobilising. Deformity •Clinical Presentation – Neurovascular Examination •Complete full examination of U, R, M, AIN& Ax ▪ Specifically: Axillary nerve injury (deltoidweakness, numbness over lateral shoulder). Vascular compromise (pulse, capillary refill, colour of the hand). •Clinical Presentation – Red Flags Open fractures, neurovascular injury, signs of compartment syndrome. • •Associated injuries (e.g., clavicle fractures, scapula fractures, dislocations).Imaging and Diagnosis – X-rays • Anteroposterior (AP): Standard view for humeral head and shaft. • Scapular Y-view: Visualizes humeral head and greater tuberosity. • Axillary View: Assess dislocation and humeral head involvement. Imaging and Diagnosis – CT Scan • Useful for complex fractures (3-part, 4-part). • Assesses comminution, displacement, and articular surface involvement. • MRI: Not routine for bony assessment. • Indicated for soft tissue injuries (rotator cuff tears, labral tears). • USS can be used to assess rotator cuff injuries when MRI is unavailable. Image from: Jordan RW, Modi CS. A Review ofManagement Options for Proximal Humeral Fractures. The Open Orthopaedics Journal. 2014;8(1):148-156.doi:https://doi.org/10.2174/1874325001408010148Classification – Neer (Overview) •1-Part, 2-Part, 3-Part, and 4- Part fractures. •Used for planning treatment and predicting outcomes.Classification – Neer Neer 1-Part: No displacement. (No fragment angulated more than 45° or displaced more than 1 cm) • Typically, stable and managed conservatively. • Majority of casesClassification – Neer Neer 2-Part Fractures •Single displaced fragment (e.g., surgical neck, greater tuberosity). •ORIF may be required for displaced fractures.Classification – Neer Neer 3-Part Fracture • Involves humeral head, greater tuberosity, and surgical neck. • Surgical intervention required (ORIF or hemiarthroplasty).Classification – Neer Neer 4-Part Fractures •Involves all four fragments. •Reverse shoulder arthroplasty (RSA) or hemiarthroplasty indicated.Neer Classification X-rays Image from: Jordan RW, ModiCS. A Review of Fractures. The OpenOrthopaedics Journal. 2014;8(1):148-156. 148:https://doi.org/10.2174/1874325001408010Other Classification Systems: AO/OTA Classification • 11-A: Simple fractures. • 11-B: Wedge fractures. • 11-C: Comminuted fractures. • Rockwood Classification: Focuses on rotator cuff involvement. • Park’s Classification: Categorizes based on fragmentation and displacement.Surgical Anatomy – Rotator Cuff, Tuberosities and Axillary Nerve Importance of tuberosities in rotator cuff function and shoulder stability. •Displacementof tuberosities affects shoulder movement. •Axillary nerve injury can result in deltoid weakness and lateral shoulder numbness. • •Pre-operative and intra-operative assessment critical.Surgical Approaches – Non-operative Management Indicated for non-displaced fractures (1-part). • Sling immobilization (Collar & Cuff) and rehabilitation. • fracture.nhs.uk/your-visit/patient-information-leaflets// Surgical Management– Open Reduction and Internal Fixation •Indicated for displaced 2-part and 3-part fractures. •Techniques: Plate and screw fixation, pin and wire fixation. •Prerequisites: •Position patient: Modified beach •Scrub Gown Glove Surgical Approaches • Deltopectoral Approach vs Deltoid Splitting Approach Xie, L.et al. (2019)‘Deltoid-split approach versusdeltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis’, Orthopaedics &amp; Traumatology: Surgery &amp;Research, 105(2),pp. 307–316.doi:10.1016/j.otsr.2018.12.004.Surgical Approaches – Open Reduction and Internal Fixation (ORIF) 1. Reducehead 2. Plate lateral to bicipital groove 3. Shaft non-locking screw 4. Adjust plate < GT 5. Adjust plate on lateral xray 6. Long locking screws proximally 1. Ensure do not penetrate articular surface 7. Sutures through tuberositiesSurgical Approaches – Hemiarthroplasty (Anatomical/Reverse) Hemiarthroplasty for humeral head involvement. • •RSAfor complex 4-part fractures or in patients with rotator cuff arthropathy.Reverse Shoulder Arthroplasty • Allows deltoid to compensate for deficient rotator cuff • Indicated: • Cuff tear arthropathy • Fractures as mentioned • Failed Arthroplasty • joints, PD)d dysfunction, Neuroarthopathy (charcotCase: 72M • Progressive pain & dysfunction in L shoulder • Active forward flexion to 70 degrees • Several glenohumeral steroid injections – minimal benefit • X-ray: GH arthritis • MRI: Rotator Cuff tear Case& Images Credit to: @shoulderspecialists https://.youtube.com/watchwwBOVo9gALRwMw?v= • Patient in modified beach chair position RSA Approach: • Incision & superficial dissection • Cephalic vein mobilized medially • What is the name of this approach?RSA • Conjoint tendon identified and mobilized mediallyRSA • Anterior humeral circumflex artery (AHCA) and its two venae comitantes are ligated to prevent BLBiceps tendon identified & longitudinally incisedQuestion: The surgeon then dissects and reflects a muscle. They states it inserts onto the lesser tubercle of the humerus. What muscle is this? ?! BONUS ?! - What action does it have on the humeral head?RSA • Humeral head exposed & osteophytes removed • Humeral Canal reamed RSA • Trial stem insertedRSA • Trial spacer inserted & joint reduced to ensure adequate ROM • Measurement confirmedRSA • Subscapularis tendon repaired • If subscapularis is poor quality – resectRSA • Deltopectoral interval repaired & wound closedQuiz • How common are proximal humerus fractures? • A – 1 in 10 • B – 1 in 20 • C - 1 in 50 • D - 1 in 100Quiz • What classification system can be used for proximal humerus fractures? • A – Gartland • B – Weber • C – Neer • D - GardenQuiz • Common surgical approaches to the proximal humerus are: • A – Triceps-Splitting and Deltoid-Splitting • B – Deltoid-Splitting and Delto-pectoral • C – Delto-Pectoral and Triceps-Sparing • D – Brachialis-Splitting and Deltoid-SplittingLocked Plating of Proximal Humerus • Provides stability with a fixed device • Less disruptive to blood supply • In young patients, when there is displacement of tuberosity with malunion, operative treatment has good outcomes • Locked plate can be dangerous if used incorrectly 28M Fell from his Mechanic. bike Right Handed Case History: Injuries to right distal Distal tibia tibia and right has been proximal treated humerusFractureof surgical neck Lesser tuberositymay also be involved Head is in varus Shafthas translated laterally Due to tuberosity malposition if not managed operatively, secondary impingement+ suboptimalresults If there is varuscollapsein a young patient should bemanaged operatively AP - Externally AP - At 90 rotated and degree to the adducted arm shoulder, to check for Internally screw position rotated in the head X rays in theatre Axillary view – Lateral - Abduct Abduct arm the arm and with the x-ray internally rotate pointing into the axilla.Deltopectoral approach Question What bony landmark will you feel for when starting the incision. 1. Clavicle 2. Greater Trochanter 3. Coracoid Coracoid. The incision is along the deltopectoral grove, however in some patients (eg obesity) this can be difficult to palpate so the incision starts at the coracoid.Deltopectoral approach + Set Up • Feel for the coracoid • Feel for the deltopectoral grove • Local anaethsthetic • Leg prepped in case there’s a need to harvest fibulaFind the cephalic vein – slowly dissect the layers Take the vein medially or laterally out of case it wentthis lateral Coracoid Deltoid Conjoint (palpation) tendon Orientation PectoralFinger dissection cm to gain access, reattached lateronasto be dissected 1 – 1.5Divide the clavipectoral fascia Coracobrachialis Work lateral to this – Why? What structure is easily damaged when working medially? 1. Musculocutaneousnerve 2. Cephalic Vein 3. Brachial Artery 4. Axillary Nerve Medial to the conjoint tendon and coracoid isthe musculocutaneous nerve.The acromion is palpable on top, coracoid on the bottom, palpating in the subacromial space, may be needed for retractor placementSub deltoid space mobilised, if the patient presents later following injury there may be adhesionsDeltoid Sub acromial area Pectoral Further release the muscle bulk Deltoid Pectoral Humoral shaftIdentify biceps tendon • Sometimes this is visible, here the surgeon is palpating to see if he can feel for the tendon, looking for somethingyou can rollDissecting superiorly to this leads you to the rotator interval bicep tendonll be 3-4mm lateral to thePlace sutures for tuberosity control to reduce the fractureDissect through the rotator intervalAs the fracture is older there is no obvious fracture line so space needs to be created and the valgus angle needs increased.Through the rotator interval a window is created for repositioningThe varus deformity has been corrected, medial arch is maintained. No medial communation so fibula graft is unnecessaryMaintain the reduction with wires, must look both AP and lateral• Axillary View • All 3 views are necessary to assess postioningPhilos plates – small holes are used for the tension bands• Plate positioning • If it is superior to the greater trochanter, it will rub on the acromion • Too inferior and the contour of the plate will not match the humeral shaft and the screws will not be correctly sited in the humeral head• Plate should be placed beneath the greater trochanter and posterior to the bicipital grove.• Sutures from the superior cuff passed through the plate Subscapularis cuff Posterior cuffFirst cortical screwPlacing screws into the humeral head • Less likely to penetrate through the humeral head with x rays3 X-ray views • Ensure none of the screws penetrate right through the humoral headTop band to prevent the head going into varus The tension bands attach it to the rotator cuff it means the patient can mobiliseClosing the rotator interval Repair pectoral tendon, soft tissues are important formaintaining reductionDeltopectoral junction Reattach pectoralSkin closureReferences • Philos Plating with Deltopectoral Approach https://youtu.be/Ni0ujZD4kiU?si=QrnxxGV8BOp56wfq (Accessed 29/01/25) • https://www.orthobullets.com/approaches/12061/shoulder-anterior- deltopectoral-approach (Accessed 29/01/25)Conclusion •Proximal humerus fractures are common account for up to 1 in 20 of all fractures. •They require careful treatment planning based on classification and fracture complexity. •Surgical approaches range from non-operative management to advanced arthroplasty techniques. •Thank you!