Shoulder Fractures: The Greater Tuberosity - Denver, … · •17-21% of Proximal Humerus ......
Transcript of Shoulder Fractures: The Greater Tuberosity - Denver, … · •17-21% of Proximal Humerus ......
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Shoulder Fractures:
The Greater Tuberosity
Robert E. Hunter, MD
Director, Orthopedic Sports Medicine Center
Heart of the Rockies Regional Medical Center
Salida, Colorado
CU Sports Medicine Symposium
September 30
Boulder, Colorado
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Conflict of Interest Disclosure
• Paid Consultant for:
• Smith & Nephew
• Biomet
• Royalties
• Biomet
• Institutional/Program Support:
• Smith & Nephew
• Biomet
• DJO
• Arthrex
• AANA:
• Member JBOT
• Member BOD
• First VP, Executive Committee
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Shoulder Trauma In
Skiing/Snowboarding
• 4-11% of All Injuries
• ~ 70,000 Injuries/Yr.
• Stable Inc. Rate
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Greater Tuberosity Fractures
• 17-21% of Proximal Humerus
Fractures
• 15-30% Associated With
Anterior DislocationBahrs et al ‘06
Kim et al ‘05
Bhatia et al ‘06
Bigliani et al ‘98
Green, Izzi ‘03
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Shoulder Fracture
Classification
• a la Neer 1970
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Displacement >10 mm
Angulation >45°
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Mutch et al ‘14
Illustration of the Morphologic Classification of greater tuberosity fractures.
A, The avulsion type involves a smaller fragment with a horizontal fracture line.
B, The depression type involves an inferiorly displaced and impacted greater tuberosity.
C, The split type is a large fragment characterized by a vertical fracture line.
Avulsion Depression Split
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GT Fracture Displacement
•163 Fractures
•57% Involved Both SS and
IS Insertions
Ogawa et al ‘03
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Rouleau et al ‘16
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Arthroscopic-Assisted Plate Fixation
for Greater Tuberosity Fractures
• 11 Patients
• Median Age: 64 y/o
• Large, Comminuted Fractures
• Displacement >5mm
• Mean Pre-op Displacement:
• Posterior: 19.5mm
• Superior: 5.5mm
• Mean F/U 26 MPark et al ‘15
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Does Fracture Assessment and Treatment
Recommendation Vary based on Imaging
Modality for GT Fractures?
• X-Ray Only vs. 2D CT vs 3D CT
• 164 Orthopedic Surgeons Randomized Into 3 Groups
• 22 Fractures
• Interobserver Agreement Did Not Vary
• Amount of Displacement
• Direction of Displacement
• Recommendations for Surgery
Janssen et al ‘16
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My Take Home?
• Posterior Displacement Can Be
Underestimated Using X-Ray
Alone
• Always Get a 3D CT to
Evaluate Proximal Humerus
Fractures
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GT Fracture Fixation Options:
• Suture/s
• Cannulated Screw (With or Without
Washer)
• Percutaneous
• ORIF With Plate/Screws
• Arthroscopic With Suture Anchors
• Combined Scope/Open
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Arthroscopic Technique vs. ORIF
Greater Tuberosity Fractures
• 32 Patients: 17 ORIF, 15 Arthroscopic Rx.
• Tuberosity Displacement: ≥5mm and <20mm
• Bias: Treatment Strategy
• Displacement >10mm
• Fragment Size >30x30mm
• Displacement <10mm
• Fragment Size <30x30mm
• F/U Ave 34 M
ORIF
Arthroscopic Rx
Liao et al ‘16
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Arthroscopic Technique vs. ORIF
Greater Tuberosity Fractures
• Arthroscopic Rx.- Longer Surgical Time
(95 Minutes vs. 62 Minutes)
• Bone Union Equal and Healed By 3 Months
• Scope Group
• Better Elevation
• Better Abduction
• Higher ASES Score
• Differences Small- ? Clinical Importance
• Complications EqualLiao et al ‘16
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Liao et al ‘16
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Liao et al ‘16
Cuff Sutures Tied
to the Plate In Cases
of Comminution
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Arthroscopic-Assisted Plate Fixation
for Greater Tuberosity Fractures
• Scope GT Reduction/Fixation With Medial Row Anchors
(Trans-tendon)
• Locking Plate of Distal Bony Fragment (Deltoid Split)
• Post-Op Displacement:
• Posterior: 0.7mm
• Superior: 2.8mm
• Partial Articular Side SS Tear: 10/11
• Elev: 138°, Abd: 135°, ER: 19°, IR: L2
• This Technique Provided Accurate Reduction
Park et al ‘15
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Park et al ‘15
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Park et al ‘15
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Rouleau et al ‘16
Use the Anterior Fracture Line
to Reduce the Fracture
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Rouleau et al ‘16
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My Take Home?
•Do What You Do Best
•Don’t Be Afraid to Convert
an Arthroscopic to A Mini-
Open Technique
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Let’s Not Call It Mini-Open
Let’s Call It:
Maxi-Arthroscopic
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Greater Tuberosity
Fracture Management
• Find Them- 3D CT
• Determine Displacement
• Fix if ≥ 5 mm Displacement (Superior and/or Posterior)
• Surgical Approach:
• Open- Split Type
• Time Matters
• Outcomes Matter
• Large, Comminuted Fx’s
• Open/Scope- Split Type and Some Avulsion Types
• Scope- Avulsion Types and Some Split Types
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Thank You