Fractures of the proximal humerus, particularly in osteoporotic bone, are still frequently referred to as unsolved fractures. The recent explosion of locking plate technology has included these fractures, but it appears that laterally placed locking plates may not be as predictable as hoped. Medial column mechanical support of these fractures may play a significant role in the ultimate stability of fixation during rehabilitation until healing occurs. We have devised a technique of using a segment of fibula allograft, placed endosteally and incorporated into the locking construct, to aid in the reduction and restoration of the mechanical integrity of the medial column of the proximal humerus.

Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixation in our study.

Locked screw and plate removal improved function both subjectively and objectively. Transsyndesmotic implant removal seems to assist improvements in the speed of rehabilitation.

No abstract

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The finding that the posterior humeral circumflex artery provides 64% of the blood supply to the humeral head provides a possible explanation for the relatively low rates of osteonecrosis seen in association with displaced fractures of the proximal part of the humerus. In addition, protecting the posterior humeral circumflex artery during the surgical approach and fracture fixation may minimize loss of the blood supply to the humeral head.

Treatment of acetabular fractures remains challenging particularly in the presence of severe osteopenia, comminution, or associated femoral head fracture. In appropriately selected patients, ORIF and primary THA provide an acceptable treatment option.

Displaced and unstable fractures of the proximal humerus are notoriously difficult to manage. Successful surgical treatment requires finding the appropriate balance between adequate exposure for reduction and rigid fixation and minimizing soft tissue dissection. The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior deltoid raphe is utilized, and the axillary nerve is identified and protected. Anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed. Over a 4-year period, 52 patients with acute displaced fractures of the proximal humerus were treated with the anterolateral acromial approach and either a locking plate or an intramedullary nail. Twenty-three patients were evaluated clinically at a minimum follow-up of 1 year (average, 28 months) by clinical examination for range of motion and nerve function and a QuickDASH score. There were no axillary nerve deficits postoperatively related to the approach, and the average QuickDASH score was 25.2 (0, best; 100, worst). This approach allowed direct access to the lateral fracture planes for fracture reduction and plate placement or safe nail and interlocking screw placement.