Edwards JBJS 2000 (20 patients): nonoperative strength comparable to normal - no absolute indication for surgery
Q28Describe the posterior approach to the shoulder.▸
Modified Judet - do not detach deltoid from spine; Classic Judet - detach deltoid from spine; Brodsky - incision parallel to lateral border
Lateral decubitus, GA, ipsilateral arm draped free; landmarks scapular spine and acromion
Incision along scapular spine then medial border (reverse 7 on right, 7 on left)
Internervous plane infraspinatus and teres minor (SSN and AN); at risk: suprascapular nerve superior, axillary nerve + posterior circumflex artery inferior to TM
Q29What is the initial management and imaging workup of a scapular neck fracture?▸
ATLS; rule out neck injury
Rule out compartment syndrome (Comoli sign)
CXR to look for scapulothoracic dissociation
Axillary/Velpeau view for dislocation; CT for glenoid articular surface, glenoid position (translation, GPA) and scapular body angulation
Q30What is the glenopolar angle?▸
Angle between a line across the superior and inferior glenoid and a line between the superior glenoid and inferior scapular angle
<20 degrees is an indication for surgery (rotational malalignment of the glenoid)
Q31What long-term complications occur if SSSC disruption is treated conservatively?▸
Nonunion, malunion
Impingement and altered shoulder mechanics
Osteoarthritis
Q32Describe the X-ray features of this comminuted proximal humeral fracture.▸
Comminuted fracture of the right proximal humerus with GT, head and neck fragments
Fracture over the anatomical head with short metaphyseal extension <8mm
Displaced with medial hinge disruption >=2mm
No fracture scapula/ribs, no pneumothorax, no underlying lytic lesion
Q33What are Hertel criteria and their significance?▸
Hertel 2004 predicts AVN of the humeral head
97% chance of AVN if all three criteria met
Minor criteria: head split, 3-4 part, dislocation
Poor predictors of ischaemia: dislocation, tuberosity displacement, angular displacement of the head, 3-4 part fracture
Q34What did the ProFHer trial show?▸
JAMA 2015 - no significant benefit of surgery at 2-year FU
Critiques: selection bias (clear indications for surgery excluded), low cases per surgeon
Fracture patterns categorised by Neer classification rather than pathomorphology
Q35What is the evidence for fixation versus replacement?▸
Gupta 2015 JOT: higher reoperation in ORIF vs HA/RSA but significantly better outcomes in ORIF
DelPhi trial JBJS 2020: for B2, C2 fractures in the elderly, RSA gives better functional outcomes
Q36What is the evidence for implant choice?▸
Fixation: nail or plate - Metanalysis 2018 Int Ortho Sun et al: no difference
Arthroplasty: Cuff et al JBJS 2013 - RSA better clinical outcomes than hemi, similar complication rate
Q37Describe the deltopectoral approach and fixation.▸
Skin incision from coracoid along deltopectoral groove; retract cephalic vein laterally
Plane between deltoid and pec major; stay lateral to the conjoint tendon; clavipectoral fascia
Tag tuberosities; enter through fracture site; head to shaft fixation with K wire +/- bone graft
Q39What is the acute management of a proximal humeral fracture?▸
Analgesics
Immobilisation with a shoulder immobiliser
Long-term management should address osteoporosis
Q40What patient and fracture factors determine whether to operate?▸
Patient: age, comorbidities, associated injuries, premorbid function
Fracture: displacement, comminution, bone quality
Q41Describe the rehabilitation phases after proximal humerus fixation.▸
Phase 1 (first 3 weeks): pendular exercises, gentle assisted motion; avoid ER for the first 6 weeks
Phase 2 (3-9 weeks): active assisted forward flexion and abduction; no abduction against resistance weeks 3-6; reduce assistance from week 6
Phase 3 (after week 9): isotonic concentric and eccentric strengthening; add passive stretching if stiff
Q42Describe this X-ray and classify the proximal humeral fracture using Neer's classification.▸
Fracture of the GT and surgical neck of the humerus with angular displacement
Likely a 3-part fracture by Neer classification
Short medial metaphyseal extension (<8mm) with disrupted medial hinge - 97% chance of AVN (Hertel 2004)
Q43What is the blood supply to the humeral head?▸
Traditional belief: mainly the arcuate branch of the ascending anterior circumflex
Mainly from the posterior circumflex according to Henrich 2010 JBJS (64%)
Q44What is Neer's classification threshold for a displaced part?▸
1cm displacement defines a displaced part
45 degree angulation also defines a displaced part
Q45How do age and AVN risk guide management?▸
Old patient, low functional demand and fit for surgery - advise hemiarthroplasty/RSA (Delphi trial)
Young patient - still attempt ORIF with plating (long-term hemiarthroplasty outcome uncertain; Gupta JOT 2015)
Q46What are the principles and key parameters of hemiarthroplasty?▸
Needs an intact CA arch
Aim: restore biomechanics of the shoulder and allow early mobilisation; principles include anatomical and stable fixation of hemiarthroplasty, correct tensioning and position of implant, secure reattachment of tuberosities
Deltopectoral approach; identify GT/LT by position of biceps tendon and tag fragments
Retroversion ~30 degrees; top of implant to GT 7-8mm; top of humeral head to upper border of pec major insertion = 5.6cm; should translate <50% of head
Q47What are the complications of hemiarthroplasty?▸
Obtain Y view or Velpeau axillary view to rule out dislocation
Q49Describe the technical steps of hemiarthroplasty for proximal humerus fracture.▸
Deltopectoral approach; identify GT/LT by the position of the biceps tendon and tag the fragments
Dislocate/retrieve the humeral head, prepare the canal by reaming, trial then cement the implant
Retroversion ~30 degrees - lateral fin slightly posterior to the bicipital groove
Height: sit on medial calcar if present, top of implant to GT 7-8mm, head top to upper border of pec major insertion 5.6cm, translate <50% of head
Head size templated from the contralateral shoulder; reattach GT/LT/SS under the collar by suture
Q50Describe the X-ray on the left.▸
Spiral fracture of the left midshaft humerus
Mild angulation on attempted AP view
Q51What is acceptable alignment and conservative management for a humeral shaft fracture?▸
Acceptable: 30 degree angulation on AP, 20 degree on lateral, 3cm shortening
Coaptation splint first for 2 weeks until swelling improves, then Sarmiento brace
Tighten brace twice weekly; do not lean on the elbow
Low threshold to ORIF as distal third fractures are prone to slip into varus
Q52Describe the X-ray on the right and why you would operate.▸
Short oblique midshaft fracture with minimal comminution, no shortening
Less contact area - higher strain per unit length, high chance of nonunion if treated conservatively
Hanging cast is contraindicated due to over-distraction
ORIF via anterior approach; lag screw + neutralisation plate/DCP (broad 4.5mm, staggered holes, 7 cortices)
Anterior approach: lateral to bicep, bicep to medial, split brachialis at lateral 1/3 b/w plane of radial nerve and MCN, risk if lateral cutaneous nerve of forearm, radial nerve at lateral border of brachialis
Q53What are the advantages and disadvantages of nailing a humeral shaft fracture?▸
Advantages: biologically friendly (does not disrupt fracture haematoma); mechanically more rigid, smaller bending strains, less fatigue failure
Disadvantages: Limited by canal diameter and preexisting shoulder stiffness (7mm); iatrogenic comminution during reaming; cuff damage; radial nerve entrapment; axillary/radial nerve injury with locking screws
Violates Perren's strain theory if no interfragmentary compression
Heineman 2012: similar union/infection/reoperation but higher total complications with nail; Ouyang 2013 J SES 2013 metaanalysis: similar outcomes, plating less occurrence of shoulder problem
Q54What are the indications for surgery in a humeral shaft fracture?▸
Open fracture, compartment syndrome
Floating elbow, vascular injury requiring repair
Relative: 2nd radial nerve palsy after CR, Holstein-Lewis fracture, >20 degree angulation in 2 planes or >3cm shortening, unable to maintain acceptable closed reduction
Q55How do you manage a radial nerve palsy with a humeral shaft fracture?▸
Overall prevalence 12%; observe if alignment good, no open fracture, no vascular/soft tissue compromise, not iatrogenic
Shao JBJS (Br) 2005 systemic review: spontaneous recovery 70%; no difference early exploration vs expectant management
Ilyas JAAOS 2020 favours early exploration: expectant 77.2%, late >8 weeks 68.1%, surgical mx within 3 weeks 89.8%, 10.5% incarceration rate, 26.8% laceration rate
Consider exploration + fracture fixation if no improvement after 3 weeks; monitor clinically (BR, ECRL/B, EDC/EPL, last EI) and with NCV
Q56Describe the technique of antegrade humeral nailing.▸
Anterolateral approach to the deltoid, enter through the rotator interval
Split the rotator cuff and insert the nail at the greater tuberosity
Proximal screws inserted laterally to avoid the axillary nerve
Distal screws inserted anteroposteriorly to avoid the musculocutaneous nerve
Q57What is a Sarmiento brace and how does it work?▸
Functional orthosis giving stability while allowing movement of the joint above and below
Uses the non-compressible nature of fluid and soft tissue
Circumferential pressure generates hydraulic pressure that stabilises the bone
Active muscle pull helps realign the fracture, promote secondary healing and provide blood supply
Q58What are the contraindications to a Sarmiento brace?▸
Shortening, length-unstable fracture, bone loss
Open fracture/poor tissue envelope, fracture of other bones in the same limb
Uncooperative patient, fracture too proximal or distal
JBJS 2000: >80% union with good alignment; radial nerve palsy is not a contraindication
Q59How is a hanging cast used for humeral shaft fractures?▸
Realigns the fracture using the weight of the arm
Long arm cast with holes at the wrist (dorsal to volar, radial side), hung on the neck by C&C
Longer C&C extends, shorter C&C flexes
More dorsal holes = apex medial; more volar holes = apex lateral
Q60What are the deforming forces in a proximal humeral shaft fracture?▸
Depends on the fracture position relative to the deltoid insertion
Proximal to deltoid: proximal fragment adducted by pectoralis major
Distal to deltoid: proximal fragment abducted by deltoid
Q61How is radial nerve recovery monitored?▸
Clinical: BR, ECRL/B, EDC/EPL, last EI
NCV immediately after injury for documentation (absent signal may be pre-existing)
Repeat at 2 months to differentiate axonotmesis from neurotmesis
Q62How is secondary/iatrogenic radial nerve palsy after surgery managed?▸
Entrapment 6-25%; laceration 20-42%
Literature generally supports non-surgical management; no single algorithm
No exploration: spontaneous recovery 70%, but 90% do not reach complete recovery
Early exploration allows repair or early grafting; late exploration lets the neurilemmal sheath thicken
Some studies show that function recovery is more complete and consistent with this approach - for me, I would choose early exploration, as the risk of bad result from postponement justifies early exploration in case of uncertain nerve damage
Q63Describe the X-ray features of this distal third humeral shaft fracture.▸
Spiral fracture of the distal 1/3 humerus with butterfly fragment
Fracture angulated into varus
Q64Why is the radial nerve prone to injury in distal third humeral fractures?▸
Tethered by the lateral intermuscular septum as it passes from posterior to anterior at the 1/3 of the humerus (15cm from lateral epicondyle)
At risk of traction injury (22%)
Q65Is radial nerve palsy an indication for surgery?▸
Traditionally believed to be an absolute indication
Found to have spontaneous recovery in 90% of cases (Elkholm JOT 2008), most due to neuropraxia
Q66Why operate on this fracture?▸
Alignment may put the nerve under more tension, affecting its capacity for good healing and recovery
Difficult to immobilise the fracture without immobilising the elbow - causes elbow stiffness
Posterior approach - split triceps or paratricipital
3.5mm extraarticular plate if very distal, or 4.5 narrow LCP
Q67What is a Holstein-Lewis fracture?▸
Distal third humeral shaft fracture associated with radial nerve palsy in 20%
CR is contraindicated as it may tear the radial nerve
If alignment unsatisfactory - plating via anterolateral approach, go through brachioradialis and brachalis, the plane in which the radial nerve lies when it goes anterior - can explore radial nerve
Posterior approach: radial nerve lies between medial and lateral head of triceps then to the lateral intermuscular septum
Q68What are the conservative options for a distal third humeral shaft fracture?▸
Brace or cast
Must immobilise the elbow as well
Q69What are the absolute indications for surgery in a humerus fracture?▸
Open fracture
Vascular compromise
Compartment syndrome
Unacceptable alignment
Q70Describe the X-ray features of this intercondylar distal humeral fracture.▸
Comminuted intercondylar fracture of the right humerus with varus angulation and metaphyseal comminution
AO type C fracture
Q71What is the assessment and pre-op workup?▸
Age, function, hand dominance, mechanism; high energy - ATLS and rule out injury in the same limb
Locally: skin wound/impingement, soft tissue condition, compartment, nerve palsy (radial nerve most at risk)
Rest in a long arm slab and get CT before OT to assess the comminution
Q72What are the principles of surgery?▸
Anatomical reduction of the articular surface
Restore the tiearch of the distal humerus
Stable fixation with double plating to allow early mobilisation
Q73What is the Jupiter classification?▸
Low T, High T
H, Y, medial/lateral lambda
Q74Describe the olecranon osteotomy.▸
Lateral decubitus, GA, Xray guidance; longitudinal incision at mid posterior curve to radial at olecranon process
Elevate full thickness fasciocutanoeous flaps; identify and protect the ulnar nerve, release through cubital tunnel to first motor branch to FCU
Proximally based V-shaped chevron osteotomy ~2cm distal to tip of olecranon, aiming at the bare area of the sigmoid notch
Predrill holes; pass gauze inside the joint to protect cartilage; drill hole at the apex to prevent propagation; saw with irrigation and finish with osteotome
JSES 2017: extraarticular step cut may be more stable with higher bone contact surface area
Q75What are O'Driscoll's principles of distal humeral fixation?▸
Respect O'Driscoll's principles: insert screws in an interdigitated manner, purchasing as many articular fragments as possible
As many screws distally as possible; each screw should engage the other side; screw as long as possible
Every distal screw should pass through the plate; plates apply compression at the supracondylar level
Do not end plates at the same level, to avoid stress rise
90/90 plating: similar biomechanics to parallel plating but better resistance to torsional loading
Q76Describe the paratricipital approach to the distal humerus.▸
Midline posterior incision
Identify the ulnar nerve and dissect 15cm proximal to the elbow and distally to the first branch to FCU
Medially elevate triceps by freeing the medial intermuscular septum; distally elevate the posterior band of MCL
Laterally identify the radial nerve if a long plate is planned; divide the anconeus distally for exposure
Q77Which posterior approaches are available for the distal humerus?▸
Requires less stripping, preserving blood supply of the lateral condyle (SK Lee Eur J O&T 2013)
Q79Should the ulnar nerve be transposed during distal humerus ORIF?▸
Not routinely - transposition does not decrease ulnar nerve palsy rate
Some studies record 4 times higher ulnar nerve dysfunction after transposition
Decide based on impingement/subluxation when screening the full range after fixation
Ilyas Hand Clinic 2018: overall incidence 19.3%; transposition 23.5%
Q80What is the rate of heterotopic ossification and is prophylaxis indicated?▸
HO reported rate 8%
Routine prophylaxis is not warranted
Indomethacin increased the rate of nonunion
Q81When is total elbow arthroplasty considered for distal humerus fracture and what are its problems?▸
For elderly patients with osteoporotic bone and comminution not amenable to stable fixation
Dehghan 2019 JSES: Type C2/C3, female >65 years - TEA is an option
Bryan Morrey approach: release triceps tendon and periosteum medial to lateral and elevate as a single unit off the olecranon, reflecting laterally
Problems: columns and collaterals are not intact - need linked implants with bearing wear/loosening; periprosthetic fracture
Q82Describe the ORIF sequence for a distal humerus fracture.▸
Reduce articular fragments and fix large pieces with lag screws, or positional screws if comminuted
Fix the articular fragment to the metaphyseal region
Choose 90/90 plating (posterolateral and medial)
Do not end the plates at the same level to avoid stress rise
Fact check
Bandari 2020 CORR meta-analysis: more nonunion with conservative (union rate 97% vs 89%) — union-rate figures appear assigned to the wrong groups — Contemporary meta-analyses show operative treatment has the higher union rate; the 97% vs 89% figures should read operative vs conservative respectively — (medium confidence) — source
Hook plates have lower functional scores and revision rates compared with CC fixation — revision-rate direction likely reversed — Uittenbogaard 2021 found hook plates had lower functional scores, no union-rate difference, but higher revision/complication rates (implant removal) than CC fixation — (medium confidence) — source
Humeral head blood supply mainly from the posterior circumflex according to the study of Henrich 2010 JBJS (64%) — citation author name is incorrect — The study is Hettrich et al., JBJS 2010;92(4):943-8, which found the posterior humeral circumflex artery supplied 64% of the humeral head — source