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Preoperative planning and imaging
Preoperative planning is important for all shoulder arthroplasty indications, but it is most crucial for fracture cases. Although proximal humeral anatomy may be somewhat distorted by prolonged wear and osteophyte formation in cases of chronic disease for which shoulder arthroplasty is performed, most reliable anatomic landmarks remain consistent despite the disease process. In fracture cases, however, these normally reliable landmarks are often displaced, thus making them useless as points of reference. Because of the lack of recognizable landmarks, preoperative planning is critical to establish the proper position for humeral stem implantation. Thorough preoperative planning minimizes the risk of placing the humeral stem at the incorrect height or version. Preoperative planning is of paramount importance and is detailed in this chapter. Additionally, important aspects of the clinical history and physical examination, the radiographic examination, and secondary imaging studies are highlighted.
Clinical History and Examination
A thorough history is taken of the antecedent trauma responsible for the fracture. Most often, these proximal humeral fractures are caused by a fall from a standing position. Elucidation of the reason for the fall should be sought to assist in evaluating any underlying contributing medical conditions (i.e., syncope as a symptom of cardiac arrhythmia). The presence of any shoulder problems before the fracture should be noted in the history. A previous history of shoulder pathology, such as a massive rotator cuff tear or glenohumeral arthritis, influences surgical decision making (i.e., the type of prosthesis to be implanted, such as an unconstrained fracture prosthesis or reverse shoulder prosthesis).
Physical examination in a patient with an acute proximal humeral fracture is limited so that the patient will not be subjected to pain unnecessarily. A detailed neurovascular examination is performed with specific attention to the sensory and motor function of the axillary nerve. The sensory function of the axillary nerve can always be evaluated by testing sensibility to touch of the posterior aspect of the upper part of the arm (superior lateral brachial cutaneous branch of the axillary nerve). Motor function of the axillary nerve may be more difficult to evaluate because pain induced by the fracture may inhibit deltoid contraction. The condition of the soft tissues, particularly anterior at the planned surgical site, is meticulously evaluated.
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