Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

Arthroscopic debridement in the treatment of patients with osteoarthritis of the elbow, based on computer simulation

We retrospectively assessed the value of identifying impinging osteophytes using dynamic computer simulation of CT scans of the elbow in assisting their arthroscopic removal in patients with osteoarthritis of the elbow. A total of 20 patients were treated (19 men and one woman, mean age 38 years (19 to 55)) and followed for a mean of 25 months (24 to 29). We located the impinging osteophytes dynamically using computerised three-dimensional models of the elbow based on CT data in three positions of flexion of the elbow. These were then removed arthroscopically and a capsular release was performed.

The mean loss of extension improved from 23° (10° to 45°) pre-operatively to 9° (0° to 25°) post-operatively, and the mean flexion improved from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively. The mean Mayo Elbow Performance Score improved from 62 (30 to 85) to 95 (70 to 100) post-operatively. All patients had pain in the elbow pre-operatively which disappeared or decreased post-operatively. According to their Mayo scores, 14 patients had an excellent clinical outcome and six a good outcome; 15 were very satisfied and five were satisfied with their post-operative outcome.

We recommend this technique in the surgical management of patients with osteoarthritis of the elbow.

Cite this article: Bone Joint J 2014;96-B:237–41.

Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment

BACKGROUND

Minimally displaced (<3 mm) and non-displaced fractures of the proximal humerus are a common source of disability; nevertheless, there is no agreement on the recommended rehabilitation program in these patients. The purpose of this study was to evaluate the outcome of this group of patients and describe the rehabilitation protocol we have used for the treatment of this injury.

METHODS

We retrospectively analyzed the records of patients diagnosed with minimally displaced (<3 mm) fractures of the greater tuberosity who were admitted to our institute between June 2007 and May 2008. Patients were treated with a three-phase protocol. In the first phase, patients were immobilized in a sling for 3 weeks. In the second phase, pendular and active assisted exercises were begun 3 to 6 weeks after the injury. In the third phase, active exercises were commenced starting 6 weeks after injury.

RESULTS

Sixty-nine patients matched our inclusion and exclusion criteria. At an average follow-up of 31 months (range, 26-41 months), the average Constant score improved from 40 points (range, 33-58 points) to 95 points (range, 75-100 points). Average satisfaction score improved from 4.2 of 10 (range, 2-6) to 9.5 of 10 (range, 7-10). The reported average duration of pain and decreased range of motion from the time of injury was 8.1 months (range, 1-24 months).

CONCLUSIONS

When the diagnosis of a minimally displaced fracture of the proximal humerus is made, the patient can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol. Nevertheless, clinicians and patients should be aware that full recovery from the injury may take an average of 8 months.

3-Dimensional prebent plate fixation in corrective osteotomy of malunited upper extremity fractures using a real-sized plastic bone model prepared by preoperative computer simulation

PURPOSE

To assess the clinical outcome and accuracy of prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a plastic bone model manufactured by preoperative computer simulation.

METHODS

Nine consecutive patients underwent computed tomography (CT)-based 3-dimensional corrective osteotomy for malunited upper extremity fractures. There were 4 cubitus varus deformities, 1 cubitus valgus deformity, and 4 forearm diaphyseal malunions. We constructed a computer model of the affected bones using the CT data and simulated the 3-dimensional deformity correction on a computer. A real-sized plastic model of the corrected bone was manufactured by rapid prototyping. We used a metal plate, prebent to fit the plastic bone model, in the actual surgery. Patients were evaluated after an average follow-up of 22 months (range, 14-36 mo). We retrospectively collected radiographic and clinical data at the most recent follow-up and compared them with preoperative data. We also performed CT after surgery and evaluated the error in corrective osteotomy as the difference between preoperative simulation and postoperative bone model.

RESULTS

The range of forearm rotation and grip strength in patients with forearm malunions improved after corrective osteotomies of the radius and ulna. Wrist pain, which 2 patients with forearm malunion had experienced before surgery, disappeared or decreased substantially after surgery. Radiographic examination indicated that preoperative angular deformities were nearly nonexistent after all corrective osteotomies. Three-dimensional errors in the corrective osteotomy using a prebent plate, as evaluated by CT data, were less than 3 mm and 2°.

CONCLUSIONS

Prebent plate fixation in corrective osteotomy for malunited upper extremity fractures using a 3-dimensionally corrected, real-sized plastic bone model prepared by preoperative computer simulation is a precise and relatively easily performed technique that results in satisfactory clinical outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluation and management of proximal humerus fractures

Proximal humerus fractures are common injuries, especially among older osteoporotic women. Restoration of function requires a thorough understanding of the neurovascular, musculotendinous, and bony anatomy. This paper addresses the relevant anatomy and highlights various management options, including indication for arthroplasty. In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. In the case of displaced fractures, when surgical intervention may be pursued, numerous constructs have been investigated. Of these, the proximal humerus locking plate is the most widely used. Arthroplasty is generally reserved for comminuted 4-part fractures, head-split fractures, or fractures with significant underlying arthritic changes. Reverse total shoulder arthroplasty is reserved for patients with a deficient rotator cuff, or highly comminuted tuberosities.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus are common injuries. The management, including surgical intervention, of these fractures varies widely. This is an update of a Cochrane review first published in 2001 and last updated in 2010.

OBJECTIVES

To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in January 2012.

SELECTION CRITERIA

All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.

DATA COLLECTION AND ANALYSIS

Two people performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed.

MAIN RESULTS

Twenty-three small randomised trials with a total of 1238 participants were included. Bias in these trials could not be ruled out. Additionally there is a need for caution in interpreting the results of these small trials, which generally do not provide sufficient evidence to conclude that any non-statistically significant finding is 'evidence of no effect'.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate self-directed exercise programme.Six heterogeneous trials, involving a total of 270 participants with displaced and/or complex fractures, compared surgical versus conservative treatment. Pooled results of patient-reported functional scores at one year from three trials (153 participants) showed no statistically significant difference between the two groups (standardised mean difference -0.10, 95% CI -0.42 to 0.22; negative results favour surgery). Quality of life based on the EuroQol results scores from three trials (153 participants) showed non-statistically significant differences between the two groups at three time points up to 12 months. However, the pooled EuroQol results at two years (101 participants) from two trials run concurrently from the same centre were significantly in favour of the surgical group. There was no significant difference between the two groups in mortality (8/98 versus 5/98; RR 1.55, 95% CI 0.55 to 4.36; 4 trials). Significantly more surgical group patients had additional or secondary surgery (18/112 versus 5/111; RR 3.36, 95% CI 1.33 to 8.49; 5 trials). This is equivalent to an extra operation in one of every nine surgically treated patients.Different methods of surgical management were tested in seven small trials. One trial comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of better function after plate fixation but also of a higher rate of surgically-related complications. One trial comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary nails found some evidence of a short-term benefit for the nailing group. Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a higher re-operation rate in one trial. Two trials found no important differences between 'polyaxial' and 'monaxial' screws combined with locking plate fixation. One trial produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial found better functional results for one of two types of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes but it is likely to be associated with a higher risk of surgery-related complications and requirement for further surgery.There is insufficient evidence to establish what is the best method of surgical treatment, either in terms of the use of different categories of surgical intervention (such as plate versus nail fixation, or hemiarthroplasty versus tension-wire fixation) or different methods of performing an intervention in the same category (such as different methods of plate fixation). There is insufficient evidence to say when to start mobilisation after either surgical fixation or hemiarthroplasty.

Isolated greater tuberosity fracture: Short-term functional outcome following a specific rehabilitation program

BACKGROUND

Evaluate the functional outcome of a specific program of rehabilitation during conservative treatment of fracture of the greater tuberosity.

METHODS

We retrospectively studied the records of 22 patients, with minimally displaced greater tuberosity fracture, according to inclusion criteria. All patients have received an early (one week after the injury) rehabilitation program based on physical analgesic therapy means, techniques for recovering range of motion, strengthening exercises, proprioceptive stabilization exercises and usability advices. The evaluation was done at baseline, one, two and three months of the end of physical treatment.

RESULTS

Pain, perceived disability and range of motion were improved significantly since the end of rehabilitation. The improvement of function (Constant score) was significant at different evaluation times. The functional result seems to be poor when patients are aged and pain is severe at baseline.

CONCLUSION

During conservative treatment of fracture of the greater tuberosity, earlier rehabilitation allows rapid range of motion and functional recovery limiting care duration. After fracture healing, the rehabilitation program becomes similar to that advocated in rotator cuff disease. Whatever the initial treatment choice, rehabilitation must be considered at the waning of the first week.

The effectiveness of therapeutic exercise for painful shoulder conditions: a meta-analysis

BACKGROUND

Shoulder pain is the third leading musculoskeletal complaint seen by general practitioners. Physical therapy is often the first line of intervention in this population; however, there is limited description of what constitutes effective physical therapy treatment. No study has examined the effectiveness of therapeutic exercise across all painful shoulder conditions. Our purpose was to examine the effectiveness of therapeutic exercise as an intervention across all pathoanatomic mechanisms of shoulder pain in terms of range of motion (ROM), pain, and function.

METHODS

Medline via Ovid, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched from 1997 through March 2011. Randomized controlled trials comparing physical therapist-prescribed exercises against any other type of intervention were included. Articles were qualitatively evaluated by use of the Physiotherapy Evidence Database scale by 5 separate reviewers. Data from included studies were extracted and synthesized with respect to the primary outcomes of ROM, pain, and function. Individual effect sizes were calculated with a standard formula, and overall effect was calculated by use of random- and fixed-effects models.

RESULTS

We qualitatively reviewed 19 articles; 17 achieved the criterion of 6 or better on the Physiotherapy Evidence Database scale. Significant heterogeneity in reporting among included studies limited quantitative assessment. Overall, therapeutic exercise has a positive effect on pain and function above all other interventions. The findings for ROM were inconclusive.

CONCLUSION

Therapeutic exercise is an effective intervention for the treatment of painful shoulder conditions; however, subsequent research is necessary for translation into clinical practice.

Screw depth sounding in proximal humerus fractures to avoid iatrogenic intra-articular penetration

Unstable and displaced proximal humerus fractures remain a treatment challenge. The use of locked plates has improved construct stability, but complication rates remain high. Biomechanical studies have emphasized the importance of anchoring screws in the subchondral bone of the humeral head to improve implant stability. However, the spherical shape of the proximal humerus and the limited tactile sensation of its soft cancellous bone make determining accurate screw length difficult, and reported rates of intraoperative screw penetration are high. Iatrogenic screw penetration, even if recognized and corrected before leaving the operating room, may lead to late failure. We present a simple technique of quickly and safely determining screw length using a blunt-tipped Kirschner wire and instruments found in basic orthopaedic sets.

Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively

OBJECTIVES

Functional and quality-of-life outcomes of conservatively treated proximal humeral fractures.

DESIGN

Prospective study.

SETTING

University orthopedic department at a hospital.

PATIENTS/PARTICIPANTS

Seventy consecutive patients between the ages of 60 and 85 years.

INTERVENTION

Conservative treatment.

MAIN OUTCOME MEASUREMENTS

Functional outcome measured according to the Constant score, quality of life assessed using EuroQol-5D, and fracture pattern analyzed with x-ray and computed tomography scan.

RESULTS

: All fractures consolidated uneventfully with no loss of reduction in either group. Four-part fractures obtained the worst functional results (33.66) followed by three-part fractures (54.64) and finally two-part fractures (65.88 and 71). Mild pain was expected in three- and four-part fractures, whereas two-part fractures achieved near complete pain relief. Nondisplaced fractures obtained a final Constant score of 73.58 and displaced fractures a score of 59.41 with significant differences in all Constant score items with the exception of external rotation. Although patients older than 75 years scored lower (54.63) than those younger than 75 years (70.83), there was no difference in the quality-of-life perception.

CONCLUSION

Conservative treatment of proximal humeral fractures in those patients older than age 75 years provides good pain relief with limited functional outcome. Despite limited functional outcome, this appears to have no effect on the quality-of-life perception in the population studied. Four-part fractures present the worst results and treatment options may need to be discussed with the patient to adjust treatment to patient expectations.

Distal radius osteotomy with volar locking plates based on computer simulation

BACKGROUND

Corrective osteotomy using dorsal plates and structural bone graft usually has been used for treating symptomatic distal radius malunions. However, the procedure is technically demanding and requires an extensive dorsal approach. Residual deformity is a relatively frequent complication of this technique.

QUESTIONS/PURPOSES

We evaluated the clinical applicability of a three-dimensional osteotomy using computer-aided design and manufacturing techniques with volar locking plates for distal radius malunions.

PATIENTS AND METHODS

Ten patients with metaphyseal radius malunions were treated. Corrective osteotomy was simulated with the help of three-dimensional bone surface models created using CT data. We simulated the most appropriate screw holes in the deformed radius using computer-aided design data of a locking plate. During surgery, using a custom-made surgical template, we predrilled the screw holes as simulated. After osteotomy, plate fixation using predrilled screw holes enabled automatic reduction of the distal radial fragment. Autogenous iliac cancellous bone was grafted after plate fixation.

RESULTS

The median volar tilt, radial inclination, and ulnar variance improved from -20°, 13°, and 6 mm, respectively, before surgery to 12°, 24°, and 1 mm, respectively, after surgery. The median wrist flexion improved from 33° before surgery to 60° after surgery. The median wrist extension was 70° before surgery and 65° after surgery. All patients experienced wrist pain before surgery, which disappeared or decreased after surgery.

CONCLUSIONS

Surgeons can operate precisely and easily using this advanced technique. It is a new treatment option for malunion of distal radius fractures.

Application of computer-aided design osteotomy template for treatment of cubitus varus deformity in teenagers: a pilot study

BACKGROUND

Treatment of cubitus varus deformity from a malunited fracture is a challenge. Anatomically accurate correction is the key to obtaining good functional outcomes after corrective osteotomy. The aim of this study was to attempt to increase the accuracy of treatment by use of 3-dimensional (3D) computer-aided design. We describe a novel method for ensuring an accurate osteotomy method in the treatment of cubitus varus deformity in teenagers by means of 3D reconstruction and reverse engineering.

MATERIALS AND METHODS

Between January 2006 and May 2008, 12 male and 6 female patients with cubitus varus deformities underwent scanning with spiral computed tomography (CT) preoperatively. The mean age was 15.7 years, ranging from 13 to 19 years. Three-dimensional CT image data of the affected and contralateral normal bones of cubitus were transferred to a computer workstation. Three-dimensional models of cubitus were reconstructed by use of MIMICS software. The 3D models were then processed by Imageware software. An osteotomy template that best fitted the angle and range of osteotomy was "reversely" built from the 3D model. These templates were manufactured by a rapid prototyping machine. The osteotomy templates guide the osteotomy of cubitus.

RESULTS

An accurate angle of osteotomy was confirmed by postoperative radiography. After 12 to 24 months' follow-up, the mean postoperative carrying angle in 18 patients with cubitus varus deformity was 7.3° (range, 5° to 11°), with a mean correction of 21.9° (range, 12° to 41°).

CONCLUSIONS

The patient-specific template technique is easy to use, can simplify the surgical act, and generates highly accurate osteotomy in cubitus varus deformity in teenagers.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Proximal humeral fractures are common injuries. The management, including surgical intervention, of these fractures varies widely.

OBJECTIVES

To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in March 2010.

SELECTION CRITERIA

All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.

DATA COLLECTION AND ANALYSIS

Two people performed independent study selection, risk of bias assessment and data extraction. Trial heterogeneity prevented meta-analysis.

MAIN RESULTS

Sixteen small randomised trials with 801 participants were included. Bias in these trials could not be ruled out.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate physiotherapy programme.Surgery improved fracture alignment in two trials but was associated with more complications in one trial, and did not result in improved shoulder function. Preliminary data from another trial showed no significant difference in complications, quality of life or costs between plate fixation and conservative treatment. In one trial, hemiarthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries.Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a high re-operation rate in one trial. One trial found better functional results for one type of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes.

Emergent evaluation of injuries to the shoulder, clavicle, and humerus

This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulder's physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.

[Update on shoulder surgery 2010: current treatment strategies for traumatic lesions of the shoulder]

The article summarizes the basic literature findings and innovations in the treatment of traumatic shoulder lesions published during the last 3 years. It covers trends in acromioclavicular joint dislocation, traumatic shoulder instability, rotator cuff tears as well as fractures of the humeral head. In particular prospective clinical studies with a high level of evidence are cited, which concern about the outcome of surgical and non-surgical treatment methods and the optimal point for treatment. The aim of this review is therefore to provide direct implications for the clinical treatment algorithm of such lesions.

Clinical and radiological evaluation of minimally displaced proximal humeral fractures

INTRODUCTION

The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization.

METHOD

Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score.

PATIENTS

There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points.

RESULTS

All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15 degrees angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement.

CONCLUSION

Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.

Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005).

Biomechanical evaluation of 3-part proximal humerus fractures: a cadaveric study

Proximal humerus fractures occur frequently, and treatment remains controversial. This study compares stiffness in axial loading for 3 methods of fixation (locking compression plate, standard (nonlocking) proximal humerus plate, and blade plate) in a 3-part proximal humerus fracture model. Twelve paired proximal humeri were obtained from embalmed human cadavers and separated into 3 groups. Osteotomies of the surgical neck and greater tuberosity were created to simulate a 3-part proximal humerus fracture. After fixation, constructs were axially loaded in 20 degrees of abduction for 200 cycles in an Instron materials testing machine (Norwood, Massachusetts). The blade plate (mean, 146.87+/-28.9 N/mm) demonstrated 29% more mean stiffness than the standard plate (mean, 113.0+/-22.3 N/mm; P=.19). The locking compression plate (mean, 130.71+/-39.2 N/mm) exhibited 15% greater stiffness compared to the standard plate in our 3-part model (P=.58). The blade plate demonstrated 12% greater stiffness than the locking compression plate (P=.64). There was no significant difference in mean stiffness between the fixed-angle devices and the standard plate. Future in vitro and clinical studies of plate devices for proximal humerus fractures would be worthwhile to determine the benefits and limitations of various implants for specific types of fractures, including clinical performance and cost of care.

Functional outcomes after nonoperative management of fractures of the proximal humerus

BACKGROUND

Prospective follow-up data after nonoperative treatment for fractures of the proximal humerus are scarce. We studied functional outcomes and rates of complication and failure after conservative management of these common injuries.

MATERIALS AND METHODS

Consecutive patients aged older than 18 years presenting to the emergency department of a large district hospital with an isolated, closed proximal humeral fracture considered suitable for functional treatment by the surgeon on charge were enrolled in a prospective, externally monitored observational study. Surgeons were free to reduce the fracture and to prescribe any type of sling or brace. Active follow-up after 12 weeks, 6, and 12 months included plain radiographs, Constant score, and Disabilities of Arm, Shoulder and Hand (DASH) score.

RESULTS

We enrolled 160 patients (118 women; mean age, 63.3 +/- 14.8 years), and 124 completed 1-year follow-up. There were 85, 71, and 4 AO 11 A, B, and C fractures, and 75 one-part, 60 two-part, 23 three-part, and 2 four-part and head-splitting fractures. After 1 year, the mean difference in Constant scores between the injured and contralateral shoulder was 8.2 (95% confidence interval [CI], 6.0-10.4). The mean difference in 1-year DASH scores to baseline assessment was 10.2 points (95% CI 7.3-13.1 points). The risk of delayed and nonunion was 7.0% (95% CI, 3.6%-12.3%). Four patients subsequently underwent surgical fixation, and 5 had arthroscopic subacromial decompression.

CONCLUSION

This study may provide reference values for future investigations and stresses ceiling effects that will make it difficult to demonstrate a significant advantage of surgical over nonoperative treatment in patients with proximal humeral fractures.

LEVEL OF EVIDENCE

Level 4; Prospective case series without a control group.

Updated classification system for proximal humeral fractures

Proximal humeral fractures can restrict daily activities and, therefore, deserve efficient diagnoses that minimize complications and sequels. For good diagnosis and treatment, patient characteristics, variability in the forms of the fractures presented, and the technical difficulties in achieving fair results with surgical treatment should all be taken into account. Current classification systems for these fractures are based on anatomical and pathological principles, and not on systematic image reading. These fractures can appear in many different forms, with many characteristics that must be identified. However, many current classification systems lack good reliability, both inter-observer and intra-observer for different image types. A new approach to image reading, following a well-designed set and sequence of variables to check, is needed. We previously reported such an image reading system. In the present study, we report a classification system based on this image reading system. Here we define 21 fracture characteristics and apply them along with classical Codman approaches to classify fractures. We base this novel classification system for classifying proximal humeral fractures on a review of scientific literature and improvements to our image reading protocol. Patient status, fracture characteristics and surgeon circumstances have been important issues in developing this system.

Three-dimensional corrective osteotomy of malunited fractures of the upper extremity with use of a computer simulation system

BACKGROUND

Three-dimensional anatomical correction is desirable for the treatment of a long-bone deformity of the upper extremity. We developed an original system, including a three-dimensional computer simulation program and a custom-made surgical device designed on the basis of simulation, to achieve accurate results. In this study, we investigated the clinical application of this system using a corrective osteotomy of malunited fractures of the upper extremity.

METHODS

Twenty-two patients with a long-bone deformity of the upper extremity (four with a cubitus varus deformity, ten with a malunited forearm fracture, and eight with a malunited distal radial fracture) participated in this study. Three-dimensional computer models of the affected and contralateral, normal bones were constructed with use of data from computed tomography, and a deformity correction was simulated. A custom-made osteotomy template was designed and manufactured to reproduce the preoperative simulation during the actual surgery. When we performed the surgery, we placed the template on the bone surface, cut the bone through a slit on the template, and corrected the deformity as preoperatively simulated; this was followed by internal fixation. All patients underwent radiographic and clinical evaluations before surgery and at the time of the most recent follow-up.

RESULTS

A corrective osteotomy was achieved as simulated in all patients. Osseous union occurred in all patients within six months. Regarding cubitus varus deformity, the humerus-elbow-wrist angle and the anterior tilt of the distal part of the humerus were an average of 2 degrees and 28 degrees, respectively, after surgery. Radiographically, the preoperative angular deformities were nearly nonexistent after surgery. All radiographic parameters for malunited distal radial fractures were normalized. The range of forearm rotation in patients with forearm malunion and the range of wrist flexion-extension in patients with a malunited distal radial fracture improved after surgery.

CONCLUSIONS

Corrective osteotomy for a malunited fracture of the upper extremity with use of computer simulation and a custom-designed osteotomy template can accurately correct the deformity and improve the clinical outcome.