3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures

Early complications of operatively treated proximal humeral fractures

Minimal information exists regarding early complications after operatively treated proximal humeral fractures. Of the 82 shoulders that had osteosynthesis, 42 had a (nonmedical) complication, with 21 requiring further surgery. Of 42 shoulders with complications, 12 were related to incomplete reduction, 16 had loss of anatomic fracture fixation, 9 had delayed healing, 3 had an infection, 1 had rotator cuff failure, and 1 had loose bodies. Fixed-angle plates had lower rates of initial malpositioning and resultant malunion. Of the 22 shoulders requiring hemiarthroplasty, 14 had an early complication. Of these, 7 had complications relating to implant insertion or tuberosity malreduction at the index operation and 7 had problems with tuberosity healing. The rate of complications after operative treatment of proximal humeral fractures is high. All efforts at fracture fragment fixation with osteosynthesis and hemiarthroplasty should be directed at obtaining anatomic fracture fixation that resists displacement.

Proposed protocol for reading images of humeral head fractures

Fractures of the proximal humerus can be treated effectively but require proper characterization. None of the existing classifications intended to facilitate characterization have been satisfactory. We studied proximal humerus fractures using radiographs alone and radiographs plus computed tomography scans to ascertain which imaging studies were most useful to characterize these fractures. We designed an assessment protocol consisting of 17 parameters divided in four groups: cephalodiaphyseal relationship (six parameters), cephalotuberosity relationship (six parameters), humeral head (two parameters), and fracture fragment description (three parameters). The computed tomography scans were assessed using 11 parameters (the same parameters used for assessing radiographs except for the six cephalodiaphyseal parameters). Four observers analyzed the parameters in 30 selected fractures with biplanar radiographic projections (30 patients) and computed tomography scans (22 patients) on two occasions. We found good interobserver reliability and intraobserver reliability with radiographs alone for the cephalodiaphyseal parameters. The best interobserver reliabilities with radiographs plus computed tomography scans were with the number of fragments, displacement of the lesser tuberosity, and extraarticular or articular fractures. Computed tomography allows better assessment of some parameters in characterizing proximal humeral fractures. The use of a structured protocol in reading images seems useful and allows better reliability than reported for other approaches.

LEVEL OF EVIDENCE

Diagnostic study, Level III (study of nonconsecutive patients without consistently applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Understanding proximal humerus fractures: image analysis, classification, and treatment

Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.

Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital

INTRODUCTION

Patients with proximal humeral fractures are mostly elderly. In addition to the proximal humeral fracture, they often have other injuries related to poor bone quality. The surgical treatment of proximal humeral fractures in elderly patients with comminuted fractures is associated with several problems and a high frequency of complications. The aims of this study were to evaluate patients with a proximal humeral fracture treated in a hospital, assess the outcome of the fracture treatment, and decide whether surgical treatment of displaced proximal humeral fractures is superior to conservative treatment or not.

MATERIALS AND METHODS

Patients with fractures of the proximal part of the humerus treated in our hospital were followed during two different periods (14 and 10 months). The study in the first time period was retrospective in design, while in the second period the patients were followed prospectively. Seventy patients, (71% women) with a mean age of 71 years, were included in the study. A functional test was performed within 12-14 months after the injury using a modified Rowe shoulder score. Surgical treatment was performed in 15 patients (21%). Neither the surgical approach nor the implants used for osteosynthesis were standardized. Fifty-five patients (79%) were treated conservatively with a modified Velpeau bandage or a sling.

RESULTS

The fractures were classified according to AO into type A (27%), type B (58%) and type C (14%). Osteoporotic risk factors were present in many of the patients, mainly characterized by other skeletal injuries than the proximal humeral fracture (43%). In the group of complex, displaced, non-impacted fractures B2, B3, C2, C3 included (20 fractures), the group treated conservatively had a mean Rowe score of 48/75 (64% of maximum score) and SD 16.8, while in the surgically treated group the mean score was 28/75 (38% of maximum score) and SD 8.1. The difference between the two treatments was significant, with a p-value of 0.01 in favour of the conservatively treated group.

CONCLUSION

The number of patients in each of the fracture groups was low, but surgery did not benefit the patients with complex, displaced fractures in this study.

Two-part and three-part fractures of the proximal humerus treated with suture fixation

OBJECTIVE

To evaluate the radiographic and clinical outcomes of patients with displaced proximal humerus fractures (two-part and three-part) treated with nonabsorbable rotator cuff-incorporating sutures.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS

There were 27 patients (28 shoulders) with displaced proximal humerus fractures. There were 13 greater tuberosity (GT) and 9 surgical neck (SN) two-part fractures and 6 GT/SN three-part fractures. The average age was 64 years (range 38 to 84 years). The average follow-up was 4.4 years (range 1.0 to 11.5 years).

INTERVENTION

All patients were surgically treated solely with heavy polyester nonabsorbable sutures.

MAIN OUTCOME MEASUREMENTS

Functional assessment was obtained using the American Shoulder and Elbow Surgeons (ASES) score and Neer's criteria, which grade outcomes as excellent, satisfactory, or unsatisfactory.

RESULTS

Overall, there were 22 (78%) excellent, 3 (11%) satisfactory, and 3 (11%) unsatisfactory results, and the average ASES score was 87.1 (range 35.0 to 100.0). All shoulders healed radiographically without evidence of avascular necrosis of the humeral head. Twenty-four shoulders (86%) had anatomic alignment on postoperative radiographs. Of four shoulders with nonanatomic alignment, three had ASES scores of >/=90, with excellent Neer scores. When comparing patients with isolated two-part GT fractures (n = 13) with patients having two-part SN or three-part SN/GT fractures (n = 15), there were no statistically significant differences with respect to range of motion (P > 0.05) and outcome measures (P > 0.05). All patients who had unsatisfactory outcomes were noncompliant with physical therapy, with ASES scores averaging 39.4 (range 35.0 to 43.3).

CONCLUSION

Two-part and three-part GT and SN fractures can be treated satisfactorily with heavy nonabsorbable rotator cuff-incorporating sutures, particularly in elderly patients. Hardware-associated complications are obviated. Patients with SN fractures treated with sutures can have outcomes similar to patients with two-part GT fractures. Although the goal is to reconstruct a "one-part" fracture pattern, some residual deformity does not preclude an excellent outcome. A compliant patient is crucial for a successful result.