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Cappellari A, Trovarelli G, Andriolo M, Berizzi A, Ruggieri P. Reverse shoulder arthroplasty for treatment of proximal humerus complex fractures in elderly: A single institution experience. Injury 2022; 53 Suppl 1:S2-S7. [PMID: 32736824 DOI: 10.1016/j.injury.2020.07.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment of complex proximal humerus fractures (PHFs) in the elderly should provide early mobilization to maintain autonomy and self-care possibility, avoiding further surgery for complications. Nowadays, there is not a gold standard for treatment. Aim of our study was to review our experience with the use of Reverse Total Shoulder Arthroplasty (RTSA) for the treatment of these fractures in the elderly, evaluating complications and functional results. MATERIALS AND METHODS Ninety-one patients older than 65 were treated with RTSA at our Institute between June 2005 and December 2017: there were 14 males and 77 females, with a mean age of 76 years (range 65-87 years). There were 58 fractures (20 Neer 3, 38 Neer 4) and 33 fracture-dislocations (7 Neer 3, 26 Neer 4). Complications were recorded, and functional outcomes were evaluated using the DASH score and Constant score (CS). RESULTS Twenty-three complications occurred: 8 cases of scapular notching, 5 neurologic palsies, 4 dislocations, 3 intraoperative diaphyseal fractures, and subclavian artery damage, deep infection, and radiolucent line in one each. No aseptic loosening or breakage was observed. Further surgeries were necessary in 3 cases only, whereas all patients retained their implant at last follow-up. Functional results were satisfactory: mean abduction was 93°, mean flexion was 110°, mean active internal-rotation reached 35°, mean active external-rotation was 25°, mean CS was 54 points and mean DASH score was 45 points. DISCUSSION Surgical treatment of complex PHFs should be a "one-shot surgery," especially in the elderly, since further surgeries could compromise patient outcomes and survival. Additional surgery due to complications is less frequent after RTSA than other techniques. A stable reconstruction permitting early mobilization is fundamental in the elderly. Usually, a prolonged immobilization is recommended after ORIF, TSA, and hemiarthroplasty to provide a stable fixation, whereas RTSA allows early mobilization. CONCLUSIONS In elderly with inadequate bone stock and needing early recovery of autonomy in daily activities, RTSA effectively treats complex PHFs. The incidence of complications requiring revision surgery is low and functional results are satisfactory and predictable.
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Affiliation(s)
- Alessandro Cappellari
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Giulia Trovarelli
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Martina Andriolo
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Antonio Berizzi
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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Aguado HJ, Ariño B, Moreno-Mateo F, Bustinza EY, Simón-Pérez C, Martínez-Zarzuela M, García-Virto V, Ventura PS, Martín-Ferrero MÁ. Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study. J Shoulder Elbow Surg 2018; 27:2021-2029. [PMID: 29803503 DOI: 10.1016/j.jse.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.
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Affiliation(s)
- Héctor J Aguado
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain; Medical School, University of Valladolid, Valladolid, Spain.
| | - Blanca Ariño
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Elías Y Bustinza
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | - Clarisa Simón-Pérez
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery (Upper Limb Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Virginia García-Virto
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Miguel Ángel Martín-Ferrero
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
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Saul D, Himmelmann T, Dresing K. Humeral Tip-apex-distance as a Prognostic Marker for Proximal Humeral Fractures in 203 Patients. Open Orthop J 2017; 11:297-308. [PMID: 28567159 PMCID: PMC5420189 DOI: 10.2174/1874325001711010297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/09/2017] [Accepted: 03/09/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare. OBJECTIVE Determination of predictive factors for the failure of osteosynthesis with the loss of fixation or migration of screws in humeral head fractures. METHOD From 1995 to 2011, 408 patients with proximal humeral fractures [mean age 66.6 years, 50.9-82.3 years] and osteosynthesis were analyzed. Two hundred and three received open reduction internal fixation (ORIF) with the PHILOS® plate. The non-locking plate was used in 80, the locking plate in 16 and humeral head prosthesis in 26 patients, in addition to 23 patients undergoing other procedures. Intraoperative reduction that achieved an anatomical alignment of the medial aspect of the humerus (humeral calcar) was assessed in 94 patients by postoperative X-ray analysis. The loss of fixation was evaluated by a follow-up of three to five X-rays and measurement of the humeral tip-apex-distance (HTAD). RESULTS For stable fixed fractures with an intact calcar, percentual HTAD was significantly higher than for unstable fixed fractures (p=0.04). Morbidity, such as hypertension, orthopedic operations or diabetes, strongly influenced the HTAD, while postoperative passive motion treatment modestly affected the HTAD over time. CONCLUSION The anatomic reconstruction of the calcar, leading to stable fixation of humeral head fractures, can significantly prevent an overproportioned decrease in the HTAD in postoperative X-rays and seems to be vital in multimorbid patients. Measurement of the HTAD over time delivers a tool for early detection of secondary loss of fixation.
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Affiliation(s)
- Dominik Saul
- Department of Trauma, Orthopaedics and Reconstructive Surgery, Georg-August-University of Goettingen, Goettingen, Germany
| | | | - Klaus Dresing
- Department of Trauma, Orthopaedics and Reconstructive Surgery, Georg-August-University of Goettingen, Goettingen, Germany
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Aguado HJ, Mingo J, Torres M, Alvarez-Ramos A, Martín-Ferrero MA. Minimally invasive polyaxial locking plate osteosynthesis for 3-4 part proximal humeral fractures: our institutional experience. Injury 2016; 47 Suppl 3:S22-S28. [PMID: 27692102 DOI: 10.1016/s0020-1383(16)30602-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The objectives of this study were to describe the surgical technique of fixation of 3-4 part proximal humeral fractures with polyaxial locking plates utilising a minimally invasive approach and to evaluate the accuracy of reduction and stability of fixation. PATIENTS AND METHODS We retrospectively reviewed 90 patients. Fractures were classified according to the Neer classification system. Different radiological parameters were measured to assess the quality of reduction and the stability of fixation. Complications and clinical outcomes were evaluated after one year of minimum follow up. RESULTS There were 76 women and 14 men, with a mean age of 67.4years ±13 (range, 29-85). There were 60 3-part and 30 4-part fractures. Frozen cancellous allograft was used in 30 cases (33.3%). All fractures progressed to union and at one year follow up, the mean Constant score was 79.6±12(range, 62-100). Mean forward flexion, abduction, external rotation and internal rotation were 155°, 148°, 39° and vertebra Dorsal 8, respectively. Complications were noted in seven patients while the postoperative "head-diaphysis angle", "greater tuberosity height" and "medial metaphysis reconstruction" were close to the anatomical parameters; no significant differences were noted at one year radiological follow up. CONCLUSION Reliable and stable fixation can be expected with the use of polyaxial locking plate through a minimally invasive approach for the treatment of 3-4 part proximal humeral fractures. Satisfactory functional results for this procedure can be obtained.
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Affiliation(s)
- Héctor J Aguado
- Trauma Unit, Orthopaedic and Traumatology Department, Hospital Clínico Universitario, Valladolid, Spain.
| | - Juan Mingo
- Trauma Unit, Orthopaedics and Traumatology Department, Complejo Asistencial Universitario, Palencia, Spain
| | - Miguel Torres
- Trauma Unit, Orthopaedics and Traumatology Department, Complejo Asistencial Universitario, Palencia, Spain
| | - Aranzazú Alvarez-Ramos
- Orthopaedics and Traumatology Department, Hospital Universitario "Río Hortega", Valladolid, Spain
| | - Miguel A Martín-Ferrero
- Trauma Unit, Orthopaedic and Traumatology Department, Hospital Clínico Universitario, Valladolid, Spain
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Iacobellis C, Berizzi A, Biz C, Camporese A. Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients. Musculoskelet Surg 2014; 99:39-44. [PMID: 24917462 DOI: 10.1007/s12306-014-0331-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 05/18/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of <8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt. MATERIALS AND METHODS There were 33 patients in this study, mean age 76.6 years (range 54-85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot. RESULTS Mean follow-up was 42.3 months (range 10-121). According to the CS, mean pain was 12.6/15 (range 3-15/15), activities of daily living 16.3/20 (range 8-20/20), ROM 21.8 (range 8-32/40) and power 5.4/25 (range 2-12/25). Total mean CS was 56.4 (range 23-80/100). The mean DASH score was 49.7 (range 32-90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28-90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %). CONCLUSIONS Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.
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Affiliation(s)
- C Iacobellis
- Orthopaedic Clinic, University of Padua, Via Giustiniani 2, 35100, Padua, Italy,
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Chowdary U, Prasad H, Subramanyam PK. Outcome of locking compression plating for proximal humeral fractures: a prospective study. J Orthop Surg (Hong Kong) 2014; 22:4-8. [PMID: 24781604 DOI: 10.1177/230949901402200104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the outcome of open reduction and internal fixation using locking compression plates for proximal humeral fractures. METHODS 54 men and 16 women aged 28 to 79 (mean, 54) years underwent open reduction and internal fixation using a locking compression plate for closed 2-part (n=22), 3-part (n=38), and 4-part (n=10) proximal humeral fractures. 10 of the patients also had dislocation of the humeral head; 4 had fractures extending to the shaft. Wound condition, functional outcome, bone union, amount of collapse, and malalignment were assessed. Functional outcome was assessed using the Constant-Murley score. RESULTS; The mean follow-up period was 15 (range, 6-24) months. All fractures achieved union after a mean of 9 (range, 6-12) weeks. The mean Constant-Murley scores for the injured and normal shoulders were 72 and 82, respectively (88% of normal). The final outcome was excellent in 14 patients, good in 28, moderate in 22, and poor in 6. In the latter 6 patients, 2 had screw penetration, 2 had plate impingement, one had a mal-reduced greater tuberosity, and one had adhesive capsulitis. All were preventable. In all, 18 patients had 20 complications: subacromial impingement of the plate (n=6), mal-reduction of the greater tuberosity (n=6), screw penetration (n=2), adhesive capsulitis (n=2), superficial infection (n=2), and haematoma (n=2); 12 of these complications were technique-related. CONCLUSION Locking proximal humeral plates enabled stable fixation in all Neer-type proximal humeral fractures. Most complications were technique-related.
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Affiliation(s)
- Umapathi Chowdary
- Department of Orthopaedics, Srinivas Institute of Medical Sciences & Research Center, Mukka, Mangalore, Karnataka, India
| | - Hari Prasad
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
| | - P Krishna Subramanyam
- Department of Orthopaedics, Kamineni Hospitals, LB Nagar, Hyderabad, Andhra Pradesh, India
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Brorson S, Frich LH, Winther A, Hróbjartsson A. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop 2011; 82:475-81. [PMID: 21657970 PMCID: PMC3237040 DOI: 10.3109/17453674.2011.588856] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 03/08/2011] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable uncertainty about the optimal treatment of displaced 4-part fractures of the proximal humerus. Within the last decade, locking plate technology has been considered a breakthrough in the treatment of these complex injuries. METHODS We systematically identified and reviewed clinical studies on the benefits and harms after osteosynthesis with locking plates in displaced 4-part fractures. RESULTS We included 14 studies with 374 four-part fractures. There were 10 case series, 3 retrospective observational comparative studies, 1 prospective observational comparative study, and no randomized trials. Small studies with a high risk of bias precluded reliable estimates of functional outcome. High rates of complications (16-64%) and reoperations (11-27%) were reported. INTERPRETATION The empirical foundation for the value of locking plates in displaced 4-part fractures of the proximal humerus is weak. We emphasize the need for well-conducted randomized trials and observational studies.
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Affiliation(s)
- Stig Brorson
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark.
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Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS). J Orthop Trauma 2011; 25:286-93. [PMID: 21464737 DOI: 10.1097/bot.0b013e3181f2b20e] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the subjective and objective longer-term outcomes after fracture fixation with the Proximal Humerus InterLocking OSteosynthesis (PHILOS) plate. DESIGN Minimum 4-year follow-up of a primary prospective cohort study. SETTING Single university trauma center. PATIENTS/PARTICIPANTS Sixty-four consecutively collected patients fulfilled the study criteria. Seven patients (11%) were lost to follow-up, resulting in 57 patients (65 ± 14 years). INTERVENTION Open reduction and internal fixation with the PHILOS® plate. MAIN OUTCOME MEASUREMENTS Standardized follow-up including functional outcome instruments (eg, Constant Murley score, Disabilities of the Arm, Shoulder and Hand), rate of complications, and secondary surgeries at 6, 12, and no less than 48 months (uni- and multivariate analysis; P < 0.05). RESULTS At the 4- to 6-year follow-up (median 5 years postinjury), patients on average achieved an 87% range of motion of the injured compared with the uninjured shoulder (eg, 133° ± 40° versus 152° ± 26° abduction). Objective and subjective outcome improved significantly during the overall follow-up, most of all in reoperated and younger patients (65 years and younger) and within the first postinjury year. We observed an overall reoperation rate of 29% and 10 patients (17.5%) demonstrated an insufficient result resulting from pain (greater than 3 visual analog scale) or restricted abduction (less than 90°) at longer-term follow-up. First, the need for revision surgery and, second, increasing age were found to be the most predictive factors for unsatisfactory results. CONCLUSIONS Fracture fixation with the PHILOS showed good to excellent longer-term results in three fourths of patients with outcome partially still improving after the first postoperative year.
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Iacobellis C, Fountzoulas K, Aldegheri R. Plating of proximal fracture of the humerus: a study of 30 cases. Musculoskelet Surg 2011; 95 Suppl 1:S43-8. [PMID: 21373914 DOI: 10.1007/s12306-011-0103-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 02/14/2011] [Indexed: 11/29/2022]
Abstract
In recent years, plate osteosynthesis with angular stable implants is frequently used for severely displaced three- and four-part proximal humeral fractures. The aim of this study is to evaluate early results of these fractures treated with insertion of LCP or Philos plates. We present results in 30 cases of proximal humeral fractures, 17 with 3 parts according to Neer and 13 with 4 parts, treated with Locking Compression Plates (LCP, 14 cases) and Philos plates (16) by the deltopectoral approach. Patients were checked with standard X-rays and clinical evaluation, according to the Constant-Murley shoulder score, Individual Constant score and Relative Constant score. Mean follow-up time was 21 months (range 6-42 months). The mean Constant-Murley shoulder scores were Pain 10.6 (3-15), Activities of Daily Living 15.3 (2-20), Range of Motion 26.8 (12-40) and Power 10.3 (3-25) and Total 63 (25-97). The Individual Constant score was 68.6% (27-98%) and the Relative Constant score 85.4% (36-130%). Fractures in 3 parts (of the surgical or anatomic humeral neck and major tubercle) had a mean Constant score of 69.1 (17 cases), but this fell to 55 (13 cases) in those in 4 parts (neck, major and lesser tubercles). Late necrosis of the humeral head occurred in two cases, both with 4-part breaks. We thus believe that 3-part fractures, in which both reduction and stable osteosynthesis are easier, show favourable prognosis and should be clearly distinguished from 4-part ones during assessments. The deltopectoral approach offers good exposure and is especially recommended in 4-part fractures, also because it provides a good view of the lesser tubercle. The osteosynthesis must be stable if early mobilisation of the shoulder and proper recovery of range of motion are to be achieved. As well as reduction and stabilisation of the tubercles, it is also important to restore the neck/shaft angle and stabilise it with oblique screws fitting the plate to avoid varus malposition.
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Affiliation(s)
- C Iacobellis
- Clinica Ortopedica, University of Padova, Via Giustiniani 2, 35100 Padova, Italy.
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