Displaced 3- and 4-part proximal humeral fractures: Evaluation and management with an intramedullary nail within 48 h, in the emergency department

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications

INTRODUCTION

Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients.

METHODS

A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS.

RESULTS

Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively.

CONCLUSION

Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures

Objective

This study was performed to evaluate the clinical effect of MultiLoc® nails (DePuy Synthes, Raynham, MA, USA) on the treatment of four-part proximal humeral fractures (PHFs).

Methods

From January 2014 to January 2018, 32 patients with four-part PHFs were treated with intramedullary MultiLoc® nails in our hospital. The operation time, bleeding volume, postoperative X-ray findings, and fracture healing status were recorded and analyzed. At the end of follow-up, the clinical outcome was evaluated based on the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant–Murley score (CMS), and occurrence of any complications.

Results

Among all patients, the average operation time was 124.5 minutes (range, 91–152 minutes), the average amount of bleeding was 90 mL (range, 55–150 mL), and the fracture healing rate was 100%. At the end of follow-up, the mean VAS score was 1.6 ± 0.4, mean ASES score was 84.4 ± 6.3, and mean CMS was 70.3 ± 6.1; no serious complications had occurred; and the patients exhibited good recovery of shoulder function.

Conclusions

MultiLoc nails® can be applied to the treatment of four-part PHFs. This surgical fixation method has no obvious complications and helps to restore shoulder function.

Is antegrade nailing a proper option in 2- and 3-part proximal humeral fractures?

PURPOSE

To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature.

MATERIALS AND METHODS

From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30 months (range 24-42). Moreover, a review of the literature was carried out.

RESULTS

The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7 months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65 years, mean follow-up of 22.2 months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws.

CONCLUSIONS

Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

Use of a locking intramedullary nail for the treatment of initial varus proximal humeral fracture: a prospective pilot study

Objective

To evaluate the feasibility of locked intramedullary nailing, rather than locking plate fixation combined with fibular allograft augmentation, for initial varus proximal humeral fractures.

Methods

This prospective pilot study enrolled patients with initial varus proximal humeral fractures that were treated with a locking intramedullary nail. Radiography was performed to evaluate fracture healing. Data about the visual analogue scale (VAS) pain score, Constant Shoulder Score (CSS), Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score and shoulder range of motion (ROM) were recorded.

Results

Twenty patients, including eight with Neer two-part and 12 with three-part fractures, were followed-up, with a mean time of 12.3 months. All patients sustained fractures that healed without re-varus. During the last follow-up, the shoulder function of the patients had recovered well, with a mean VAS pain score of 1.4, a mean CSS of 83.1, a mean DASH score of 80.8, a mean ASES score of 84.0 and a satisfactory ROM. In one patient, the proximal locking screw came out and was removed via a second surgery.

Conclusions

The use of a locking intramedullary nail alone for initial varus proximal humeral two-/three-part fractures was feasible. This treatment has advantages, such as preventing re-varus and causing milder surgical trauma, than that seen with a locking plate.

Multifragmentary dislocated humeral head fracture-A case report of a successful head preserving treatment strategy despite delayed presentation

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Case report of multifragmentary and luxated humeral head fracture treated headpreserving despite delayed surgery (120 h).

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“Avoiding arthroplasty inspite of extrmely high risk of avascular necrosis due to compromised blood supply in luxation oft he humeral head.

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The headpreserving treatment showed excellent functional and radiologic results keeping a high “quality of life level”.

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Divergent from the recommended standard−treatment (trauma arthroplasty) of luxated humeral headsplit fractures in a “delayed situation” a head preserving option should be taken into consideration.

Introduction

Head preserving, delayed osteosynthesis five days after a luxated, multifragmentary humeral head fracture is rarely seen and a challenge for the surgeon.

Presentation of case

This case history describes the case of a 69-year-old female with delayed head preserving treatment of a dislocated multifragmentary humeral head fracture using intramedullary nailing, avoiding a primary trauma arthroplasty after strict refusal of the patient despite poor prognosis and high risk of avascular humeral head necrosis.

Discussion

The treatment of the humeral head fracture is still a matter of debate, the “golden standard” does not exist, especially in the deferred luxated situation. With the use of modern implants head preserving treatment is reasonable and possible. It should therefore always be taken into account as an alternative for arthroplasty.

Conclusion

Excellent postoperative outcome can be achieved by joint reconstruction eliminating the possible side effects of shoulder endoprosthesis.