Reconstruction of the valgus-impacted humeral head fracture

Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus

BACKGROUND

The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality.

METHODS

Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs.

RESULTS

All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side.

DISCUSSION

A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head.

CONCLUSION

Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.

Incidence of secondary displacement after osteosynthesis of proximal humerus fractures: a retrospective study of 185 cases

Proximal humerus fractures are the third most common fracture in patients over 65 years of age. There is no clear consensus regarding their treatment. The objective of this retrospective observational study was to calculate the incidence of secondary displacement after osteosynthesis of these fractures and to identify possible risk factors. 185 cases were reviewed and all osteosynthesized fractures between January 2008 and December 2016 were included. Data collected included age, sex, body mass index, alcohol and tobacco use, bone mineral density of the proximal humerus, fracture type, initial displacement, management time, type of treatment, surgeon's experience and expertise, and postoperative reduction quality. A radiographic follow-up was done at least 3 months following the fracture (until consolidation). The definition of secondary displacement was: varus/valgus displacement >10°, tuberosity translation >5 mm, articular effraction or material breakage. 53 secondary displacements were found, with an incidence of 28.6%. Seventy-two percent were diagnosed at the first follow-up visit, which occurred at an average of 29 days postoperatively. Among all factors studied, only two were statistically significant for secondary displacement: 1) low proximal humeral bone density (defined by a Tingart index <4) appears to be a risk factor, with a calculated relative risk of 2.71 (p = 0.04); and 2) the operator's specialization in the upper limb appears to be a protective factor, with a relative risk of 0.27 (p = 0.01). A similar high incidence of complications after osteosynthesis of the proximal humerus is found in the literature, confirming the difficulty in managing these fractures. More attention should be given to patients with low bone density.

Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges

Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.

Risk factors for intra-articular involvement in proximal humeral fractures

INTRODUCTION

Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures.

MATERIALS AND METHODS

One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks.

RESULTS

Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface.

CONCLUSION

Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making.

LEVEL OF EVIDENCE

Basic science; anatomy study.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BACKGROUND

The surgical treatment of displaced proximal humeral fractures is commonly affected by implant-related complications. We evaluated the functional and radiographic results of transosseous suture fixation in a series of displaced proximal humeral fractures (PHF).

METHODS

Sixty-four patients were retrospectively classified by age, sex, and the Neer fracture classification. Two-part greater tuberosity (2pGT) displaced fractures and 3-part (varus and valgus) and 4-part valgus impacted fractures were managed with fragment reduction and transosseous suture fixation. Patients with minimum follow-up of 24 months and assessed with the Constant-Murley score (CMS) were included. Radiological and medical complications, as well as reinterventions were also recorded.

RESULTS

Forty-six patients with a mean follow-up of 58 (24-132) and a mean age of 58 years old were analyzed. Patients with 2pGT (n = 10) fractures had a CMS of 76 points (59-89); patients with 3-part fractures (n = 22) had a score of 67 points (13-91); and those with 4-part fractures (n = 14) had a score of 64 (24-76) points. The overall complication rate was 6 out of 46, and 4 patients required reintervention for different reasons. Patients presenting with 3-part varus fractures had significantly lower functional outcomes scores (p = 0.007). Humeral head osteonecrosis was present in 9 patients and significantly affected the functional outcomes (p < 0.05). However, only three out of nine patients with osteonecrosis required subsequent surgery at the indicated follow-up.

CONCLUSIONS

The fracture reduction and transosseous fixation technique represents a safe technique with low complication and reintervention rates. The presence of humeral head necrosis did not lead to subsequent surgical intervention because no hardware had protruded.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Modified Use of a Fibular Strut in the Reduction and Stabilization of 2-Part Osteoporotic Proximal Humerus Fractures

PURPOSE

This study introduces a modified use of a fibular strut allograft as an adjunct to lateral locked plating in the treatment of osteoporotic two-part fractures of the proximal humerus.

METHODS

A prospective series of 13 consecutive patients (mean age 68; range, 60 to 88) with displaced two-part fractures of the proximal humerus were included. The main outcome measures included radiographic healing, clinical and radiographic findings of complications, assessment of shoulder function measured with the Shoulder Function Index, and ultrasonography assessment of rotator cuff disruption.

RESULTS

At postoperative month four, every fracture healed as evidenced on radiographic assessment. Clinically, patients achieved an average shoulder forward flexion of 141.5°, external rotation of 37°, and abduction of 98°. The mean Shoulder Function Index score was 73.2 (range, 64 to 77). No patients were included who required a major or a minor revision surgery. The average follow-up was 13.2 months (range, 12 to 15). Ultrasonography demonstrated no tears of the rotator cuff.

DISCUSSION

In a series of 13 patients, our technique facilitated fracture reduction while avoiding additional soft-tissue dissection at the fracture site and enabled supplementary stabilization after application of a lateral locking plate. Using this technique, we had minimal complications, a high rate of osseous healing, and achieved favorable clinical outcomes in a challenging patient population.

Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures

PURPOSE

Valgus impacted proximal humeral fractures with substantial displacement may severely compromise shoulder function and open reduction can therefore be considered. Internal fixation hardware may eventually however constitute problems. In a small subset of these fractures, in which there is no medial comminution and intact blood supply it is possible to use a least possible fixation method with solely sutures through the tendons of the rotator cuff and the shaft as described by Bigliani 1990. The aim of the present study was to investigate the outcome of this fixation method in a retrospective series of patients.

METHODS

Twenty-seven patients, 23 women and 4 men, with a mean age of 66 years (53-83) and minimum follow-up time of 2 years (2-11 years) accepted follow-up with standard shoulder radiographs and 22 were examined with Oxford Shoulder Score (OSS), Constant-Murley (CM) shoulder score and Numeric Rating Scale for pain (NRS). Reoperations or adverse events were recorded.

RESULTS

The median OSS was 45 (range 5-48) and CM 63 (range 21-98). The relative CM score was 81% of the uninjured side and median NRS 0 (range 0-5). No reoperations were undertaken. One patient had a complete avascular necrosis (AVN), 3 patients had a partial AVN of the humeral head and two a partial resorption of the greater tuberosity.

CONCLUSION

The use of sutures only for fixation of displaced valgus-impacted proximal humeral fractures provided a relatively reliable outcome with good functional scores and no reoperations. There appears to be no need for the use of hardware for fixation of this rare subset of fractures.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results

BACKGROUND

On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome.

MATERIALS AND METHODS

Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed.

RESULTS

A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients.

CONCLUSION

This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

[Reduction techniques for minimally invasive stabilization of proximal humeral fractures]

OBJECTIVE

The aim of surgical stabilization of proximal humerus fractures is to restore the anatomical relations between the greater and lesser tubercle, to reconstruct the joint and preserve the vascular supply of the fragments.

INDICATIONS

Approximately 80% of proximal humeral fractures can be treated conservatively. Surgical treatment is indicated based on the fracture pattern, patient-related factors and the risk of avascular head necrosis. Two-part fractures with a metaphyseal comminution zone and 3/4-part fractures can benefit from near to anatomic reconstruction depending on the patient's demands and bone quality. Minimally invasive stabilization procedures allow for an anatomical reconstruction in the majority of fresh proximal humeral fractures with or without a proximal shaft fracture, provided that intraoperative traction allows the fracture to be aligned axially in the image intensifier by ligamentotaxis. Indirect, combined with direct reduction maneuvers, allow for an almost anatomical reconstruction, despite minimal invasive approaches.

SURGICAL TECHNIQUE

Beach chair position. The arm is held in a pneumatic articulating traction device. Evaluation of the indirect reduction potential by ligamentotaxis with visualization of the alignment of the head fragments in relation to the shaft by traction, abduction/adduction, flexion/extension and rotation. The traction device and a foam roll in the axilla to neutralize the tension of the pectoralis major and teres major muscles while simultaneously adducting the elbow hold the reduction. Insufficient reduction of the fragments requires additional direct reduction maneuvers. Opening of the bursa and fixation of the rotator cuff with sutures to adjust reposition. A 2.5 mm-threaded K‑wire is inserted into the head fragment as a joystick. Under protection of the axillary nerve, the plate is inserted under protection of the axillary nerve. Temporary fixation of the plate with Kirschner wires for positioning the plate 5-8 mm below the greater tubercle and 2-3 mm laterally of the sulcus of the long biceps tendon and subsequent radiographic control. Reduction of the shaft against the plate with a cortex screw. The threaded K‑wire in the head can be used to adjust the varus and valgus alignment and to achieve adequate support of the calcar. Finally, complete the osteosynthesis with angular stable screws.

POSTOPERATIVE MANAGEMENT

Immediate active assisted exercise in the shoulder under physiotherapeutic supervision. Temporary immobilization for patient comfort. Standard active and resistive mobilization after the first clinical and radiological checkup 6 weeks after surgery. Further radiological checks after 3 and 6 months and 1 year. No routine plate removal.

Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients

Background

The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention.

Objectives

The present study reports the midterm clinical and radiological results of a large series of consecutive patients with 4-part VI fractures treated with a minimal invasive technique of internal fixation.

Methods

Over a ten-year period (2004-2014), we treated 56 patients with a true 4-part valgus impacted fracture of the proximal part of the humerus. Four patients were lost to follow-up and three died, leaving 49 patients (33 female, 16 males, average age 60,1 years) available for the study. Fracture fixation was achieved through the lateral transdeltoid approach with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding gross disimpaction of the humeral head from the valgus position. Functional outcome assessment was performed using the parameters of the Constant-Murley score within a mean follow up period of 43,8 months (range, 24 to 115 months).

Results

All fractures were united within the first 3 months except one that showed late displacement and finally nonunion. The median Constant score was 81,7 points and the functional score in comparison with the unaffected shoulder was 86.2%. There were three patients with total Avascular Necrosis (AVN) of the head revised to hemiarthroplasty. The nonunion case was revised to reverse shoulder arthroplasty 12 months after surgery. In five cases, absorption of the greater tuberosity was noted in the last radiographic control without any serious consequences to the shoulder function.

Conclusion

Advantages of this minimally invasive technique can be summarized as shorter operative time, no use of hardware, minimal soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with "tension band effect" and adequate rotator cuff repair allowing for early joint motion.

Fracture line morphology of complex proximal humeral fractures

BACKGROUND

The aim of this study was to assess proximal humeral fracture patterns using 3-dimensional computed tomography images and relate them to the normal osseous landmarks and soft-tissue attachments.

METHODS

Forty-eight 3-dimensional computed tomography scans of proximal humeral fractures were retrospectively collected, and the fractures were transcribed onto proximal humeral templates. We analyzed the common location and orientation of the fracture lines, with a focus on fractures of the articular surface, tuberosities, metaphysis, and proximal diaphysis. These fractures were compared with the attachments of the rotator cuff and glenohumeral capsule.

RESULTS

Fifty-two percent of the fractures involved the articular surface. No fractures passed through the bicipital groove, and fractures were more commonly found on the posterior lesser tuberosity and on the anterior greater tuberosity, coinciding with the intervals between the rotator cuff tendon insertions. Intracapsular fractures of the calcar were more common (68%) than extracapsular fractures (32%). On the anterolateral aspect of the proximal humerus, fractures radiated from the articular margin, vertically down through the tuberosity zone between the rotator cuff footprints, meeting horizontally oriented fractures in the metaphyseal zone. On the posterior aspect, vertical fractures from the tuberosity zone continued downward to the metaphyseal zone adjacent to the infraspinatus and teres minor footprints.

CONCLUSIONS

Fractures of the proximal humerus follow characteristic patterns. Fractures frequently split the greater tuberosity and are closely related to the intervals of the rotator cuff attachments.

Outcomes of non-arthroplasty surgical treatment of proximal humeral head fractures

Objective

This study aimed to assess the outcomes of patients with humeral head fractures treated by reduction and osteosynthesis.

Method

A total of 53 shoulders (52 patients) with humeral head fractures were operated between October 1996 and December 2009. Patients previously treated with primary arthroplasty and/or those who had less than two years follow-up were excluded. A total of 34 shoulders of 34 patients were therefore reassessed. In the sample studied, 23 patients were male and mean age was 47 years. Cases were assessed based on the UCLA score.

Results

Mean post-operative follow-up was 50 months. Twelve patients evolved with excellent outcome, seven good, five regular, and ten with poor outcome (55.8% satisfactory and 44.2% unsatisfactory outcomes). Mean UCLA score was 26 points. Mean post-operative range of motion measurements was 117° elevation, 36° LR and L1 MR. At the immediate post-operative radiography, anatomic reduction was evident in 17 patients (50%). Necrosis was detected in 18 patients, six Grade II and 12 Grade III cases. Female gender and anatomically reduced fractures were statistically better at UCLA scale (p = 0.01 and p = 0.0001 respectively).

Conclusions

Female patients had a higher mean UCLA score than male patients (p = 0.01). Anatomically reduced fractures had higher UCLA scores (p = 0.0001) and lower necrosis rate (p = 0.0001). Reconstruction of humeral head fractures had a satisfactory outcome in 55.8% of cases and should be indicated in young and active patients.

Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review

The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. Level of evidence: systematic review of literature (level IV) as most of the studies were level IV.

Fracture of the proximal humerus with disruption of the tendon of the pectoralis major

Combined pectoralis major disruption and proximal humeral fractures are uncommon. A simple radiologic diagnostic tool which consists of the measurement of the displacement from the humeral shaft to the lateral side of the humeral head (lateral to the outer proximal cortex) can help to diagnose this combined lesion.

The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation

After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months.

INTRODUCTION

This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate.

METHODS

A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18 months of follow-up. Constant score was calculated at 6 and 18 months of follow-up.

RESULTS

Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7 %) had a CBTAVG of less than 4 mm. At 3 months of follow-up, 7 cases (22.5 %) had significant loss of reduction and the mean amount of impaction was 2.8 mm. At 18 months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3 mm (p < 0.05). At 6 months follow-up, the mean Constant score was 58 %; while at 18 months, it was 70 % (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013).

CONCLUSIONS

Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3 months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.

Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft

PURPOSE

To evaluate the clinical and radiological outcomes of unstable proximal humeral fractures (PHFs) treated with a locking plate and fibular strut allograft.

METHODS

This study included 36 patients [7 men, 29 women; mean age, 68 years (range, 22-94 years)] with unstable PHFs with medial column disruption. All patients were treated with open reduction and internal fixation using a locking plate and fibular strut allograft. Post-operative assessment included clinical outcomes, shoulder range of motion, radiographic examination, and any complications. Post-operative radiological assessment including the humerus neck-shaft angle (NSA) and the humeral head height was performed.

RESULTS

At the mean two year follow-up visit, the mean American Shoulder and Elbow Society (ASES) and University of California, Los Angeles (UCLA) scores were 77 and 28, respectively. According to the UCLA rating scale, the result was excellent in six, good in 20, fair in six, and poor in four cases. According to the Paavolainen method, 31 patients had good results with an NSA of 130 ± 10°; three patients showed fair results with an NSA of 100-120°, and two patients experienced a poor result with an NSA of <100°. When calculating the humeral head height, the mean loss of reduction was measured as 1.6 mm (from 10.8 or 9.2 mm). Varus collapse and avascular necrosis of the humeral head was noted in two patients for each condition.

CONCLUSIONS

For unstable proximal humerus fractures, particularly in elderly patients with severe osteoporosis or in younger patients with a four-part fracture, locking plate fixation with a fibular strut allograft provided rigid medial support and showed satisfactory clinical and radiological outcomes.

Percutaneous Fixation of Proximal Humeral Fractures

Introduction

The percutaneous approach to proximal humeral fixation emphasizes minimum dissection with the goal of preserving vascularity of the articular segments and thereby decreasing the risk of osteonecrosis.

Step 1: Preoperative Planning

Perform preoperative imaging to assess fracture displacement and comminution in order to confirm that percutaneous treatment is appropriate.

Step 2: Closed Fracture Reduction

Attempt closed fracture reduction prior to incision.

Step 3: Surgical Approach for Humeral Head and Shaft Reduction

Obtain anatomic humeral head reduction, insert terminally threaded pins, and check pin placement fluoroscopically.

Step 4: Tuberosity Fracture Reduction and Fixation of the Tuberosity Fragments

Fix the tuberosity fracture(s).

Step 5: Wound Closure

Cut the pins below the skin and irrigate and close the wounds.

Step 6: Postoperative Rehabilitation

Begin passive shoulder motion after pin removal, and initiate active motion at six weeks after pin removal.

Results

The results of this technique in twenty-seven patients with an average age of 58.8 years (range, forty-two to seventy-six years) at the time of injury were reported previously⁶.

Indications

Contraindications

Pitfalls & Challenges

Lessons learned from treating patients with unstable multifragmentary fractures of the proximal humerus by minimal invasive plate osteosynthesis

INTRODUCTION

The authors present clinical and radiographic results of minimal invasive plate osteosynthesis (MIPO) for three- or four-part fractures of the proximal humerus.

PATIENTS AND METHODS

Twenty-six patients with three- or four-part proximal humeral fractures treated with the MIPO technique through the deltoid splitting approach were clinically and radiographically evaluated at a minimum of 12 months with an average of 20.1 months. The valgus-impacted type of three-part fracture was excluded to verify the results of the MIPO with unstable multifragmentary fractures of the proximal humerus.

RESULTS

Twenty female patients and six male patients were included (mean age 67 years; range 18-90 years). No cases of nonunion were seen. The mean forward flexion, abduction, and external rotation were 145°, 119°, and 48°, respectively. The mean visual analog scale (VAS) for pain was 1.47 points. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 14.5 points, and the mean UCLA score was 29.6 points. The mean neck-shaft angle was 134°. Twenty-three patients had adequate medial support, and three patients did not have adequate medial support on initial postoperative radiographs. Five shoulders (19 %) developed complicated results. Two cases of proximal malposition of the plate (7.7 %) and two intra-articular screw penetrations (7.7 %) were observed. One case of osteonecrosis of the humeral head was identified at the final follow-up (3.8 %).

CONCLUSION

The MIPO technique provides reliable radiologic and functional outcomes for three- and four-part proximal humeral fractures. Our results might support the use of MIPO for treating unstable multi fragmentary fractures of proximal humerus such as three- or four-part fractures to decrease osteonecrosis of humeral head.

The amount of humeral head impaction of proximal humeral fractures fixed with the Humerusblock device

PURPOSE

The Humerusblock is a minimally invasive device allowing fixation of proximal humeral fractures. A drawback of the device is possible K-wire perforation of the head with the need for early removal of the implant. We assessed the amount of humeral head impaction and its role in the postoperative varus/valgus deviation of the humeral head in fractures of the upper humerus treated with Humerusblock.

METHODS

Fractures were classified according to the Codman-Lego system. The length of the posteromedial metaphyseal extension and integrity of medial hinge were measured; metaphyseal comminution was assessed. Accuracy of fracture reduction was classified as excellent to poor. An original method of measurement of amount of postoperative impaction of the humeral head was developed. The impaction and varus/valgus inclination of the heads were measured comparing postoperative and three-month follow-up radiographs. Constant score and its relation to sintering was calculated at 12-month follow-up.

RESULTS

Forty-three fractures were available for follow-up. The amount of humeral head impaction was 3.9 mm on average and was directly correlated with patient's age, sex, Codman-Lego classification, varus inclination and mataphyseal comminution. The postoperative cervico-diaphyseal angle was restored in 35 cases, with 81 % good results. The Humerusblock was removed in 41 % of cases because of K-wire perforation of the humeral head. A negative correlation was found between impaction and Constant score.

CONCLUSIONS

The amount of humeral head impaction is related to patients' age, sex, and fracture patterns, being the most prone to compaction those with metaphyseal comminution. Humeral head impaction negatively affects final Constant score.

[Humeral head replacement in acute proximal humerus fractures]

Complex proximal humerus fractures with an avascular head fragment and unreconstructable fracture types represent indications for humeral head replacement. Special prosthetic designs allow modular anatomical restoration of the centre of rotation and alignment and stable fixation of the tuberosities. These play a key role with respect to the functional outcome and are often prone to complete or partial osteolysis with secondary rotator cuff deficiency. Because the operational procedure is technically demanding, attention must be paid to correct implantation. The functional results which can be expected are reliable with a moderate Constant score of 50 to 60 points and a low pain level. In elderly patients with poor bone quality and an associated increased tuberosity-related complication rate, a primary inverse prosthetic design has to be considered as a reasonable alternative. The overall revision rate is approximately 11 %.

Proximal humeral fracture treatment in adults

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.

Results of open reduction and internal fixation of severe fractures of the proximal humerus in elderly patients

OBJECTIVE

To evaluate clinical and radiological results with open reduction and internal fixation of severe fractures of the proximal humerus in the patients over the age of 60 years.

METHODS

Between June 1992 and February 2011, 21 patients with FGEPU over the age of 60 years were treated by open reduction and internal fixation at the Group of Shoulder and Elbow Department of Orthopaedics and Traumatology of Santa Casa de São Paulo Medical School. 18 patients were reviewed.

RESULTS

Two patients had excellent results, 12 good, three regular and one bad. Therefore, we find that 77.7% of these had good and excellent results. All patients were satisfied with the treatment and only three patients did not return to previous activities. Mean postoperative mobilities were 122° elevation (90-150°), 39 lateral rotation (20-60°) and medial rotation of T11 (T5 to sacro iliac joint).

CONCLUSION

Open reduction and internal fixation of FGEPU may also be indicated for elderly patients and obtained 77.7% of good and excellent results. Statistically (p < 0.05), the anatomical reduction of the fracture was found to be important for obtaining good results.

Malunion of the proximal humerus

Malunion of a proximal humerus fracture is difficult to manage once bone union has been achieved in a wrong position. Malunion may be encountered after conservative treatment or internal fixation of fractures, and also around a joint prosthesis. The malunion can involve the greater and lesser tuberosities, humeral head, bicipital groove, or the entire epiphysis. The nature of the malunion must be precisely characterized. Malunion can affect bone structures and the articular surface; any resulting displacements must be carefully measured. Clinical assessments will help to evaluate the functional repercussions and determine the need for correction. Radiographic imaging and CT scan guide the treatment plan. Arthroscopic surgery (acromioplasty or tuberoplasty) can be used to treat biceps tenosynovitis or impingement syndrome in cases where full correction of the malunion is not required. Corrective surgery of a metaphyseal malunion is used to realign the proximal humeral into the proper position. Tuberosity osteotomy is the main predictor for a poor outcome following secondary arthroplasty.

Surgical treatment of three and four-part proximal humeral fractures

Three- and four-part fractures of the proximal humerus are usually treated surgically. Open reduction with internal fixation (ORIF) is the method of choice in younger patients. Anatomic reduction of the tuberosities is crucial to ensure that, in the event of poorly tolerated avascular necrosis of the humeral head, hemiarthroplasty can be performed under optimal conditions. Suboptimal outcomes may occur after ORIF, as less-than-perfect reduction and fixation is poorly tolerated at the shoulder. Preoperative computed tomography must be performed routinely to analyse fragment displacement and comminution, classify the fracture, assess humeral head vitality, and evaluate the mechanical properties of the underlying bone. Fracture reduction relies on principles that are shared by the various available techniques. Reduction of each fragment should be assessed separately. Reduction of the humeral head to the shaft should be performed before reduction of the tuberosities. The fixation technique should ensure stability of the anatomic reduction, with secure fixation of the tuberosities and a minimal risk of material migration into the joint. Here, we provide a detailed discussion of the various techniques, with their advantages and drawbacks, to help surgeons select the method that is most appropriate to each individual patient.

Is it worth fixing proximal humeral fractures at increased vascular risk?

OBJECTIVE

To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion.

DESIGN

Prospective, consecutive, multicenter based.

SETTING

Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study.

METHODS

Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.

RESULTS

There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score.

CONCLUSION

Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.

LEVEL OF EVIDENCE

Level IV: prospective study.

Percutaneous pinning of three- or four-part fractures of the proximal humerus in elderly patients in poor general condition: MIROS® versus traditional pinning

PURPOSE

Elderly subjects often have fractures of the proximal humerus, which may be difficult to manage in patients in poor general condition. The MIROS is a new percutaneous pinning device allowing correction of angular displacement and stable fixation of fracture fragments. We evaluated the results of percutaneous fixation of three- or four-part fractures of the proximal humerus of patients in the American Society of Anesthesiologists physical status three or four treated either with MIROS or traditional percutaneous pinning (TPP).

METHODS

A total of 31 patients treated with MIROS and 27 undergoing TPP were enrolled in the study. Pre-operatively anteroposterior and transthoracic or axillary radiographs were obtained in all cases and computed tomography scans in patients with the most complex fractures. Follow-up evaluations were carried out at three, six, 12 and 16 weeks, and six months, one year and two years postoperatively, using the Constant Score (CS) and subjective shoulder value (SSV) methods.

RESULTS

Of the 58 patients, 52 could be evaluated at all follow-ups. In both three- or four-part fractures there were significantly higher CS and SSV scores in the MIROS compared to the TPP group at all the late follow-ups. Lower rates of deep infection, pin tract infection and pin mobilisation were found in the MIROS group (p < 0.001). In both groups there was a significant association between the final result (CS) and either the type of fracture or complications (p < 0.001).

CONCLUSIONS

The MIROS resulted in better clinical results and less complications than TPP in elderly patients. This method, however, may not be indicated for younger patients in good general condition.

Endosteal strut augment reduces complications associated with proximal humeral locking plates

BACKGROUND

Locking-plate technology has renewed interest in plate fixation for treating proximal humerus fractures. Complications associated with these devices, including loss of reduction, screw cutout, and intra-articular penetration, are frequent. Establishing a second column of support may reduce complications and improve clinical outcome scores.

QUESTIONS/PURPOSES

We asked whether addition of an endosteal cortical allograft strut, used as an augment to locking-plate fixation for displaced proximal humerus fractures, would reduce complications and improve clinical outcome scores.

PATIENTS AND METHODS

We retrospectively reviewed the charts and radiographs of 38 patients treated by this method. All patients were evaluated with serial radiographs, as well as the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores. There were seven two-part, 19 three-part, and 12 four-part fractures. The minimum followup was 49 weeks (average, 75 weeks; range, 49-155 weeks).

RESULTS

No patient had intra-articular screw penetration or cutout. No patient had complete osteonecrosis, but one had partial osteonecrosis. The reduction was lost in one patient. The mean Disabilities of the Arm, Shoulder, and Hand score was 15 (range, 0-66.4). The mean Constant-Murley score was 87 (range, 51-95).

CONCLUSIONS

Low rates of complication and high clinical outcome scores can be achieved when treating complex proximal humerus fractures with locking-plate fixation and an endosteal strut augment.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Retrograde intramedullary multiple pinning through the deltoid "V" for valgus-impacted four-part fractures of the proximal humerus

BACKGROUND

The "palm tree-like wiring" introduced by Kapandji and its modifications for proximal humeral fractures should be given the generic name "retrograde intramedullary multiple pinning through the deltoid 'V'" (IMPV). IMPV is still preferable for treating valgus-impacted four-part fractures in which K-wires have the advantage of working as an internal fixation material as well as a tool in fracture reduction.

METHODS

Three 2.4-mm K-wires formed into the desired shape are used as the intramedullary pins and a 3.0- to 3.2-mm upwardly angled hole for each wire is opened in the deltoid "V." After the tips of two wires are introduced into the lateral aspect of the head, the valgus deformity of the head is gradually corrected by alternately tapping the two wires under fluoroscopy. When the head and metaphysis are strongly compressed together, open reduction is attempted. If required, the tuberosity fragments are surgically reduced and stabilized. We performed IMPV on one C2.1 fracture and nine C2.2 fractures with 1 year or more follow-up.

RESULTS

No nonunion was observed, but avascular head necrosis with collapse was observed in two C2.2 fractures, of which constant score ratios to the normal side were 55% and 64%, respectively. The constant score ratios of the other eight patients were 92% ± 8% (70-96%).

CONCLUSIONS

IMPV is considered to be a preferable reducing and stabilizing method for valgus-impacted four-part fractures regardless of patient age. Additionally beneficial is being able to use the intramedullary pins as a tool for bone fragment reduction.

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.

Da Vinci System: clinical experience with complex proximal humerus fractures

The purpose of this study is to report the clinical and radiographic outcomes after open reduction and internal fixation of displaced proximal humerus fractures with the "Da Vinci System". It is a triangle-shaped cage whose opposite faces are pierced, and it represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. The new device is an interesting innovation to treat the difficult problem of fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization. According to the technique, authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage, and they are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. If the fracture line involves the proximal portion of the diaphysis, it is possible to use a short low profile plate. Between May 2005 and November 2009, we treated 71 patients (34 men and 37 women), even though we included in our study only 59 patients, who had a minimum follow-up of 12 months. The first patient has been treated in May 2005 and the last one in September 2008. The mean age was 60.8 years (minimum 27, maximum 78). There were 8 displaced 3-part fractures, 20 displaced 4-part fractures, 10 4-part fracture-dislocations, 5 head splitting, 12 unclassified multifragmentary fractures, 1 2-part fracture with multifragmentary calcar and 3 malunions of 4-part fracture. The functional results were evaluated by the Constant score. With a mean follow-up of 24 months (minimum 12, maximum 36 months), the mean Constant score was 80.25. The results were excellent or good in 48 cases, bad in 2 cases and satisfactory in 9; the mean active anterior elevation (AAE) was 160 degrees . All fractures but one healed; in one case, we had a deep infection after 80 days since the operation, treated with a preformed cement spacer.

Displaced proximal humeral fractures: an Indian experience with locking plates

Background

The treatment of displaced proximal humerus fractures, especially in elderly, remains controversial. The objective of this study was to evaluate functional outcome of locking plate used for fixation of these fractures after open reduction. We also attempted to evaluate the complications and predictors of loss of fixation for such an implant.

Methods

Over two and a half years, 56 patients with an acute proximal humerus fracture were managed with locking plate osteosynthesis. 47 of these patients who completed a minimum follow up of 1 year were evaluated using Constant score calculation. Statistical analysis was done using SPSS 16 and a p value of less than 0.05 was taken as statistically significant.

Results

The average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation.

Conclusion

Locking plate osteosynthesis leads to satisfactory functional outcomes in all the patients. Results are better than non locking plates in osteoporotic fractures of the elderly. However the surgery has steep learning curve and various complications could be associated with its use. Nevertheless we believe that a strict adherence to the principles of locking plate use can ensure good result in such challenging fractures.

The medial periosteal hinge, a key structure in fractures of the proximal humerus: a biomechanical cadaver study of its mechanical properties

The medial periosteal hinge plays a key role in fractures of the head of the humerus, offering mechanical support during and after reduction and maintaining perfusion of the head by the vessels in the posteromedial periosteum. We have investigated the biomechanical properties of the medial periosteum in fractures of the proximal humerus using a standard model in 20 fresh-frozen cadaver specimens comparable in age, gender and bone mineral density. After creating the fracture, we displaced the humeral head medial or lateral to the shaft with controlled force until complete disruption of the posteromedial periosteum was recorded. As the quality of periosteum might be affected by age and bone quality, the results were correlated with the age and the local bone mineral density of the specimens measured with quantitative CT. Periosteal rupture started at a mean displacement of 2.96 mm (SD 2.92) with a mean load of 100.9 N (SD 47.1). The mean maximum load of 111.4 N (SD 42.5) was reached at a mean displacement of 4.9 mm (SD 4.2). The periosteum was completely ruptured at a mean displacement of 34.4 mm (SD 11.1). There was no significant difference in the mean distance to complete rupture for medial (mean 35.8 mm (SD 13.8)) or lateral (mean 33.0 mm (SD 8.2)) displacement (p = 0.589). The mean bone mineral density was 0.111 g/cm(3) (SD 0.035). A statistically significant but low correlation between bone mineral density and the maximum load uptake (r = 0.475, p = 0.034) was observed. This study showed that the posteromedial hinge is a mechanical structure capable of providing support for percutaneous reduction and stabilisation of a fracture by ligamentotaxis. Periosteal rupture started at a mean of about 3 mm and was completed by a mean displacement of just under 35 mm. The microvascular situation of the rupturing periosteum cannot be investigated with the current model.

Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial

Background

Fractures of the proximal humerus are common injuries and account for 4–5 percent of all fractures, second only to hip and wrist fractures. The incidence is positively correlated with age and osteoporosis, and is likely to increase. Displaced four-part fractures are among the most severe injuries, accounting for 2–10 percent of proximal humeral fractures. The optimal intervention is disputed. Two previous randomised trials were very small and involved a noticeable risk of bias, and systematic reviews consequently conclude that there is inadequate basis for evidence-based treatment decisions. We aim to compare the effect of osteosynthesis with angle-stable plate with non-surgical management, and the effect of primary hemiarthroplasty with both osteosynthesis and non-surgical management.

Methods/Design

We will conduct a randomised, multi-centre, clinical trial including patients from ten national shoulder units within a two-year period. We plan to include 162 patients. A central randomisation unit will allocate patients. All patients will receive a standardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation. Patients will be followed at least one year. The primary outcomes will be the overall score on the Constant Disability Scale, and its pain subscale, measured at 12 months. A blinded physiotherapist will carry out the assessments. Other secondary outcomes are Oxford Shoulder Score, and general health status (Short Form-36).

Locked intramedullary nailing for treatment of displaced proximal humerus fractures

Controversy surrounds the optimal technique for fixation of displaced fractures, although locked intramedullary nailing is emerging as a preferred technique in managing displaced proximal humerus fractures in appropriately selected patients. This technique provides stable fracture fixation allowing early postoperative mobilization critical in ensuring a pain-free shoulder with a functional range of motion. Additional advantages include the ability to insert by way of a minimally invasive approach with limited soft tissue dissection, achieve accurate anatomic reduction, provide a secure construct even in the situation of osteopenic bone or comminution, and manage fractures of the proximal humerus extending into the shaft.

Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial

OBJECTIVES

To evaluate the safety and functional outcome of a recently described surgical technique of percutaneous plating for proximal humerus fractures.

DESIGN

Prospective clinical trial.

SETTING

: Two urban Level 1 university trauma centers.

PATIENTS

From February 2002 to December 2003, 34 consecutive patients underwent surgery by 5 trauma surgeons from 2 teaching hospitals. Twenty-seven patients had 1-year follow-up.

INTERVENTION

The technique involved 2 minimal incisions with a lateral deltoid split and a more distal shaft incision. A proximal humerus-specific locking plate was implemented.

MAIN OUTCOME MEASUREMENTS

DASH (disabilities of the arm, shoulder, and hand) and Constant-Murley evaluation scores were used for functional evaluation. The presence of complications was noted.

RESULTS

Specifically, there were no axillary nerve injury injuries and no loss of reduction. The average Constant score at 1 year was 82 and the DASH score was 26.

CONCLUSION

This study demonstrated that the functional outcome results correspond to a normal age-adjusted score signifying an acceptable result.

The use of intramedullary helix wire for the treatment of proximal humerus fractures

OBJECTIVE

To present the functional and radiographic outcome 1 and 6 years after application of a new intramedullary fixation device for proximal humerus fractures.

DESIGN

Retrospective case series.

SETTING

Level II orthopaedic surgery hospital.

PATIENTS

Twenty-six consecutive patients (average age 68.9 years) with 2-, 3- and 4-part fractures of the proximal humerus were operated at a single institution. Follow-up was performed after 1 year (26 patients) and 6 years (16 patients).

INTERVENTION

All patients were treated with closed reduction and intramedullary helix wires.

MAIN OUTCOME MEASUREMENTS

The Constant-Murley score and the University of California Los Angeles (UCLA) score. Clinical complications and radiological posttraumatic arthritis were recorded.

RESULTS

The average Constant-Murley score was 70.3 (points) and 70.7 after 1 and 6 years, respectively; the average UCLA score was 27.2 and 31.5 after 1 and 6 years, respectively. Major complications were 4 revisions for 3 secondary fragment displacements and 1 nonunion with partial avascular osteonecrosis in the first postoperative year. Complications were found predominantly in 4-part fractures (3/5, 60%). There were no further complications or progressive posttraumatic arthritis up to 6 years following surgery.

CONCLUSION

The helix wire is well suited for displaced or unstable 2- and 3-part proximal humerus fractures. Adequate functional outcome, a low number of implant displacements, a low number of application morbidity, and infrequent implant removals were recorded. The use of this device is not recommended for 4-part fractures.

Current concepts in the treatment of proximal humeral fractures

Preoperative classification of proximal humeral fractures in addition to thorough knowledge of the specific anatomy and vascular blood supply is more important for successful treatment than the choice of implant. If reduction and fixation is necessary, aggressive reduction maneuvers can compromise humeral head perfusion with subsequent humeral head necrosis regardless of the implant used. Modern implants such as intramedullary proximal humeral nails and anatomically designed proximal humeral angular stable plates offer high primary stability even in osteoporotic bone with preservation of periosteal blood supply to the humeral head. These implants allow early functional exercises and showed good to excellent results in the majority of patients with an acceptable complication rate. Increasing experience with these relatively new implants and further technical development might improve clinical results and reduce complications. Minimally invasive, percutaneous techniques also demonstrate favorable results comparable to those mentioned above, although mean patient age tends to be younger in these studies and complications requiring reoperation tend to be more pronounced in elderly patients due to poor bone quality. Alternatively, nonoperative treatment of displaced two- and three-part fractures in elderly patients with severe morbidity and high perioperative risks should be considered. In elderly patients with selected displaced four-part fractures or fracture dislocations and head-split fractures, hemiarthroplasty offers high subjective patient satisfaction despite moderate function with most of the patients being pain free.

Reverse shoulder arthroplasty for the treatment of proximal humeral fractures

Proximal humeral fractures occurring in elderly patients often lead to significant functional disability. The outcome of nonoperative management is disappointing. Treatment with open reduction and internal fixation may result in osteonecrosis of the humeral head, and pain. Hemiarthroplasty is often associated with tuberosity nonunion and poor function. Reverse shoulder arthroplasty is an attractive alternative because of the ability of the prosthesis to compensate for tuberosity complications. Early studies have shown promise in using the prosthesis to treat these difficult patients. The next step will require prospective, randomized studies to determine which patient groups derive any benefit from reverse shoulder arthroscopy. The technology should be used judiciously.

Transosseous suture fixation of proximal humeral fractures

BACKGROUND

The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus.

METHODS

Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis.

RESULTS

All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%.

CONCLUSIONS

The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

A biomechanical comparison of locking plate and locking nail implants used for fractures of the proximal humerus

The aim of this study was to determine the biomechanical behavior of 2 different implants used in the fixation of proximal humeral fractures. The 2 implants in this study are specifically designed for the fixation of proximal humeral fractures, and both are based on the concept of fixed-angle locking screws. A reproducible 3-part fracture was created in paired human cadaveric bone and then fixed via the locking screw implants. Stress/strain curves for the bone-implant construct were created for loads applied in different directions to determine the relative stiffness below the yield point. After this, each construct was tested to failure with a valgus bending load. The locking nail implant provided a significantly stiffer construct to valgus, extension, and flexion cantilever bending loads below the failure threshold. The valgus load to failure was significantly higher for the nail. The mode of failure was different between implants.

Outcomes after percutaneous reduction and fixation of proximal humeral fractures

The purpose of this study is to report the outcomes after closed or percutaneous reduction with percutaneous fixation of displaced proximal humeral fractures. This study included 35 patients from 3 institutions. Of these, 27 were followed up for a minimum of 1 year after surgery. The mean age at injury was 61 years. There were seven 2-part, eight 3-part, and twelve valgus-impacted 4-part proximal humeral fractures. All fractures were reduced and stabilized with percutaneous techniques only. The mean duration of follow-up was 35 months. All fractures healed after the index procedure. The mean pain score on a visual analog scale was 1.4. The mean American Shoulder and Elbow Surgeons and Constant scores were 83.4 and 73.9, respectively. Four patients healed with malunion, and in four, glenohumeral joint osteoarthritis developed. Fracture type, age, malunion, or osteoarthritis had no significance influence on measured outcomes. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications.

Innovations in the management of displaced proximal humerus fractures

The management of displaced proximal humerus fractures has evolved toward humeral head preservation, with treatment decisions based on careful assessment of vascular status, bone quality, fracture pattern, degree of displacement, and patient age and activity level. The AO/ASIF fracture classification is helpful in guiding treatment and in stratifying the risk for associated disruption of the humeral head blood supply. Nonsurgical treatment consists of sling immobilization. For patients requiring surgery, options include closed reduction and percutaneous fixation; transosseous suture fixation; open reduction and internal fixation, with either conventional or locking plate fixation; bone graft; and hemiarthroplasty. Proximal humerus fractures must be evaluated on an individual basis, with treatment tailored according to patient and fracture characteristics.

Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury).

Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries.

A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

Treatment of proximal humeral fractures with a new intramedullary nail

We have developed a new intramedullary nail (All-in-One Nail) that is specifically designed for elastic fixation of a surgical neck fracture of the humerus. This nail has three pins and a plate, and the pins become divergent as the nail is inserted into the marrow cavity through the deltoid tuberosity and then advanced to the humeral head. We reviewed 31 patients with an age range of 58-91 years (mean 75 years) who underwent surgery with this nail for A3.2 (two-part), B2.2 (three-part), or C2.1 (valgus-impacted) fractures of the proximal humerus. Bony union was obtained in 29 patients, and these patients had a Japanese Orthopaedic Association shoulder score of 60-92 (mean 78) in a follow-up examination performed 6-32 months (mean 13 months) postoperatively. The All-in-One Nail system is easy to use, provides an acceptable clinical outcome, and is a treatment option for unimpacted surgical neck fractures and valgus-impacted fractures of the humerus.