Surgical treatment of complex fracture of the proximal humerus

Clinical and Radiological Outcome of Dual Plating for Proximal Humerus Fractures

Introduction Proximal humerus fractures account for approximately 4%-5% of all fractures. It accounts for approximately 45% of all humeral fractures. Proximal humerus fractures which are mostly stable or minimally displaced fractures are usually managed non-operatively with good outcomes. Displaced or unstable fractures may require reduction and stabilization. For proximal humerus fractures, conservative treatments often result in stiffness and malunion of the shoulder. In comminuted proximal humerus fractures the use of a proximal humeral internal locking system (PHILOS) only does not provide the required stable fixation which usually leads to complications such as varus collapse, malunion, anterior-posterior angulation, screw cutout, metal failure and nonunion and thus open reduction and internal fixation with dual plating are recommended for proximal humerus fractures. Material and methods The Institutional Ethics Committee of Dr. D. Y. Patil Vidyapeeth in Pune approved this prospective study. We included a sample size of 52 patients and conducted a study on these patients who were admitted under the Orthopedics department at Dr. D. Y. Patil Medical College and Hospital, Pune. Results In this study, 52 patients were treated with dual plating for proximal humerus fracture, an additional plate is used along with PHILOS. In our study, the majority of the study population belonged to > 50 years (34.6%), followed by 41-50 years (26.9%), 31-40 years (23.1%), and 21-30 years (15.4%). The mean age of the patient was 53.7 years including 33 male and 19 female patients. The majority of the patient in the study included was with RTA 40 patients and 12 patients with a history of falls from height. The fracture was classified using Neers classification, Neer type 2 fracture (23.1%), Neer type 3 fracture (46.2%), and Neer type 4 fracture (30.7%). In the current study, the mean DASH score at Baseline was 58.88±6.29, at three months was 36.23±5.05 and at six months was 31.85±4.16. The mean DASH score decreased significantly from baseline to three months to 6 months. As per the Paavolainen method, it was good among 40 (76.9%) and fair among 10 (19.2%), and poor among two (3.8%) cases. Out of 52 patients, we found varus collapse in immediate postop x-ray in two patient and screw protrusion in the glenohumeral joint in one patient. Conclusion Satisfactory clinical and radiological outcomes were noted. This dual mechanism prevents varus displacement of the proximal fragment, and as a result, it provides a good functional outcome with dual plates in proximal humerus fractures.

Outcomes of Locking Plates in Proximal Humeral Fractures: A Systematic Review

A systematic review of the clinical and radiological outcomes of locking plates in proximal humeral fractures in the current English literature was performed using Medline, CINAHL, AMED and EMBASE electronic databases to July 2009 via Ovid. There were 1266 proximal humeral fractures included in the review. The mean age of the patients was 61.7 years and there were 70.3% women. Based on the Neer classification, the review included 27% two-part, 39.5% three-part and 23.6% four-part fractures. At final follow-up, the Constant score was in the range 59 to 80, and the Disabilities of the Arm, Shoulder and Hand scores were in the range 15.2 to 51.8. The most frequent postoperative complication described was intra-articular screw perforation in 8.5% of fractures. Other complications included avascular necrosis (5.1%), subacromial impingement (3.1%), loss of reduction (3.7%) and implant failure (3.15%). Unplanned secondary surgical procedures were undertaken in 14.2% of cases. This systematic review has demonstrated that locking plate systems are suitable for stabilizing proximal humeral fractures. The current evidence base presents a number of methodological weaknesses and randomized controlled trials at independent centres reporting long-term results are required to compare locking plate systems with alternative fixation techniques used in the treatment of proximal humeral fractures.

The Deltoid Lift: A Cadaveric Analysis and the Literature Review of a Novel Surgical Approach to the Proximal Humerus

Obtaining adequate exposure of the proximal humerus for anatomic reduction of complex intra-articular fractures or in the surgical treatment of tumor may be difficult. Here we describe a novel approach to the proximal humerus: the deltoid lift, and perform a cadaveric analysis objectively quantifying the exposure. The deltoid lift offers significantly greater exposure to the proximal humerus as compared with the deltopectoral approach.

Management of Proximal Humeral Fractures with Proximal Humerus Locking Plate—A Prospective Study

Background

Displaced proximal humeral fractures, which used to be treated conservatively in the past, often had compromised functional results. With the advancement of technology, these fractures are now more often managed operatively, fulfilling the demands of an active and productive life style by the patients. The aim of this study was to assess the functional outcome of management of proximal humeral fractures with Philos (Synthes; Johnson and Johnson, West Chester, Pennsylvania, USA) plate fixation.

Methods

In this prospective study, 40 patients aged 18–80 years (mean age 52.4 years) with fractures of the proximal humerus, including two-, three-, and four-part fractures, were treated by open reduction internal fixation with Philos plating. Patients were functionally evaluated based on subjective (35 points) and objective (65 points) parameters as per the constant scoring system.

Results

All these operated patients were followed up for 18–36 months (average 27.3 months). Functional outcome based on the constant scoring system showed excellent results in 20 (50%), good in eight (20%), and moderate in eight (20%) patients. Four (10%) patients had poor functional results. Out of six cases of four-part fracture dislocations, avascular necrosis of the humeral head was observed in two patients. One of these two patients had avascular necrosis of the head along with nonunion of the fragment to the shaft.

Conclusion

Philos plate fixation for proximal humeral fractures provides good stable fixation with good functional outcome and minimal complications.

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.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Functional and radiographic medium-term outcome evaluation of the Humerus Block, a minimally invasive operative technique for proximal humeral fractures

BACKGROUND

Conservative treatment of severe displacement of proximal humeral fracture fragments yields bad functional results, but open operative techniques have a high risk of avascular necrosis of the humeral head. We performed a medium-term outcome evaluation of the Humerus Block (Synthes, Oberdorf, Switzerland), a minimally invasive technique used in selected patients with proximal humeral fractures, to investigate the functional and radiographic outcome.

MATERIALS AND METHODS

Of 47 patients operated on with the Humerus Block, 34 with a minimum follow-up of 30 months and a mean follow-up of 4 years and 4 months, were invited for interview, radiographic evaluation, and functional analysis by the Constant, Disabilities of Arm, Shoulder and Hand (DASH) and the University of California, Los Angeles (UCLA) scorings. Paired t test was used to investigate equivalence of the geometric mean scores of the trauma and control arm, for the scores of the functional analyses, and for the scores for mobility of the shoulder.

RESULTS

Scorings and clinical examination showed that 85% of shoulder function and motion were preserved compared with the control arm. Radiographic evaluation showed very good healing and positioning of the fracture fragments, and only 10% developed avascular necrosis of the humeral head.

CONCLUSIONS

With very satisfied patients; good clinical, functional, and radiographic outcomes; a short hospital stay; few complications; a reduced cost of implant; and a low incidence of avascular necrosis, this technique is a valuable alternative for operative treatment of proximal humeral fractures.

Three-part head-splitting proximal humerus fracture through a unicameral bone cyst

Unicameral bone cysts are rare in adults and are most often found incidentally on radiographs. However, they can persist from the adolescent period and may be present in locations that predispose to or exacerbate fractures.This article describes a case of a healthy 40-year-old woman who sustained a proximal humerus trauma that involved a large unicameral bone cyst, resulting in a 3-part head-splitting fracture. The epiphyseal location of the cyst contributed to the severity and extent of the fracture that resulted from a simple fall. Given the age of the patient, open reduction and internal fixation with a locking plate and lag screws was performed. The patient chose open reduction and internal fixation to preserve a hemiarthroplasty procedure in case of future revision. Successful humeral head reconstruction was achieved, and the patient fully recovered. One year postoperatively, the patient underwent arthroscopic debridement to alleviate subjective stiffness and decreased range of motion.Multipart head-splitting fractures require complex repair strategies. The gold standard for the treatment of these injuries is hemiarthroplasty. However, the decision process is difficult in a young patient given the average survival of autoplastic prostheses and the added difficulty of later revision. The current case demonstrates the complexity of decision making resulting from a rare injury in a young, healthy patient and shows that open reduction and internal fixation can provide acceptable reconstruction in such situations.

A pedicled bone graft from the acromion: an anatomical investigation regarding surgical feasibility

OBJECTIVE

To investigate the technical feasibility of harvesting a vascularized bone graft from the acromion pedicled on the acromial branch.

BACKGROUND

Complex fractures of the proximal humerus may result in partial or total avascular necrosis of the head fragment. Treatment of avascular necrosis of the humeral head is dependent upon the stage of disease as well as the dimension and location of necrosis. In general, the outcome is poor and complete restoration of the shoulder function is rarely attained. Contrary to osteonecrosis of carpal bones (where vascularized bone grafts have been routinely carried out for decades), reports of analogous procedures at the humeral head are anecdotal.

METHODS

Based on selective post-mortem computer-tomographic angiography of 5 and the dissection of 30 embalmed human cadaver shoulders, we describe the anatomy of the acromial branch of the thoracoacromial trunk. The main focus was the constancy of its anatomical course, its dimensions and potential use as a nutrient vessel for a pedicled bone graft from the acromion.

RESULTS

The course of the acromial branch revealed a constant topographic relationship to anatomical landmarks. Its terminal branches reliably supplied the anterior part of the acromion. The vascularized bone graft could be sufficiently mobilized to allow tension-free transfer to the humeral head as well as to the lateral two-thirds of the clavicle.

CONCLUSION

We demonstrated the feasibility of vascularized bone graft harvesting from the acromion. This technique could be a joint-preserving procedure for osteonecrosis of the humeral head or may assist in the revision of a clavicular pseudoarthrosis.

Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches

BACKGROUND

Locking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures.

METHODS

Between April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeon's preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed.

RESULTS

There were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group.

CONCLUSION

We found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Biological osteosynthesis of complex proximal humerus fractures: surgical technique and results from a prospective single center trial

INTRODUCTION

Locked plating for complex proximal humerus fractures through a deltopectoral incision can be difficult due to the fracture morphology and need for fixed angle screws. Although good results have been reported with the deltopectoral approach; technical difficulties, excessive soft tissue stripping and fears of avascular necrosis have lead to the use of minimal access techniques.

METHOD

Fifteen patients with three or four part fractures were treated by locked plating through a mini-invasive lateral trans-deltoid approach. All patients were relatively young with good bone quality and had sustained a high-velocity injury. Initial closed reduction was attempted in all patients, but majority of the patients (9/15) required open reduction to achieve a satisfactory reduction.

RESULTS

Union was achieved in all patients. All fractures united with an acceptable alignment. There were no incidences of axillary nerve palsy. There were no incidences of hardware failure or loss of reduction. There were no incidences of avascular necrosis at 1-year follow-up. The mean normalized constant score at last follow-up was 85.24.

CONCLUSION

Locked plating through lateral trans-deltoid incision may offer a better alternative to the deltopectoral approach in these complex fractures where locked plating is contemplated. It respects the fracture biology, allows ease in placement of the locking plate and angle stable screws and offers a stable construct with less surgical morbidity.

Intraoperative distraction in the upper extremity

Intraoperative distraction aids in the restoration of length, facilitates reduction, assists in maintaining rotational alignment, and provides a temporary stable platform for definitive fixation of acute fractures, malunions, and nonunions. This technique has been described at length in the lower extremity; however, there is a paucity of literature regarding its use in the upper extremity. Distraction is the application of tension across a fracture site. Proximal and distal fixation may be achieved in several ways, with common instrumentation including the use of an external fixator set. Intraoperative distraction may be invaluable in the treatment of displaced fractures of the upper extremity. The objective of this paper was to detail the technique of intraoperative distraction in the surgical treatment of fractures of the clavicle, humerus, radius, and ulna.

Closed reduction and external fixation for displaced proximal humeral fractures

PURPOSE

To assess results of closed reduction and external fixation for displaced proximal humeral fractures.

METHODS

18 men and 2 women aged 18 to 60 (mean, 38) years underwent closed reduction and external fixation using a standard AO fixator for displaced fractures of the proximal humerus. Injury mechanisms were road traffic accident (n=15) and fall from a height (n=5). 15 were 2-part fractures of the surgical neck, 4 were 3-part fractures of the greater tuberosity and surgical neck, and one was a 4-part fracture. One patient also had a grade-1 open fracture. The quality of reduction and shoulder function were assessed.

RESULTS

The mean duration of external fixation was 38 (range, 29-46) days. The mean time to radiological union was 11 (range, 9-13) weeks. The mean follow-up period was 11 (range, 6-18) months. Reduction was good (position equivalent to minimal displacement) in 12 patients and fair (good bony contact between the fragments) in 8 patients. Seven patients had pin site infection; all responded to local dressings and oral antibiotics. No patient had avascular necrosis of the humeral head. The mean Neer score was 85 (range, 42-98) out of 100. Shoulder function was excellent in 10 patients, satisfactory in 6, unsatisfactory in 2, and a failure in 2.

CONCLUSION

External fixation preserves the vascularity of the fracture fragments, enables early mobilisation, and achieves safe healing and good function. It is effective for management of displaced proximal humeral fractures.

Philos plate fixation for proximal humeral fractures

PURPOSE

To evaluate the efficacy of Philos plate fixation for proximal humerus fractures.

METHODS

Functional outcomes of 31 men and 27 women aged 36 to 73 (mean, 61) years who underwent Philos plate fixation for proximal humeral fractures were retrospectively reviewed. Indications for surgery were 3-part (n=33) or 4-part (n=25) closed proximal humeral fractures with angulation of more than 45 degrees or displacement of more than 1 cm. Functional outcomes and shoulder range of movement were assessed based on the Constant scoring system.

RESULTS

Patients were followed up for 12 to 18 (mean, 15) months. All fractures healed satisfactorily, except in one patient with a valgus 4-part fracture who had malunion. No wound infections, vascular injuries, avascular necrosis, or loss of fixation ensued. Two patients with axillary nerve palsy recovered spontaneously within 3 months. Functional outcome was excellent in 13 patients, good in 36, moderate in 8, and poor in 1. The mean Constant score was 80 (range, 40-100).

CONCLUSION

The Philos plate fixation is appropriate treatment for proximal humeral fractures.

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.

Health status as an important outcome factor after hemiarthroplasty

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury. Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock.

A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery.

Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing.

The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm.

The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

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.

Functional results of angular-stable plate fixation in displaced proximal humeral fractures

INTRODUCTION

The availability of angular-stable plate/screw systems led to a euphoric use of these implants for the treatment of displaced proximal humerus fractures. The high implant costs seem to be justified by a potentially improved outcome.

PATIENTS AND METHODS

Thirty one patients (20 female, 11 male, mean age: 62+/-16 years) with two-, three- and four-part proximal humerus fractures (Neer classification) were operated using the proximal humeral internal locking system (PHILOS). The mean follow-up time was 19+/-3 postoperative months (range: 340-720 days). Functional results (Constant score, UCLA-score) were analysed and compared to an equivalent historic control group of 60 patients operated for the same fracture types using two one-third tubular plates. Additionally, total implant costs for each technique were compared.

RESULTS

Complications in the PHILOS group included one implant failure with refracture, one secondary dislocation, two cases of subacromial impingement, and two cases of partial avascular necrosis of the humeral head. The mean Constant score (age- and sex-matched) was 80+/-11% for the affected side and 104+/-13% for the healthy side. The UCLA scores were excellent in 10%, good in 67%, and fair in 23% of the patients. Complication rate and functional results did not differ significantly from the control group treated with one-third tubular plates. Implant costs were significantly higher for the PHILOS group (684+/-40 Euro vs. 158+/-20 Euro, p<0.05).

CONCLUSION

Our study showed similar functional results using either plate. Although the PHILOS plate may provide important advantages in specific situations, such as osteoporotic bone, its use as a standard must be carefully judged under the economic aspect of the significant higher implant costs.

Proximal humeral fractures: a systematic review of treatment modalities

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

The block-bridge system: a new concept and surgical technique to reconstruct articular surfaces and tuberosities in complex proximal humeral fractures

Surgical treatment of complex displaced fractures of proximal humerus has changed in the last few years. Osteosynthesis has a high rate of nonunion, malunion, and avascular necrosis, and the results of hemiarthroplasty are not always functionally satisfactory. We report the results of a new technique for the reconstruction of the proximal humerus around a triangular-shaped bone block positioned inside the head and the metaphysis. The fragments are stabilized with minimal osteosynthesis by Kirschner wires, screws, or sutures. From 2001 to 2005, we treated 33 patients (20 men, 13 women) aged 34 to 74 years. The functional results were evaluated by the Constant score, with a mean follow-up of 24 months (range,12-36 months) The mean Constant score was 68 (range, 47-90). The results were excellent or good in 23 patients. The mean active anterior elevation was 160 degrees , all were pain free, and they returned to their preoperative activities, including sports. One patient had a symptomatic avascular necrosis that was treated with a hemiarthroplasty. The results show that this new technique has good clinical results with a low percentage of complications.

New intramedullary nail for the surgical neck fracture of the proximal humerus in elderly patients

BACKGROUND

Fractures of the proximal humerus are common and the repair of displaced fractures generally requires an operative approach. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. We have developed a new intramedullary nail (pin lock nail) for the repair of surgical neck fractures of the proximal humerus in patients with osteoporotic bones. A retrospective review is presented of the cases of 19 elderly patients with two-part or three-part fractures of the proximal humerus treated using the pin lock nail.

METHODS

We treated 19 elderly patients with a mean age of 70.5 years. There were 13 two-part surgical neck fractures, 3 two-part surgical neck fractures with non-displaced greater tuberosity fracture, and 3 three-part surgical neck fractures with greater tuberosity fracture. All fractures were treated using the pin lock nail. Clinical results were evaluated using the Japanese Orthopaedic Association score at the last follow-up examination. On radiographic evaluation, duration to bone union of the fracture, backing out of the pin and screw, penetration of the proximal pin, and varus angulations of the humeral neck were examined.

RESULTS

Mean duration of follow-up was 14 months (range 6-54 months). All fractures had united at an average of 3.3 months after surgery. No backing out of the pin and screw or penetration of the proximal locking pin was seen at the time of last follow-up. Thirteen of the 16 patients had no or minimal varus angulations of the humeral neck (< or =10 degrees). The mean overall JOA score was 84.3 points (range 65.5-100).

CONCLUSIONS

Our data show that using the pin lock nail for the treatment of two-part and three-part humeral fractures is a reliable procedure, providing good results with careful postoperative management.

Internal fixation of proximal humerus fractures using the Polarus intramedullary nail

INTRODUCTION

It has been stated that proximal humeral fractures are the last unsolved fractures in orthopedics. In this study, we evaluate the results of the Polarus nail, in order to constitute to the controversial problem of the treatment of proximal humerus fractures.

PATIENTS AND METHODS

Between 2003 and 2005, 27 patients with severely displaced proximal humeral fractures were treated with the Polarus intramedullary system. The fractures were classified according to the Neer classification system. There were 16 2-part fractures and 11 3-part fractures. At the 12-months follow up we graded the clinical outcome of the patients according to the Neer scoring system.

RESULTS

The duration from time of injury to operation ranged from 1 to 6 days. The mean operative time was 55 min and no need of blood transfusion was recorded. Bony union was obtained in 27 patients. There were no cases of nonunion and the period from operation to the appearance of sufficient bridging callus on radiographs was 5-11 weeks (mean 6 weeks). In one patient, a backed-out proximal screw was recorded. Stiffness of the shoulder was seen in one patient and avascular necrosis of the head of humerus in another. Related to the clinical outcome, six patients had an excellent result, 15 patients had a satisfactory result, four patients had an unsatisfactory result, and two patients had a poor result. The 77.78% of the patients had an excellent or satisfactory clinical outcome. There was significant difference in the functional outcome between patients younger than 65 years (91.55) and those older than 65 years (80.22) (P < 0.05). No significant difference was recorded in the Neer score between the patients with a 2-part fracture and the patients with a 3-part fracture (80.18) (P > 0.05).

CONCLUSION

The Polarus nail is designed to provide stable fixation with a straightforward insertion and targeting procedure. The fact that 77.78% of the patients had an excellent or satisfactory clinical outcome, suggest that Polarus humeral rod system can be a worthy alternative to traditional operative methods for displaced proximal fractures of the humerus.

Age- and gender-related distribution of bone tissue of osteoporotic humeral head using computed tomography

Treatment of proximal humeral fractures is very challenging in elderly patients with osteoporosis. Difficulty in obtaining a stable osteosynthesis remains the main problem for the surgeon. Knowing more details about the bone quality of the humeral head can be helpful for treatment. The purpose of this study was to evaluate the bone quality of the humeral head based on age, sex, and location. Three groups of patients were identified according to age: group A (aged <30 years), group B (aged >40 years but <60 years), and group C (aged >60 years). Computed tomography (CT) was performed on each patient to evaluate the humeral head bone quality. The distribution of bone density was assessed by the CT value expressed in Hounsfield units. The maximum, minimum, and mean CT values were calculated in the cancellous bone of the humeral head for each image. The humeral head was then divided into 3 equal zones, and a map of the 3 zones was made. The results showed that there was a significant difference between men and women in our series with regard to the percentage of bone tissue. There was also a significant difference among the 3 groups (age-related), as well as between the medial and lateral sides, with regard to the percentage of bone tissue. Osteopenic change in the humeral head has a negative correlation with aging. The medial side, especially the articular side, has more bone tissue than other areas. These results suggest that, when we treat humeral head fractures of elderly patients, we need to define bone quality for each case. We should then take care when establishing the site and angle of insertion for fixation to obtain optimal fixation on the lateral side.

Defining the relationship between rotator cuff injury and proximal humerus fractures

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.

Early complications of operatively treated proximal humeral fractures

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

Open intramedullary nailing with tension band and locking sutures for proximal humeral fracture: hot air balloon technique

To reduce complications and increase fixation after the internal fixation of proximal humeral fractures, interlocking intramedullary nailing and tension-band and locking sutures were used simultaneously, and their results are reviewed. Twenty-six consecutive patients who underwent open intramedullary nailing with tension-band and locking sutures for proximal humeral fractures were selected. The mean follow-up period was 39 months. With regard to the functional evaluation, the mean Neer score was 90 points and the mean American Shoulder and Elbow Surgeons score was 85. When patients were divided into those aged less than 65 years and those aged 65 years or greater and into those with 2-part fractures and those with 3-part fractures, postoperative pain, the American Shoulder and Elbow Surgeons score, and the Neer score showed no difference between the 2 groups. Open intramedullary nailing accompanied by tension-band and locking sutures for proximal humeral fractures shows sufficient fixation in older patients, and therefore, good postoperative shoulder function can be expected.

Effectiveness of Locked Nailing for Displaced Three-Part Proximal Humeral Fractures

BACKGROUND

Published reports about locked nailing for displaced comminuted proximal humeral fractures are few and the results contradictory.

METHODS

Locked nailing was used to treat 27 selective patients with displaced three-part proximal humeral fractures. The average age of patients was 54.3 years. The operative indications were persistent severe displacement, intact or minimally displaced lesser tuberosity, tolerance of anesthesia, and adherence to rehabilitation programs. Three patients had associated shoulder dislocation and two had fractures with diaphyseal extension. By transdeltoid approach, the fractures were reduced and then fixed by antegrade nailing with either upward or downward locking screws. The patients were prospectively followed up for an average of 24 months.

RESULTS

All fractures achieved eventual union. Three patients with proximal screw loosening required screw removal. On the basis of Neer criteria, excellent or satisfactory results were obtained in 21 patients whose scores averaged 87.5 points. Six patients had unsatisfactory outcomes, with an average of 75.8 points. Two patients with the complication of avascular necrosis still had a satisfactory outcome. Varus deformity of shoulder joints, deformity of the greater tuberosity, collapse of the humeral head, and old age could adversely affect shoulder elevation. However, the anatomic abnormalities might have limited effects on the pain scale, muscle power, and shoulder stability.

CONCLUSIONS

Locked nailing can be an effective treatment for selected severely displaced three-part proximal humeral fractures. It is particularly useful for fractures with diaphyseal involvement. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful treatment results.

New trends in the treatment of proximal humerus fractures

For complex proximal humeral fractures, most authors agree on the importance of anatomic reduction and stable fixation to allow early range of motion. Currently a variety of techniques are used such as K-wires, t-plates, and primary prosthesis among others. However, no current treatment guidelines have been established. Newer implants provide greater angular stability, better biomechanical properties, and enhanced anchorage in these complex injuries. These implants therefore have a potential for achieving better results in treating complex fractures. We discuss current treatment concepts and focus on biomechanics and early results of new implants designed to provide angular stability.

LEVEL OF EVIDENCE

Expert Opinion, Level V. See the Guidelines for Authors for a complete description of levels of evidence.

The treatment of proximal humeral fractures with intramedullary titanium helix wire by 97 patients

INTRODUCTION

The displaced proximal humeral fracture continues to be a problem and remains the "unsolved fracture". Many guidelines for surgical treatment of different types of these fractures have been described. A conservative functional therapy is recommended as well as a closed or open reposition and internal fixation. Other authors prefer the primary prosthetic replacement of the displaced humeral head. The purpose of this article is to describe a minimal invasive technique--the intramedullary titanium helix wire--and to analyse results and specific problems of this method compared to other techniques.

MATERIALS AND METHODS

In a prospective study done over a period of 5 years from 1998 to 2002, 97 patients with two-, three- and four-part-fractures of the proximal humerus were treated with the intramedullary titanium helix wire and given follow-up clinical and radiological checks after 12 months. The functional outcome was evaluated with a 1-year follow-up in 95 of 97 patients.

RESULTS

Our 1-year results include: 41 very good, 24 good, 16 satisfactory, 14 poor (average 76 points Constant functional score, 30.7 points UCLA score).

CONCLUSION

The advantages of the method arising from the results lie in both the simple operation approach without nerve lesions or wound infections, and also in the indirect, intramedullary splinting of the fracture without damage to the surrounding soft parts, while iatrogenic necroses of the humeral head can be avoided.

Complications of operative fixation of proximal humeral fractures in patients with rheumatoid arthritis

Currently, there is no information in the literature on operative treatment of proximal humeral fractures in patients with rheumatoid arthritis. Eleven patients underwent osteosynthesis of the proximal humerus from December 1987 to December 2002. Nine patients were treated for acute fractures, and two were treated for nonunions. Four had loss of initial anatomic reduction, two were treated nonoperatively with resultant malunion, and two required revision fixation. Two patients with symptomatic pseudarthrosis were treated with internal fixation and bone grafting. Both had complications (1 requiring hemiarthroplasty after painful nonunion and 1 with chondrolysis). All patients with acute fractures achieved fracture union. One patient had an excellent result, four had satisfactory results, and six had an unsatisfactory result. Patients and treating physicians should be aware of the high rate of complications and unsatisfactory results in patients with rheumatoid arthritis who undergo operative treatment of proximal humeral fractures.

Two-incision technique for treatment of complex proximal humerus fractures

The treatment of complex proximal humerus fractures that involve displacement of the greater tuberosity remains challenging. Good functional outcomes and decreased pain are possible with open reduction and internal fixation. Keys to a successful outcome include preservation of blood supply through decreased soft-tissue stripping, restoration of normal anatomic relationships (particularly the greater tuberosity), and stable internal fixation that allows early range of motion. To attain these goals, we advocate fixation with a fixed-angle locking proximal humerus plate using a 2-incision approach. A deltopectoral incision is used to expose the humeral shaft and head while the greater tuberosity is visualized by using a lateral incision. The fracture fragments are reduced and the plate is secured by working through these 2 incisions.

Internal fixation of displaced proximal humeral fractures with two one-third tubular plates

BACKGROUND

Operative treatment of displaced proximal humeral fractures often results in poor functional outcome. We report a technique that provides improved rotational stability of the fracture and thus allows early functional treatment.

METHODS

Seventy-one consecutive patients (67 +/- 18 years) with displaced fractures of the proximal humerus (two-part, n = 10; three-part, n = 41; four-part, n = 20) were treated by open reduction and internal fixation using two one-third tubular plates on the anterior and lateral aspects of the proximal humerus. Passive motion was started on the third postoperative day, followed by actively assisted exercises on day 6.

RESULTS

Seven patients (12%) had complications (fracture redisplacement, avascular necrosis of the humeral head, frozen shoulder, subacromial impingement, and implant loosening) that required further surgical intervention. Sixty patients (85%) were available for follow-up evaluation 17 +/- 10 months after the injury. Using the Constant score, 34% of the patients had very good results, 29% had good results, 25% had fair results, and 12% had poor results. Age (< 60 years or > or = 60 years) and fracture type had no influence on functional outcome.

CONCLUSION

These results demonstrate the high stability of internal fixation with two one-third tubular plates that allowed early mobilization of the shoulder in all patients and emphasize this technique as a preferred treatment option for displaced fractures of the proximal humerus.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Proximal humeral fractures are common yet the management of these injuries varies widely. In particular, the role and timing of any surgical intervention have not been clearly defined.

OBJECTIVES

To collate and evaluate the scientific evidence supporting the various methods used for treating proximal humeral fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register, the Cochrane Central Register of Controlled Trials, PEDro, MEDLINE (1966 to May week 4 2003), EMBASE (1980 to 2003 week 22), CINAHL (1982 to May week 3 2003), AMED (1985 to May 2003), the National Research Register (UK), Current Controlled Trials, and bibliographies of trial reports. The search was completed in May 2003.

SELECTION CRITERIA

All randomised studies pertinent to the treatment of proximal humeral fractures were selected.

DATA COLLECTION AND ANALYSIS

Independent quality assessment and data extraction were performed by two reviewers. Although quantitative data from trials are presented, trial heterogeneity prevented pooling of results.

MAIN RESULTS

Twelve randomised trials were included. All were small; the largest study involved only 86 patients. Bias in these trials could not be ruled out. Eight trials evaluated conservative treatment, three compared surgery with conservative treatment and one compared two surgical techniques. In the 'conservative' group there was very limited evidence indicating that the type of bandage used made any difference in terms of time to fracture union and the functional end result. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that 'immediate' physiotherapy, without routine immobilisation, compared with that delayed until after three weeks immobilisation resulted in less pain and both faster and potentially better recovery in patients with undisplaced two-part fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated pain in the short term without compromising long term outcome. Two trials provided some evidence that patients, when given sufficient instruction to pursue an adequate physiotherapy programme, could generally achieve a satisfactory outcome if allowed to exercise without supervision. Operative reduction improved fracture alignment in two trials. However, in one trial, surgery was associated with a greater risk of complication, and did not result in improved shoulder function. In one trial, hemi-arthroplasty resulted in better short-term function with less pain and less need for help with activities of daily living when compared with conservative treatment for severe injuries. Fracture fixation of severe injuries was associated with a high rate of re-operation in one trial, comparing tension-band wiring fixation with hemi-arthroplasty. There was very limited evidence that similar outcomes resulted from mobilisation at one week instead of three weeks after surgical fixation.

REVIEWER'S CONCLUSIONS

Only tentative conclusions can be drawn from the available randomised trials, which do not provide sufficient evidence for many of the decisions that need to be made in contemporary fracture management. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long term outcomes. There is a need for good quality evidence for the management of these fractures.

Open fractures of the proximal humerus treated with the Ilizarov method: 12 patients followed 3-8 years

We followed 12 patients who had been treated with the Ilizarov method for open proximal humeral fractures for more than 3 years. No wound infection occurred. Avascular necrosis and nonunion were each detected in 1 patient. According to Neer's criteria, the outcome was excellent or satisfactory in 8 patients.