Outcomes of 188 Proximal Humeral Fractures Treated with a Dedicated External Fixator with Follow-up Ranging from 2 to 12 Years

Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

A Rare Combined Injury in Children during Side Impact: The Possible Mechanism and Treatment Results

OBJECTIVE

Proximal humeral fracture combined with contralateral midshaft clavicle fracture is an extremely rare injury in children. Few studies focus on the injury mechanism and treatment scheme. The aim of this study is to propose the possible mechanism of this injury and present the treatment results.

METHODS

This retrospective study included children diagnosed with proximal humeral fractures combined with contralateral midshaft clavicle fractures from August 2016 to March 2019 in the corresponding author's institution. The patients received elastic stable intramedullary nails and external fixation as treatment. The radiological and clinical outcomes of treatments were evaluated using the imaging and the Constant-Murley score (CMS) in follow up.

RESULTS

Twelve patients (eight males and four females) with an average age of 7.83 years old (age 5-12) were included in this research. All the patients had suffered a side impact in a road traffic accident or outdoor environment. Hypothesis about the mechanism was the proximal humerus was directly impacted at first and caused the surgical neck fracture, then the contralateral shoulder hits the solid object and the contralateral midshaft clavicle was fractured. During the average 45.2 months (range 36-57) follow-up, all the patient's fractures achieved clinical and radiological union before 14 weeks without complications. Every patient had a satisfactory score (range from 92 to 100) on the CMS criteria for both shoulders.

CONCLUSION

The hypothesis about the mechanism of this combined injury in this study sounds reasonable. It highlights the need for safety-related education about using a safety seat or wearing a seat belt to parents and caregivers, so as to avoid such injury even if the treatment with external fixation (EF) and proximal humeral and elastic stable intramedullary nailing (ESIN) showed good results.

Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study

BACKGROUND

Open reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation.

METHODS

We retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors.

RESULTS

There were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was.

CONCLUSIONS

Nonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.

The Role of External Fixation in the Management of Upper Extremity Fractures

External fixation is a powerful tool in the armamentarium of the active orthopaedic surgeon. The upper extremity, however, poses unique challenges in the techniques of external fixation because of the smaller soft-tissue envelope and the proximity of neurovascular structures, which may be entrapped in fracture fragments or traversing in line with pin trajectories. This review article summarizes the indications, techniques, clinical outcomes, and complications of external fixation of the upper extremity in the setting of proximal humerus, humeral shaft, distal humerus, elbow, forearm, and distal radius fractures.

Efficacy analysis of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of proximal humerus fractures in skeletally immature patients

OBJECTIVES

The objective of this study is to evaluate the efficacy of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients.

METHODS

A retrospective analysis was performed on 22 cases of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients who were treated with a double-Schanz screw external fixator combined with anti-rotating Kirschner wire. Patients included were the Neer-Horowitz (N-H) type 2, 3, and 4 of fracture. The basic information of the patients was recorded, fracture healing and shoulder range of motion were assessed at the last follow-up visit. The disabilities of the arm, hand (DASH) score and Constant-Murley score of the shoulder were performed to observe the occurrence of complications.

RESULTS

The mean age at the time of surgery was 12.41 years, and all patients completed a median follow-up of 18.18 months. There were two cases of N-H type 2, 12 cases of N-H type 3, and eight cases of N-H type 4 among the patients. At the last follow-up, all patients were able to achieve pain-free shoulder movement. There was no significant difference in shoulder function between the injured side and the uninjured side. The DASH score mean was 2.43 (95% CI 1.44-3.52). The constant score mean was 98.55 (95% CI 97.73-99.27). All patients returned to their pre-injury daily life and physical activities, and there was no significant difference in bilateral limb length at the last follow-up (p < 0.05). The most common complication of double-Schanz screw external fixator combined with anti-rotating Kirschner wire surgery was pin tract infection, which occurred in 5 cases (22.7%). There were no complications such as deep infections, vascular and nerve damage, failure of fixation, secondary fracture displacement, non-union of fracture, osteonecrosis of the humerus, joint stiffness, rotator cuff weakness and limb deformity.

CONCLUSION

The double-Schanz screw external fixator combined with anti-rotating Kirschner wire is a safe and effective treatment for displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients over the age of 10 years.

Focus on stability: biomechanical evaluation of external fixation technique versus locking plate osteosynthesis in 3-part proximal humeral fractures

BACKGROUND

The purpose of this study was to investigate the primary stability and displacement tendencies of an external fixation system in 2 different configurations in comparison to locking plate fixation in a 3-part proximal humeral fracture model.

METHODS

Twenty-one fresh-frozen human cadaveric proximal humeral specimens were divided into 3 groups of 7 stripped specimens. An unstable 3-part fracture of the proximal humerus was set. Construct A consisted of the Galaxy Fixation Shoulder System, with fixation in accordance with the manufacturer's recommended technique (3 pairs of threaded wires). Construct B was fixed with an additional pair of threaded wires according to the recommendations of Gumina et al (4 pairs of threaded wires). The remaining 7 specimens were fixed with a locking plate. By use of an optical motion capture system, relative motion at the fracture site and failure load were evaluated during a cyclic loading protocol.

RESULTS

Plate osteosynthesis showed the highest cyclic load to failure (895 ± 239 N; range, 597-1135 N), followed by construct B (692 ± 121 N; range, 432-788 N) and construct A (350 ± 190 N; range, 139-615 N). Statistically significant differences were found between plating and construct A (P < .001), between plating and construct B (P = .031), and between construct B and construct A (P = .013). Relative motion at the fracture site, in terms of change in distance during cyclic loading, was lowest with construct B measured at the peak load of 395 N after 11 steps (1.73 ± 1.98 mm; range, 0.53-5.96 mm) and highest with construct A (8.46 ± 10.67 mm; range, 2.26-20.79 mm). Angular change measured at the peak load after 11 steps was lowest with construct B (1.19° ± 0.36°; range, 0.59°-1.7°) and highest with construct A (2.44° ± 1.63°; range, 0.77°-4.04°). Statistically significant differences were found between construct A and construct B and between construct A and plating at various steps of cyclic loading.

CONCLUSION

In this biomechanical study of unstable 3-part proximal humeral fractures, locking plate osteosynthesis demonstrated the highest possible load application. External fixator application with 8 threaded wires (construct B) revealed the least relative motion at the fracture site, without a statistically significant difference compared with locking plates. It therefore represents another valid technique for treatment regarding primary stability. The use of external fixator application with 6 threaded wires (construct A) resulted in the lowest stability and the highest rates of displacement.

No implant, no solution, lost cases to surgery: orthopedic trauma triage for surgery in an NGO hospital in Sierra Leone

INTRODUCTION

In low-income countries (LIC), international surgeons face the fact that there are patients they cannot treat. The goal of this study was to identify and analyze patients lost to treatment.

MATERIAL AND METHODS

We analyzed retrospectively the data of 282 trauma victims from a non-governmental organizational (NGO) hospital in Sierra Leone, Africa. During a 3-month period (10.10.2015-08.01.2016), these patients had 367 injuries and underwent 263 orthopedic surgeries. Despite a clear indication, some patients did not receive surgical treatment. We identified these injuries and the reason why they could not be operated. The anatomic region of the injury was evaluated and if they had a bone or soft tissue defect or were infected.

RESULTS

We identified 95 (25.89%) injuries in 70 patients (47 males; 23 females) that were not be operated. The reasons were lack of specific implants (no implant group; N = 33), no treatment strategy for the injury (no solution group; N = 29), and patients that were lost (lost patient group; N = 33), almost equally distributed by 1/3. In the no implant group were mainly closed fractures and fractures of the pelvis and the proximal femur. The implants needed were locking plates (N = 19), proximal femoral nails (N = 8), and implants for pelvic surgery (N = 6). In the no solution group were nearly all bone (P < 0.0000), soft tissue defects (P < 0.00001) and infections (P = 0.00003) compared to the rest and more open fractures (P < 0.00001). In the lost patients group, most fractures were closed (24 out of 33, P = 0.033). These fractures were mostly not urgent and were postponed repeatedly.

CONCLUSION

One quarter of the patients did not receive the surgical treatment needed. Besides acquisition of implants, surgical skills and expertise could be a solution for this issue. Nevertheless, these skills must be passed to local surgeons.

Operative choice for displaced proximal humeral fractures in adolescents with open visible physis: A comparative study of external fixator vs. Kirschner wire

BACKGROUND

For adolescents with severely displaced proximal humeral fracture (PHF), surgery is a good choice yielding excellent outcomes, and Kirchner wire (KW) is a cost-effective choice for fixation. Purpose of this study is to compare the clinical outcomes of external fixator (EF) and KW for the treatment of PHF in adolescents.

METHODS

Patients of PHF operated at our institute, from January 2008 to January 2016, were reviewed retrospectively. Demographic data, including sex, age at the time of surgery, operated side, and hardware choice, were collected from the hospital database. Preoperative radiographs were reviewed and classified according to Neer-Horwitz classification. Shoulder function was evaluated at the last follow-up using the American Shoulder and Elbow Surgeons (ASES) score. Complications, including infection, malunion, nonunion, stiffness of the shoulder joint, and failure of fixation were also recorded.

RESULTS

Thirty-five patients, including 23 males and 12 females, were included in the EF group, whereas 40 patients, including 25 males and 15 females, were included in the KW group (P = 0.867). The average age of patients in the EF group was 13.3 ± 1.7 years, and that of KW was 13.6 ± 1.8 years (P = 0.409). Patients in both groups were followed-up for at least 12 months. The operative time in the EF group (42.4 ± 11.2 min) was significantly shorter than those in the KW group (54 ± 13.6 min) (P < 0.001). The frequency of fluoroscopy in the EF group (12 ± 2.4 times) was significantly less than those in the KW group (17 ± 2.8 times (P < 0.001). The rate of open reduction was significantly higher in KW (35%) group than those in the EF group (0%) (P < 0.001). There was no case of nonunion and malunion in both groups.

CONCLUSION

External fixator is superior to Kirschner wire in the treatment of proximal humeral fractures in adolescents with shorter operative time and lower rate of open reduction with comparable clinical outcomes.

Stable osteosynthesis of cage in cage technique for surgical treatment of proximal humeral fractures

Background

The treatment of a displaced proximal humeral fracture is still a matter of controversy. The purpose of this study was to report outcomes at a long-term follow-up after fixation augmentation using peek (polyether-ether-ketone) cage and locking compression plate (LCP).

Methods

A total of 27 patients (average age 53.8 years, range 19–86 years) were treated with peek cage and LCP. All of them had a minimum radiographic and clinical follow-up of 1 years. Outcomes were assessed using the Constant-Murley score (CMS), disability of the arm, shoulder and hand (DASH) score. Complications were also recorded during follow-up.

Results

The average follow-up was 28 months (range 12–48 months). The mean functional outcomes were as follows: CMS, 73.3 (range 61–86); DASH, 45.9 (range 27–68). A total of 4 patients had complications: osteonecrosis developed in one patient, loss of reduction was observed in 1 patient and stiffness was occurred in two patients.

Conclusion

The use of peek cage and LCP has been a valuable option in the treatment of proximal humeral fractures. The complication rate was acceptable. Suitable void filler in the proximal humerus for reconstructing the medial column integrity attains mechanical stability in reducing the incidence of the complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01235-x.