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

Should valgus-impacted proximal humerus fractures necessarily be operated on? Radiological versus functional results

Background/aim

Impacted valgus proximal humerus fracture has been known to be challenging in terms of treatment and outcomes since it was defined. Moreover, it is a type of fracture that is difficult to treat. In addition, exact limits have not yet been determined regarding which parameters affect patients' functional and reported outcomes. The purpose of this study was to compare the radiological results of patients with impacted valgus proximal humerus fractures treated conservatively and surgically and to evaluate the effect of these radiological parameters on functional outcomes.

Materials and methods

A total of 79 patients who were treated between 2015 and 2021 with a diagnosis of impacted valgus fracture were evaluated retrospectively. Patients treated conservatively (Group 1) and surgically (Group 2) were evaluated in terms of radiological measurements (tubercle displacement (TD), cephalodiaphyseal angle (CDA), medial hinge (MH), cephaloglenoid angle (CGA), medial hinge impaction (MHI), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant Shoulder Score, and functional outcomes (range of motion). The effect of radiological parameters on clinical outcomes was analyzed by a correlation test.

Results

In the postoperative period, the ASES and Constant scores of the patients in Group 2 were significantly higher than those of the patients in Group 1. Additionally, Group 2 had better results in terms of passive extension, active internal rotation, and active/passive external rotation. Patients in both groups exhibited improvements in radiological parameters, and the correlation test showed that MH and MHI were mostly related to ASES and Constant scores.

Conclusion

The monitoring and treatment of impacted valgus proximal humerus fractures remain controversial. Although radiological parameters are a guide for orthopedic surgeons, the limits have not been clearly defined. In this study, in addition to all parameters, the effect of MH and MHI on functional results was emphasized.

Management options for proximal humerus fractures - A systematic review & network meta-analysis of randomized control trials

AIMS

The purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures.

MATERIALS & METHODS

Based on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score.

RESULTS

Our study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively).

DISCUSSION & CONCLUSION

RSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities.

LEVEL OF EVIDENCE

I - Systematic Review & Meta-Analysis of Randomized Control Trials.

Outcome measures reported for the management of proximal humeral fractures: a systematic review

BACKGROUND

The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

METHODS

A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

RESULTS

Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

CONCLUSION

Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Anatomic locking plates for complex proximal humeral fractures: anatomic neck fractures versus surgical neck fractures

BACKGROUND

Continued debate exists on the management of displaced 3- or 4-part proximal humeral fractures. Only a few studies have compared the efficacy of proximal humeral locking plates (PHLPs) for treating anatomic neck fractures (ANFs) and surgical neck fractures (SNFs).

METHODS

The medical data of 31 consecutive patients with displaced 4-part proximal humeral fractures treated with PHLPs between May 2013 and April 2015 were reviewed retrospectively. We divided the patients into the ANF and SNF groups and assessed the neck-shaft angle (NSA), sum of the screw tip-articular surface distance, and other parameters postoperatively at 3 days and at 12 months using shoulder radiographs. The Constant-Murley scores were assessed at 3 days, 12 months, and last follow-up.

RESULTS

The ANF group had a significantly lower mean age and significantly greater mean operative duration, estimated blood loss, and rate of bone grafting. Full or partial osteonecrosis of the humeral head developed in 7 patients and 1 patient in the ANF and SNF groups, respectively. Screw cutout and/or pullout complications occurred in 8 cases in the ANF group but not in the SNF group. In the ANF group, the values for NSA and the sum of the screw tip-articular surface distance changed significantly from 3 days to 12 months postoperatively. There were no significant correlations among the tested parameters.

CONCLUSION

ANFs resulted in more complications at a younger age than SNFs. ANF treatment using PHLPs is more prone to a decreased NSA and humeral head osteonecrosis and has poorer clinical outcomes than SNF treatment using PHLPs.

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.

Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw

Valgus-impacted proximal humerus fracture is a classic but rare entity in shoulder traumatology. Surgical treatment is controversial, with increasing use of minimally invasive techniques. Our technique uses a minimally invasive approach under fluoroscopic control. Raising the humeral head to reduce the valgus enables spontaneous and well-positioned reduction of the tuberosities and screw fixation between the greater tuberosity and the humeral shaft. Indications comprise valgus-impacted fracture without comminution of the medial epiphyseal-metaphyseal hinge or greater tuberosity; the rotator cuff contributes to reduction and must be intact. This type of fixation restores proximal humerus anatomy and achieves consolidation with low risk of secondary necrosis. Minimally invasive single-screw fixation is an alternative of choice for surgical treatment of valgus-impacted proximal humerus fracture.