Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

INTRODUCTION

Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.

METHODS

A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.

RESULTS

Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.

CONCLUSION

This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

Clinical outcomes of retrograde intramedullary multiple pinning for proximal humeral fractures using a modified palm tree technique

BACKGROUND

Retrograde intramedullary multiple pinning using a modified palm tree technique for proximal humeral fractures has attracted interest from surgeons because of its minimal invasiveness into the soft tissue around the shoulder joints. We aimed to evaluate the clinical and radiological outcomes of this procedure.

METHODS

This retrospective study included 21 patients who underwent surgery using a modified palm tree technique for proximal humeral fractures between March 2010 and March 2022. Patients with two- and three-part proximal humeral fractures that could be reduced by closed manipulation under general anesthesia were included in this study. All patients were clinically evaluated using the Japanese Orthopaedic Association (JOA) and University of California at Los Angeles (UCLA) shoulder scores. Postoperative radiographic findings, including fracture healing and signs of pinning-related complications, were evaluated.

RESULTS

Twenty-one shoulders in 21 patients (9 men and 12 women) with mean age at surgery of 66.3 ± 19.3 years were evaluated. The mean period until bone union was 2.6 ± 0.7 months. The mean JOA and UCLA shoulder scores at the final follow-up were 84.8 ± 12.1 and 27.5 ± 5.4, respectively. Perforation of the humeral head by Kirschner (K) wires was observed in 9 of the 21 (42.9 %) shoulders. The JOA and UCLA shoulder scores at the final follow-up were not significantly different between the groups with and without perforations (p = 0.41 and 0.27, respectively). The oblique or Y-view detected significantly more wires with perforation of the humeral head than did the anteroposterior view (6 vs. 15 wires, p < 0.01).

CONCLUSIONS

The modified palm tree technique for proximal humeral fractures demonstrated good postoperative clinical outcomes and early fracture healing. However, modifications in postoperative management and surgical techniques should be considered to reduce the high rate of perforation of the humeral head by K-wires.