Traitement des fractures de l’extrémité proximale de l’humérus par clou Télégraph ®: Étude prospective de 34 cas

Abstract

Purpose of the study Many developments have been devoted to improving osteosynthesis of proximal humeral fractures, but indications remain controversial. Anterograde nailing using a locked self-stabilizing nail is an attractive conception which has provided promising results. The purpose of this study was to assess the early results observed in a series of patients treated with a first-intention Telegraph ® nail. Material and method Thirty-four patients were reviewed for a prospective clinical and radiological assessment.Mean follow-up was 13.6 months (range 3-34 months). Mean age at the time of the accident was 68 years (20-90 years). There were 24 women and 10 men: the left shoulder was fractured in 22 patients. All fractures healed within 1 to 4 months. Groups for statistical analysis were determined by type of fracture using the Neer and Duparc classifications. Qualitative functional analysis used the Constant score in comparison with the opposite side. Anatomic analysis of fracture reduction after healing was based on plain x-rays (ap view in neutral rotation) by measuring the angle of inclination of the head in relation to the diaphyseal axis (αF). Normal was 45° reduction was considered adequate for an αF angle between 30° and 60°. The lateral view was used to search for posterior or anterior tilt of the humeral head. Results Necrosis of the humeral head was observed in four shoulders (11.8%). Three of them after displaced joint fractures. These cases were retained for the analysis.Considering all patients in the study, the raw mean Constant score was 62 points and the age- and sex-weighted score was 82.5%. For two- and three- fragment extra-articular fractures, the mean Constant score was 82.3% (21 shoulders); it was 89% for simple joint fractures (5 shoulders) and 79% for complex joint fractures (8 shoulders).The differential Constant scores, comparing the healthy side with the operated shoulder, showed a difference of 20 points on average (range 0-43 points). 52.9% of patients reviewed displayed mild deficit, 20.6% moderate deficit, and 26.5% major deficit. The mean αF angle was 38° (range 0-80°). Reduction was considered good in 18 shoulders with a mean Constant score of 88.7%. Reduction was considered poor in 16 shoulders with a mean Constant score of 75.6%. Four shoulders exhibited posterior tilt of the humeral head, all associated with healing in a valgus position. Discussion The Telelgraph ® nail provides reliable fixation for the treatment of extra-articular and simple articular fractures of the proximal humerus. Dislocated fractures are classical indications for arthroplasty, with acceptable results for a only slightly invasive procedure. The risk of osteonecrosis does not necessarily deteriorate shoulder function and secondary revision for insertion of a prosthesis is still possible. The radio-clinical correlations show the importance of reduction quality to obtain a good final clinical result. Among the nine cases of poor outcome, six were related to a misaligned callus with persistent valgus deviation of the head (αF < 30°) and in some cases, excessive posterior tilt. The solidity and stability achieved with the Telegraph nail enabled healing in all cases of fracture in this series with immediate postoperative reduction in most. The stability being related to the quality of bone stock, primary arthroplasty remains an important indication when it appears that a solid osteosynthesis cannot be achieved.