Complex Proximal Humerus Fractures Research Articles

Long contoured locking plate fixation of traumatic proximal humeral fractures with distal extension.

There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) = 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI = 32.0 to 50.4), mean OSS was 29.1 (95% CI = 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI = 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures.

Intramedullary Allograft Fibula as a Reduction and Fixation Tool for Treatment of Complex Proximal Humerus Fractures With Diaphyseal Extension

In this study, we present a novel technique for reduction and fixation of complex, unstable proximal humerus fractures with diaphyseal extension with the assistance of fibula allograft. We treated 14 patients using this technique since 2009 and found that it improves the reduction and enhances fixation while making the surgical procedure technically more manageable, and allows for early postoperative motion. In the first part of this study, we describe in detail the indications and surgical technique applied to these fractures. In the second part, we review the clinical and radiographic outcomes of these patients. Using this new technique, we have achieved an excellent union rate with minimal incidence of complications when treating these challenging fractures.

Management of proximal humerus fractures in adults.

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Large metaphyseal volume hemiprostheses for complex fractures of the proximal humerus

Results of hemiarthroplasty after acute complex proximal humerus fractures are controversial. The main problem is the fixation and healing of the greater tuberosity (GT). To address this problem a hemiarthroplasty with a large metaphyseal volume was designed and introduced. Thirty hemiarthroplasties were implanted for acute, complex, proximal humeral fractures in30 consecutive patients (average age: 63.3years; range, 41-78). One patient was lost; 2 patients could only be interviewed telefonically. Two patients had to be revised because of secondary displacement of the GT within the first 2 postoperative years. The remaining 25 patients were assessed clinically, radiographically, and with computer tomography (CT) imaging after a mean of 25months (range, 24-29). Greater tuberosity healed in situ in 23 patients. In 12 cases, CT documented severe resorption of GT without displacement of a measurable bone fragment and an intact clinical cuff function with a radiographically preserved acromio-humeral distance. The mean Constant score was 59 points (range, 26-81), the mean relative Constant score 75% (range, 31-100). The mean anterior elevation was 117° (range, 45-160). The mean subjective shoulder value was 70% (range, 25-98). In 4 cases (14%), tuberosity dislocation occurred which was associated with an increase of fatty infiltration and poor result. The 2-year results with a large metaphyseal volume fracture-prosthesis showed good to excellent results, with a failure rate of 14%. Substantial resorption of the greater tuberosity was frequent, but was not associated with functional incompetence of the rotator cuff. The overall results obtained justify its continued use.

Delta III reverse shoulder arthroplasty in the treatment of complex 3- and 4-part fractures of the proximal humerus: 6 to 42 months of follow up

BackgroundThere is a growing tendency for complex proximal humerus fractures (PHF) in osteoporotic patients to be treated with reverse shoulder arthroplasty (RSA). It has been proposed that RSA has more benefits than other treatment options. The aim of our study was to investigate preoperative characteristics as well as clinical and radiological outcomes in patients with complex 3- or 4-part PHF who had undergone primary RSA.MethodsPatients with a minimum follow-up of 6 months who had undergone a primary RSA after 3- or 4-part PHF in the period between 2008 and 2011 were eligible for the study. Clinical records, X-rays and CT-scans were investigated and a clinical examination was performed. Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant-Murley score (CMS) were calculated. Sixteen patients were examined as part of the study. The mean follow-up was 20 months (range 6-42 months). According to Codman-Hertel classification we encountered 15 Hertel “12” and 1 Hertel “8” type fractures.ResultsThirty-two patients (27 female – 84.4%) with a mean age of 72 years underwent operations to treat complex 3- and 4-part fractures of the proximal humerus. Sixteen patients were reexamined. In 14 cases the dominant upper extremity was on the right, in 2 cases it was on the left, in 6 cases the right side was affected and in 10 cases the left side was affected. The mean CMS was 54.8 (range 18-95) and the mean DASH was 37.5 (range 2.9-81). A trend was established between the CMS and dominance of the affected shoulder. The CMS was better if the affected shoulder was on the non-dominant side (p-value 0.051). No statistical difference was noted between age and clinical outcome.ConclusionsOur mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. RSA can provide immediate relief and good shoulder function in elderly patients. Nevertheless, the question of longevity of these implants remains to be observed.

English

Background: Our study is planned to evaluate functional evaluation of proximal humeral fractures treated with open reduction and internal fixation with locking plates in view of range of movement, possible returns of basic functions around shoulder girdle, radiological outcome and resultant remaining disability in the course of healing and after completion of healing. Materials and methods: Over two and half years 35 patients with proximal humerus fractures were managed With locking plate .34 of them completed mean follow up 11months and evaluated using SPADI score. Result: Average SPADI score for different fracture type according to Neers classification were suggestive of there is no statistically significant difference between these fracture types managed with locking plate. We found approximately equal Mean SPADI score in all 2 part, 3 part and 4 part fractures. Overall functional outcome found to be moderate to good in 92% of our patient but 8% patient had poor outcome due to associated complications postoperatively. Conclusion: Proximal humeral locking plate is an exciting new method of osteosynthesis for complex proximal humerus fractures allowing early mobilization, good functional outcome and is a superior treatment option to hemiarthoplasty.

Hemiprothese bei proximaler Humerusfraktur

Complex proximal humerus fractures with an avascular head fragment and unreconstructable fracture types represent indications for humeral head replacement. Special prosthetic designs allow modular anatomical restoration of the centre of rotation and alignment and stable fixation of the tuberosities. These play a key role with respect to the functional outcome and are often prone to complete or partial osteolysis with secondary rotator cuff deficiency. Because the operational procedure is technically demanding, attention must be paid to correct implantation. The functional results which can be expected are reliable with a moderate Constant score of 50 to 60points and a low pain level. In elderly patients with poor bone quality and an associated increased tuberosity-related complication rate, a primary inverse prosthetic design has to be considered as a reasonable alternative. The overall revision rate is approximately 11 %.

Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon

BackgroundThe primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology. MethodsWe investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells. ResultsA strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions. ConclusionOur results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.

Study of operative management for complex fracture of upper end of Humerus

Background: Proximal humerus fractures are very common fractures occurring in the skeleton. They account for approximately 4 – 5% of the fracture attendance at the hospital. It is the most common fracture of shoulder girdle. It is the 3rd most common fracture in elderly. Till date various methods are used including percutaneous and open reduction & fixation according to fracture type. Aims & Objective: To study the occurrence, mechanism of injury and displacement of various types of fractures and different modalities of the fixations in proximal humerus fractures. Come to conclusion about preferred modality of treatment of proximal humerus fractures according to the pattern of fracture. Material and Methods: In present study 44 patients of complex fracture of proximal humerus treated with either open reduction internal fixation or percutaneous fixation from 2009 to 2012. Follow up assessment was done by Constant score. Results: Radiological union occur at about 8 to 12 weeks. Closed reduction and percutaneous k wire or cancellous screws fixation showed excellent results in majority cases of 3 -part fracture. All 4 part fractures are treated with ORIF. Open reduction and internal fixation with locking compression plates showed good results among all implants used. Conclusion: Principle of fixation is reconstruction of the articular surface, including the restoration of the anatomy, stable fixation, with minimal injury to the soft tissues preserving the vascular supply, should be applied. Majority of poor results are due to poor surgical techniques and lack early physiotherapy.

Treatment of complex acute proximal humerus fractures using hemiarthroplasty

ObjectiveEvaluate the clinical and radiological results of hemiarthroplasty for treatment of complex proximal humerus fractures MethodsSixty-seven patients were included, with follow-up of 12 to 62 months. Mean age was 65 years (44 to 88), and 47 patients were female (70%). Clinical assessment was performed using the University of California Los Angeles score (UCLA) and measurement of range of motion (ROM) according to the American Academy of Orthopaedic Surgeons criteria. A standardized radiological evaluation was conducted, with special attention to healing and position of tuberosities. Patients were divided into two groups: A (anatomical healing of tuberosities) and B (without anatomical healing of tuberosities). Statistical analyses were performed using the t test. Level of significance was set at p < 0.05 ResultsConsidering the entire sample, the mean UCLA score was 26 points, with 8 points for pain and 64 patients subjectively satisfied (96%). The mean values for active ROM were 104° of forward flexion and 36° of external rotation. In group A, with 33 patients, we found a mean of 122° forward flexion and 29.5 points on UCLA. In group B the mean forward flexion were 87° and 22.7 points for UCLA. Comparing these parameters in the two groups, we found statistically significant differences for both forward flexion (p < 0.0001) and UCLA. (p < 0.0001). ConclusionWe conclude that hemiarthroplasty for treatment of complex proximal humerus fractures has a low incidence of complications and a high subjective satisfaction rate, with favorable results related to pain. A good functional result is less predictable and depends on anatomical reestablishment of proximal humerus anatomy, particularly healing of the greater tuberosity.

Tratamento das fraturas complexas agudas da extremidade proximal do úmero com o uso de hemiartroplastia

ObjectiveEvaluate the clinical and radiological results of hemiarthroplasty for treatment of complex proximal humerus fractures. MethodsSixty-seven patients were included, with follow-up of 12 to 62 months. Mean age was 65 years (44 to 88), and 47 patients were female (70%). Clinical assessment was performed using the University of California Los Angeles score (UCLA) and measurement of range of motion (ROM) according to the American Academy of Orthopaedic Surgeons criteria. A standardized radiological evaluation was conducted, with special attention to healing and position of tuberosities. Patients were divided into two groups: A (anatomical healing of tuberosities) and B (without anatomical healing of tuberosities). Statistical analyses were performed using the t test. Level of significance was set at p < 0.05. ResultsConsidering the entire sample, the mean UCLA score was 26 points, with 8 points for pain and 64 patients subjectively satisfied (96%). The mean values for active ROM were 104° of forward flexion and 36° of external rotation. In group A, with 33 patients, we found a mean of 122° forward flexion and 29.5 points on UCLA. In group B the mean forward flexion were 87° and 22.7 points for UCLA. Comparing these parameters in the two groups, we found statistically significant differences for both forward flexion (p < 0.0001) and UCLA (p < 0.0001). ConclusionWe conclude that hemiarthroplasty for treatment of complex proximal humerus fractures has a low incidence of complications and a high subjective satisfaction rate, with favorable results related to pain. A good functional result is less predictable and depends on anatomical reestablishment of proximal humerus anatomy, particularly healing of the greater tuberosity.

Outcomes of the long philos plate for open reduction and internal fixation of complex proximal humerus fractures

Outcomes of the long philos plate for open reduction and internal fixation of complex proximal humerus fractures

Complex fractures of the proximal humerus in the elderly—outcome and complications after locking plate fixation

Open reduction and internal fixation (ORIF) with locking plates or primary arthroplasty remains a controversial issue in the management of complex proximal humerus fractures. Aim of this study was to evaluate the surgeon- and patient-based outcome of patients older than 65 years who underwent ORIF using locking plate fixation of a 3- or 4-part fracture of the proximal humerus. Twenty-seven patients older than 65 years were treated with locking plate fixation (PHILOS, Fa. Synthes, Umkirch, Germany). At an average follow-up of 44 months, the clinical and the subjective outcome were evaluated, and complications were analyzed. The mean age- and gender-related Constant score was 70% (30–100%) compared with 92% (47–108%) of the contralateral non-injured shoulder. The mean DASH score was 29 points (0–71). Five patients (18.5%) showed clinical signs of an impingement, which was related to malpositioning of the plate in 3 cases. Screw cutout was seen in 22.2% (6 patients). Avascular necrosis of the head or the tubercula was found in 8 patients (29.6%). The revision rate was 29.6%. However, the patients considered the functional status of their shoulder as “good” or “satisfactory.” The functional and patient-orientated results of the locking plate fixation of complex displaced proximal humerus fractures in the elderly are comparable to those of primary arthroplasty and minimally invasive treatment. Proper surgical technique (screw length, plate position) is mandatory for reducing the revision rate.

Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant

Treatment of displaced proximal humerus fractures remains challenging. The introduction of locking plates has renewed interest in treating these fractures with joint-preserving techniques rather than hemiarthroplasty, but high complication rates are still reported. Avascular necrosis is not solely dependent on the initial fracture pattern, but can also result from intraoperative and postoperative vascular insults. We describe a technique to minimize disruption of humeral head blood supply and maximize fracture fixation. A total of 34 patients with complex proximal humerus fractures were treated with a locking plate and endosteal implant through an anterolateral approach and followed for an average of 66 weeks to determine the rates of avascular necrosis. No patient suffered complete osteonecrosis (0%) and only one patient suffered partial necrosis (2.8%) of the humeral head. The length of the posteromedial hinge was not predictive of this complication. Use of the anterolateral approach and endosteal augment of a lateral locking plate can minimize avascular necrosis following proximal humerus fracture.

Endosteal Strut Augment Reduces Complications Associated With Proximal Humeral Locking Plates

Locking-plate technology has renewed interest in plate fixation for treating proximal humerus fractures. Complications associated with these devices, including loss of reduction, screw cutout, and intra-articular penetration, are frequent. Establishing a second column of support may reduce complications and improve clinical outcome scores. We asked whether addition of an endosteal cortical allograft strut, used as an augment to locking-plate fixation for displaced proximal humerus fractures, would reduce complications and improve clinical outcome scores. We retrospectively reviewed the charts and radiographs of 38 patients treated by this method. All patients were evaluated with serial radiographs, as well as the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores. There were seven two-part, 19 three-part, and 12 four-part fractures. The minimum followup was 49weeks (average, 75weeks; range, 49-155weeks). No patient had intra-articular screw penetration or cutout. No patient had complete osteonecrosis, but one had partial osteonecrosis. The reduction was lost in one patient. The mean Disabilities of the Arm, Shoulder, and Hand score was 15 (range, 0-66.4). The mean Constant-Murley score was 87 (range, 51-95). Low rates of complication and high clinical outcome scores can be achieved when treating complex proximal humerus fractures with locking-plate fixation and an endosteal strut augment. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Anatomical plate for the treatment of proximal humeral fractures 30 Cases

Objective To analyze the clinical application and efficacy of anatomical plate in the treatment of complicated proximal humeral fractures. Methods Retrospective analysis was carried out to 30 cases in our hospital from January 2001 to December 2008, for analyzing surgical methods and treatment effect by surgical incision anatomical repositioning plate fixation treatment of part 3, 4 complexity proximal humeral fractures. Results Followed-up 9 to 28 months (14 months as average), all the 30 patients were assessed by the Neer classification and assessment criteria, 23 cases recovered excellently,good in 5 cases and common in 2 cases, the fine rate was 90%, no wound infection, fracture nonunion and humeral head avascular necrosis occurred. Conclusion The anatomical plate fixation can be used to treat complex proximal humerus fractures with good results. Key words: Proximal humeral fractures; Anatomical plate; Fixation

Complex proximal humeral fractures: A prospective study of 22 cases treated using the “Bilboquet” device

Despite recent improvements in surgical devices, complex proximal humerus fractures internal fixation still encounters frequent mechanical failures. The aim of this study was to confirm that the Bilboquet device (a design mimicking the cup-and-ball game) helps solving mechanical difficulties associated with these fractures internal fixation and to present a simplified version of the original surgical procedure. This non-randomised prospective study included 22 fractures in 22 patients, mean age: 70 years. According to the Neer classification there were three-part fractures in seven cases and four-part fractures in 15 cases. Fractures were all reduced and treated by internal fixation in a simplified surgical procedure using the Bilboquet device. Mean postoperative follow-up was 34 months. The mean Constant score was 66 and the weighted Constant score was 86. Mean active forward elevation was 108° and mean active external rotation was 28°. No per- or postoperative complications occurred. Initial reduction of the tuberosity was incomplete in four cases. Union was obtained in all fractures. There was no secondary tilting of the head, and no migration or pseudarthrosis of the tuberosities. Five patients developed postoperative avascular necrosis of the humeral head. The Bilboquet staple component provides a supporting platform for the entire humeral head area. This peripheral stabilization associated with tension band wiring explains the lack of secondary displacement in these cases. Although the Bilboquet device provides a solution to the mechanical problems of complex fractures of the proximal humerus, it does not solve the problem of secondary avascular necrosis of the humeral head, which occurred in 23% of the patients in this series and in 33% of patients in the four-part fractures subgroup. IV (non-randomised prospective study).

Computer assisted reconstruction of complex proximal humerus fractures for preoperative planning

Operative treatment of displaced fractures of the proximal humerus is among the most difficult problems in orthopedic shoulder surgery. An accurate preoperative assessment of fragment displacement is crucial for a successful joint restoration. We present a computer assisted approach to precisely quantify these displacements. The bone is virtually reconstructed by multi-fragment alignment. In case of largely displaced pieces, a reconstruction template based on the contralateral humerus is incorporated in the algorithm to determine the optimal assembly. Cadaver experiments were carried out to evaluate our approach. All cases could be successfully reconstructed with little user interaction, and only requiring a few minutes of processing time. On average, the reassembled bone geometries resulted in a translational displacement error of 1.3±0.4 mm and a rotational error of 3.4±2.2°, respectively.

Tuberosity Fracture Management: Surgical Macramé

Arthroplasty performed for complex proximal humerus fractures has traditionally been associated with reliable pain relief but inconsistent patient outcome and satisfaction. Tuberosity displacement or nonunion is most often associated with poorer results. Careful restoration of height and version maximize the opportunity for anatomic tuberosity healing and therefore shoulder function. The use of caution during the rehabilitation phase may also minimize stress of the repair. Attention to these intraoperative and postoperative details may improve tuberosity healing and therefore patient outcome.

Locking plate and shoulder joint replacement for treatment of complex proximal humerus fractures

随着社会老龄化及生活方式的改变,肱骨近端骨折尤其是粉碎骨折的发生率在逐年增加.老年人骨质疏松骨折后治疗难度大,功能恢复不够理想.近年来,手术技术、内固定材料和人工关节假体的进展,锁定钢板和肩关节置换治疗肱骨近端复杂性骨折都获得了比较满意的疗效。