Four-part Proximal Humerus Fractures Research Articles

Treatment Preferences for Displaced Three- and Four-Part Proximal Humerus Fractures

To assess the treatment preferences of orthopaedic surgeons for displaced three- and four-part proximal humerus fractures. Cross-sectional survey. Academic and nonacademic institutions across Canada. Members of the Canadian Orthopedic Trauma Society and the Joint Orthopedic Initiative for National Trials of the Shoulder. Mailed questionnaire requesting treatment preferences for eight clinical scenarios with differing patient age (45 or 68 years), patient activity level (active/healthy or frail/low demand), and fracture type (Neer III or IV). Treatment preference for each clinical scenario using a five-level ordinal scale. Thirty-six completed questionnaires were included in the analysis. Internal fixation, particularly with locking plates, was the preferred treatment for young patients regardless of fracture type or activity level. Treatment preferences for elderly patients demonstrated the least consensus. Hemiarthroplasty, locked plating, and nonoperative management all received high treatment preferences depending on the fracture type and activity level of the patient. This survey quantifies treatment preferences for a wide range of strategies used to manage displaced proximal humerus fractures. The results of this survey suggest that, despite consulting orthopaedic trauma and shoulder experts, a wide range of treatments appear acceptable for displaced fractures in the elderly. Prospective clinical trials are needed to guide effective treatment decisions for these patients.

Early results for treatment of valgus impacted four-part proximal humerus fractures using the PHILOS plate system

Objective To evaluate the clinical results of open reduction and internal fixation of valgus impacted four-part proximal humerus fractures with the AO proximal humeral internal locking system (PHILOS). Methods Eleven patients (mean age 42 years) with four-part valgus impacted fracture of the proximal humerus underwent operations. The exposure was limited tothe lateral side of the intertubercular sulcus and the periosteal continuity of the lesser tubercle was preserved. When the humeral head was reduced, autograft or allograft bone was implanted to the site of bone defects, and subsequently the PHILOS plate was used to fix the fractured bone. Results All cases were followed up 20 months after the surgery. Avascular necrosis of the humeral head was found in one case. The necrosis ratio was 9.1%. The mean angle of anterior flexion of the shoulder was 150°. The mean angles of external and internal rotation of the shoulder were 20° and Thl2, respectively. The mean JOA score was 91. Conclusion Open reduction and internal fixation with PHILOS locking plate can gain satisfactory therapeutic effects in the treatment of valgus impacted four-part proximal humerus fractures. Key words: Humerus; Fractures, bone; Treatment outcome; PHILOS plate

Osteossíntese das fraturas da extremidade proximal do úmero com sistema de placa de ângulo fixo com parafusos bloqueados: técnica e resultados

OBJETIVO: Descrever os resultados do tratamento cirurgico das fraturas da extremidade proximal do umero com a placa de sistema bloqueado Philos. METODOS: Entre marco de 2003 e outubro de 2004 foram avaliados, de forma prospectiva, 24 de 26 pacientes com fratura da extremidade proximal do umero tratados com a placa Philos. A media de seguimento foi de 12 meses e da idade dos pacientes, de 57 anos. Seis pacientes tinham fraturas em quatro partes, 11 em tres partes e nove em duas partes. A avaliacao clinica foi feita por meio dos criterios da University of California at Los Angeles (UCLA). RESULTADOS: A media do escore da UCLA foi de 30 pontos (17-35). Todas as fraturas consolidaram. Em tres pacientes a fratura consolidou em varo. Nesses, o indice da UCLA medio foi de 27 pontos. CONCLUSAO: A osteossintese com a placa Philos permite fixacao estavel com bom resultado funcional.

Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture

Specifically located humeral head biopsies from three-part proximal humerus fractures taken at the time of hemiarthroplasty will show greater tetracycline labeling under fluorescent microscopy than those biopsies taken from four-part fractures. Additionally, biopsies from younger patients would show greater fluorescence than older patients. Nineteen consecutive adult patients (range 43-83 years) underwent hemiarthroplasty as definitive treatment for 20 displaced three- and four-part proximal humerus fractures after having received 500 mg of tetracycline hydrochloride orally every six hours for the immediate five preoperative days. Humeral head biopsies were taken from four pre-determined locations intraoperatively. The biopsies were prepared and analyzed with fluorescent microscopy. All specimens in each biopsy location demonstrated fluorescence. There was no difference between the mean rank gray values for the four biopsy locations (p = 0.78 with the Friedman test). There was no difference between the mean rank gray values for the four biopsy locations when analyzed according to three-part vs four-part fracture (p > 0.05 with the Mann-Whitney test). There was an inverse relationship between age and fluorescence for the anterosuperior biopsy location (p = 0.033 with Spearman correlation). Vascular supply is preserved in displaced three- and four-part proximal humerus fractures. With intact vascularity to the humeral head, head-preserving techniques utilizing stable, site-specific fixation and minimal dissection should be considered in the treatment of displaced three- and four-part proximal humerus fractures. Vascular supply is preserved in displaced three- and four-part proximal humerus fractures, especially in younger patients in the anterosuperior aspect of the humeral head. Basic Science Study.

OSTEOSYNTHESIS OF PROXIMAL HUMERAL END FRACTURES WITH FIXED-ANGLE PLATE AND LOCKING SCREWS: TECHNIQUE AND RESULTS

Describe the results of proximal humeral fractures surgically treated with the Philos locking plate system. Method: Between March 2003 and October 2004 we prospectively reviewed 24 of 26 patients with proximal humerus fractures treated with a Philos plate. The mean follow-up time was 12 months and the mean age of patients was 57 years. Six patients had four-part proximal humerus fractures, 11 patients had three-part proximal humerus fractures, and nine patients had two-part proximal humerus fractures. Clinical evaluation was performed using the University of California at Los Angeles (UCLA) criteria. Results: The mean UCLA score was 30 points (17-34). All fractures showed union. Three patients showed fracture union at varus position. The mean UCLA score for these patients was 27 points. Conclusion: Osteosynthesis with Philos plate provides a stable fixation method with good functional outcome.

Artificial semi-shoulder joint replacement for humerus proximal fractures

Objective To investigate the effects of artificial semi-shoulder joint replacement for humerus proximal fractures in the aged patients. Methods From January 2004 to February 2007, 42 elderly patients who had been diagnosed as three or four-part fractures of proximal humerus received humeral head replacement. The rotor cuffs were repaired during operation, and the lesser tuberosity and greater tuberosity were reconstructed. Early functional exercise was carried out according to the Neer rehabilitation principles. Results All the patients were followed up for 10 to 28 (mean, 12.7) months postopera-tively. Their shoulder functions were assessed by the ASES (American Shoulder and Elbow Surgeon) score. Obvious pain relief was observed. Eleven cases were excellent, 24 good, 4 fair and 3 poor. The good-to-excellent rate was 83.3%. No prosthetic loosening was noted in this group, but upward shift of the shoulder prosthesis occurred in 3 cases, slight limitation of upward movement in 1 case and absorption of lesser or greater tuberosity in 4 cases. Conclusion Artificial semi-shoulder replacement can be applied for three or four-part fractures of proximal humerus in the aged patients. Key words: Humeral fractures; Arthroplasty, replacement; Joint prosthesis; Fractures,comminuted

Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures

Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures

Functional results of angular-stable plate fixation in displaced proximal humeral fractures

The availability of angular-stable plate/screw systems led to a euphoric use of these implants for the treatment of displaced proximal humerus fractures. The high implant costs seem to be justified by a potentially improved outcome. Thirty one patients (20 female, 11 male, mean age: 62+/-16 years) with two-, three- and four-part proximal humerus fractures (Neer classification) were operated using the proximal humeral internal locking system (PHILOS). The mean follow-up time was 19+/-3 postoperative months (range: 340-720 days). Functional results (Constant score, UCLA-score) were analysed and compared to an equivalent historic control group of 60 patients operated for the same fracture types using two one-third tubular plates. Additionally, total implant costs for each technique were compared. Complications in the PHILOS group included one implant failure with refracture, one secondary dislocation, two cases of subacromial impingement, and two cases of partial avascular necrosis of the humeral head. The mean Constant score (age- and sex-matched) was 80+/-11% for the affected side and 104+/-13% for the healthy side. The UCLA scores were excellent in 10%, good in 67%, and fair in 23% of the patients. Complication rate and functional results did not differ significantly from the control group treated with one-third tubular plates. Implant costs were significantly higher for the PHILOS group (684+/-40 Euro vs. 158+/-20 Euro, p<0.05). Our study showed similar functional results using either plate. Although the PHILOS plate may provide important advantages in specific situations, such as osteoporotic bone, its use as a standard must be carefully judged under the economic aspect of the significant higher implant costs.

Evaluation and Management of Valgus Impacted Four-part Proximal Humerus Fractures

A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation. Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Intramedullary Wiring of Proximal Humerus Fractures

The treatment of proximal humerus fractures is a matter of continuing scientific discussion. This study presents our results with the use of retrograde intramedullary fixation as a minimally invasive, soft tissue-preserving treatment for two-part and certain three- and four-part fractures of the proximal humerus. Patients and Method: Between 01/1994 and 02/1998, 68 consecutive patients with 69 humeral head fractures were stabilized by retrograde intramedullary wiring. Fracture reduction was performed using a closed technique and stabilized with multiple intramedullary wires, which were inserted 2 cm above the olecranon fossa. All study patients had a minimum postoperative follow-up of 12 months. Results: From these 57 follow-up patients 65% had excellent Neer and Constant scores. 25% showed a satisfactory, 10% an unsatisfactory or poor result. Conclusion: Retrograde intramedullary wiring following closed indirect reduction is a minimally invasive treatment technique that preserves soft tissue and is especially useful for treating two- and minimally displaced three- and four-part proximal humerus fractures.

Displaced Three- and Four-Part Proximal Humerus Fractures: Evaluation and Management

Three- and four-part fractures are the most severe injuries in the spectrum of fractures of the proximal humerus. Despite the shortcomings of the currently available imaging techniques, fracture displacement remains an important principle in guiding management. As a result, increasing emphasis has been placed on the use of Neer's criteria in intraoperative decision making. Patients with four-part fractures with valgus impaction of the head fragment should be treated with limited open reduction and minimal internal fixation, as the blood supply to the humeral head is better preserved than with other fracture patterns and the potential for osteonecrosis is less. In the case of displaced three- and four-part fractures, the physiologic age and bone quality also help guide treatment selection. In young patients with good bone quality, attempts to preserve the humeral head by meticulous handling of soft tissues and the use of low-profile implants to secure fracture fragments is recommended. Vertical fixation alone with Rush rods in patients with poor bone quality and in those with four-part fractures is no longer considered adequate and should not be used. For selected patients with three-part fractures and satisfactory bone quality, fixation with Ender rods and tension-band wiring may be appropriate. Elderly patients and those with poor bone quality have a greater risk of loss of reduction after open reduction and internal fixation, and the current consensus is that early hemiarthroplasty is the appropriate treatment. Late reconstruction necessitated by malunion and soft-tissue contracture is technically difficult, and the outcome is less favorable. The outcome of treatment of three- and four-part fractures is dependent on the surgeon's ability to analyze the fracture pattern and execute appropriate techniques to restore anatomy and function. The use of cement for prosthetic fixation and rigorous attention to tuberosity stabilization and anatomic reduction are two factors that will optimize outcome. Adequate pain relief after hemiarthroplasty has been consistently demonstrated, but return of motion and function is less predictable.

Hemiarthroplasty in the Treatment of Comminuted Intraarticular Fractures of the Proximal Humerus

Thirty-eight patients with four-part proximal humerus fractures and fracture dislocations were treated with humeral head replacement between 1989 and 1995. At followup (mean, 37 months; range, 12-48 months) the patients were evaluated for postoperative pain, active range of motion, muscular strength, overall function in every day activities, and patient satisfaction. Complications developed in five patients and consisted of humeral component malposition (one shoulder), rotator cuff insufficiency (two shoulders), and heterotopic ossification (two shoulders). According to the Neer criteria, the overall results were: 32 (84%) patients had no pain and improved motion (active forward elevation averaged 130 degrees, external rotation 45 degrees, and average internal rotation to the first lumbar vertebra); in this group strength and function 6 months postoperatively was 80% of the normal side and reached 90% of the normal side at 1 year postoperatively under continuous stretching and strengthening exercises; and 34 patients (90%) were satisfied with their treatment. The results of the study indicate that humeral head replacement is a dependable method to restore comfort and function to patients with acute or old four-part fractures of the proximal humerus. However, recovery of function and range of motion are much less predictable in patients with an old injury.

Hemi-arthroplasty--primary or secondary measure for 3- and 4-fragment fractures of the proximal humerus in the elderly?

Successful treatment of three- and four-part proximal humerus fractures is a therapeutic challenge to the surgeon, particularly in the case of elderly patients. Open reduction and internal fixation have been advocated, but have not consistently produced acceptable results. The results of humeral head replacement as a salvage procedure after non-union or failed open reduction and internal fixation are less predictable. The outcome of hemiarthroplasty (Neer II) performed for three- and four-part proximal humerus fractures in elderly patients was studied. The average patient follow-up was 42.9 months (range 5-98). Eighteen women and eight men with an average age of 64.5 years were evaluated according to the UCLA. Constant-Murley and HSS Score. A Visual Score (0-100 points) was also used. Hemiarthroplasty was performed in 11 patients within 4 weeks of trauma and in 15 patients after 4 weeks. Fair, good, or excellent results were achieved in 80% (UCLA and Visual), 73% (HSS) and 46% (Constant-Murley) of the patients, respectively. Ninety-six percent of the patients reported only slight or no pain. The range of motion was limited in almost all cases. The outcome was not significantly influenced by age, sex and follow-up time. However, there was a significant correlation between the outcome and the length of time between injury and humeral head replacement (r = -0.5). The outcome after early hemiarthroplasty was better than after late humeral head replacement (UCLA: 27.1 +/- 4.6 vs 22.5 +/- 5.6 P = 0.04; Constant-Murley: 65.6 +/- 18.5 vs 47.5 +/- 18.6, P = 0.02; HSS: 74.0 +/- 14.4 vs 63.5 +/- 17.6, P = 0.17). Self-assessment did not differ between these two groups. After early hemiarthroplasty, active forward flexion was significantly better. This study indicates that early humeral head replacement for three- and four-part proximal humerus fractures in elderly patients achieved better functional outcome than delayed humeral head replacement. The decision to perform prosthetic humeral head replacement in these cases should be made as early as possible after trauma.

Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures

Twenty-three shoulders in 23 patients with failed treatment of three- and four-part proximal humerus fractures subsequently treated with prosthetic arthroplasty were reviewed. The initial treatment was closed in 10 cases and open in 13. The complications of treatment included malunions in 17, nonunions in four, traumatic arthritis in 14, avascular necrosis in nine, humeral shortening in six, and deltoid paresis in four. In 20 cases prosthetic arthroplasty was performed an average of 15.8 months after injury. Three other cases had arthroplasty 19, 20, and 22 years after the original fracture. Seventeen were treated with a total shoulder arthroplasty, and six had a humeral head replacement. Thirteen had a tuberosity osteotomy, and eight had lengthening of the subscapularis tendon. Prosthetic arthroplasty reduced the shoulder pain in 22 (95%). Average active forward elevation increased from 68 degrees to 92 degrees, and active external rotation increased from 6 degrees to 27 degrees. After arthroplasty 53% of the patients were able to do activities at or above shoulder level compared with 15% before arthroplasty. Late surgery for failed early treatment is technically difficult, and the results are inferior to those reported for acute humeral head replacement. These findings should be considered when treatment is selected for acute three- and four-part proximal humerus fractures. Nonetheless late arthroplasty is a satisfactory reconstructive option when primary treatment of proximal humerus fractures fails.

Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures

Twenty-six hemiarthroplasties were performed for acute three- and four-part proximal humerus fractures between March 1986 and December 1991. Postoperative pain, active range of motion, and function were evaluated in 22 patients at a mean follow-up period of 30 months (range 12 to 66 months) with the American Shoulder and Elbow Surgeons evaluation form. Seventy-three percent of patients reported only slight or no pain. Active forward elevation averaged 107 degrees, external rotation averaged 31 degrees, and the average internal rotation was to the second lumbar vertebra. Strength and stability were rarely problematic. Seventy-three percent of patients reported difficulty with at least three of 15 functional tasks tested. Lifting, carrying a weight, and using the hand at or above shoulder level were the most common limitations. This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

Humeral head replacement for acute, four-part proximal humerus fractures

Twenty-eight patients with acute, four-part proximal humerus fractures and fracture dislocations were treated with humeral head replacement. At an average follow-up of 37 months (range 12 to 96 months) one author examined 24 patients and evaluated them according to the criteria of the American Shoulder and Elbow Surgeons. There were no infections. One patient had subsequent surgery for joint contracture. Nine (38%) patients had no pain, eight (33%) had occasional slight pain, three (13%) had pain with unusual activity, and four (17%) had moderate pain. No patient had marked pain or pain at rest. Average active forward elevation was 110°, average passive forward elevation was 139°, average active external rotation was 31°, and average passive internal rotation was to the L1 level. Active forward elevation of patients younger than 60 years old was significantly greater than that of older patients. Functional outcome was variable. Although most patients could perform activities below the shoulder, only about one half could perform activities at or above the shoulder level. Eighty-nine percent of patients were satisfied with their treatment. Humeral head replacement for acute, four-part fractures reliably prevented the development of shoulder pain. Functional outcome varied and was dependent on patient age, individual functional requirements, and rotator cuff integrity.