Humeral Neck Research Articles

The Effect of Humeral Avulsion of the Glenohumeral Ligaments and Humeral Repair Site on Joint Laxity: A Biomechanical Study

The aims of this cadaveric study were to assess the effect of different sizes of humeral avulsion of the glenohumeral ligament (HAGL) lesions on joint laxity and to investigate any difference between repairs with anchors placed in a juxtachondral position and repairs with anchors placed in the humeral neck. Glenohumeral specimens were tested on a shoulder laxity testing system with translations applied anteriorly up to 30 N, with the joint in 60° of glenohumeral abduction. Testing was conducted in neutral rotation and under 1-Nm external rotation for 5 specimen states: intact, medium HAGL lesion (4:30 to 5:30 clock-face position), large HAGL lesion (3:30 to 6:30 clock-face position), repair with juxtachondral suture anchors, and repair with humeral neck suture anchors. Significant increases in translation were observed between the intact and large HAGL lesion states for neutral rotation (1.46 mm [SD, 2.33 mm] at 30 N; P = .049) and external rotation (0.81 mm [SD, 0.72 mm] at 30 N; P = .005). Significant reductions in translation were also observed between the large HAGL lesion and humeral neck repair states for neutral rotation (-1.78 mm [SD, 2.23 mm] at 30 N; P = .022) and external rotation (-0.33 mm [SD, 0.37 mm] at 30 N; P = .015). Large HAGL lesions can increase the passive motion of the glenohumeral joint in both neutral and external rotation, although these differences are small and may be difficult to measure clinically. A repair using anchors placed in the humeral neck is more likely to restore the normal restraint to anterior translation than a juxtachondral repair. Medium HAGL lesions are unlikely to show significant increases in joint translation, and repair of large HAGL lesions should be achieved with anchors placed in the humeral neck if possible.

Management of First-Time Dislocations of the Shoulder in Patients Older Than 40 Years

To evaluate the prevalence of iatrogenic humeral neck fracture after attempted closed reduction in patients older than 40 years who present with a first-time anterior dislocation. Retrospective cohort study, evidence-based medicine level IV. Ninety-two patients older than 40 years (mean 66.6 years of age) with a first-time anterior dislocation of the shoulder. Closed reductions by the emergency medicine physicians under conscious sedation, in the emergency department. Prevalence of iatrogenic fracture on postreduction radiographs. Nineteen (20.7%) patients were diagnosed with a concomitant greater tuberosity fracture on initial radiograph. In the postreduction radiographs, 5 patients (5.4%) were identified with a postreduction humeral neck fracture, and all of them had a greater tuberosity fracture on initial radiographs. A highly significant association (P < 0.0001) was observed between the finding of a greater tuberosity fracture on the initial radiographs and the occurrence of iatrogenic humeral neck fracture after close reduction. Previous case reports have described an iatrogenic humeral neck fracture with reduction attempt of shoulder dislocation. In our retrospective study, 21% of the cohort of patients older than 40 years had a concomitant greater tuberosity fracture; 26% of them had an iatrogenic humeral neck fracture after reduction attempt under sedation in the emergency room. These patients ended up with poor outcome. Patients older than 40 years, presenting with a first-time anterior shoulder dislocation with an associated fracture of the greater tuberosity have a significant rate of iatrogenic humeral neck fracture during closed reduction under sedation.

Clinical results of the hemiarthroplasty for humeral neck fractures using the cable wire system

Clinical results of the hemiarthroplasty for humeral neck fractures using the cable wire system

Shoulder Dislocation In Ontario, Canada From 1994 To 2011: The Incidence, Rate And Risk Factors For Recurrence

Objectives:Recurrent shoulder dislocation is influenced by age, activity level and bone loss. Original estimates of recurrence risk approached 90% among persons under the age of 20, but declined with increasing age. Recent literature, however, suggests that the rate of recurrent dislocation is lower. The goals of this study were to: (1) define the incidence of primary shoulder dislocation in Ontario, Canada, and (2) identify the rate of and risk factors for recurrent dislocation among demographic variables.Methods:Administrative databases (OHIP) were used to build the cohort of patients aged 15 to 70 that underwent a primary closed shoulder reduction by a physician in Ontario between July 1994 and October 2009. Exclusions included: associated humeral neck fracture, posterior dislocation, previous shoulder dislocation, prior shoulder arthroplasty, and non-Ontario residents. After cohort entry, subsequent shoulder relocations by a physician were sought. The yearly incidence (per 100,000 person-years) was calculated among all eligible Ontario residents. Kaplan-Meier survival curves to subsequent dislocation were generated. A Prentice, Williams and Peterson conditional proportional hazards survivorship model of time-to-recurrence was applied examining the influence of age, gender, income quintile, physician specialty and concurrent tuberosity fracture at index dislocation on the risk of recurrence (alpha set at 0.05). Hazard Ratios (HR) with confidence intervals were calculated.Results:The primary dislocation cohort consisted of 37,356 patients. Median age was 34 years (IQR 22-50) and 74% were male. The average yearly incidence of primary shoulder dislocation was 23.1/100,000 person-years overall, but 45.2/100,000 person-years for patients younger than 20. Recurrent dislocation events were identified in 23% of the cohort (8573 patients), most of whom were younger (median age 24 years) and male (80%). In fact, patients younger than 20 had a 37.8% rate of recurrence (HR 1.9 (1.7-2.1), p<0.0001; compared to patient aged 36-40). Kaplan-Meier survival curves showed most recurrent dislocations took place in the first year: 93.4% at 6-months, 89.4% at 1-year, 85.2% at 2-years and 79.4% at 5-years. Protective factors against recurrence included primary relocation performed by an Orthopaedic Surgeon (HR 0.87 (0.79-0.94), p=0.001), age over 50 years (5.5% rate; HR 0.70 (0.61-0.80, p<0.0001) and an associated tuberosity fracture (HR 0.51 (0.42-0.63), p<0.0001), while lowest income quintile was a risk factor for recurrence (HR 1.1 (1.04-1.16), p=0.0007). Interestingly, at 2.5 years from the primary dislocation, only 14.7% of the cohort had undergone surgical shoulder stabilization.Conclusion:Patients under 20 had twice the incidence of primary dislocation and twice the risk of recurrent shoulder dislocation compared to the median cohort age. A recurrence rate of 38% in patients under 20 is high, but less than previous reports.

The Usefulness of Range of Motion Exercises Utilizing Humeral Neck Axis Rotation

〔目的〕肩関節拘縮を伴う高齢患者を対象に，上腕骨解剖頸軸回旋humeral neck axis rotation; HNARを用いた関節可動域運動（range of motion exercise; ROM-ex）の有用性と適応について検討した．〔対象〕平均年齢は86.6±7.2歳の女性20名を対象とした．〔方法〕従来のROM-exとHNARを用いたROM-exを，それぞれ約20回実施し，屈曲，外転，内転，外旋（第1肢位）角度を測定した．〔結果〕従来のROM-exでは，有意な増加が認められなかったが，HNARを用いたROM-exでは，全測定可動域において，有意な増加が認められた．〔結語〕HNARを用いたROM-exは不動による可動域制限を改善するための一手段として，有用性が示唆された．

Reproducibility of three classifications of proximal humeral fractures

To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra- and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study. A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis. The mean intra-observer Kappa agreement index (k = 0.687) of the new classification, was higher than both the Neer classification (k = 0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k = 0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k = 0.028). the new classification considering bone compression had higher results for intra- and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system.

Axillary artery lesions from humeral neck fracture: A study in relation to repair

Whether axillary artery injuries associated with proximal humeral fractures must be repaired is uncertain. The present study reports three cases treated with various approaches. In case 1, the left humeral surgical neck was broken, the radial pulse disappeared and the arm temperature was significantly reduced. Computerized tomography angiography (CTA) revealed a 3-cm filling deficiency in the axillary artery. The injured artery was reconstructed with a segment of the greater saphenous vein after the fracture was reduced and fixed with a plate. In case 2, the axillary artery was compressed by the broken humeral segment, which caused the right hand to become cool. The fracture was fixed but the axillary artery embolism was not treated. In case 3, the humeral neck was broken with injury to the brachial plexus, although the patient’s hand remained warm. Digital subtraction angiography (DSA) revealed that the axillary artery was injured badly but there was extensive collateral circulation. The proximal humeral fracture was reduced and fixed without artery reconstruction. The three cases all resulted in a good outcome with the bone healed and limb alive. No ischemic necrosis occurred. However, the neurapraxia did not dissappear completely. Axillary artery injury resulting from humeral neck fracture is a rare but disabling traumatic event. Early diagnosis based on signs of acute ischemia of the arm enables early treatment and a favourable outcome. An angiogram is the best way to diagnose the artery injury and evaluate the condition of the collateral circulation. The injured artery in a cold arm should be repaired, while in a warm arm reconstruction is unnecessary due to rich collateral circulation.

Aseptic Osteonecrosis

Aseptic Osteonecrosis

Injuries of the terminal branches of the infraclavicular brachial plexus

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.

Three surgical treatments of two-part humeral proximal fractures in the elderly patients

Objective To compare humeral intramedullary nailing (HIN),open reduction and internal fixation (ORIF) and minimally invasive percutaneous plate osteosynthesis (MIPPO) in treatment of two-part humeral proximal fractures in the elderly patients. Methods From January 2006 to December 2009,49 patients with fracture of humeral surgical neck were treated by HIN,ORIF and MIPPO.They were 12 men and 37 women,with an average age of 65.7 years (from 54 to 71 years).There were 18 cases in group A (HIN),12 in group B (ORIF) and 19 in group C (MIPPO).The preoperative conditions,fracture healing,complications and functional recovery were compared between the 3 methods. Results All the 49 patients were followed up for 8 to 36 months (average,17.8 months).The mean incision length was 7.1 ±0.3 cm in group A,13.7 ±0.9 cm in group B and 12.1 ±0.8 cm in group C; the mean operative blood loss was 58.3±20.7 mL in group A,283.3 ±44.4 mLin group B and 96.3±9.0 mL in group C.There were significant differences between the 3 methods(P ＜ 0.05).The HIN had the shortest incision and the least operative blood loss.In the mean operative time,HIN[(90.5 ± 18.5) min] was signifieandy better than ORIF [[( 111.3 ± 16.7 ) min] and MIPPO[( 112.4 ± 9.9) min] ( P ＜ 0.05).There were no significant differences in the fracture healing time and functional recovery between the 3 groups ( P ＞ 0.05 ). Conclusions Although the 3 methods can produce similar efficacy in the treatment of two-part humeral proximal fractures in the elderly patients,the humeral intramedullary nailing has an advantage over the other two in operative invasion and operative time. Key words: Humeral fractures, proximal; Fracture fixation, internal; Bone plate

Irreducible luxatio erecta humeri caused by an aberrant position of the axillary nerve

Luxatio erecta humeri, or inferior dislocation of the glenohumeral joint, is a rare entity accounting for fewer than 0.5% of all shoulder dislocations. Anterior (95%-97%) and posterior (2%-4%) dislocations account for the vast majority. 7,11 Inferior shoulder dislocation is caused by a hyperabduction stress that forces the humeral neck superiorly against the acromion process, thereby levering the humeral head out of the glenoid fossa inferiorly. Middeldorpf and Scharm 8 were was the first investigator to describe the injury pattern at autopsy examination in his 1859 case report of an open inferior glenohumeral dislocation. Patients typically present with the affected arm in a ‘‘hands-up’’ position or with the palm of the hand resting on top of their head. The humerus is typically locked between 110 � and 160 � of abduction. 12 Closed reduction is the initial and often definitive treatment resulting in favorable outcomes. We report a case of luxatio erecta where the axillary nerve was a block to reduction, necessitating an open procedure. The case was further complicated by an ipsilateral, both-bone forearm fracture and concomitant forearm compartment syndrome.

Treatment of Surgical Neck Nonunions of the Humerus with Locked Plate and Autologous Fibular Strut Graft

Objectives: To determine whether using a fixed-angle locked plate plus a fibular strut autograft to treat humeral surgical neck nonunions can result in improved union. Patients and Methods: The study cohort included 5 females and 2 males with an average age of 58.4 years (range 45–76) who presented with atrophic nonunion of the surgical neck of the humerus. All patients underwent revision surgery with locked plating plus a nonvascularized autologous fibular strut bone graft. Clinical and radiological union was documented in all patients. Results: The mean time from initial trauma to last revision surgery was 20.1 ± 12.6 months (range 12–48). The average time between revision surgery and the date of union was 6.1 months (range 5–8). The average active forward flexion was 124° (range 70–160) at final follow-up. The Constant-Murley score increased from an average of 25.7 points preoperatively to 77.7 points postoperatively (p < 0.001). The average analog scale of pain decreased from 7.57 points (range 6–10) preoperatively to 0.57 points (range 0–2) postoperatively (p < 0.001). Conclusions: Locked plate fixation and autologous fibular strut bone graft facilitated the successful treatment of humeral surgical neck nonunions.

Hemiarthroplasty in a Patient With Pigmented Villonodular Synovitis of the Shoulder

We report the 2-year follow-up results of a hemiarthroplasty in a 29-year-old patient with pigmented villonodular synovitis (PVNS) with extra-articular extension and severe bony destruction. The patient presented with diffuse pain and swelling of the right shoulder for several years. Radiographs showed severe osteolytic lesions in the humeral head and neck, greater tuberosity, and a small osteolytic lesion in the glenoid neck area. Further examination with magnetic resonance imaging of the shoulder joint showed a large, lobulated soft tissue mass extending from the subdeltoid area to the chest wall invading the adjacent bony structures. The operative findings included a large, multilobulated, yellowish-brown mass extending from the subdeltoid area to the axillary pouch, subacromial space, and thoracic wall. The mass invaded the anatomical neck area of the humeral head and caused a fracture of the humeral head. We observed a complete rupture of the long head of the biceps tendon, supraspinatus tendon, and infraspinatus tendon, but the subscapularis tendon was partially ruptured. We performed the complete excision and cemented hemiarthroplasty. At 2-year follow-up, no signs of local recurrence were present. The patient had no significant pain and achieved a good functional result.To the best of our knowledge, 1 report with shoulder hemiarthroplasty in PVNS of the shoulder has been published in the English literature. For PVNS of the shoulder with a large extra-articular extension and bony destruction, shoulder arthroplasty with total synovectomy produces the lowest recurrence rates because of better access and excision to the posterior location of the PVNS lesion.

The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus

BackgroundExperience treating proximal humerus fracture sequelae with reverse total shoulder arthroplasty is limited. We report our results. PatientsForty-four patients with sequelae of a proximal humeral fracture were treated with a reverse total shoulder prosthesis. There were 26 women and 18 men, with a mean age of 77years (range, 74–84years). The mean follow-up after reverse arthroplasty was 48months (range, 40–84months). ResultsThe mean Constant score increased from 28 preoperatively to 58 postoperatively (p < 0.0001). The average anterior elevation increased from 40° to 100° (p < 0.0001), abduction from 41° to 95° (p < 0.0001), external rotation from 15° to 35° (p < 0.0001) and internal rotation from 25° to 60° (p < 0.0001). The average subjective shoulder score increased from 13% preoperatively to 56% postoperatively (p < 0.0001). All but six patients would undergo the same procedure again if faced with the same problem. Twenty-four patients were very satisfied, 14 satisfied and 6 unhappy with the operation. Six prosthetic dislocations occurred (13.6%). Two of them were successfully treated by adding an extension to the humeral neck component to increase the offset and tension. In the other four dislocations this procedure failed, and the prosthesis was revised and converted to a hemiarthroplasty. There was one case of glenoid component loosening that was converted to a hemiarthroplasty. ConclusionsThe reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the dislocation rate is high.

Reprise d’hémiarthroplastie pour usure douloureuse de la glène : prothèse totale anatomique ou prothèse inversée ?

An anatomic study of 65 cadaveric humeri allowed determination of the main features of the superior part of the humerus and design of a modular and adaptable humeral prosthesis. This cemented prosthesis is made in 3 different stem sizes, 7 humeral head sizes, and a variable humeral neck component. The 4 different humeral necks (125°, 130°, 135°, and 140°) allow the head to be cut at the level of the anatomic neck and adaptation of the prosthesis to the patient's anatomy with respect to the variable inclination and retroversion. An eccentric dial is located on the undersurface of the head; 8 positions are possible reproducing the posterior and medial offset of the humeral head with regard to the diaphysis. The large variety of components used for the first 101 implanted prostheses confirm the extreme variability of the anatomy and the need for a flexible shoulder prosthesis system. The glenoid component is made of polyethylene and is available in 3 different sizes to be used with a cemented keel. Eighty-six shoulders, which were monitored from 24 to 65 months, were evaluated with the Constant score. Primary glenohumeral arthritis (46 cases) and avascular necrosis (11 cases) yielded the best results, with scores of 95% and 86%. Rheumatoid arthritis (20 cases) scored 78%, although post-traumatic arthritis (11 cases) and cuff tear arthropathy (13 cases) had a less satisfactory result: 66% and 61%, respectively. Radiologic results showed 2 glenoids loosening and 48% of glenoids with radiolucent lines, with half of them being partial. An 8% complication rate has been observed, leading to 6 revisions (6%), in 2 cases for infection, 2 cases for secondary rupture of the subscapularis, and 2 cases for glenoid loosening.

Percutaneous locking plate osteosynthesis for fracture of surgical neck of humerus: an anatomical and clinical report

Objective To explore the feasibility and clinical effects of minimally invasive percutaneous plate osteosynthesis (MIPO) for humeral surgical neck fractures.Methods In 8 cadaveric specimens of adult upper limbs, a 4 cm transverse incision was made about 2 cm subacromially along the muscle fibers to dissect the muscle layers.A percutaneous locking plate was inserted along the submuscular tunnel and close to the bone surface before it was fixated at both ends with screws.The distances between the axillary nerve and the bony signs of the shoulder, as well as the distances between the axillary nerve and the lateral edges of the plate, were measured.From March 2009 to September 2010, the percutaneous locking plate was used to treat 18 cases of humeral surgical neck fractures after closed reduction.They were 6 men and 12 women, aged from 47 to 86 years (average, 67.4 years).Operation time, blood loss, postoperative hospital stay, postoperative complications, fracture healing time, and ranges of motion of the shoulder and the elbow were documented.Results The distances between the axillary nerve and the acromion, the humeral head and the lower edge of the humeral anatomical neck were respectively 69.09 + 6.07, 55.54 +4.64 and 16.23 +2.91 mm.The 18 patients were followed up for 8 to 16 months (average, 12.6 months).On average, the operative time was 106 + 36 min, intraoperative blood loss 82 + 38 mL, and postoperative hospital stay 6 + 2 days.All fractures healed without wound infection.The average healing time was 16.3 weeks (from 14 to 36 weeks) .No iatrogenic injury to the axillary nerve occurred. Conclusion MIPO is a fine treatment for humeral surgical neck fractures. Key words: Humeral fractures; Fracture fixation, internal; Dissection

Arm pain after syncope: Diagnosis

Quiz case

Reconstructive Surgical Treatment Without Bone Grafting in Nonunions of Humeral Surgical Neck Fractures

To evaluate reconstruction surgery without bone grafting in humeral surgical neck nonunions using either a blade plate or the "Humerusblock" implant in small head fragments. Retrospective cohort study, Evidence-Based Medicine Level IV. Paracelsus Medical University Salzburg, Department of Traumatology and Sports Injuries. Fifty-five patients (mean age, 66.2 years) with symptomatic nonunion after humeral surgical neck fractures were subjected to surgical reconstruction. In 45 patients, open reduction and internal fixation using a blade plate was performed (Group 1). In 10 patients, the Humerusblock device was used (Group 2), because the head fragment of each of these patients was too small for plating. In no patients was bone grafting used. Shoulder function, level of pain, and bone healing. After a mean follow-up time of 74 months, the overall mean Constant score improved from 30.4% preoperatively to 83.2% postoperatively. The improvement was from 30.5% to 85.3% in Group 1 and from 32.2% to 75.4% in Group 2, which represented statistically significant improvements for both groups (P < 0.01). Radiologic bone healing was achieved in 51 patients (93%). The overall complication rate was high, 15%, and complications included plate loosening, avascular head necrosis, persistent nonunion, and infection. Nonunion of humeral surgical neck fractures can be successfully treated by surgical reconstruction without bone grafting using either a blade plate or the Humerusblock for small head fragments. However, an increased complication rate is associated with this challenging posttraumatic pathology.

Simultaneous Bilateral Proximal Humeri Anterior Fracture Dislocations in a Patient with 1st Onset Seizure. A Case Report and Review of the Literature

Bilateral anterior fracture-dislocations of humeral neck in a patient with seizure are extremely rare. We describe a rare case of a 33 -year-old Chinese gentleman who presented post seizure secondary to subdural gliosis, sequelae from a previous subdural haematoma. Following physical examination and radiographic assessment, including a Computed Tomography scan (CT scan), Rarely fracturedislocation of bilateral proximal humeri were diagnosed; similar fracture patterns were noted. Open reduction and internal fixation with PHILOS proximal humeral locking plate allowed early shoulder rehabilitation.

소아에서 동측 상완골 외과적 경부 골절을 동반한 외상성 견관절 후방 탈구 - 증례 보고 -

Purpose: Traumatic posterior dislocation of the shoulder in a child is extremely rare, and posterior dislocation of the shoulder concomitant with ipsilateral humeral surgical neck fracture has not been reported in a child previously in Korea. Materials and Methods: The authors treated a 10-year-old with posterior dislocation of left shoulder and an ipsilateral humeral surgical neck fracture, that occurred during Taekwondo practice, by open reduction of the shoulder and pin fixation under general anesthesia. Results: A normal range of motion with complete union and good remodeling was achieved without redislocation or avascular necrosis of humeral head at 1 year after surgery. Conclusion: The authors report a successfully treated case of traumatic posterior dislocation of the shoulder with an ipsilateral humeral surgical neck fracture in child.