4-part Proximal Humeral Fractures Research Articles

Health status as an important outcome factor after hemiarthroplasty

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury. Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Modified Rush Pin Technique for Two- or Three-Part Proximal Humeral Fractures

To report the outcomes of modified Rush pin fixation for proximal humeral fractures. 42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery. Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury. The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

Outcomes for open reduction and internal fixation of 4-part proximal humeral fractures

Objective To discuss the indications of plate fixation of 4-part proximal humeral fractures (PHFs) and evaluate the clinical results. Methods From Feburary 2004 to September 2007 twenty-one patients who sustained 4-part PHFs were treated by open reduction and plate internal fixation. The patients were classified into three groups according to Neer classification. There were 11 patients, whose ages were (53.4±9.3) years, in the abduction impacted 4-part PHFs group, 6 patients in the typical 4-part PHFs group with an average age of (55.8±4.5) years, and 4 patients in the 4-part fracture-dislocation group with an average age of (52.5 ± 3.7 ) years. Constant- Murley score (CMs) and simple shoulder test (SST) were used to assess shoulder function. Results Nineteen patients were available for follow up while two patients in the abduction impacted 4-part group were lost to follow-up. The mean follow-up period for the the abduction impacted 4- part PHFs group was (28.1±15.4 ) months. Their mean CMs was ( 81.0 ± 7.3 ), and SST was (9.6±1.0). CMs of the typical 4-part PHFs group was(72.2±9.4), while SST was (8.3± 1.5). They were followed up for (31.2±14.2) months on average. Greater tubercle absorption appeared in one patient in this group and his CMs and SST was 59.0 and 7.0 respectively. Patients of the fracture- dislocation group were followed up for(22.0±18.5) months. Their CMs was(40.5±11.2) and SST was (4.7±1.6). One patient in this group had humeral head osteonecrosis, two patients had greater tubercle absorption, and one suffered both. Conclusion Selection of proper treatment procedures is critical in the management of 4-part proximal humeral fractures. ORIF is an effective treatment for younger patients with abduction impacted fractures. For typical 4-part and fracture-dislocation PHFs anatomical reduction and rigid fixation are required.

The extended deltoid-splitting approach to the proximal humerus

The recent technological developments in implant design and the wider availability of bone graft substitutes have stimulated a renaissance in the operative treatment of complex proximal humeral fractures. However, one of the remaining problems of the operative treatment of these injuries has been the limited surgical access to the posterior aspect of the shoulder afforded by the deltopectoral approach. In this article, we describe a novel extended deltoid-splitting approach, in which the area traversed by the axillary nerve is identified and protected during the surgery. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3- and 4-part proximal humeral fractures.

Functional outcome following one-part proximal humeral fractures: A prospective study

A prospective study was undertaken to determine if patients recover pre-injury level of shoulder function 1 year after 1 part proximal humeral fractures. Of the 67 patients enrolled, 43 were female and 24 male with an average age of 64.8 years (range, 25-90 years). All patients underwent a similar treatment protocol consisting of early therapy for range of shoulder motion and strengthening. Baseline demographics and functional assessment, including the American Shoulder and Elbow Surgeons (ASES) evaluation form and the SF-36, were obtained at the time of injury. Functional and demographic data were evaluated with a Student's t test. Fifty-four patients (80%) completed a 1-year follow-up. By 3 months, all patients attained radiographic and clinical evidence of union and no loss of reduction. At 1 year, the ASES score was similar to pre-injury status (93.7 vs 99.1; P = .12). The range of shoulder motion of the affected side was diminished compared to the unaffected extremity in internal rotation (P < .001) and external rotation (P < .001) but not forward flexion. Patients, who sustain minimally displaced proximal humeral fractures treated nonoperatively, largely returned to preoperative functional status at 1-year follow-up. Patients should be counseled and made aware of the decreased range of shoulder motion following this fracture.

The Extended Deltoid-Splitting Approach to the Proximal Humerus

The recent technological developments in implant design and the wider availability of bone graft substitutes have stimulated a renaissance in the operative treatment of complex proximal humeral fractures. However, one of the remaining problems of the operative treatment of these injuries has been the limited surgical access to the posterior aspect of the shoulder afforded by the deltopectoral approach. In this article, we describe a novel extended deltoid-splitting approach, in which the area traversed by the axillary nerve is identified and protected during the surgery. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3- and 4-part proximal humeral fractures.

Outcomes after percutaneous reduction and fixation of proximal humeral fractures

The purpose of this study is to report the outcomes after closed or percutaneous reduction with percutaneous fixation of displaced proximal humeral fractures. This study included 35 patients from 3 institutions. Of these, 27 were followed up for a minimum of 1 year after surgery. The mean age at injury was 61 years. There were seven 2-part, eight 3-part, and twelve valgus-impacted 4-part proximal humeral fractures. All fractures were reduced and stabilized with percutaneous techniques only. The mean duration of follow-up was 35 months. All fractures healed after the index procedure. The mean pain score on a visual analog scale was 1.4. The mean American Shoulder and Elbow Surgeons and Constant scores were 83.4 and 73.9, respectively. Four patients healed with malunion, and in four, glenohumeral joint osteoarthritis developed. Fracture type, age, malunion, or osteoarthritis had no significance influence on measured outcomes. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications.

Early experience with computer-assisted shoulder hemiarthroplasty for fractures of the proximal humerus: Development of a novel technique and an in vitro comparison with traditional methods

A computer-assisted technique was developed for treatment of 4-part proximal humeral fractures via a hemiarthroplasty and tuberosity fixation. This was compared with a standard traditional method in 7 pairs of cadaveric shoulders. The computer-assisted technique used preoperative computed tomography data and computer simulations of anatomic characteristics of the contralateral humerus. This allowed accurate anatomic reconstruction by use of an electromagnetic tracking system and real-time intraoperative feedback. Various anatomic measurements were used to quantify the accuracy of the reconstruction. The differences between the intact and reconstructed values were improved with the computer-assisted technique for 5 of 7 characteristics. However, this was statistically significant only for humeral head offset (P < .05). With further investigation and refinement, this technique should allow for a more anatomic reconstruction of the proximal humerus, potentially resulting in improved patient outcomes. The technique may also prove to be a valuable resource for the laboratory training of inexperienced surgical trainees.

The Polarus intramedullary nail for proximal humeral fractures Outcome in 28 patients followed for 1 year

Background One of the new treatment options for proximal humeral fractures is the minimally invasive intramedullary nail. In this study, we reviewed the early clinical results after 1 year.Patients and methods 35 patients with proximal humeral fractures were treated using the Polarus nail. In 14 cases the initial treatment was operative; the other 21 patients were initially treated nonoperatively. 19 patients had a 2-part fracture, 5 had a 3-part fracture and 2 had a 4-part fracture. In 9 patients the fracture extended metaphyseally. The functional outcome was assessed by the Constant score.Results 28 patients were available for 1-year followup. 17 patients showed excellent functional outcome (with an average Constant score of 81%). 6 patients required revision surgery, 1 because of nonunion and 1 because of an avascular necrosis. 4 others were reoperated because of inadequate position of the osteosynthesis or migration of the screws.Interpretation The Polarus nail is of value for (displaced) 2-, 3-, and even 4-part proximal humeral fractures and enables early postoperative mobilization with a limited amount of pain.

Management of Proximal Humeral Fractures with Intramedullary Flexible Nails

Background: Treatment of unstable, displaced fractures of the proximal end of the humerus has remained controversial in the literature. Conservative treatment often results in stiffness of the shoulder and malunion. Open reduction and internal fixation may result in avascular necrosis of the fragments of the humerus. Fixation of 2- or 3-part proximal humeral fractures with retrograde intramedullary, flexible nails seems to provide appropriate stabilization without further damage to the vascularity of the bony fragments. The purpose of this retrospective study is to evaluate the results of closed reduction and retrograde intramedullary flexible nail fixation of proximal humeral fractures. Patients and Methods: From 1990 to 1998, closed reduction and retrograde intramedullary, flexible nail fixation was performed on a total of 46 patients with 2- or 3-part fractures of the proximal humerus. 10 patients were lost to follow-up. All of the fractures were classified according to the Neer classification. 26 female and 10 male patients with a mean age of 51 years (range: 30-78) were reviewed clinically and radiologically with a mean follow-up of 82 months (range: 42 -44). The shoulder function was evaluated with the Constant scoring system and compared with the opposite shoulder. Radiographic evaluation was done in the anteroposterior, lateral and axillary views of the shoulder after surgery and at final follow-up. Angulation and displacement of the fracture, occurrence of non-union, partial or total avascular necrosis of the head and hardware failure were noted. Results: The mean Constant score was 78 in 3-part fractures and 84 in 2-part fractures at the final follow- up. 91.6 % of the patients were still satisfied with the clinical outcome of the treatment. 3 patients with partial humeral head necrosis were noted. Neither non-union nor total avascular necrosis of the humeral head was noted in any patient. Nail perforation of the humeral head was seen in 14 cases, especially in the elderly. Conclusions: From the results of our study, we suggest that 2-part fractures and minimally displaced 3-part fractures of the proximal humerus can be treated with retrograde, flexible intramedullary nails successfully.

Arthroscopically treated proximal humeral fracture malunion

Articles describing the treatment of proximal humerus malunion are limited. Although in most of the cases, shoulder arthroplasty is the treatment of choice, when the articular surface of the humeral head is intact, other techniques can be considered and successfully used as well. Using arthroscopic techniques for proximal humerus malunion treatment is rarely reported in the literature. We could find only a few cases in which arthroscopic subacromial decompression was used to treat greater tuberosity malunion. Arthroscopic debridement and capsulotomy are also considered in the treatment of proximal humeral malunion cases with shoulder joint stiffness. This case report describes the completely arthroscopic treatment of a 4-part proximal humeral fracture malunion associated with pain and restricted range of motion. The main deformity in our case was medially displaced malunited lesser tuberosity that was blocking the internal rotation of the humerus. Isolated displaced lesser tuberosity fractures are rare injuries. Open techniques are usually the treatment of choice. We did not find any reports of arthroscopic treatment of lesser tuberosity malunion as a separate entity or as a component of a proximal humerus malunion. The early result in our case strongly encourages using arthroscopic techniques for lesser tuberosity malunion treatment as well as expanding the indications for shoulder arthroscopy in proximal humerus malunion cases.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 9 (November-December), 2002: pp 1020–1023

上腕骨近位端骨折に対するＥｎｄｅｒ髄内釘の治療成績

We treated 2-or 3-part proximal humeral unstable fractures with closed intramedullary fixation using Ender nails. Over 5 years (1994-1998), we treated 10 patients consisting of a man and 9 women whose age at operation ranged from 27 to 82 years (average; 61.6 years). 8 cases were 2-part fractures and 2 cases were 3-part. We perfomed fixation using 2 Ender nails from 2 entrance portals at the medial and lateral epicondyle of the distal humerus. Within 2 weeks after surgery, the patient was allowed to begin active and passive range of motion exercise.There were no infections and non-unions. Clinical and radiographical results were acceptable in 8 cases, and poor in 2. One of the nails cut out in 3 patients, requiring reversion or extraction in 2.

Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus

Thirty-nine consecutive patients with 3- and 4-part proximal humeral fractures and fracture dislocations were treated with hemiarthroplasty. After an average of 42 months (range 5 to 98 months) of follow-up, 17 women and 8 men (average age 64.5 years) were evaluated with the University of California-Los Angeles (UCLA) scale, the Constant-Murley scale, the Hospital for Special Surgery (HSS) scale, and the visual analogue scale. Fair, good, or excellent results were achieved in 80% of the patients on the UCLA and Visual scales, in 72% of the patients on the HSS scale, and in 44% of the patients on the Constant-Murley scale. The highest correlation was between the HSS score and the Visual analogue score. According to the UCLA and Constant-Murley results, the outcome after early (<4 weeks) humeral head replacement was significantly better than after late (≥4 weeks) humeral head replacement (UCLA score, P = .02; Constant-Murley score, P = .01). After early hemiarthroplasty active forward flexion was significantly better (P = .035). Thus the decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.