Treatment Of Complex Proximal Fractures Research Articles

Advantages of percutaneous minimally invasive plate internal fixation in the treatment of complex proximal humeral fractures

Objective To explore the clinical advantages of minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of proximal humerus fractures of Neer typeⅢ andⅣ. Methods From May 2015 to May 2018, 78 cases of proximal humerus fractures of Neer type Ⅲ and Ⅳ were treated with MIPPO and open reduction and internal fixation (ORIF). There were 36 cases in MIPPO group, 20 males and 16 females, including 21 cases of Part Ⅲ fractures and 15 cases of Part Ⅳ fractures; and 42 cases in ORIF group, 24 males and 18 females, including 26 cases of Part Ⅲ fractures and 16 cases of Part Ⅳ fractures. The length of incision, the amount of bleeding, the time of operation, the time of fracture healing, the UCLA score of shoulder joint before and 3, 6 months after operation, the Constant-Murley score of shoulder joint function at 3, 6, 12 months after operation, the classification of joint function at the last follow-up, the axillary nerve injury and other complications were compared. The shoulder joint function of MIPPO group was evaluated after fracture healing. Results All the 78 patients were follow-up for (17.3±2.8) months. The incision length, fracture healing time and intraoperative bleeding in MIPPO group were significantly shorter than those in ORIF group. The UCLA scores of shoulder joint in MIPPO group were 29.04±1.63 and 30.95±1.69 at 3 and 6 months after operation, which were higher than those in ORIF group 22.11±2.33 and 25.96±2.01. The shoulder function Constant-Murley scores of MIPPO group were 55.64±2.83 and 75.01±5.71 at 3 and 6 months after operation, which were higher than those of ORIF group 45.03±6.32 and 64.61±6.77. However, there was no significant difference between the two groups in the shoulder function Constant-Murley score and the last shoulder function grade at 12 months after operation. After fracture healing, the shoulder function of MIPPO group was further evaluated: the average flexion angle was 170.5 ° (ranged, 161° to 180°), the average external rotation angle was 71° (ranged, 63.5° to 83.5°), the average internal rotation angle was 73.6 ° (ranged, 68° to 79°) and the recovery of mobility was good. The complication rate of MIPPO group was 5.56%, which was better than that of ORIF group 11.90% (P<0.05). Conclusion Both MIPPO and ORIF can treat proximal humerus fractures of Neer type Ⅲ and Ⅳ. The former is superior to the latter in incision length, bleeding volume, fracture healing time, shoulder joint function recovery at 3 and 6 months after operation, complications and other aspects, which is worth clinical promotion. Key words: Humeral fractures; Fracture fixation,internal; Axillary nerve injury; Minimal invasive

Early efficacy evaluation of the treatment of complex proximal humeral fractures in the elderly with reverse shoulder arthroplasty

Objective To evaluate the short-term efficacy of one-stage reverse shoulder arthroplasty in the treatment of complex proximal humeral fractures in the elderly. Methods Data of 43 elderly patients with complex proximal humeral fractures who were treated by reverse shoulder arthroplasty from July 2017 to January 2019 were retrospectively analyzed. There were 12 males and 31 females with an average age of 72 years (range, 66-78 years). All fractures were fresh and close which caused by trauma. The average time from injury to operation was 8.0 days (range, 6-11 days). According to Neer classification, 21 cases (48.8%, 21/43) were three-part fractures, 22 cases (51.2%, 22/43) four-part fractures. Visual analogue scale (VAS), Neer shoulder replacement evaluation system and Constant-Murley score were used to evaluate the postoperative results. Results All operations were successfully completed. The average operation time was 141.3 minutes (range, 120-170 minutes. The mean blood loss was 407 ml (range, 250-700 ml) and intraoperative blood transfusion was 446.5 ml (range, 400-800 ml). All patients were followed up for 10.9 months (range, 6 to 16 months). All patients were discharged within 7 days after operation, and no wounds related complications occurred. The bigger and lesser tuberosities of all patients healed completely within 8 weeks. At the latest follow-up, no loosening or dislocation of prosthesis occurred, and the forward elevation was 133.0° (range, 100°-165°); external rotation was 29.5° (range, 20°-35°); internal rotation was 46.7° (range, 30°-60°). VAS score was 0.8 (range, 0-3). The Neer score was 87 (range, 73-98), with 20 cases (46.5%, 20/43) excellent, 16 cases (37.2%, 16/43) good, and 7 cases (16.3%, 7/43) fair. Constant-Murley score was 88.7 (range, 70-98). A 71-year-old patient had symptoms of axillary nerve injury after operation and recovered completely 6 weeks after the operation, which did not affect the functional rehabilitation exercise or the stability of the prosthesis. During the follow-up, no other complications such as infection, acromial stress fracture and scapular notching were found in all patients. Conclusion The short-term effect of one-stage reverse shoulder arthroplasty for the treatment of complex proximal humeral fractures in the elderly is satisfactory. Key words: Aged; Humeral fractures; Arthroplasty, replacement

Curative effect of anatomic plate internal fixation for complex proximal humeral fractures combined with humeral shaft fractures

Objective To investigate the efficacy of anatomic plate internal fixation in treatment of complex proximal humeral fractures combined with humeral shaft fractures. Methods This retrospective case series study included 58 patients with complex proximal humeral fractures combined with humeral shaft fractures admitted from July 1998 to July 2015. There were 31 males and 27 females, with a mean age of 63 years (range, 18-86 years). According to the Neer classification of proximal humeral fractures, three-part fractures were noted in 42 patients and four-part fractures in 16 patients. Four patients were combined with compressed or splitting fractures of the head of humerus and 38 patients with dislocation of the shoulder. According to the site classification of femoral shaft fractures, proximal 1/3 shaft fractures were noted in 36 patients, middle and distal 1/3 shaft fractures in 19, and multisegmental shaft fractures in three. All patients underwent anatomic reduction and anatomic plate internal fixation. Bone healing, Neer score of function outcome and complications were evaluated after operation. Results Mean duration of follow-up was 8.6 years (range, 1-18 years). Bone union was observed in all patients after 10 to 24 weeks (mean, 14.5 weeks). According to the Neer score, the outcomes were excellent in 23 patients, good in 25, fair in eight and poor in two, with the excellent rate of 83%. Complications such as infection, nerve injury and vascular injury were not observed after operation. Six patients suffered from limitations of shoulder anterior flexion and rise, one patient had humeral head necrosis and treated by shock wave treatment, and one patient had poor incision healing with hemorrhagic effusion and cured after dressing. Conclusion Anatomic plate internal fixation can contribute to fast functional recovery and few complications in treatment of complex proximal humeral fractures combined with humeral shaft fractures. Key words: Humeral fractures; Fracture fixation, internal; Reduction

Reverse total shoulder arthroplasty for treatment of complex proximal humeral fractures

Objective To evaluate the clinical results of reverse total shoulder arthroplasty for the treatment of complex proximal humeral fractures.Methods From August 2008 to August 2012,40 consecutive patients underwent reverse total shoulder arthroplasty for the treatment of complex proximal humeral fracture and were followed up for no less than one year.They were 8 men and 32 women with an average age of 73.4 years (range,67 to 86 years).The dominant side was affected in 24 patients.Of the 30 patients with fresh fracture or fracture-dislocation,the average duration from injury to surgery was 11.4 days; 5 were three-part,22 fourth-part and 3 head-split by the Neer classification.Of the 10 patients with obsolete fracture or fracture-dislocation,the average duration from injury to surgery was 509.0 days; 7 were complicated with locking dislocation,and 3 old fracture nonunion or malunion.Results The mean follow-up time was 24.9 months (range,12 to 60 months).At the last follow-up,the forward elevation averaged 134.9°,external rotation 24.7° and internal rotation the L3 level.The visual analogue scale (VAS) pain score averaged 0.9 (from 0 to 5),American Shoulder and Elbow Surgeons (ASES) score 77.3 (from 50 to 98),Constant-Murley score 73.4 (from 44 to 90),and University of California at Los Angeles (UCLA) score 28.1 (from 19 to 34).One patient was found with stress fracture of the acromion postoperatively.There were no complications like infection,prosthetic loosening or neurovascular injury related to the surgery.Conclusion Reverse total shoulder arthroplasty for complex proximal humeral fractures may yield good clinical results with a high healing rate of tuberosities. Key words: Shoulder fractures; Arthroplasty, replacement; Prostheses and implants

Kapandji pinning and tuberosities fixation of three- and four-part fractures of the proximal humerus

The Kapandji pinning was initially described for the treatment of surgical neck fractures of the humerus in young patients. The aim of our study was to evaluate functional and radiological outcomes of the Kapandji modified technique in displaced complex three- and four-part fractures. From 2005 to 2009, 32 patients (23 three-part and nine four-part fractures) were included retrospectively. The mean age was 63 years old (range, 22-86), and the dominant shoulder was involved in 40% of the cases. At a mean follow up of 25 months (12-72), the mean absolute Constant score achieved 68 points (35-98) and adjusted score 80% (47-100). Patients had an average forward elevation of the shoulder of 132° (80°-180°), an average external rotation of 36° (0°-90°), and an average internal rotation to the level of L1 (sacrum to the level of T6). The older the patients were the worst was the active anterior elevation recovery (r = -0.3; p = 0.01). Reduction and fixation of initial varus-displaced fractures was not as reliable as in valgus. In eight cases (25%), K-wire migrations were observed and were correlated with age over 70 years old (p = 0.001). Two partial osteolysis of the greater tuberosity and two avascular necrosis of the humeral head (one was associated with a non-union) were identified. Moreover, three patients developed adhesive capsulitis. The Kapandji technique with fixation of tuberosities provides satisfactory results for the treatment of complex proximal fractures of the humerus. However, we do not recommend this technique for patients older than 70 years and in cases of varus displaced fractures.

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。

Replacement of humeral head for treatment of complex proximal humerus fractures in elderly patients

目的 探讨和分析采用人工肱骨头置换术治疗复杂肱骨近端骨折的适应证、手术技术要点和早期疗效.方法 对12例肱骨近端四部分骨折伴肱骨头脱位的高龄患者,早期手术行人工肱骨头置换.手术采用三角肌胸肌间入路,先复位大小结节,确定假体高度,骨水泥固定假体保持30°左右的后倾,大小结节再复位固定,必要时取骨折的肱骨头自体骨植骨,术后早期功能锻炼.结果 术后平均随访16.6个月,术后未发生感染、神经损伤、关节脱位和假体周围骨折.采用Neer评分系统评定人工关节功能,平均为84.4分,90分以上(优)3例,80～89分(满意)7例,70～79分(不满意)2例,满意率为83.3%.12例患者疼痛方面平均得分为33.5分,功能方面为25.6分,运动方面为16.5分,解剖重建方面为8.8分.结论 在正确选择手术适应证、掌握手术技术以及合理的术后康复等前提下,人工肱骨头置换术是治疗高龄患者复杂肱骨近端骨折的有效方法,尤其在减轻创伤后肩关节疼痛方面效果最为显著.但在恢复肩关节活动度方面仍欠满意,需加强对患者术后关节康复训练的指导工作。