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PubMed2004

Anatomical considerations for percutaneous proximal humeral fracture fixation.

PURPOSE: To investigate the hypothesis that percutaneous wire fixation of proximal humeral fractures is prone to regional neurovascular injury. MATERIALS AND METHODS: 40 cadaveric shoulders had percutaneous wires inserted from anterior and lateral humeral shaft entry points into the humeral head. The shoulders were then dissected to identify the neurovascular structures in this area. RESULTS: The axillary nerve trunk and posterior circumflex humeral artery were found to be within the field of dissection. The axillary nerve was damaged on three occasions by the lateral wires, two of which were direct nerve penetrations. The anterior wires caused a single perineural injury of a terminal branch. The main neurovascular leash was 57 mm (range 35-70 mm) from the acromion tip laterally and 51 mm (range 35-85 mm) anteriorly, with a width of 6 mm (range 4-13 mm) laterally, and 12 mm (range 7-15 mm) anteriorly. CONCLUSIONS: Percutaneous wire stabilisation is an attractive fixation option but this study highlights the close proximity of the important neurovasculature. Such fixation should be performed utilising a limited open approach, with dissection to bone under direct vision, with the subsequent use of a drill-sleeve for soft-tissue protection.

Aged↗
PubMedDate not supplied

Trochlear deformity occurring after distal humeral fractures: magnetic resonance imaging and its natural progression.

Eighteen children (mean age 50.7 months) with trochlear deformities occurring after and related to distal humeral fractures (12 Salter-Harris type 2, 5 supracondylar, 1 Salter-Harris type 4) were evaluated with serial radiographs. The carrying angle and range of motion were measured throughout the follow-up period (up to 13 years after trauma) after definitive treatment. Bony defects on the medial (17 patients) and central (1 patient) regions of the trochlea were observed at a mean of 3.4 months after the trauma. They also persisted up to 4 to 7 years (latest follow-up in an intermediate follow-up group) and eventually reossified by skeletal maturity (in a long-term follow-up group). Magnetic resonance imaging was performed on eight patients after a mean of 1.9 years from injury. Low signal intensity on T2 indicative of cartilage necrosis and an intact articular surface were found. Cubitus varus deformity, which developed in almost all patients, was observed to be nonprogressive after 3 to 4 years but persisted until maturity. Limitation of motion and late neuropathy were not seen.

Child↗
PubMed1993

Assessment and treatment of equine humeral fractures: retrospective study of 54 cases (1972-1990).

Fractures of the humerus were diagnosed in horses at The Ohio State University Veterinary Teaching Hospital. Twenty-four horses (44.4%) were destroyed after radiographic assessment (mean age of 5.0 years). Surgical treatment was elected in 13 horses (24.1%, mean age of 0.42 years). Conservative management, consisting of prolonged stall rest, was chosen for 17 horses (31.5%, mean age of 2.2 years). In the surgically treated group, 3 foals (23.1%) all less than 2 months of age at the time of fracture and treated with intramedullary stack pinning, survived and became athletically sound. After conservative treatment, 9 (52.9%) horses were considered successful, 4 becoming athletically sound and 5 becoming pasture sound. The mean age at the time of presentation in the 9 horses considered successful was 1.81 years. With current fixation techniques, conservative management of equine humeral fractures appears to be as good an option as surgical treatment.

Age Factors↗
PubMed2005

Proximal humeral fractures treated with arthroplasty.

OBJECTIVE: To explore arthroplasty in treating 3- and 4-part fractures of the proximal humerus. METHODS: A total of 132 patients with proximal humeral fractures were treated in our hospital from July 1997 to February 2003. According to Neer's classification, the fractures of 45 patients (14 males and 31 females, aged 31-78 years, 56.1 years+/-7.8 years on an average) belonged to 3- or 4-part fractures (10 patients with 4-part fracture and 35 with 3-part comminuted fracture) and they were treated with shoulder joint arthroplasty. Unipolar prosthesis replacement of the head of humerus was made in 28 cases, while bipolar prosthesis replacement in 2 cases and total shoulder joint replacement in 15 cases. RESULTS: During the follow-up period (range: 12-72 months, mean: 37.3 months+/-4.1 months), among the 45 patients who suffered from fractures of the proximal humerus and underwent arthroplasty surgery, 44 patients (97.8%) had no postoperative pain and were satisfied with the active range of motion and with the whole treatment results. And radiography showed that the prostheses were at their good position. One patient had postoperative pain because he had so narrow medullary cavity that the humeral prosthesis could not be put deeply enough and the prosthesis head was a little higher over the anatomic level. He did not have good postoperative active range of motion, either. Then he received a review surgery and got satisfied results. Temporary shoulder stiffness was observed in one patient. Manual release of these adhesions improved the shoulder function. No evidence of nonunion of the fracture segments around the humeral prosthesis stem was found. CONCLUSIONS: Shoulder arthroplasty is a dependable method to restore the comfort and function of the shoulder joints of the patients with 3- or 4-part fractures of the proximal humerus.

Adult↗
PubMed1999

Plate fixation of proximal humeral fractures with indirect reduction: surgical technique and results utilizing three shoulder scores.

To determine the outcome after indirect reduction and buttress plate fixation of displaced and unstable proximal humeral fractures, we retrospectively evaluated 98 patients, an average of 34 months (range 24-72 months) after fracture fixation. The patients were reviewed and results were evaluated clinically according to the Neer, UCLA and Constant score. A radiographic evaluation of fracture healing, avascular necrosis and degenerative changes of the shoulder joint was performed in all patients. Any complications of treatment were assessed. Results were, according to the UCLA-rating system, good to excellent in 76% of fractures. According to the Constant-score and the Neer score, good to excellent results were obtained in 69 and 59% of fractures, respectively. Poor results were mainly due to secondary malunion. The avascular necrosis rate was 4%. Non-union was seen in one case. Secondary varus deformity and retroversion of the humeral head as a result of lack of rotational and angular stability of the plate developed in twelve (12%) and eight (8%) cases, respectively. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus, enabling early functional after-treatment. The incidence of avascular necrosis and nonunion are low, when fracture reduction is performed indirectly. Poor rotational and angular instability can lead to a loss of reduction.

Adult↗
PubMed2003

[Proximal humeral fracture in the elderly. Primary head replacement as one alternative].

The treatment of humeral fractures in old patients is still an orthopedic problem. Different surgical schools suggest different treatments for head-preserving procedures. Because of new implants and functionally disappointing results in primary hemiarthroplasty, the indication for hemiarthroplasty was examined more critically. The decision of which procedure to choose is complicated by the lack of proper studies with comparable fracture types and enough cases regarding the specific problems of operative fracture treatment in the elderly. Correctly, besides range of movement, the number of necessary reoperations, length of time until pain reduction, and earliest possible axial weight-bearing of the injured limb should influence the therapeutic decision. Regarding all these topics, primary hemiarthroplasty in old patients and specific fracture situations is still to be recommended.

Age Factors↗
PubMed1999

Two-prong splint in the treatment of proximal humeral fracture.

Twenty-nine patients with two-, three- and four-part proximal humeral fractures were treated by two-prong splint. At the latest follow-up, 22 patients had excellent and satisfactory results according to the Neer criteria, with only two failures. Avascular necrosis was detected in only one patient. Given these results, we conclude that the present method can be the treatment of choice for these injuries.

Journal Article↗
PubMed1999

Two-prong splint in the treatment of proximal humeral fracture.

Twenty-nine patients with two-, three- and four-part proximal humeral fractures were treated by two-prong splint. At the latest follow-up, 22 patients had excellent and satisfactory results according to the Neer criteria, with only two failures. Avascular necrosis was detected in only one patient. Given these results, we conclude that the present method can be the treatment of choice for these injuries.

Adolescent↗
PubMed1993

Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band.

Thirty-five patients with four-part displaced proximal humeral fractures and fracture-dislocations were retrospectively reviewed from the years 1977-1990. Thirty-three patients were available for study. All fractures were treated by open reduction and internal fixation allowing early motion. Surgical technique was as atraumatic as possible with the goal of restoring normal anatomy of the proximal humerus with a minimal fixation system. The fixation device consisted of two modified Kirschner wires introduced through the tuberosities and reinforced by a tension band wiring. Neer's criteria were used to evaluate results. With a mean follow-up of 7 years, results were excellent and satisfactory in 21 cases, nonsatisfactory in 10, and poor in two. The most common complication was avascular necrosis (nine patients). All cases of fracture-dislocations corresponded with the nonsatisfactory and poor results. Because of our results, we conclude that in four-part displaced fractures, open reduction and internal fixation with our system of osteosynthesis should be indicated initially. Prosthetic replacement should be considered as primary treatment in cases with marked comminution of the humeral head, in fracture-dislocations, and in patients > 75 years of age.

Adult↗
PubMed2002

Intra-articular corrective osteotomy for the malunited intercondylar humeral fracture: a case report.

A 35-year-old patient sustained comminuted intercondylar fracture of the distal humerus. At six months post-open reduction and internal fixation, the malunion was corrected with an intra-articular osteotomy. The patient obtained a painless, functional elbow joint with increased grip strength after corrective osteotomy, although she had complained of severe elbow pain, limited range of motion, and loss of grip strength before osteotomy. A 15 degrees cubitus varus deformity was also corrected . Radiographs of the elbow joint did not show accelerated degenerative changes at over three years follow-up post-corrective osteotomy. Intra-articular corrective osteotomy should be considered as a salvage procedure for the treatment of a malunited intercondylar humeral fracture, especially in patients who are thought to be too young for elbow arthroplasty.

Adult↗
PubMedDate not supplied

The Bryan-Morrey triceps-sparing approach to open reduction of T-condylar humeral fractures in adolescents: cybex evaluation of triceps function and elbow motion.

Nine patients who underwent open reduction of a T-condylar distal humerus fracture through a Bryan-Morrey triceps-sparing approach were evaluated for triceps function and elbow motion. The average follow-up was 3 years 5 months. The average range of motion was -8 degrees to 136 degrees. Measured by Cybex testing, the average triceps deficit compared with the uninvolved arm was 6% at 60 degrees/sec, 7% at 120 degrees/sec, and 10% at 180 degrees/sec. Compared with another study that tested triceps function after open reduction with the Campbell triceps-splitting approach, no statistically significant difference in function or range of motion was found. In this small series, early postoperative continuous passive motion was found to significantly increase range of motion. The Bryan-Morrey triceps-sparing approach can be used in children and adolescents who require open reduction for T-condylar distal humeral fractures.

Adolescent↗
PubMed2001

Biomechanical evaluation of Hackethal's intramedullary bundle pin fixation of humeral neck fractures.

Humeral neck fractures can be stabilized using a bundle of intramedullary pins as described by Hackethal. In order to decrease the risk of pin migration, packing of the medullary cavity with as many pins as possible is sometimes recommended, but others believe that stability can be decreased by destruction of cancellous bone in the humeral head by a large bundle of pins. A surgical neck fracture was created with a saw in 30 frozen cadaveric humeri. Bone quality was evaluated by radiography and densitometry. Fractures were stabilized using Hackethal's technique of retrograde intramedullary pinning with varying numbers of 2.5-mm diameter pins; increasing torsion or bending moments of force were then applied to the bones studied. Stability was found to improve with an increasing number of pins and with higher humeral head density. Based upon these findings, the use of a large number of pins is recommended to reduce the risk of pin migration. Up to eight pins, the risk of destruction of cancellous bone in the humeral head appears very low.

Biomechanical Phenomena↗