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PubMed2003

Internal fixation versus arthroplasty of comminuted fractures of the distal humerus.

BACKGROUND: A comminuted distal humerus fracture in an older patient is a difficult clinical problem. Open reduction internal fixation (ORIF) carries the risks of nonunion, loss of fixation, infection, and stiffness. Arthroplasty carries the risks of loosening, infection, and periprosthetic fracture. Both procedures are technically challenging, and complications following these procedures are frequent. OBJECTIVE: To evaluate best available evidence to assist in guiding clinical decision making for ORIF versus arthroplasty of intraarticular distal humeral fractures in elderly patients. HIGHEST AVAILABLE EVIDENCE: 1. Case series of internal fixation or arthroplasty of acute interarticular distal humerus fractures in the elderly (level IV). 2. Review of expert opinion without explicit critical appraisal or controlled research (level V). STUDY IDENTIFICATION: 1. Computerized data search 1969-2003, Cochrane Database, OVID Search Engine. 2. Reviews of bibliographies of selected articles.

Aged↗
PubMed2004

Four part fractures of the proximal humerus.

BACKGROUND: Four part fractures of the proximal humerus represent approximately 5% of all proximal humeral fractures. Treatment options for these displaced fractures include nonoperative treatment, open reduction and internal fixation, and arthroplasty. Presently, there is a lack of consensus on the optimal management strategy for this complex injury. OBJECTIVE: To determine the effect of alternate devices in the management of four part proximal humerus fractures in patients on the risks of reoperation, need for implant removal at 1 year, and pain.

Arthroplasty↗
PubMed2006

Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate.

OBJECTIVES: The increasing number of fractures of the proximal humerus, especially in the elderly, carries with it the unsolved problem of the optimal treatment for the displaced or unstable fractures. The authors' goal was to analyze whether fixation with a bent valgus angled blade plate could improve the outcomes reported in the literature to date. DESIGN: Prospective clinical study. SETTING: Urban level 1 university trauma center. PATIENTS: Over a 27-month period, 42 consecutive patients were treated for an unstable or displaced proximal humerus fracture. INTERVENTION: Open reduction and internal fixation with a 90-degree cannulated angled blade plate prebent to 110 degrees. MAIN OUTCOME MEASUREMENTS: Active follow-up for 1 year with assessment of objective and subjective functional results (ie, motion; strength; Constant score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog scale (VAS)) and radiographic assessment (reduction, alignment, necrosis, and nonunion). RESULTS: Follow-up was completed for 86% of the patients, who achieved a mean Constant score of 66 points (82% of the contralateral side) with a mean forward flexion of 125 degrees and an average strength of 72% of the contralateral side. Low disability (mean DASH score 22) and pain values (mean VAS 2) were demonstrated after this type of stabilization. The overall complication rate was 33% (12/36), with protrusion of the blade into the glenohumeral articulation as the most frequent problem (8/36, 22%). The negative impact of an adverse event on subjective and objective outcomes was only significant for forward flexion (P = 0.02). Neither clinical outcome nor complication rate was different when compared to patients with regard to fracture type (3 versus 4 parts) or age (younger or older than 70 years). CONCLUSIONS: Fixation of displaced proximal humeral fractures with an angled blade plate provided sufficient stability. Blade perforation into the humeral joint occurred in every fourth patient and was found to be the major reason for a high complication rate. In view of this major problem, the technique described here cannot be recommended, even though the absence of nonunions in our series seems to support the low invasiveness of this surgical approach.

Adult↗
PubMed1995

Isolated avulsion fracture of the lesser tuberosity of the humerus.

Six cases of isolated avulsions of the lesser tuberosity of the humerus were encountered within a short period of time. Although it seldom has been described in the literature, it might be a more common fracture than suspected. Physical examination revealed a painful shoulder with limited function in all six patients. In retrospect, all diagnoses could have been made on the primary plain roentgenograms. However, the fragment of the lesser tuberosity was easily misdiagnosed. An axillary view showed the fragment clearly in all cases. Computed tomography is useful for making an accurate diagnosis because it establishes the size and displacement of the fragment and determines additional injuries, such as a ruptured biceps tendon. Five patients with displacement of the lesser tuberosity were operated on after several weeks or months. The lesser tuberosity was reattached in all cases. After 6 months three patients had slight impairment of elevation and external rotation, and one of them suffered from pain during movements of the arm. The patient with no fracture displacement was treated conservatively with a good result. In conclusion, we recommended an axillary roentgenogram as part of the posttrauma radiologic series of the shoulder. A nondisplaced avulsion fracture of the lesser tuberosity of the humerus can be treated conservatively. We recommend reattachment of displaced fractures.

Accidental Falls↗
PubMed1996

Surgical neck fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques.

OBJECTIVE: A biomechanical cadaver study was performed to compare the stability and ultimate strength of ten standard fixation techniques used for the treatment of surgical neck fractures of the proximal humerus. DESIGN: One hundred twenty (60 fresh frozen, 60 embalmed) proximal humerus specimens were selected and divided into two groups: fresh frozen specimens represented a nonosteopenic group and embalmed specimens an osteopenic group. Simulated fractures were created at the level of the surgical neck, reduced, and randomly assigned to one of ten methods of fixation (six fresh frozen and six embalmed specimens per fixation group). These constructs were then mechanically tested with the humeri oriented to create primarily shear loading of the fixation. RESULTS AND CONCLUSIONS: The T-plate and screws provided significantly stronger fixation (p < 0.005) in the fresh frozen specimens than all other methods. The Ender nails/tension band construct was the second strongest fixation technique, providing significantly stronger fixation (p < 0.01) than all the remaining techniques. Four Schanz pins with one pin placed through the greater tuberosity followed by the T-plate and screws provided the strongest fixation in embalmed specimens. Tension band fixation in both humeral groups was shown to provide the least effective fixation.

Biomechanical Phenomena↗
PubMed2005

A new locking plate for unstable fractures of the proximal humerus.

UNLABELLED: In a prospective study, 28 patients with 29 proximal humeral fractures were treated with the Locking Proximal Humerus Plate from 2001-2002. Most of these fractures were complex, Type B (n = 15) and Type C (n = 9) fractures, according to the AO classification. Followups included radiographs, clinical examinations, and recording Constant scores. After 1 year, the average Constant score for all fractures was 74.6 (range, 37-96). For Type A fractures, it was 82.6 (range, 60-96), for Type B it was 78.3 (range, 37-95), and for Type C it was 64.6 (range, 40-91). Complications related to the implant included breakage of the plate in one patient and redislocation of the fracture in four patients (one fracture was associated with deep infection), which required reoperation in two patients. Partial osteonecrosis was seen in two patients, once after deep infection. There were no nonunions. Our data show that using the Locking Proximal Humerus Plate for treatment of proximal humeral fractures of all types is a reliable procedure, with good results being obtained with careful planning and familiarity with the special features of the operative technique. LEVEL OF EVIDENCE: Therapeutic study, Level II-1 (prospective cohort study).

Activities of Daily Living↗
PubMed2005

Location of treatment of supracondylar fractures of the humerus in children.

A change in the locations where children are treated for supracondylar fractures of the humerus has occurred during the past 13 years. Pediatric orthopaedic surgeons at specialist centers are seeing an increased number of such fractures. In New England, the number of supracondylar fractures of the humerus treated by closed reduction and percutaneous pinning has remained relatively constant between 1991 and 1999 with a range of 276 to 346 fractures per year, averaging 320 per year. In 1991, 63% of patients were treated by general orthopaedic surgeons in a nonspecialist setting. By 1999, 68% of the fractures were treated at centers with pediatric orthopaedic specialists available whereas only 32% were treated in a general orthopaedic setting. Associated with this change is a decreased length of stay from 2.2 (+/- 0.6) days in nonspecialist centers to 1.4 (+/- 0.4) days average in specialist centers.

Age Distribution↗
PubMed2006

Clinical importance of comorbidity in patients with a proximal humerus fracture.

UNLABELLED: The aim of this prospective study of 100 consecutive patients with a proximal humerus fractures primarily was to investigate the prevalence and importance of poor health and comorbidity. Seventeen men and 83 women with a mean age of 73 years were involved together with 138 age and gender-matched controls. Twenty patients with a mean age of 81 years, were severely ill with a physical and/or mental disorder when they got their proximal humerus fracture. The 1-year mortality of this subgroup was 40% compared with 8% in the control group. Fifty-seven patients with a mean age of 74 years reported concomitant disorders compared with 54 of 78 (69%) controls. Twenty-three patients with a mean age of 67 years, reported no comorbidity compared with 25 of 34 (74%) in the control group. Sixty-seven patients were followed up on for 1 year and were evaluated clinically and radiographically. The Constant-Murley shoulder assessment was used. The 12 surviving severely ill patients were not able to attend the followup evaluation. In the remaining patients there was no significant difference after 1 year in pain, function, Constant-Murley score or radiographic healing of the injured shoulder between individuals with or without comorbidity. Patients with symptomatic shoulders at followup initially had significantly more frequently displaced fractures. LEVEL OF EVIDENCE: Prognostic study, Level II (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2006

Fixation of proximal humerus fractures using the PHILOS plate: early experience.

UNLABELLED: Proximal humeral fractures, especially in elderly patients, remain a challenging problem for the surgeon because the complication rate for these fractures still remains high. The internal locked system (PHILOS) plate is a new device used for proximal humerus fracture fixation is designed to decrease the high complication rate. We prospectively evaluated our early experience using this system. Twenty patients with fractures of the proximal humerus were treated with a PHILOS plate from September 2001 to January 2004 at Princess Alexandra Hospital in Harlow, UK. Functional assessment was done using the Constant shoulder score. Two patients who had brachial plexus injury were evaluated only with the visual analogue score because we thought that the Constant objective assessment would be unreliable. Complications were monitored. The mean Constant score was found to be 76.1% (range, 30-100%). The preliminary results seem to be satisfactory. According to our experience, the plate design provides stable fixation with a good functional outcome and eliminates most hardware problems such as failure and impingement syndrome. The PHILOS plate is suitable for the majority of fractures providing that the correct surgical technique is used. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMedDate not supplied

Two-incision technique for treatment of complex proximal humerus fractures.

The treatment of complex proximal humerus fractures that involve displacement of the greater tuberosity remains challenging. Good functional outcomes and decreased pain are possible with open reduction and internal fixation. Keys to a successful outcome include preservation of blood supply through decreased soft-tissue stripping, restoration of normal anatomic relationships (particularly the greater tuberosity), and stable internal fixation that allows early range of motion. To attain these goals, we advocate fixation with a fixed-angle locking proximal humerus plate using a 2-incision approach. A deltopectoral incision is used to expose the humeral shaft and head while the greater tuberosity is visualized by using a lateral incision. The fracture fragments are reduced and the plate is secured by working through these 2 incisions.

Adult↗
PubMed2003

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3).

BACKGROUND: A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus. METHODS: After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending). RESULTS: Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws. CONCLUSION: Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.

Biomechanical Phenomena↗
PubMed2002

Skeletal traction and delayed percutaneous fixation of complicated supracondylar humerus fractures due to delayed or unsuccessful reductions and extensive swelling in children.

The functional and radiological results of 13 supracondylar humerus fractures of 13 children were evaluated to determine the efficiency of delayed percutaneous fixation of the fractures after a period of skeletal overhead traction. All the fractures were complicated by delayed reduction, extensive swelling or unsuccessful reduction manipulations. As the unfavourable preexisting factors subsided under skeletal traction, anatomical reduction and fixation of fractures by percutaneous pinning were performed under general anesthesia. The average follow-up period was 21 months. Bauman and lateral capitellohumeral angles were measured and statistically analyzed. Functional and cosmetic results were evaluated by physical examination of the elbows. There were 11 excellent and two fair functional results while all cosmetic results were excellent or good. As a result, skeletal traction and delayed percutaneous pinning is accepted as an alternative method of treatment for complicated supracondylar humerus fractures in children.

Bone Nails↗
PubMed1984

Operative reduction and fixation of a difficult supracondylar extension fracture of the humerus.

We evaluated the results of the operative treatment of a difficult supracondylar fracture of the elbow. A series of 45 consecutive children, the majority presenting initially with a complete dislocation of the humerus, was reexamined. Thirty-two of the patients had undergone an early operation applying the anterior cubital approach and 13 patients had been treated by traction. The lengths of the follow-up periods were 3.1 +/- 1.5 and 8.8 +/- 2.6 years, respectively. Normal range of extension-flexion and rotation movements was preserved almost invariably by either modality of therapy, whereas the carrying angle of the elbow was reduced significantly more often in the group treated by traction. None of the patients presented with permanent nerve dysfunction, keloid formation, or myositis ossificans. The two preventable early complications, slipping of the osteosynthesis and entrapment of the ulnar nerve, were related to the fixation of the fracture. There were no early or late infectious complications. When the anterior approach was used, operative reduction and fixation of a difficult supracondylar fracture of the humerus proved to be both safe and timesaving. Anatomical results of operation were superior to those attained by traction therapy in our series.

Child↗
PubMedDate not supplied

Neurovascular injury and displacement in type III supracondylar humerus fractures.

From July 1987 to January 1991, 59 consecutive type III supracondylar humerus fractures in children were identified at Children's Hospital, Boston. Twenty-nine patients (49%) had evidence of neurovascular compromise. The median nerve was involved in 15 (52%) of these patients and was associated with posterolateral displacement in 87% of cases. The radial nerve was involved in eight (28%) of these patients and was associated with posteromedial displacement in every case. Injuries to the brachial artery occurred in 11 (38%) of these patients and was associated with posterolateral displacement in 64% and posteromedial displacement in 36% of cases. We conclude that posterolateral displacement in type III supracondylar humerus fractures is strongly associated with median nerve injuries. Posteromedial displacement is responsible for injuries. Posteromedial displacement is responsible for injuries to the radial nerve in virtually every instance. Brachial artery injuries may occur with either type of displacement. Neurovascular injury is higher than previously reported in these fractures.

Blood Vessels↗
PubMedDate not supplied

Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures.

The radiographs and patient charts of 47 children treated with closed reduction and percutaneous pin fixation of displaced supracondylar humerus fractures were reviewed. Twenty-seven fractures were fixed with crossed medial and lateral pins. Twenty fractures were treated with two parallel laterally placed pins. Baumann's angle on the anteroposterior elbow film and the humerocapitellar angle on the lateral elbow film were independently measured by the three authors on initial postoperative films and on films taken at the time of pin removal. No statistically significant differences regarding maintenance of reduction were found when comparing the two fixation groups. There were two complications in the medial pin group (one cubitus varus and one ulnar nerve injury) and none in the lateral-pin group. We conclude that crossed-pin fixation offers no clinically significant advantage over two laterally placed pins in the treatment of supracondylar humerus fractures.

Bone Nails↗
PubMedDate not supplied

Percutaneous pinning of pediatric supracondylar humerus fractures with the semisterile technique: the Miami experience.

Pediatric supracondylar humerus fractures are common injuries. The standard of care for management of displaced supracondylar fractures has become closed reduction and percutaneous pinning of the fracture in the operating room. We have been using a "semisterile" surgical technique, similar to what is used when placing a traction pin at the bedside. The purpose of this study was to evaluate our cases from 2000-2004 requiring closed reduction and percutaneous pinning to determine if this method had an infection rate comparable to what is reported in the literature. A total of 304 cases were identified. There were no superficial pin track infections or deep infections requiring treatment in any patient. A review of the literature regarding percutaneous pinning of supracondylar humerus fractures reveals an overall infection rate of 2.34% (45/1922) with a deep infection rate of 0.47% (9/1922). Consequently, the use of the semisterile technique is safe and an efficient way to handle these cases in saving time, cost, and materials. We also found that the administration of perioperative antibiotics may not be necessary as 68% of our patients did not receive any antibiotics during the perioperative or postoperative period. Finally, we found that 37% of our patients were discharged home the same day the surgery was performed, and there were no cases of compartment syndrome or Volkmann ischemic contracture. This indicates that observation overnight in the hospital may not be necessary for every patient.

Antibiotic Prophylaxis↗
PubMed2005

Thrower's fracture of the humerus with radial nerve palsy: an unfamiliar softball injury.

A fracture of the normal humerus in a healthy young adult most commonly results from significant direct trauma. Throwing sports have become increasingly popular outside of North America and bring with them a novel injury mechanism for clinicians. A 21 year old woman sustained a "thrower's fracture" of the distal humerus and radial nerve palsy while throwing a softball. She was treated by internal fixation. Her fracture united, and radial nerve neurapraxia resolved after 8 weeks. Clinicians should be aware of this entity so that prodromal symptoms can be recognised early and thrower's fractures are not investigated unnecessarily.

Adult↗
PubMed1989

Isolated avulsion fracture of the lesser tuberosity of the humerus: report of two cases.

Isolated avulsion fractures of the lesser tuberosity of the humerus are exceptionally rare. Two cases are reported here, each involving a 12-year-old boy. The mechanism of injury appears to be a strong external rotatory force applied while the arm is at maximum external rotation and approximately 60 degrees of abduction. In children and adolescents the fracture most likely occurs through the apophyseal plate of the lesser tuberosity (traction epiphysis). In adults, clinical differentiation from the far more common calcific peritendinitis of the rotator cuff can be difficult. Whereas large, displaced fractures can be easily demonstrated on anteroposterior radiographs with internal and external rotation of the humerus, the axillary view is often necessary to detect smaller fragments with little displacement.

Accidental Falls↗