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PubMed1994

[Hemi-alloplasty in the treatment of proximal humeral fractures].

Twenty-four cases of displaced proximal humeral fractures were treated by hemiarthroplasty. No postoperative infections were seen. Follow-up was 24 month (range 12 to 62) in 19 patients. Pain relief was satisfactory in all patients but one. Functional results according to a modified Neer score system were good in nine, fair in eight and poor in two cases. No statistical differences in results in relation to postinjury delay or other parameters were found. Hemiarthroplasty is thus a safe treatment for displaced humeral fractures with a satisfactory end result.

Aged↗
PubMed2006

Effectiveness of locked nailing for displaced three-part proximal humeral fractures.

BACKGROUND: Published reports about locked nailing for displaced comminuted proximal humeral fractures are few and the results contradictory. METHODS: Locked nailing was used to treat 27 selective patients with displaced three-part proximal humeral fractures. The average age of patients was 54.3 years. The operative indications were persistent severe displacement, intact or minimally displaced lesser tuberosity, tolerance of anesthesia, and adherence to rehabilitation programs. Three patients had associated shoulder dislocation and two had fractures with diaphyseal extension. By transdeltoid approach, the fractures were reduced and then fixed by antegrade nailing with either upward or downward locking screws. The patients were prospectively followed up for an average of 24 months. RESULTS: All fractures achieved eventual union. Three patients with proximal screw loosening required screw removal. On the basis of Neer criteria, excellent or satisfactory results were obtained in 21 patients whose scores averaged 87.5 points. Six patients had unsatisfactory outcomes, with an average of 75.8 points. Two patients with the complication of avascular necrosis still had a satisfactory outcome. Varus deformity of shoulder joints, deformity of the greater tuberosity, collapse of the humeral head, and old age could adversely affect shoulder elevation. However, the anatomic abnormalities might have limited effects on the pain scale, muscle power, and shoulder stability. CONCLUSIONS: Locked nailing can be an effective treatment for selected severely displaced three-part proximal humeral fractures. It is particularly useful for fractures with diaphyseal involvement. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful treatment results.

Adult↗
PubMed2004

Periprosthetic humeral fractures after shoulder arthroplasty.

BACKGROUND: Currently, there is little information concerning periprosthetic humeral fractures after shoulder arthroplasty. Therefore, we reviewed our experience with these fractures to determine the results of treatment, the risk factors for periprosthetic fracture, and the rates of reoperation. METHODS: Between 1976 and 2001, nineteen postoperative periprosthetic humeral fractures occurred among 3091 patients who had undergone shoulder arthroplasty at our institution. Sixteen patients had a complete series of radiographs and were included in this study. The average time from the arthroplasty to the fracture was forty-nine months. Seven patients had severe osteopenia. Twelve fractures occurred at the tip of the prosthesis; of these, six extended proximally (type-A fractures) and six did not (type-B fractures). Three fractures occurred distal to the implant and extended into the distal humeral metaphysis (type-C fractures). One fracture occurred in the proximal metadiaphyseal region because of osteolysis. RESULTS: Six fractures healed after an average of 180 days of nonoperative treatment. Five fractures were treated operatively after an average of 123 days of unsuccessful nonoperative treatment. The remaining five fractures had immediate operative treatment. All sixteen fractures healed. One patient required multiple operations over a period of three years before union was achieved. With the exclusion of this patient and one other patient who received a custom prosthesis, the average time between the first operative procedure and union was 278 days. CONCLUSIONS: Our data do not clearly indicate the need for operative treatment of type-A fractures unless the humeral component is loose. A trial of nonoperative treatment may be considered for well-aligned type-B fractures that are associated with a well-fixed humeral component; however, operative intervention should be considered for type-B fractures that have not progressed toward union by three months. If the component is well fixed, open reduction and internal fixation may be performed. If the component is loose, revision with a long-stem component is recommended. For type-C fractures, a trial of nonoperative treatment is recommended.

Adult↗
PubMed2004

Distal humeral fractures treated with noncustom total elbow replacement.

BACKGROUND: The purpose of this study was to review the cases of patients with a distal humeral fracture that was treated with a noncustom total elbow arthroplasty. We hypothesized that, on the basis of the functional and clinical outcome, total elbow replacement is a reliable option for the treatment of elderly patients with a severe, comminuted fracture of the distal part of the humerus. METHODS: We retrospectively reviewed forty-nine acute distal humeral fractures in forty-eight patients who were treated with total elbow arthroplasty as the primary option. The average age of the patients was sixty-seven years. Forty-three fractures were followed for at least two years. According to the AO classification, five fractures were type A, five were type B, and thirty-three were type C. The average age of the forty-three patients was sixty-nine years and the average duration of follow-up was seven years. Fourteen patients died during the review period. Postoperative clinical function was assessed with use of the Mayo elbow performance score, and anteroposterior and lateral radiographs made at follow-up examinations were reviewed. RESULTS: At the latest follow-up examination, the average flexion arc was 24 degrees (range, 0 degrees to 75 degrees ) to 131 degrees (range, 100 degrees to 150 degrees ) and the Mayo elbow performance score averaged 93 of a possible 100 points. Heterotopic ossification was present to some extent in seven elbows, with radiographic abutment noted in two. Thirty-two (65%) of the forty-nine elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Fourteen elbows (29%) had a single complication, and most of them did not require further surgery. Ten additional procedures, including five revision arthroplasties, were required in nine elbows; five were related to soft tissue and five were related to the implant or bone. CONCLUSIONS: Complex distal humeral fractures should be assessed primarily for the reliability with which they can be reconstructed with osteosynthesis. When osteosynthesis is not considered to be feasible, especially in patients who are physiologically older and place lower demands on the joint, total elbow arthroplasty can be considered. This retrospective review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humeral fracture when strict inclusion criteria are observed.

Adult↗
PubMedDate not supplied

Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures.

This study quantified the torsional resistance provided by locking plates and angled blade plates used to stabilize proximal humeral fractures. Three-part proximal humeral fractures were created in 6 pairs of cadaveric humeri. One specimen of each pair was reconstructed with a proximal humeral locking plate, whereas the other specimen was reconstructed with an angled blade plate. An external rotation torque, varying from 0 to 5 N-m, was applied to the humeral head until the head rotated 30 degrees or 10,000 loading cycles were applied. The mean initial torsional stiffness was significantly larger for the locking plates (0.99 N-m/degree) than for the blade plates (0.59 N-m/degree). For each pair, the maximum rotation was larger for the blade plate than for the locking plate. For this in vitro model of a reconstructed 3-part proximal humeral fracture, the locking plate provided better torsional fatigue resistance and stiffness than the blade plate.

Aged↗
PubMed2005

Distal humeral fractures treated with noncustom total elbow replacement. Surgical technique.

BACKGROUND: The purpose of this study was to review the cases of patients with a distal humeral fracture that was treated with a noncustom total elbow arthroplasty. We hypothesized that, on the basis of the functional and clinical outcome, total elbow replacement is a reliable option for the treatment of elderly patients with a severe, comminuted fracture of the distal part of the humerus. METHODS: We retrospectively reviewed forty-nine acute distal humeral fractures in forty-eight patients who were treated with total elbow arthroplasty as the primary option. The average age of the patients was sixty-seven years. Forty-three fractures were followed for at least two years. According to the AO classification, five fractures were type A, five were type B, and thirty-three were type C. The average age of the forty-three patients was sixty-nine years and the average duration of follow-up was seven years. Fourteen patients died during the review period. Postoperative clinical function was assessed with use of the Mayo elbow performance score, and anteroposterior and lateral radiographs made at follow-up examinations were reviewed. RESULTS: At the latest follow-up examination, the average flexion arc was 24 degrees (range, 0 degrees to 75 degrees ) to 131 degrees (range, 100 degrees to 150 degrees ) and the Mayo elbow performance score averaged 93 of a possible 100 points. Heterotopic ossification was present to some extent in seven elbows, with radiographic abutment noted in two. Thirty-two (65%) of the forty-nine elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Fourteen elbows (29%) had a single complication, and most of them did not require further surgery. Ten additional procedures, including five revision arthroplasties, were required in nine elbows; five were related to soft tissue and five were related to the implant or bone. CONCLUSIONS: Complex distal humeral fractures should be assessed primarily for the reliability with which they can be reconstructed with osteosynthesis. When osteosynthesis is not considered to be feasible, especially in patients who are physiologically older and place lower demands on the joint, total elbow arthroplasty can be considered. This retrospective review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humeral fracture when strict inclusion criteria are observed.

Arthroplasty, Replacement↗
PubMed1986

A new classification of proximal humeral fractures.

Neer's classification of humeral fractures was proved on 657 patients. This classification enables the radiologist to estimate the risk of avascular necrosis of the head of the humerus. The problematic group is that of four part lesions, which has a 19% incidence of humeral head necrosis. Since in this group minimal osteosynthesis produces better functional results than extensive osteosynthesis, a detailed pre-operative radiological description of the fracture type is necessary in order to spare the patient from extensive surgery which could have unsatisfactory results.

Humans↗
PubMed2006

[Comminuted distal humeral fractures treated with Y-type anatomical plate].

OBJECTIVE: To explore the efficacy of Y-type anatomical plate in patients with distal humeral fracture. METHODS: Thirty three patients suffered from comminuted distal humeral fracture undertook the operation. Among them, 15 were supracondyle fracture, and the other 18 were intercondyle fracture. All patients were treated with middle post elbow incision, reposition, and fixed with Y-type anatomical steel plate. RESULTS: All patients were followed up for 16 months after the operation, and all fractures healed. The average healing time was 3. 5 months. The elbow joint function according to Aitken and Rombeck's elbow function rating system was evaluated, and the results were as follows: the function recovery was excellent in 29 patients, good in 2 and fair in the other 2 patients. The excellence rate was 93. 9%. CONCLUSION: Y-type anatomical steel plate is excellent in the treatment of distal humeral fracture.

Adolescent↗
PubMed2004

Epidemiology of humeral fractures in Malawi.

We analysed and determined retrospectively the location, age, gender and side of the body of humeral fractures from 258 antero-posterior radiographs of all patients aged 3-81 years over a 5-year period. It was observed that 160 fractures occurred on the left side while 98 were on the right side with 156 occurring in males and 102 in females. Forty-eight percent of the fractures occurred at the lower end of the humerus while 41% occurred at the mid-shaft with only 10% occurring at the upper end. Furthermore, the age group of 3-12 years had the highest incidence of fractures (40.7%) with the age group of 30-39 years the lowest incidence (6.2%). Most supracondylar fractures (75.4%) occurred in children, with teenagers accounting for the majority of mid-shaft fractures (51.9%). However, middle-aged and elderly individuals had the highest incidence of upper humeral fractures (73.1%). There was significant relationship between the site of these fractures, age, gender and body side of the patients studied (p<0.001). These results are, however, not in agreement with some previously documented studies. The importance of epidemiological study of humeral fractures in planning, training and resource management in a given population is therefore stressed.

Adolescent↗
PubMed2001

Treatment of proximal humeral fractures by intramedullary Kirschner wires.

BACKGROUND: This study is a retrospective analysis of a case series of 41 proximal humeral fractures treated by multiple intramedullary Kirschner (K) wires. METHODS: Forty-one proximal humeral fractures in patients aged 17 to 62 years were treated by closed intramedullary K-wires. There were 18 patients with the 2-part fractures, 11 with the 3-part fractures and 12 with the 4-part fractures according to Neer's classification. Patients were placed supine on the table, under general anesthesia. The arm was held vertically up by transolecranon traction, and the C-arm was kept parallel to the ground and opposite to the affected arm. A cortical window was created approximately 1.5 cm proximal to the olecranon fossa, by splitting the triceps. Under fluoroscopic control, multiple K-wires were introduced retrograde into the medullary cavity to reach the humeral head across the fracture. The wire tips were kept divergent to provide rotational stability at the fracture site. Postoperatively, the limb was supported in an arm sling. The patients were evaluated for pain, range of motion, strength, anatomic restoration, function of the involved limb, and radiographic union of fracture. RESULTS: An objective evaluation of the results using Neer's criteria showed 92.7% excellent to satisfactory results. Three patients developed painful shoulder-one from the 3-part and two from the 4-part fracture group. One patient from the 4-part group developed avascular necrosis of the humeral head. CONCLUSION: This surgical technique is effective for proximal humeral fractures. It is recommended for routine management of the 2-part and the 3-part fractures. For the 4-part fractures, it can be used in selected, young and active patients. An endoprosthesis is advised for the old, osteoporotic patients.

Adolescent↗
PubMed2001

Surgical treatment of three-part proximal humeral fractures.

The majority of proximal humeral fractures may be managed with nonsurgical treatment. However, three-part displaced fractures require surgery with two goals: obtaining an anatomic reduction and providing enough stability to allow an early rehabilitation program. This article describes a simple technique of internal fixation with Kirschner wires that can be applied in fracture-dislocations and three-part fractures of the proximal humerus. A retrospective study of 29 consecutive cases of three-part fractures of the proximal humerus treated with this procedure is presented. Excellent or satisfactory results were achieved in 79.3% of cases using Neer's criteria at minimum 12 months follow-up. Eighteen patients (62.1%) had no pain or had only mild pain not interfering with daily activities. Twenty-four shoulders (75.9%) had more than 130 degrees active elevation, and 15 patients (51.7%) had at least 130 degrees active abduction. The complications were one avascular necrosis, one osteitis and one early loss of reduction that required a new operation. In conclusion we recommend this technique for operative treatment of three-part fractures of the humerus because of its simplicity and satisfactory results.

Activities of Daily Living↗
PubMed1987

Internal fixation techniques for proximal humeral fractures.

Operative treatment of proximal humeral fractures is performed with a variety of fixation techniques. Selection of the optimum device for fixation is dependent on anatomic considerations, fracture characteristics, surgical exposure, and biomechanical features of fixation devices. Fixation objectives are evaluated in light of Neer's four segment classification. An extended deltopectoral approach with release of anterior deltoid distal insertion as well as the proximal pectoralis major raphe provides a wide exposure. The approach heals rapidly and allows rapid rehabilitation. The shoulder fracture fragments are adaptable to tension band wiring. With loss of bone stock, tension band wiring becomes increasingly important because compression or shearing forces can be expended in the tendinous insertion of the fragments. Fixation principles are applied according to specific fracture patterns. Whatever the choice of fixation method, a protracted and vigorous rehabilitation program is essential to achieve maximal functional recovery.

Fracture Fixation, Internal↗
PubMed2001

The epidemiology of proximal humeral fractures.

We present a 5-year prospective study of the epidemiology of 1,027 proximal humeral fractures. These fractures, which tend to occur in fit elderly persons, have a unipolar age distribution and the highest age-specific incidence occurs in women between 80 and 89 years of age. The commonest was the B1.1 impacted valgus fracture, found in one-fifth of the cases in this series, a type that is not included in the Neer classification. We used both Neer and AO classifications. The AO classification proved to be more comprehensive because in the Neer classification, half of the fractures are minimally displaced and almost nine-tenths fall into only three categories. In the AO classification, the B1.1, A2.2, A3.2 and A1.2 sub-groups comprise over half of all proximal humeral fractures, while the AO type C fractures occur in only 6%. We suggest that the literature does not adequately reflect the spectrum of proximal humeral fractures.

Activities of Daily Living↗
PubMed2003

Functional outcome of AO type C distal humeral fractures.

PURPOSE: To review the functional outcome of AO type C distal humeral fractures (bicondylar fractures) managed with dual orthogonal plate fixation. METHOD: Twenty-three patients were reviewed retrospectively at a mean of 45.1 months. Patient-rated outcomes (Disabilities of the Arm Shoulder and Hand [DASH], Patient Rated Ulnar Nerve Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and Short Form-36 [SF-36]), clinical, radiographic, and objective evaluations were used to assess outcomes. RESULTS: Almost 40% of patients required a third plate for adequate fixation. Patients identified minimal subjective deficits (10%) with a mean satisfaction of 93%. The arc of motion was decreased in the flexion-extension plane (122 degrees relative to 138 degrees, p <.01), whereas strength was lower for both elbow flexion-extension and forearm rotation (p <.05). The overall complication rate was 48%, however, most were minor and resolved without further surgery. No ulnar neuropathies were identified at follow-up after routine ulnar nerve transposition. CONCLUSIONS: Outcomes of AO type C distal humeral fractures were good with dual orthogonal plating, ulnar nerve transposition, and early motion. Additional plating may be required with distal fracture patterns or osteopenic bone.

Adolescent↗
PubMed2006

[Approaches to distal humeral fractures in adults and comparison of treatment results].

OBJECTIVES: We compared the results of surgical techniques used in the treatment of distal humeral fractures. METHODS: The study included 22 patients (15 men, 7 women; mean age 52 years; range 21 to 80 years) who were treated for closed distal humeral fractures. The fractures were classified according to the Müller's classification (18 type 3, 4 type 4) and Mehne-Matta's classification of intraarticular fractures. Following open reduction, internal fixation was performed with the use of double reconstructive plates in seven patients (32%), multiple K-wires in eight patients (36%), and multiple screws in seven patients (32%). The mean follow-up period was 42 months (range 24 to 72 months). The results were assessed using the Mayo Elbow Performance Scoring system. RESULTS: The results were very good in five patients (22.7%), good in eight patients (36.4%), fair in five patients, and poor in four patients (18.2%). Valgus and varus deformities were found in six (27.3%) and three (13.6%) patients, respectively, and 12 patients (54.6%) had decreased muscle strength. Two patients (9.1%) in the K-wire group developed instability due to insufficient union. Heterotopic ossification was detected in five patients (22.7%). None of the patients had persistent or severe pain. Two patients (9.1%) were free of pain, while 11 patients (50%) had occasional and mild pain, and nine patients (40.9%) had moderate pain on activity. The mean Mayo Elbow Performance scores were 88, 72, and 55 with plate, screw, and K-wire applications, respectively. CONCLUSION: It was concluded that open reduction followed by internal fixation with double reconstructive plates was superior to K-wire and screw fixations in the treatment of distal humeral fractures.

Adult↗
PubMed2000

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach.

BACKGROUND: While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires). METHODS: We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing. RESULTS: The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy. CONCLUSIONS: The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

Adult↗
PubMed2002

Closed retrograde nailing of pathological humeral fractures.

We treated 19 patients with 21 pathological humeral fractures secondary to metastatic disease. All patients were stabilized using retrograde Ender's nails. Open reduction was required in one patient and mean operative time was 40 min (range 30-65 min). All patients retained satisfactory elbow and shoulder function while 16 patients reported good pain relief. Functional recovery was rated as good in 15 patients, fair in three, and poor in one. In our experience the retrograde technique using Ender's nails provides secure stabilization with minimal morbidity, minimal blood loss, and short operative time, and is well suited for this category of patients.

Adult↗