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PubMed2006

[Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures].

BACKGROUND: Proximal fracture of the humeral head is the third most frequent fracture in humans. Most (70%) of those affected are over 60 years old. It is hoped that advanced locking medullary screws or plates will reduce the risk of secondary dislocation of screws or fracture segments when the bone of the humeral head is osteoporotic. METHODS: From January 2002 to August 2005, 225 displaced humeral head fractures in 223 patients aged on average 66+/-15 years were treated with a new locking proximal humeral plate. RESULTS: In 176 patients in whom follow-up was possible, the average Constant Score after 9 months was 70+/-19 points (raw data), or 81+/-22% in the normalized score. No significant difference was detected between the younger group up to 65 years of age (73% points) and those over 65 years of age (80% points). Axial deviations by more than 30 degrees were noted in 11 (5%), and of 159 displaced tubercles, malreduction by more than 5 mm was noted in 14 (9%). Two infections and two haematomas had to be treated so far. Primary screw perforations were seen in 24 (11%) cases as well as further implant dislocations in 3 (1,7%). Plate dislocations out of the shaft existed in 4 (2,4%) and 14 collapses of the humeral head with secondary screw perforations were recorded. All other complications arose out of technical faults, such as 24 screw perforations (11%) into the glenohumeral joint and 3 (1.7%) cases of secondary implant dislocation from the humeral head and 5 (3%) from the shaft, and 14 (8%) sinterings with glenohumeral screw perforation. So far, in addition to 1 case of pseudarthrosis with a broken plate, 5 (3%) cases of total and 9 (5%) of partial avascular humeral head necrosis have been observed. CONCLUSION: The new implant provides superior stability in the fixation of humeral head fragments and has proved its worth in everyday clinical practice when additional indirect fixation of the tubercle is needed, as it frequently is in elderly patients.

Aged↗
PubMed2003

Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants.

Several aspects of the management of displaced supracondylar fractures in children remain controversial. Displaced supracondylar humeral fractures (Type III) in children have traditionally been considered orthopaedic emergencies. Recent studies have suggested that closed Type III supracondylar fractures without vascular compromise may be treated in a delayed manner without compromise to functional and cosmetic outcome. Debate continues over the fixation method of choice in these difficult fractures. A postal questionnaire of 121 practising paediatric orthopaedic consultants in the UK was performed to explore these issues. Seventy-seven replies were obtained (63.6%). The 54.5% of the respondents managed displaced supracondylar fractures without vascular compromise in a delayed manner (more than 8h from presentation). The incidence, initial assessment and factors which influence the timing of surgery of these fractures are discussed. The fixation method of choice reported was closed reduction and the use of smooth Kirshner wires (93.4%). Of these, crossed pin fixation is used by 83.9% of respondents and 9.7% employed laterally placed wires. The majority of consultants (69.7%) considered the operative treatment of these fractures a consultant-led procedure. This survey has established an overview of the current practices of paediatric orthopaedic consultants in the UK in the management of these difficult fractures.

Bone Nails↗
PubMed2000

The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions.

Adequate exposure is a prerequisite for treatment of distal humeral fractures, as with most surgical procedures. Challenging as they may be to reduce and fix, these fractures can be made more or less difficult to treat based on exposure; complications of successful treatment may arise as a result of the exposure. In this article the authors describe the triceps-reflecting anconeus pedicle (TRAP) approach to the distal humerus, which provides an extensile and versatile approach for treatment of fractures and nonunions. The TRAP approach provides almost the same exposure as an olecranon osteotomy, without the complications of the osteotomy, and has the added advantage of retaining the whole olecranon to use as a template against which to assemble the articular fragments of the trochlea.

Fractures, Ununited↗
PubMedDate not supplied

The triceps-dividing approach to open reduction of complex distal humeral fractures in adolescents: a Cybex evaluation of triceps function and motion.

Triceps function and elbow motion were evaluated in nine elbows after open reduction of complex distal humeral fractures through a triceps dividing approach. At 3-year 6-month follow-up, the patients had an average flexion/extension of 136 degrees to -6 degrees. Triceps peak torque decreased slightly, measured by Cybex testing with a 6% deficit at 60 degrees/s, 3% deficit at 120 degrees/s, and 3% deficit at 180 degrees/s. We recommend triceps division rather than olecranon osteotomy in children who require open reduction of complex distal humeral fractures.

Adolescent↗
PubMed2002

Treatment of complex proximal humeral fractures with minimally invasive fixation of the humeral head combined with flexible intramedullary wire fixation - introduction of a new treatment concept.

The treatment of three- or 4-part proximal humerus fractures is still a matter of scientific discussion. The following study presents the results of a combined procedure using limited invasive fixation techniques for reconstruction of the humerus head and retrograde intramedullary wiring with elastic nails for the treatment of displaced three- or 4-part fractures. A prospective study of 24 patients with 3-part and 4-part fractures was performed from September 1995 to December 1998. Combined biologic fixation for reconstruction of the humerus head, including intramedullary wiring, was utilized. Fracture reduction was performed in an open soft-tissue-preserving technique through a limited lateral approach. Fixation of the head fragments was performed using screw and/or cerclage wire fixation. The reconstructed humerus head was stabilized to the shaft with intramedullary wires, with retrograde insertion 2 cm above the olecranon fossa. Supportive fixation of the head fragments was achieved using fully threaded cancellous screws. At the 1-year postoperative follow-up, 40% of the 18 patients had excellent results using the Neer and Constant score. Forty-five percent had satisfactory and 15% unsatisfactory results. The initial results of this study reveal that a combination of limited internal fixation of the humerus head and retrograde elastic intramedullary wiring provide stable fixation with limited soft-tissue destruction. This approach has been shown to be especially useful for the combined treatment of three- or four-part fractures of the humeral head.

Adult↗
PubMed1987

Displaced proximal humeral fractures. Selecting treatment, avoiding pitfalls.

This article, based on years of modified classification of displaced proximal humeral fractures, presents the treatment alternative for each type of injury and the problems to be avoided with each method. The authors recommend reduction and fixation in active patients with displaced proximal humeral fractures. Percutaneous pin fixation for two-part fractures, tension band fixation for three-part fractures, and hemiarthroplasty for four-part fractures are advocated.

Aged↗
PubMed1986

Displaced proximal humeral fractures. Seven years' experience with a modified Zickel supracondylar device.

A modified Zickel supracondylar rod was used in a prospective study for the fixation of 31 fractures of the proximal humerus in a patient population an average of 55 years of age. The follow-up period averaged 18 months and the overall Neer score at the time of final follow-up examination was 83. Six two-part fractures, ten three-part fractures and fracture dislocations, seven four-part fractures and dislocations, four pathologic fractures, and four humeral shaft fractures were treated with the device. The Neer score did not vary significantly among the groups, although the group with four-part fractures and dislocations was much younger than the overall group. Radiographic evidence of avascular necrosis occurred in the four-part group, but this was not associated with collapse or clinical findings. There was a slight correlation between increasing age and decreasing clinical result. There were no nonunions, vascular injuries, or infections in any patient.

Adult↗
PubMed2006

Y-T humeral fractures with supracondylar comminution in five cats.

Five cats with Y-T fractures of the humeral condyle were reviewed. Breeds presented included domestic shorthair (four cats) and Maine Coon (one cat). Age ranged from two to 16 years. All the cats were neutered males. A road traffic accident was suspected in all cases. Four of the fractures were severely comminuted and one fracture had four fragments. The fractures were repaired via combined medial and lateral approaches. Fixation of the epicondylar ridges was performed using buttress plates in four cases and neutralisation plates in one case. The intracondylar fracture was stabilised using a 2.7 mm lag screw in four cases and a 3.5 mm lag screw in the other. A corticocancellous bone graft was applied in two cases. The intracondylar fracture was accurately reduced in all cases. Complete radiographic healing was documented in two cases 6 and 11 weeks following surgery. Failure of the fixation occurred in the most severely comminuted fracture five days postoperatively. Surgical revision was not performed, and the limb was amputated. Three cats were free of lameness and had resumed outdoor activities at follow-up (five to eight months after surgery). Marked lameness due to loss of elbow movement was observed in the other case.

Animals↗
PubMed2002

[Role of external fixators for treatment of humeral fractures: report of 23 cases using Orthofix fixators].

From 1991 to 1998, 23 humeral fractures has been treated using the Orthofix external fixator. Average age of the patient was 42 y and average follow-up 55.5 m. Initial trauma was: 13 traffic accidents, four falls at home, two devastating farming accidents, two sports accidents, one aggression and one gun accident. AO classification was used and location of the fracture was classified using Hackethal classification modified by de la Caffinière. Majority of fractures were located at the one-third distal humerus and the majority was also comminuted. At follow-up, elbow range of motion was 130 degrees, shoulder range of motion 161 degrees, external rotation 69.5 degrees and internal rotation 92.5 degrees. Using the classification of Stewart and Hundley, eight excellent, seven good, three fair and two bad results were obtained. There were no postoperative radial nerve palsy. Two external fixators had to be removed because of pin mobility. Failures were: non union and pin mobility in one patient which has to be reoperated on; two non unions have been grafted on and plated. There were no malunion in the postoperative X-rays. This device is our favourite for this type of injury because of its rigidity and the possibility of secondary dynamization. The external fixator was removed after union: this explains the long delay of union in our series.

Accidents↗
PubMed1991

Shoulder arthroplasty in complex acute and chronic proximal humeral fractures.

From 1983 to 1988, 42 shoulder arthroplasties were performed on comminuted acute or chronic proximal humeral fractures. Patients were categorized according to the post-fracture operative delay; there were 15 four-part fractures, with median post-fracture delay of 13 days (range: 7 to 21), and 27 chronic fractures, including 11 four-part fractures, 9 three-part fractures, and 7 two-part fractures, with median post-fracture delay of 14 months (range: 4 to 72). Follow up was approximately 2 years in both groups (range: 1 to 5). All patients were evaluated according to a modified Neer score-system and classified into four groups. Pain relief was satisfactory in the acute group, but was unpredictable in the chronic group. The results in the acute group were significantly superior (P less than .05). In the acute group, 3 (20%) patients had an excellent result and 6 patients (40%) had a good result, compared to a good result obtained by 6 patients (22%) in the chronic group. Two patients (13%) in the acute group and 11 patients (40%) in the chronic group had a poor result. There were no statistical differences between two-part, three-part, or four-part fractures in the chronic group. Five cases of persistent instability were seen in shoulders formerly treated with osteosynthesis (one acute and four chronic cases). Two of these cases developed an infection. Good results can be expected after prosthetic replacement in acute proximal humeral fractures. Failed primary treatment reduces the possibility of a good result with revision arthroplasty.

Adult↗
PubMed2007

Reconstructing proximal humeral fractures using the bicipital groove as a landmark.

Controversy persists in the literature regarding the use of the bicipital groove as an anatomic landmark to restore humeral head retroversion when treating complex proximal humeral fractures with arthroplasty. We quantified the three-dimensional geometry of the bicipital groove in 49 dried humeri relative to the intramedullary axis, quantified the reliability of using the bicipital groove as an anatomic landmark, and compared this reliability with that of the conventional technique that uses a fixed, average angle relative to the epicondylar axis to establish humeral head retroversion. The data show the anterior offset of the bicipital groove is nearly constant from proximal (7.3 mm +/- 2.8 mm) to distal (7.2 mm +/- 1.5 mm) relative to the intramedullary axis. Given the consistency, the distal bicipital groove (at the level of the surgical neck) is a reasonable landmark to establish humeral head retroversion after complex proximal humeral fractures having reliability (angular error of 7.9 degrees +/- 5.8 degrees) as good as or better than the conventional fixed-angle technique.

Humans↗
PubMed1996

[Results of a differentiated therapy concept for dislocated subcapital humeral fractures in elderly patients].

Between 1990 and 1994 94 patients over 65 years of age with subcapital humeral fractures were treated by plate osteosynthesis combined with a modified postoperative treatment including intensive physical exercise in the early postoperative period. Three months after surgery all osteosynthesis materials were removed using a differentiated treatment of the subacromial area. In the follow-up study 69 of the 94 patients were examined; 22 patients showed an excellent, 26 a good, 9 a satisfactory, and 12 an unsatisfactory result. Thus, we recommend plate osteosynthesis of subcapital humeral fractures in elderly people in combination with our standardized postoperative regimes.

Aged↗
PubMed2006

Ipsilateral dislocation of the shoulder and elbow joints with contralateral comminuted humeral fracture.

Ipsilateral dislocation of the shoulder and elbow joints is a rare and complex injury. During the last 25 years, only 3 cases have been reported in the literature. We report a 50-year-old woman who suffered ipsilateral elbow and shoulder dislocation with contralateral comminuted humeral fracture. Both shoulder and elbow joints were reduced, but the elbow was dislocated subsequently at follow-up. The reduction in the elbow was stabilized by a Kirschner wire that was removed at 3 weeks, and the elbow was then stable. A U-shaped coaptation splint was applied for the contralateral comminuted humeral fracture. At 6 months, she had acquired a nearly full range of motion of both shoulder and elbow with complete healing in the contralateral humerus. Although rare and complex, ipsilateral shoulder and elbow dislocation, which is the result of a high-energy trauma, can be treated conservatively.

Elbow Joint↗
PubMed2001

[The displaced proximal humeral fracture: is there evidence for therapeutic concepts?].

INTRODUCTION: There is no general agreement on the operative treatment of displaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have been favoured during the past decade. The indication for primary shoulder prosthesis is controversial. The purpose of this report was to evaluate the scientific evidence of current treatment recommendations. METHODS: Relevant articles were retrieved from "Medline" and "Knowledge-Finder" using the combined search strategy for the keywords "proximal humerus" and "fracture". Retrieved articles were evaluated according to the criteria of evidence-based medicine. RESULTS: The analysis retrieved 3 randomized, 4 prospective, and 26 retrospective studies and a number of review articles relevant to the subject. Limitations of most publications were due to small study populations, differences in patient selection and fracture classification as well as measurements of outcome. According to these studies good functional results can be achieved in dislocated two-part fractures treated with minimal osteosynthesis in the elderly and T-plate fixation in younger patients. For three- and four-part fractures minimally invasive techniques seem to be more favourable in the elderly. However, there is some evidence that alternative therapies such as conservative treatment and plating can be successful in defined populations. A general indication for primary implantation of a prosthesis in four-part fractures in the elderly is not supported by the literature. CONCLUSION: We conclude from our analysis that the scientific evidence for treatment recommendations of displaced proximal humeral fractures is still limited.

Adult↗
PubMed1987

Epidemiology of proximal humeral fractures.

In an urban population of half a million, all proximal humeral fractures were recorded in 1983. A total of 565 fractures, of which 77 per cent occurred in women, were seen. The overall incidence per 100,000 was 48 in men and 142 in women, with an exponential increase from the 5th decade of age. This rise was due to a higher incidence of minimally displaced fractures associated with moderate trauma, and thus of fractures associated with osteoporosis.

Age Factors↗
PubMed2002

Diaphyseal humeral fractures: treatment options.

All of the current modalities have a place in the treatment of diaphyseal humeral fractures. Functional bracing renders a high rate of union and seems to be a safe method of treatment for most closed fractures. Type II and III open fractures seem to respond best to plate fixation or external fixation, particularly when there are associated neural or vascular pathologic findings. Patients with polytrauma who are unable to walk are also best treated with plate fixation. Plate fixation is also the best method of treatment when adequate alignment cannot be obtained with nonsurgical methods. Intramedullary nailing remains controversial because its complication rate is higher than that associated with either plate fixation or functional bracing. None of the treatments described is a panacea, and complications may occur with each one of them. An appropriate appreciation of the biologic response to the three modalities; an understanding of the indications, contraindications, and possible complications of the treatments; and a mastery of the techniques of application are essential for the attainment of satisfactory clinical results.

Biomechanical Phenomena↗
PubMed2004

[Results of the provision of unstable proximal humeral fractures in geriatric patients with a new angle stabilizing antegrade nail system].

Treating unstable proximal humeral fractures in elderly patients with osteoporosis and limited compliance is still demanding for trauma surgeons. The failure rate of operative treatment is high. We studied the use of a new antegrade intramedullary humeral nail with special locking bolts for head fixation. The first 41 procedures in 39 patients with a mean age of 81 years (61-102) were analyzed. Half of the patients were mentally deranged. There were 16 two-part, 22 three-part, and 3 four-part fractures of the humeral head treated. After closed or partial open reduction, antegrade nailing was performed via a delta split and limited incision of the rotator cuff. Greater and lesser tuberosities were fixed with screws through threaded holes of the proximal nail leading to high stability. Early functional active treatment was performed avoiding maximal rotation. Follow-up was 13 months (7-21 months). Clinical examination was performed in 32 cases. Four patients were questioned by phone. Three patients died (mean age: 92 years) before follow-up. The mean Constant score was 57+/-12. The mean age-related and side-related Constant scores were 86+/-17% and 90+/-7%. All fractures healed. Activities of daily life were possible in every case. There was only one loss of reduction after a fall out of bed. After hemiarthroplasty the patient was excluded from the study. One shaft fissure occurred during distal interlocking and healed uneventfully. Because of stable fixation, rehabilitation without immobilization was possible and led to good functional results. In comparison to common implants, the new antegrade intramedullary nail allowed a stable osteosynthesis in unstable proximal humeral fractures in old and very old patients with limited compliance without the usual implant-related complications.

Aged↗
PubMedDate not supplied

A new prosthetic design for proximal humeral fractures: reconstructing the glenohumeral unit.

A new shoulder prosthesis design for proximal humeral fractures has been developed. The rim of the articular component of this prosthesis has several holes to which the bone-tendon junction of the rotator cuff is fixed, to allow an anatomic reconstruction of the glenohumeral unit. The strength of the tuberosity fixation to this prosthesis is investigated in a cadaveric study. Artificial 4-part fractures were created in 18 human, fresh-frozen, paired shoulder joints with intact rotator cuffs. Two methods of tuberosity fixation were used in a matched-pair fashion. In group I the tuberosities were sutured to the rim of the prosthetic head, and in group II the tuberosities were circumferentially tension band-wired. Strength testing was performed on a material-testing machine, and displacement was recorded with an opto-electronic device. Both fixation methods proved to be equally reliable in the forces exerted during activities of daily living without significant displacement of the fracture fragments.

Aged↗