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PubMed1997

Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation.

OBJECTIVES: The purpose of this study was to investigate the mechanical strength and durability of intramedullary nailing (IM) and percutaneous pinning (PP) for fixation of three-part proximal humeral fractures using a cadaveric model. DESIGN: Three-part surgical neck fractures were created in paired embalmed cadaveric humeri. Fractures were fixed with IM and PP fixation. The fixation stiffness and durability was assessed under cyclic rotational loading (infraspinatus) ramping from 0.1 to 1.25 Newton-meters for 10,000 cycles. The specimen were then torsionally loaded to failure. SETTING: Mechanical testing was performed using a servohydraulic test system (MTS, Minneapolis, MN, U.S.A.). INTERVENTION: PP fixations were accomplished using standard multiplane techniques. IM fixation was attained using an 11.0-millimeter-diameter curved rod interlocked proximally with three splayed 5.0-millimeter cancellous screws and distally with three 3.5-millimeter cortical screws. MAIN OUTCOME MEASUREMENTS: During cyclic loading the reconstruction stiffness, angular migration, and angular displacement per cycle were measured and compared between fixation methods. The ultimate torque at failure, absolute angular migration, and reconstruction stiffness during failure were recorded and compared between fixation methods during destructive testing. RESULTS: The intramedullary device had greater stiffness and less angular displacement of fragments during cyclic loading. When loading the reconstructions to failure, the intramedullary device proved to have greater failure torques, stiffness, energy absorbed, and angular displacement before failure. CONCLUSIONS: This biomechanical study showed that the IM device provided a stronger, more stable, and durable fixation option than did PP fixation for large-fragment multipart proximal humeral fractures with minimal comminution.

Biomechanical Phenomena↗
PubMedDate not supplied

Treatment of proximal humeral fractures with Polarus nail fixation.

A chart review of 20 patients who sustained acute proximal humeral fractures and who were treated by surgical stabilization with locked antegrade humeral intramedullary nails (Polarus nails) was undertaken. The clinical outcome measurements were fracture healing, infection, and neurologic injury. Radiologic outcome measurements included fracture alignment, loosening, fixation and hardware failure, and malunion and nonunion. Of 20 fractures, 11 healed without complications. The mean immediate postoperative and final radiographic valgus neck/shaft angulation measured 131 degrees. Of the 20 implants, 3 had proximal fixation screw loosening. Of the 20 implants, 2 underwent revision surgery for proximal fixation failure. With certain fracture types, the Polarus intramedullary humeral nail can be an effective implant. In fracture cases involving an unstable or comminuted lateral metaphyseal fracture, if the starting point extends into the greater tuberosity, fixation failure or fracture displacement may result.

Adolescent↗
PubMed2006

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children.

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.

Bone Wires↗
PubMedDate not supplied

Periprosthetic humeral fractures: management and classification.

Six patients (67 to 94 years of age) sustained a periprosthetic humeral fracture at an average of 43 months after shoulder arthroplasty (range 13 to 85 months). These fractures were classified depending on fracture anatomy and implant stability. Type A fractures occur about the tuberosities. Type B fractures occur about the stem and are subclassified by fracture anatomy and implant stability: B1 fractures are spiral fractures with a stable implant, B2 fractures are transverse or short oblique fractures about the tip of the stem with a stable implant, and B3 fractures are those fractures about the stem with an unstable implant. Type C fractures occur well distal to the tip of the stem. Five of the 6 fractures required surgery, 4 with revision to a long-stemmed component. All fractures united with restoration of range of motion and function. Satisfactory results may be anticipated if these fractures are managed in an appropriate fashion.

Adult↗
PubMed1993

Proximal humeral fractures. Management techniques and expected results.

During a ten-year period (1978-1988), 143 of 1386 patients with proximal humeral fractures were treated with internal osteosynthesis. Ninety-seven proximal humeral osteosynthesis cases had adequate documentation, and 77 (80%) were available for clinical review. The 97 fractures were graded by the AO/ASIF classification and included 44 Group A, 32 Group B, and 21 Group C fractures. Exercise-stable osteosynthesis using T-plate, cloverleaf plate, or small condylar plate was performed in 70% of patients. In the remaining patients, a less rigid fixation, with Kirschner wires or screws and cerclage wires, was used. Fifty-two percent of the patients had excellent and good results, 15% had fair results, and 33% had poor results. Most poor results occurred in patients with four-part fractures (61% of poor results). Of the cases involving four-part fractures, however, 22% had an excellent result after internal fixation. Displaced four-part fractures or fracture-dislocations should be treated by reconstruction of the proximal humerus, especially in young patients. The use of minimal fixation rather than rigid fixation is considered after careful assessment of the condition of the soft tissue and blood supply of the humeral head fragments. Primary treatment with endoprostheses is required when internal fixation is impractical in AO/ASIF fracture Types C 2/3 and C3 fractures. Improved clinical results may be achieved, particularly in the more severe fracture types, with increased experience in techniques of internal fixation of proximal humeral fractures.

Female↗
PubMed2002

[Long-term functional results of adult intra-articular distal humeral fractures treated by open reduction and plate osteosynthesis].

OBJECTIVES: We assessed the long-term functional results of surgical treatment of distal intra-articular humeral fractures, together with the factors having influence on the outcome. METHODS: Thirty-four patients (25 males, 9 females; mean age 38 years; range 20 to 78 years) who were treated by open reduction and plate osteosynthesis were retrospectively evaluated. All fractures were type C according to the AO classification. Five patients had open fractures. Thirty-three patients had surgery within the first two days after trauma. Posterior (n=19), lateral (n=13), and lateral and medial (n=2) incisions were used. Intra-articular olecranon osteotomy was performed in 11 patients in whom a posterior incision was used. The mean follow-up period was 81.5 months (range 24 to 141 months). Functional evaluation was made according to the criteria described by Jupiter et al. RESULTS: Postoperative complications included infection in four patients, nerve lesion in four patients, nonunion of the olecranon in one patient, and fixation failure in one patient. The mean elbow flexion was 115.1 degrees, and the mean extension loss was 26.3 degrees. Four patients had severe pain and deformities. According to the criteria by Jupiter et al., the results were excellent in six (17.7%), good in 15 (44.1%), fair in nine (26.4%), and poor in four (11.8%) patients. The rate of excellent and good results were higher in closed fractures, in males, in patients at 20 to 40 years of age, in those undergoing posterior incisions and intra-articular olecranon osteotomy, and in patients in whom double-plate osteosynthesis was used. CONCLUSION: Our results suggest that age, gender, infection, preservation of neural function, successful rigid fixation, an anatomic restoration of the joint surface, and early rehabilitation are effective factors on the functional outcome.

Adult↗
PubMed2004

Helix wire osteosynthesis for proximal humeral fractures: unacceptable nonunion rate in two- and three-part fractures.

INTRODUCTION: Fractures of the proximal humerus are very common, but controversy still exists about the preferred type of operative treatment in displaced fractures. MATERIALS AND METHODS: We followed 15 patients (12 female and 3 male, average age 70 years) with 15 dislocated type II (9) and III (6) proximal humeral fractures after helix wire osteosynthesis. RESULTS: A nonunion developed in seven cases (47%). Three patients were reoperated (prosthesis: 2, repair: 1). Seven patients were available for follow-up (average: 14 months). Three patients had a Constant score of 80 or more and four patients had a score under 70 points. CONCLUSION: The results of the helix wire osteosynthesis for proximal humeral fractures are poor and we do not recommend its further use.

Adult↗
PubMed2001

Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial.

This was a randomized controlled trial of 28 children 1 year to 12 years of age with closed totally displaced supracondylar humeral fracture. The purpose of the study was to compare closed reduction and pinning (group A) and open reduction and pinning (group B). Each group consisted of 14 children. The general characteristics of both groups (age, sex side, displacement, nerve injury preoperatively) were statistically the same (P > 0.05). All cases healed with good alignment without cubitus varus, without infection and with a good range of motion except for one. The mean +/- standard deviation of the Baumann's angle difference between the injured and uninjured side were 2.32 +/- 1.6 degrees in group A (range, 0-6.5 degrees) and 2.45 +/- 1.8 degrees in group B (range, 0-6.5 degrees). This difference was statistically not significant (P = 0.8). By Flynn criteria, group A had good to excellent results in 100%, and group B had good to excellent results in 93% and fair in 7%. This difference was not statistically significant (P = 1). The satisfaction score (0-10) was significantly higher in group A for both parents' and evaluator's (blinded to treatment) perspective (P = 0.017 and 0.019, respectively). The author concludes that both treatments gave good results. Closed reduction should be performed first and, if it fails, then open reduction can be performed. This will produce good results in the hands of an experienced surgeon.

Child↗
PubMed2004

Proximal humeral fractures with minimal displacement treated conservatively.

We reviewed 27 patients with a minimally displaced proximal humeral fracture treated conservatively after a mean follow-up of 25 (12-34) months. All fractures had united. Patients were evaluated using the Constant-Murley scoring system, and isokinetic muscle strength was tested using a Cybex dynamometer. Finally, all shoulders were examined ultrasonographically. The mean Constant score for all patients were 81 (54-100). Twenty-three patients had no or only mild pain, while three had moderate and one severe pain necessitating regular use of oral analgesics. Twenty patients were able to perform all activities of daily living, but seven had mild trouble in overhead activities and weight carrying. Only in one patient, the abduction peak torque equalled the one of the opposite shoulder. In all other patients, the peak torque was lower than, and in 14 patients below, 50%. In nine patients, rotator cuff tears were seen at ultrasonography.

Adult↗
PubMed2004

[A new implant for proximal humeral fracture: experimental study of the basket plate].

PURPOSE OF THE STUDY: We conducted a comparative study of three ostheosynthesis systems for proximal humeral fractures. The conclusions led to the elaboration of a rigid extramedullary osteosynthesis implant. This novel implant allows specific fixation of the tuberosities via six adjustable and removable hooks organized like a basket. There are two versions, with and without a central cephalic locking screw. We report two static biomechanical studies conducted to analyze this material. MATERIAL AND METHODS: The two studies were performed on fresh frozen cadaver specimens with known bone density and with an experimental model of a four-fragment fracture of the proximal humerus. The first tests were designed to measure axial pressure reproducing the physiological movement applying the most stress on the head of the humerus. This allowed a global analysis of the mechanical behavior of the implant and an assessment of the contribution of the central cephalic locking screw. The second series of tests were traction tests used to analyze the behavior of the tuberosities fixed with the hooks. We assess the assemblies by measuring the mechanical resistance: rigidity of the fixation was recorded in mm/100N. Pre- and post-procedure x-rays and photographs were obtained to allow a subjective assessment of fragment displacement. RESULTS: The first series of tests demonstrated that the implant, with the central cephalic locking screw, presented good overall mechanical properties. The notion of better stability of the tuberosities obtained with the hooks, as seen during the first tests, was reinforced by the data from the second tests, although no statistically significant difference was demonstrated. We also noted that there was no statistically significant correlation between bone density and the slopes of the force-resistance curves. DISCUSSION: This prototype implant has an overall mechanical resistance equivalent to the reference implant, with at least equivalent performance. Proof of the usefulness of the central locking screw was not established, even though improved tolerance to loading by better force distribution seemed apparent. The contribution of the hook basket was not demonstrated. Data from the observations do however suggest the expectations of the implant will be fulfilled. Tests conducted on a larger scale would probably demonstrate a difference. It is clear that the small number of implants used here limited the study. Comparison with data in the literature show that this new prototype is adapted to the mechanics of the proximal humerus. Resistant to physiological stress, the implant allows pendular movement and passive physical therapy during the early post-operative period.

Biomechanical Phenomena↗
PubMed2006

Radial nerve injuries associated with humeral fractures.

A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Although treatment for this injury pattern is a controversial subject among upper-extremity surgeons, certain principles of management need to be applied in all cases. As our understanding of the pathoanatomy of the humerus and surrounding neurovascular structures has evolved, surgeons have adapted their strategies to improve outcome and avoid long-term morbidity. The principles of management and the clinical outcomes of various treatment strategies, defined in the literature, are reviewed in this article.

Braces↗
PubMed1998

[Antegrade or retrograde intramedullary nailing in diaphyseal or sub-capital humeral fractures in the adult].

The aim of this retrospective study was the evaluation of three current medullary nailing techniques and their approach related problems in diaphyseal and proximal humeral fractures. 28 patients (15 female, mean age 65 y; 13 male, mean age 53 y) with either diaphyseal (n = 22) or proximal humeral (n = 6) fractures treated with different nailing systems were reviewed (mean follow up 18.3 months). Two main groups were formed according to the surgical approach: an anterograde nailing group (AN), stabilized with Seidel (Howmedica) nails (n = 12) versus a retrograde nailing group (RN) with either Prévot (Landos) nails (n = 7) or Hackethal (Ulrich) nails (n = 9). The two groups were comparable regarding to age, follow up and fracture type. The subjective scores (global function, all day activity, pain, ROM) of the two groups (AN and RN) showed no statistically significant differences. Subacromial impingement led to reoperation in 50% (6/12) of the AN patients (Seidel nail). In 3/16 patients a reoperation was necessary due to secondary proximal or distal nail migration (Hackethal or Prévot nails). Delayed union was found either in one. Seidel or one Prévot nailed humerus. No postoperative infections or neurological problems (3 preoperative radial palsies recovered) due to the operative pro cedure were seen. The AN related subacromial impingement seems to be more disabling than RN related reduction of elbow function (extension deficit).

Adult↗