Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus

BACKGROUND: Controversy persists concerning the preferred treatment of displaced fractures of the proximal part of the humerus. The present study was undertaken to evaluate the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus and the functional limitations of patients in whom avascular necrosis of the humeral head develops as a complication of this fracture. METHODS: We assessed the intermediate and long-term results for sixty patients with a three or four-part fracture of the proximal part of the humerus who had undergone open reduction and internal fixation with cerclage wires or a T-plate. The Constant score and a visual analog score for pain were calculated, and radiographs of the proximal part of the humerus were evaluated. RESULTS: After an average of ten years of follow-up, fifty-two patients (87%) had a good or excellent result on the basis of the Constant score whereas eight patients (13%) had a poor result. Fifty-one patients (85%) were satisfied with the result at the time of the most recent examination. Twenty-two patients (37%) had development of avascular necrosis of the humeral head, and seventeen (77%) of these twenty-two patients had a good or excellent Constant score. CONCLUSIONS: Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. This option should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head, as this complication did not preclude a good result.     

Treatment of humeral shaft fractures by closed fixation using multiple intramedullary Kirschner wires

BACKGROUND: The purpose of this study is to present the results of closed fixation of humeral shaft fractures with multiple intramedullary Kirschner wires. METHODS: Twenty-nine humeral shaft fractures in patients 14 to 60 years old were treated by closed fixation with multiple intramedullary Kirschner wires. Each patient was placed supine on the table and was administered general anesthesia. The fractured arm was held vertically up by a transolecranon traction, while 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, after splitting the triceps. Under fluoroscopic control, multiple Kirschner wires were introduced retrograde therein, into the medullary cavity, to reach the humeral head. The wire tips were kept splayed to stabilize the fracture. Postoperatively, the limb was supported by an arm sling. RESULTS: Twenty-five fractures (86.4%) healed with excellent clinical and functional results, in an average of 11 weeks. Union was delayed in two patients, and one fracture had a nonunion after repeated trauma. Movements at the shoulder and the elbow were excellent to good in 27 patients (93%), whereas 2 patients (6.8%) had significant limitation of extension at the elbow. CONCLUSION: This technique has been found simple and effective in providing a stable fixation of transverse and short oblique fractures of the humeral diaphysis. Further study is required to evaluate this procedure in more extensive fracture patterns, as well as to compare the results with other methods of internal fixation.     

肱骨近端内固定锁室系统接骨板治疗肱骨近端外翻嵌插四部分骨折的疗效分析

目的 探讨利用AO肱骨近端内固定锁室系统(proximal humeral internal locking system,PHILOS)接骨板切开复位内固定治疗肱骨近端外翻嵌插四部分骨折的术后疗效.方法 对11例平均年龄42岁的肱骨近端外翻嵌插四部分骨折的患者进行手术治疗.术中注意保护小结节内侧的骨膜连续性,仅在结节间沟外侧进行显露,肱骨头复位后骨缺损处行自体骨或同种异体骨移植,PImDS接骨板板内固定.结果 经平均20个月的随访发现1例肱骨头坏死,坏死率为9.1%.肩关节平均前屈上举150°、外旋20°、内旋Th12,JOA评分平均91分.结论 利用PHILOS接骨板切开复位内固定治疗肱骨近端外翻嵌插四部分骨折取得了良好的疗效.     

内固定治疗肱骨近端骨折(Neer 3型)的生物力学研究

目的通过生物力学研究,对比三种治疗肱骨近端骨折(Neer 3型)内固定结构的稳定性及耐久性。方法按照统一标准制作肱骨近端3部分外科颈大结节骨折模型,分别予空心钉、克氏针及三叶草钢板固定。所有标本进行循环外展实验、循环屈伸实验及压扭负载。结果加压空心钉的结构稳定性较克氏针好而次于三叶草钢板。空心钉及克氏针内固定结构稳定性与骨密度(BMD)有很大的相关性。结论加压空心钉治疗肱骨近端骨折是一种微创的内固定手术,手术时间短,能满足内固定的要求,提供术后患者进行功能锻炼的结构稳定性,是一种治疗老年肱骨近端骨折的可靠方法。     

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.     

Early asymptomatic intrathoracic migration of a threaded pin after proximal humeral osteosynthesis

Pinning with metallic wires is a suitable therapeutic option for proximal humeral fractures. Loosening and migration of such devices from this site is uncommon. Despite infrequently occurring, however, the literature reports dramatic and potentially lethal complications related to wires dislocation. A 69-year-old woman underwent closed reduction and fixation of a proximal 3-part humeral fracture by mean of two retrograde Kirschner wires and one anterograde threaded pin. One month after surgery, during a routine follow-up control, it was diagnosed the migration of the threaded pin in the left lung parenchyma. In the meantime, the only symptom the patient complained was an episodic intercostal pain of mild intensity, with referred onset 1 week after surgery. The migrated pin was removed through thoracoscopic approach in the emergency setting, without intra- or post-operative complications. Only a few authors reported similar complications after fixation of proximal humeral fractures. Immediate surgical removal of the device is always mandatory. When considering pinning fixation for shoulder girdle''s fractures, orthopedic surgeons should take into account the risk for wire dislocation, and take up adequate precautions during surgery and follow-up control visits.     

双切口克氏针及外侧可吸收张力带内固定治疗儿童肱骨髁上骨折

目的：探讨双侧克氏针结合外侧可吸收张力带内固定治疗儿童肱骨髁上骨折的临床疗效。方法：2006年至2010年采用双侧切口切开,交叉克氏针并可吸收张力带内固定治疗82例儿童肱骨髁上骨折,男53例,女29例;年龄5～12岁,平均7岁。根据骨折临床愈合后肘关节屈伸功能及肘部提携角结果,按Flynn评定标准综合评定疗效。结果：82例均获随访,时间0.5年,肘关节屈伸活动受限（2.8±3.7）°,提携角（12.7±2.2）°。依据疗效评定标准,优80例,良2例。结论：采用双侧切口交叉克氏针并可吸收张力带内固定治疗儿童肱骨髁上骨折,能早期进行肘关节功能锻炼,具有创伤小、固定牢固、恢复快的特点,是目前手术治疗儿童肱骨髁上骨折较理想的方法。     

Die winkelstabile Plattenosteosynthese bei Frakturen am proximalen Humerus mit der LPHP (Locking Proximal Humerus Plate)

OBJECTIVE: Stable fixation of unstable proximal humerus fractures until bony consolidation. Early mobilization of the shoulder and early active rehabilitation program to ensure a good functional outcome and a good restoration of the activities of daily living. INDICATIONS: Unstable two-, three- and four-part fractures of the proximal humerus (classified according to the AO classification as: 11-A2, A3, B1, B2, B3, C1, C2, C3). Nonunions of the proximal humerus, especially at the neck. Pathologic fractures of the proximal humerus. CONTRAINDICATIONS: Comminuted humeral head fractures in old patients, which cannot be reconstructed adequately. Proximal humerus fractures in the immature patient. Local infection after previous surgery. SURGICAL TECHNIQUE: Deltopectoral approach. Blunt mobilization of the deltoid muscle. Suture loops through the supraspinatus tendon, the infraspinatus tendon, and the subscapularis tendon close to their bony insertion. Careful indirect reduction of the fracture fragments without further damage to their blood supply. Correct positioning of the LPHP (Locking Proximal Humerus Plate) on the lateral side of the humerus, approximately 5 mm below the tip of the greater tuberosity. Indirect approximation of the subcapital fracture component to the plate, by tightening a standard 3.5-mm cortical bone screw inserted into the first hole distal to the metaphyseal fracture line. Temporary fixation of the plate with 1.8-mm Kirschner wires. Fixed-angle fixation of the plate to the bone, using locking screws. Additional stabilization of the tuberosities to the plate with suture loops. RESULTS: Between January 1, 1997 and April 30, 2002, 64 patients with acute fractures of the proximal humerus were treated with fixed-angle plating at the UKH Graz. 36 patients meeting the inclusion criteria (that is primary operative stabilization within 14 days after trauma in a standardized way and minimal follow-up period of 12 months) were assessed 31 months after surgery on average, using the Constant Score and the DASH Score. The mean age of the 22 women and 14 men was 57.5 years (21-78 years). According to the AO classification eight fractures were classified as 11-A3, one fracture as B1, five fractures as B2, three fractures as B3, one fracture as C1, 16 fractures as C2, and two fractures as C3. A mean Constant Score of 62.6 points and an age-related Constant Score of 80.7% on average, as well as a DASH Score of 18.0 points were obtained, constituting a satisfactory result in three quarters of all patients. Complications observed were two humeral head necroses, one partial necrosis after a head-splitting fracture with nevertheless good clinical result, and a deep infection in two cases. Breakage of the plate was seen in one patient with an A3.3 fracture without medial buttress; no further surgery was necessary; the fracture healed after a short period of immobilization.     

Surgical management for late presentation of supracondylar humeral fracture in children

PURPOSE: To report the results of surgical management for late-presenting displaced supracondylar fractures of the humerus in children. METHODS: Between February 2002 and June 2003, 40 children (mean age, 7 years) with late presentation (range, 2-12 days) of displaced supracondylar humeral fractures were prospectively recruited. Gentle closed manipulation under image intensification was attempted in all patients, except one with a compound open fracture. Manipulation was successful in 25 patients and percutaneous skeletal stabilisation with Kirschner wires was performed. The remaining 15 patients were treated with open reduction and Kirschner wire fixation, using a mediolateral approach. RESULTS: The mean delay in presentation was approximately 4 days. No patients presenting more than 7 days after injury had the fracture reduced by closed manipulation. The mean hospital stay was 41 hours. At the final follow-up (mean, 18 months), 88% of the patients had a satisfactory result, according to Flynn's criteria. CONCLUSION: Operative treatment for late presentation of supracondylar humeral fractures in children is effective. It minimises the risk of complications and the need for continuous traction or corrective osteotomy.     

锁定钢板治疗不稳定肱骨近端骨折

目的探讨锁定钢板治疗肱骨近端骨折的临床疗效。方法从2003年至2005年,对58例肱骨近端骨折的患者采用有成角稳定的肱骨近端锁定钢板治疗,其中二部分骨折38例,三部分骨折14例,四部分骨折6例,经三角肌胸大肌间入路,钝性分开三角肌,间接复位并尽量减少对骨折血运的破坏,将锁定钢板置于肱骨的侧方,大结节下方5mm处,克氏针临时固定,锁定螺钉固定钢板,将移位的大小结节固定于钢板上。结果术后患者平均随访11.5个月,按N eer功能评定,术后功能优21例,良28例,可7例,差2例,仅有2例肱骨头坏死,其中1例术后功能较好。结论锁定钢板有高度的稳定性,是治疗肱骨近端骨折,尤其是粉碎性及骨质疏松性骨折的理想方法。     

Perkutane Osteosynthese der proximalen Oberarmfraktur

OBJECTIVE: Reduction and fixation of displaced fractures of the humeral head by percutaneous methods. Early functional postoperative management. INDICATIONS: Simple subcapital fractures of the humerus, AO 11A2, A3. Multifragmentary fractures of the proximal humerus, AO 11B1, B2, C1, (C2). CONTRAINDICATIONS: Head split fractures. Fracture dislocations. Severe osteoporosis. SURGICAL TECHNIQUE: The head fragment, generally impacted in valgus, is lifted by means of an elevator inserted percutaneously. The head is brought into the correct position and fixed to the shaft with two crossed Kirschner wires. The Kirschner wires are clamped into a locking device attached to the lateral cortex of the humerus by one screw to prevent slippage. Displaced tubercles are also reduced percutaneously by the aid of small bone hooks and are stabilized by insertion of cannulated screws. POSTOPERATIVE MANAGEMENT: Shoulder bandage for 3 weeks. Depending on the stability achieved during operation gentle exercising can be commenced from the 1st postoperative day with the arm bandaged. RESULTS: 200 patients (78 men, 122 women) were followed up at least 2 years (24-81 months) postoperatively. The average age was 61.6 years (14-103 years). The average Constant Score for four-part fractures was 87%. 24% of the patients had to be operated on a second time (shortening of the wires or reosteosyntheses). In 8.5% secondary change of management was necessary. In 3% clinically relevant avascular head necrosis occurred, and pseudarthrosis in 3%.     

锁定接骨板治疗肱骨近端骨折的近期疗效

目的探讨锁定接骨板治疗肱骨近端骨折的近期疗效。方法采用切开复位锁定接骨板内固定治疗28例肱骨近端骨折患者。结果 28例均获得随访,时间7个月~4年。骨折均获得骨性愈合。未出现切口感染、骨不连及内固定物松动断裂等并发症。肩关节功能按照Neer评分标准:优17例,良8例,可3例,优良率25/28。结论肱骨近端锁定接骨板治疗肱骨近端骨折损伤较小,固定可靠,可早期进行肩关节锻炼,术后功能恢复好,近期疗效满意。     

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

IntroductionVarious surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.MethodsA retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.ResultsBetween 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.ConclusionThis technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.     

New intramedullary nail for the surgical neck fracture of the proximal humerus in elderly patients

Background Fractures of the proximal humerus are common and the repair of displaced fractures generally requires an operative approach. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. We have developed a new intramedullary nail (pin lock nail) for the repair of surgical neck fractures of the proximal humerus in patients with osteoporotic bones. A retrospective review is presented of the cases of 19 elderly patients with two-part or three-part fractures of the proximal humerus treated using the pin lock nail. Methods We treated 19 elderly patients with a mean age of 70.5 years. There were 13 two-part surgical neck fractures, 3 two-part surgical neck fractures with non-displaced greater tuberosity fracture, and 3 three-part surgical neck fractures with greater tuberosity fracture. All fractures were treated using the pin lock nail. Clinical results were evaluated using the Japanese Orthopaedic Association score at the last follow-up examination. On radiographic evaluation, duration to bone union of the fracture, backing out of the pin and screw, penetration of the proximal pin, and varus angulations of the humeral neck were examined. Results Mean duration of follow-up was 14 months (range 6–54 months). All fractures had united at an average of 3.3 months after surgery. No backing out of the pin and screw or penetration of the proximal locking pin was seen at the time of last follow-up. Thirteen of the 16 patients had no or minimal varus angulations of the humeral neck (≤10°). The mean overall JOA score was 84.3 points (range 65.5–100). Conclusions Our data show that using the pin lock nail for the treatment of two-part and three-part humeral fractures is a reliable procedure, providing good results with careful postoperative management.     

锁定接骨板治疗老年肱骨近端骨折的近期疗效

目的 探讨锁定接骨板治疗老年肱骨近端骨折的近期疗效.方法 采用切开复位锁定接骨板内固定治疗26例老年肱骨近端骨折患者.结果 26例均获随访,时间6个月～2年.患者全部获得骨性愈合.未出现切口感染、骨不连及内固定物断裂等并发症.肩关节功能按照Neer评分标准:优17例,良7例,可2例.结论 肱骨近端锁定接骨板治疗老年肱骨近端骨折,损伤小、固定可靠,可提供早期功能锻炼、术后功能恢复好,近期疗效满意.     

Functional evaluation of comminuted intra-articular fractures of the distal humerus (AO type C). Long term results in twenty-six patients

The authors present the results achieved in 26 patients who presented with intra-articular fractures of the distal humerus (8 AO type C1, 8 C2 and 10 C3) and who were operatively treated between 1999 and 2001; they were retrospectively evaluated after a mean follow-up period of 70.2 months. There were 12 males and 14 females with a mean age of 46.1 years. After a standard posterior approach with olecranon osteotomy, internal fixation was achieved with unilateral or bilateral plates and screws, or isolated screws and/or Kirschner wires. Anterior intramuscular transposition of the ulnar nerve was performed in 14 of the patients. The results were evaluated using the criteria of Morrey. The results were graded as excellent in 6 patients (23.1%), very good in 15 (57.6%) and fair in 5 (19.3%). Complications included postoperative ulnar nerve palsy (1), wire migration (4), heterotopic ossification (3), infection (2) and material failure (2). The overall re-operation rate was 38.4%. The authors conclude that careful preoperative planning, transolecranon approach for good visualisation, routine ulnar nerve exploration and stable internal fixation facilitating early active rehabilitation, remain the gold standard for the treatment of intra-articular fractures of the distal humerus.     

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.     

切开复位内固定治疗严重嵌插外展型肱骨近端骨折

目的 评价切开复位内固定治疗严重嵌插外展型肱骨近端骨折的临床效果.方法 004年4月-2008年2月,手术治疗严重嵌插外展型肱骨近端骨折23例,采用改良的Thompson切口切开复位,用肱骨近端锁定钢板固定,其中20例行一期自体骨移植,8例术中发现有明显的肩袖撕裂而行修补术.术后进行系统的肩关节功能锻炼.结果 23例获得1年以上的随访,平均随访时间为17个月(12～33个月).所有骨折均于术后2个月内愈合,最近一次X线片检查未出现内固定失效和肱骨头坏死.采用肩关节Neer评分系统评分:优9例,良10例,可3例,差1例;优良率为82.6%.患者主观满意率为91.3%.5例出现供骨区髂部疼痛.结论 采用切开复位LPHP内固定治疗严重嵌插外展型肱骨近端骨折有利于早期功能锻炼,疗效满意.     

经皮顺行克氏针固定治疗肱骨近端骨折

目的：对应用经皮顺行克氏针固定治疗肱骨近端骨折的适应证、手术方法和疗效进行总结分析。方法：应用经皮顺行穿针固定治疗肱骨近端闭合骨折32例，男7例，女25例；年龄28-75岁，平均49．25岁。Neer外科颈2部分骨折20例，3部分骨折9例，4部分骨折3例。结果：32例均获随访，随访时间8-34个月，平均13．5个月。按Con—stant-Murley功能评分标准：优21例，良9例，可2例。结论：经皮顺行穿针固定治疗肱骨近端骨折，结合有计划的康复治疗，操作简单、疗效可靠。不但可用于治疗外科颈2部分骨折，而且还可选择性地应用于3、4部分骨折的治疗。     

关节镜下治疗肱骨近端骨折内固定术后冻结肩

目的探讨肩关节镜下治疗肱骨近端骨折术后冻结肩的疗效。方法对61例肱骨近端骨折切开复位内固定术后冻结肩患者采用全身麻醉肩关节镜下治疗联合关节松解、内固定装置取除术。比较手术前后肩关节活动范围、UCLA评分及ASES评分。结果关节镜下肱骨近端骨折内固定术后冻结肩常见有关节内病变。52例完成术后12~18个月的随访,9例失访。52例肩关节活动度、UCLA评分和ASES评分末次随访均较术前改善(P<0.05)。结论肩关节镜下治疗联合关节松解、内固定装置取除术有助于改善肱骨近端骨折内固定术后冻结肩患者的肩关节功能。