Does timing of surgery affect the outcome of open articular distal humerus fractures

Background

Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes.

Patients and methods

Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in <6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30–100); in the second, mean MEP was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). There were no statistically significant differences between two groups, MEP t(28) = 0.935, p < 0.358; DASH t(28) = ?0.636, p < 0.530.

Conclusion

Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications.     

Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy

Background

Although open reduction and internal fixation (ORIF) is a standard fracture treatment method, the optimal way to expose a fracture prior to ORIF is debated. We compared the effects of two exposure methods, the triceps-sparing approach and olecranon osteotomy, on the functional outcomes of ORIF-treated type C distal humerus fractures in elderly people.

Methods

From January 2006 to January 2011, 75 elderly patients with type C distal humerus fractures were treated with ORIF, and we retrospectively reviewed their medical records, radiographs, and follow-up charts to identify any complications. Patients’ Mayo Elbow Performance Score (MEPS) and range of motion were determined at their final clinic visit.

Results

Sixty-seven patients (89 %) attended the final visit. Of these patients, 36 received olecranon osteotomy and 31 received the triceps-sparing approach. For patients with type C1 and C2 fractures, we observed reductions in procedure times, blood loss, complication rates, and MEPS outcomes (all P < 0.01) with the triceps-sparing approach compared with olecranon osteotomy. Except for MEPS outcomes, all of these approach-related improvements were also statistically significantly for type C3 fractures (all P < 0.01). Overall, we did not observe any cases of fracture nonunion, implantation breakage or loosening, or elbow stiffening in our series.

Conclusions

In our study, we found better functional outcomes for type C1 and C2 distal humerus fractures that were exposed using the triceps-sparing approach rather than olecranon osteotomy. Even for the most complex type of fracture, C3 fractures, similar recoveries in elbow function were achieved using either approach.

Level of evidence

Level III.     

Elastic stabilisation of proximal humeral fractures with a new percutaneous angular stable fixation device (ButtonFix®): a preliminary report

Introduction

The ButtonFix^® system represents a new angular stable percutaneous fixation device for stabilisation of fractures of the proximal humerus. The purpose of this study was to present a preliminary report of the radiological and clinical outcome after minimally invasive stabilisation of selected proximal humerus fractures with the ButtonFix^®.

Patients and methods

Seventeen patients with fractures of the proximal humerus were treated in our department with the ButtonFix^® system. The mean final follow-up was performed 19 months postoperatively. Follow-up included assessment of postoperative reposition, range of motion, the DASH score, the Constant–Murley score, and the Short Form 36 (SF36).

Results

Twelve patients showed anatomical head-to-shaft angles, four revealed minor valgus replacement, and one minor varus replacement. In one patient unplanned revision surgery was necessary due to early secondary fracture dislocation requiring ORIF with an angular stable form plate. Implant removal was performed after 6 weeks in all patients. At the final follow-up, mean range of motion was: flexion 135°, extension 45°, abduction 142°, internal rotation 51°, and external rotation 62°. The mean Constant–Murley score was 70. The mean DASH score was 26 points and the average SF36 score was 76 points. One patient showed radiological signs of avascular necrosis.

Conclusion

The ButtonFix^® system represents a valuable tool in the treatment of proximal humeral fractures with results indicating fewer complications compared to prior percutaneous fixation devices. Moreover, the ButtonFix^® seems to be able to maintain reduction even in elderly patients with potentially reduced bone mass.     

Primärer endoprothetischer Ellbogengelenkersatz bei komplexen intraartikulären distalen Humerusfrakturen

Introduction

Open reduction and internal fixation of multifragmentary intra-articular fractures of the distal humerus often do not provide satisfactory results in elderly patients with osteoporosis.

Method

From December 2001 to January 2008 a total elbow arthroplasty (Coonrad-Morrey, Zimmer, USA) was performed on 12 patients (average age 81±9  ears) who presented with a type C distal humeral fracture. The mean time of follow-up with clinical and radiological assessment was 28±17 months.

Results

The Mayo score showed a good functional result with an average of 81±9 out of 100. DASH and SECEC scores showed a fair result with respect to elbow function (43±8 and 68±7 points, respectively). The average range of motion of all patients was 120-33-0°. Heterotopic ossifications were found by X-ray examination in 4 cases and asymptomatic radiolucent lines in 4 cases.

Conclusion

Primary total elbow arthroplasty for complex intra-articular distal humerus fractures in elderly patients has good functional results and is an alternative to osteosynthesis.     

Outcomes of Proximal Humerus Fracture Open Reduction Internal Fixation with Concomitant Ipsilateral Shoulder Girdle Injuries: a Case Control Study

Background

Proximal humerus fractures treated in the face of ipsilateral injuries to the shoulder girdle may be predisposed to worse clinical outcomes.

Questions/Purposes

The purpose of this investigation was to examine outcomes of proximal humerus fractures treated with open reduction internal fixation (ORIF) using an endosteal augment in the presence of a concomitant shoulder girdle injury in comparison to isolated proximal humerus fractures treated with ORIF and endosteal augment.

Methods

A prospective database was used to identify proximal humerus fractures with ipsilateral shoulder girdle injuries (glenohumeral and acromioclavicular dislocation, fractures of the acromion, clavicle, scapula, or humeral diaphysis). These were compared to isolated proximal humerus fractures treated in the same fashion (ORIF with endosteal augment). Minimum of 1 year follow-up was required for inclusion. Outcomes assessed included range of motion (ROM), development of avascular necrosis (AVN), hardware-related complications, reoperation, and subjective outcome assessments including the Disabilities of Arm Shoulder and Hand questionnaire (DASH), Constant score, UCLA rating scale, and the Short Form-36 (SF-36).

Results

Fifteen ipsilateral injuries were seen in 14 patients. Seventy-seven isolated proximal humerus fractures were available for comparison. The ipsilateral injury group had significantly worse forward flexion (141 vs 156°, p?=?0.02), external rotation (56 vs 64°, p?=?0.03), higher rates of avascular necrosis (4 of 14, 28.6% vs 1 of 77, 1.3%, p?=?0.002), and inferior SF-36 physical health scores (48.5 vs 63.5; p?=?.04). Despite these differences, no significant differences were seen with hardware-related complications or DASH, Constant score, or UCLA rating scale results. No patients required secondary reconstructive procedures.

Conclusion

Despite a statistically higher rate of AVN and decreased ROM, patient-based outcomes of proximal humerus fractures with ipsilateral shoulder injuries approached those seen in isolated proximal humerus fractures. This suggests that these injuries can achieve similarly good clinical results provided any associated shoulder pathology is identified and treated appropriately.

     

Treatment for type C fractures of the distal humerus with the LCP distal humerus system

Background

Although the locking compression plate-distal humerus system (LCP-DHS) is a biomechanically proven implant for fractures of the distal humerus, few have reported its clinical results.

Methods

Thirteen cases of type C intercondylar fractures of the distal humerus according to AO classification that were treated with the LCP-DHS followed for a minimum of 1?year were enrolled for this study. The mean age at the time of operation was 46.8?years (range, 26–80?years), and the mean follow-up period was 25.1?months (range, 13–39?months). The timing of bone union, implant failure, and loosening around screws were assessed on simple radiographs. For clinical evaluations, we analyzed range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS), and patient satisfaction.

Results

Bone union was achieved radiologically in all cases. The mean timing of bone union was 8.5?weeks (range, 5–18?weeks) after operation. At the last follow-up, the mean range of motion was 16 degrees (range, 0–40 degrees) in flexion and 131 degrees (range, 130–150 degrees) in extension deficit. The MEPS was 87.3 points (range, 45–100 points); the DASH score, 17.6 points (range, 0–86.7 points); and the VAS, 1.5 (range, 0–4). Complications included screw loosening and delayed union in 1 case, limited range of motion that led to adhesiolysis in 1 case, and transient ulnar nerve palsy in 1 case.

Conclusions

The internal fixation using the LCP-DHS for type C fractures of the distal humerus was stable, enabling early postoperative mobilization and good clinical results.     

AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases

Background

LCP extra-articular plate designed by AO has been used in extra-articular fractures of the distal humerus, mal-unions, and nonunions of the distal humerus. They provide anatomically shaped and angular stable fixation system for extra-articular fractures of the distal humerus. We extended the usage spectrum of this plate to the extra-articular with intra-articular distal humerus fractures and compared it with the standard orthogonal locking plate fixation.

Methods

We included 22 consecutive distal humerus intra-articular fractures with metaphyseal and diaphyseal extension into the study. Each case underwent osteosynthesis with LCP extra-articular plate fixation and augmented the intra-articular fragments with 4.0 mm partially threaded cancellous screws. The cost, surgical time, VAS, Modified Mayo Clinic Performance Index for elbow, and postoperative complications were recorded. The radiological union and postoperative elbow range of motion were assessed at 6 weeks, 6, and 12 months of follow-up. Twenty cases completed the scheduled follow-up. The results were compared with retrospective data of 20 cases from our institute where similar fractures were treated with standard orthogonal LCP distal humerus plate (LCPDHP).

Results

The radiological union rates and the range of motion at 6 weeks, 6, and 12 months in both the groups were comparable and did not vary significantly (p > 0.05). The cost and operative time with the LCP extra-articular plates were significantly less (p < 0.05) when compared to the group LCPDHP.

Conclusion

The usage spectrum of extra-articular distal humerus locking plate can be extended to intra-articular fractures. It provides good results and significantly reduces the cost and operative time.     

Welche Vorteile bietet die volare Plattenosteosynthese gegenüber der Kirschner-Drahtstabilisierung bei distalen Radiusextensionsfrakturen des alten Menschen?

Purpose

The purpose of this retrospective study was to compare the outcome of open reduction and internal fixation (ORIF) followed immediately by physiotherapy and of percutaneous K-wire-fixation and casting for unstable distal radius fractures in elderly patients, considering the results both in general, for all such fractures, and selectively for A3 and C2fractures.

Methods

Follow-up examinations were performed 26 (18–48) months after surgery in 43 patients (median age 67 (60–83) years) treated with K-wire fixation and 9 (5–17) months after surgery in 46 patients (median age 76 (60–90) years) treated with ORIF, and the outcome of each was recorded as Disabilities of the Arm, Shoulder and Hand (DASH), Gartland-Werley and Castaing scores; the radiological loss of correction was also assessed. Statistical analysis was performed first without reference to the specific type of fracture for the K-wire- and the total ORIF –groups, and then selectively for A3 and C2 –fractures only; in the second analysis the patients were divided into three groups: KD, ORIF with and ORIF without angular stability.

Results

The Garland-Werley and Castaing scores do not indicate any significant difference between the procedures specified. According to the Garland-Werley score 37 patients (86%) treated by K-wire fixation and 39 (85%) treated by ORIF achieved “excellent” and “good” results; according to the Castaing score there were 33 (77%) “good” results after K-wire fixation and 34 (74%) good results after ORIF. The radiological loss of correction (K-wire fixation/ORIF) as measured by the radial inclination (median 2/2.5°), the palmar tilt (median 3/5°) and the radial shortening (median 1/1°mm) do not differ significantly. Suboptimal radiological results do not always correlate with results that are only “fair” or “poor”. The non-fracture-specific DASH score suggests a higher degree of patient satisfaction after K-wire fixation (7 [0–87] points) than after ORIF (17 [0–82] points), which is not confirmed by fracture-specific evaluation. There is a significantly earlier return to the “activities of daily living” (4 as against 8 weeks) after ORIF.

Conclusion

All the treatments compared are suitable for the treatment of A3 and C2 fractures. The important advantages of ORIF are the early functional physiotherapy without casting and without obligatory second surgery and the earlier return to “activities of daily living”, which are all of decisive importance for older patients, who are the ones most frequently affected.     

Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator

Background

Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture.

Methods

Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique.

Results

There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°–9°) in the coronal plane and 1.2° (range 0°–8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3–38.4 weeks) and a mean follow-up of 20.8 months (range 13.5–31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation.

Conclusions

Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.

Level of Evidence

IV     

Shoulder hemiarthroplasty for complex humeral fractures: a 5 to 10-year follow-up retrospective study

Purpose

The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, strength recovery and predictors of successful treatment.

Methods

Seventy unstable proximal humeral fractures were treated with open reduction internal fixation (ORIF) with the use of locking proximal humerus plate. At an average follow-up of 31 months, the clinical and subjective outcomes were evaluated, and complication was analysed.

Results

The average Constant score was 72. The mean disabilities of the arm, shoulder and hand score was 23. The average range of motion was as follows: mean range of anterior elevation and abduction 120°–150°; external rotation in abduction 64° and in adduction 44°; and internal rotation T12.

Conclusion

On the basis of the overall functional and clinical outcome obtained, it is possible to suggest that the ORIF of the proximal humerus fractures using locking plate represents a helpful option that can lead to a good clinical and functional outcome even in the most complex fractures. Level of evidence, Case Series, Treatment Study, Level IV.     

Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates

Background

The aim of this retrospective study was to compare outcomes and complications of displaced fractures of the shaft of the humerus treated with limited-contact dynamic compression plates (LCDCPs) and locking compression plates (LCPs).

Materials and methods

Two hundred and twelve patients with displaced fractures of the shaft of the humerus, treated with plate osteosynthesis from January 2005 to December 2009 were reviewed. One hundred and two patients (group A) were treated with LCDCP osteosynthesis and 110 patients (group B) were treated with LCP osteosynthesis. Clinical and radiological assessments were made at monthly intervals for the first 6 months and then at 2-month intervals for the next 6 months. Primary outcome measures like operative time, duration of hospital stay, time to fracture union, union rate and secondary outcome measures (functional outcome and complications such as infection, malunion, delayed union, nonunion, implant failure and iatrogenic radial nerve palsy) were compared between both groups. The ULCA scoring system and Mayo elbow performance index (MEPI) were used to assess shoulder and elbow functions, respectively. Rodriguez-Merchan criteria were used to assess the functional outcomes of the fracture fixation.

Results

There was no significant difference found between the two groups in terms of primary outcome measures. According to Rodriguez-Merchan criteria, comparison of functional outcomes of both groups showed insignificant difference (p = 0.48). There was no significant difference found between the two groups regarding mean ULCA score (p = 0.34) and mean MEPI sore (p = 0.54). In terms of complications, no significant difference was found between the two groups.

Conclusion

This study concludes that the principle of fracture fixation was more important than plate selection in fractures of the shaft of the humerus.

Level of evidence

Level 3.     

Delayed ORIF of proximal humerus fractures at a minimum of 3 weeks from injury: a functional outcome study

Purpose

To evaluate the clinical results of open reduction and internal fixation (ORIF) in proximal humerus fractures with delayed presentation.

Design

Retrospective comparative study.

Setting

Level III.

Methods

From June 2005 to June 2010, thirty-nine (39) proximal humerus fractures were treated with ORIF after a delay of 21–120 days from the initial injury. Patients were divided into three groups: (1) isolated 2-part greater tuberosity fractures; (2) part surgical neck fractures; and (3) 3- and 4-part complex fractures. The range of motion (ROM), visual analogue scale (VAS), Constant–Murley score, University of California Los Angeles (UCLA) scoring system score and Simple Shoulder Test (SST) score were all recorded. The results were analyzed with the use of the Mann–Whitney U test and stratified by age, gender, side of injury, interval from injury to surgery, and postoperative functional results. Additionally, the results of different fracture types and complications were compared across the three groups.

Results

The mean forward flexion was 143.8° ± 28.9°, external rotation was 33.2° ± 19.6°, and internal rotation was up to the T10 level. The mean VAS was 0.8 ± 1.2; the mean Constant score was 82.0 ± 15.0; the UCLA score was 27.2 ± 7.1; and the mean SST was 9.5 ± 2.0 at the last follow-up. There were no significant differences among the three groups except in internal rotation. Compared to those without any complications, patients with complications demonstrated worse ROM and a lower functional score (p < 0.05).

Conclusions

Delayed treatment of proximal humerus fractures is a challenging problem. With appropriate surgical technique, satisfactory results can be expected with respect to different fracture types, and complications may be avoided regardless of delay.

Level of evidence

Therapeutic Level IV.     

Proximal fractures of the humerus in patients older than 75?years of age: should we consider operative treatment?

Background

Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.

Materials and methods

In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.

Results

Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).

Conclusion

This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.

Level of evidence

According to OCEBM Working Group, Level IV.     

Open reduction and bi-columnar internal fixation of intra-articular distal humerus fractures through a combined medial and lateral approach

Purpose

The aim of this retrospective study was to investigate the suitability of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of intra-articular distal humerus fractures.

Methods

Nineteen cases of intra-articular distal humerus fractures were treated with open reduction and bi-columnar internal fixation through a combined medial and lateral approach. The reduction in the articular surface and functional recovery of the affected elbows was assessed at an average follow-up of 15.8 ± 7.9 (7–43) months.

Results

The gap in the main articular fragments was less than 1 mm in 16 cases, while a gap of more than 1 mm and less than 2 mm was identified in 2 cases and of 3.7 mm in one case. All the fractures were united. At the latest follow-up, the mean flexion–extension of the elbows was 113.4° ± 20.7°, while the pronation–supination of the forearms was 158.3° ± 8.5°, and the mean Mayo Elbow Performance Index was 93.7 ± 9.1 points, leading to 13 excellent outcomes, and 6 with good results.

Conclusions

Intra-articular fractures of the distal humerus can be effectively treated by open reduction and internal fixation through a combined medial and lateral approach at the elbow.     

Healing process after rigid plate fixation of humeral shaft fractures revisited

Objective

The purpose of this study was to describe the radiological healing process after open reduction and internal fixation (ORIF) of humeral shaft fractures with plate.

Materials and methods

We reviewed the data of 53 consecutive patients who had undergone rigid plate fixation of OTA 12 A or B humeral shaft fracture. The mean age of the patients at the time of surgery was 39.4 (range 16–82). Quality of reduction and healing process was analysed on radiographs. Clinical symptom and disabilities of the arm, shoulder and hand (DASH) scores were recorded at follow-up visits.

Results

There were 28 compression and 25 neutralization platings. The mean gap size on the postoperative radiograph was 1.4 (range 0.1–6.1). 50 cases (94.3 %) healed, while three cases ended up with non-union. 28 (52.8 %) cases showed primary healing and 22 cases (41.5 %) showed secondary healing with callus bridging. Among the cases with secondary healing, callus formation with resorption was identified in 13 cases. The type of fracture, mode of compression and size of gap on radiographs after rigid plate fixation were found to be statistically significant factors for healing type (p = 0.026, 0.002, and <0.001, respectively). Three cases with non-union showed no improvement in DASH scores.

Conclusion

Both primary and secondary healing processes were observed after rigid plate fixation of OTA 12 A or B humeral shaft fractures. Our study revealed that size of gap, mode of compression, type of fracture could affect the type of healing, and that periosteal callus formation can occur after rigid plate fixation.     

Intraoperative panoramic image using alignment grid, is it accurate?

Background

Minimally invasive orthopedic trauma surgery relies heavily on intraoperative fluoroscopic images to evaluate the quality of fracture reduction and fixation. However, fluoroscopic images have a narrow field of view and often cannot visualize the entire long bone axis.

Objectives

To compare the coronal femoral alignment between conventional X-rays to that achieved with a new method of acquiring a panoramic intraoperative image.

Materials and methods

Twenty-four cadaveric femurs with simple diaphyseal fractures were fixed with an angulated broad DCP to create coronal plane malalignment. An intraoperative alignment grid was used to help stitch different fluoroscopic images together to produce a panoramic image. A conventional X-ray of the entire femur was then performed. The coronal plane angulation in the panoramic images was then compared to the conventional X-rays using a Wilcoxon signed rank test.

Results

The mean angle measured from the panoramic view was 173.9° (range 169.3°–178.0°) with median of 173.2°. The mean angle measured from the conventional X-ray was 173.4° (range 167.7°–178.7°) with a median angle of 173.5°. There was no significant difference between both methods of measurement (P = 0.48).

Conclusion

Panoramic images produced by stitching fluoroscopic images together with help of an alignment grid demonstrated the same accuracy at evaluating the coronal plane alignment of femur fractures as conventional X-rays.     

Treatment of Two-Part Proximal Humerus Fractures: Intramedullary Nail Compared to Locked Plating

Background

Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate.

Purpose

The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN.

Methods

A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function.

Results

Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant.

Conclusions

Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.     

Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows

Treating intra-articular fractures about the osteoporotic distal humerus poses a significant challenge. The purpose of this retrospective study was to evaluate functional outcomes for distal humeral fractures treated with total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) in a nonarthritic elderly population with osteoporosis. We reviewed the records of all women older than age 60 who had undergone surgical treatment for intraarticular distal humerus fractures (Orthopaedic Trauma Association types 13B and 13C) by 1 of 2 surgeons. Demographic and operative data were obtained, charts were reviewed, and patients were asked to have their outcomes evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). Twenty-two patients (23 elbows) were identified, and 2 of these (3 elbows) were excluded. Of the remaining 20 patients, 9 had undergone cemented, semiconstrained TEA as initial treatment, and 11 had undergone ORIF. These 2 groups were compared. Mean follow-up was 14.8 months (range, 6-38 months). There were no significant differences between the TEA and ORIF groups with respect to demographic factors. Final elbow range of motion was 92° flexion-extension arc (arthroplasty group) and 98° (fixation group). Two patients in the arthroplasty group and 2 in the fixation group died. For the remaining patients, mean DASH scores were 30.2 (arthroplasty) and 32.1 (fixation), and mean MEPI scores were 79 (arthroplasty) and 85 (fixation). These differences were not statistically significant. Four TEAs developed radiographic loosening by a mean of 15 months, and 1 of these underwent revision with good outcome. Ten of the 11 fractures in the fixation group healed radiographically; the 1 nonunion with collapse continued to be asymptomatic. Two patients in the fixation group underwent contracture release after union for limited elbow range of motion. Many factors come into play in the treatment of intra-articular distal humerus fractures in patients with osteoporosis. Implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF.     

Posterior percutaneous plating of the humerus

Objective

This is a prospective case series study, which was designed to evaluate the clinical outcome of posterior percutaneous plating of the humerus.

Materials and methods

From the year 2010 to 2011, 37 patients with middle and distal third humeral fractures who met the inclusion criteria were surgically treated by minimally invasive plate osteosynthesis through posterior approach. Their age ranged from 19 to 43 with an average of 27.8 years. Type of fractures varied from B to C, and all of them were traumatic.

Results

Patients were followed up for a period varied from 12 to 24 months with an average of 18. There were no cases of intraoperative complications, infection or metal failure. Union was achieved in all of them within 16–21 weeks with an average of 18. Iatrogenic postoperative temporary neuropraxia of the radial nerve palsy was observed in two patients. All patients achieved normal range of shoulder and elbow motion within 3 months after surgery. The average Quick DASH score at 12-month follow-up was 30. According to patient’s satisfaction, all of them returned to the usual pre-injury activity level within 6 months.

Conclusions

This study suggests that the principles of minimally invasive plate osteosynthesis can be applied safely through posterior approach of the humerus to treat middle and distal third humeral fractures. This approach has the advantage of preserving the triceps anatomy and function facilitating rapid postoperative rehabilitation.