Axillary artery injury secondary to anterior shoulder dislocation: report of two cases

Vascular injuries secondary to isolated shoulder dislocation are rare. Unawareness for closed axillary artery trauma by many physicians treating shoulder dislocations, counts often for missed or delayed diagnosis. The authors describe two cases that presented with an anterior shoulder dislocation, complicated by a disruption of the axillary artery with subsequent thrombosis. The various pathogenic mechanisms are discussed. The pathognomic triad consists of anterior shoulder dislocation, absent or diminished distal pulse and an axillary protruding hematoma. Prompt surgical arterial repair is mandatory.     

Minimally displaced proximal humeral fractures

We analyzed 507 consecutive minimally displaced proximal humeral fractures and showed that, if the AO classification is used, there is variation in the incidence of minimally displaced fractures in the different AO sub-groups. Patients with Type A minimally displaced fractures are significantly younger than those with Type B or C fractures. 376 patients were followed for 1 year and 88% achieved excellent or good results with nonoperative management. Age was the main determinant of outcome, according to the Neer score and the time taken to return to activities of daily living. Subjectively, older patients felt that the results of treatment were better than the objective measurement of gleno-humeral function would indicate. Many patients with fair or poor results had co-morbidities that prevented a good result. The length of the physiotherapy course affected the outcome at 1 year.     

Severely displaced proximal humeral epiphyseal fractures

The purpose of this study was to document the late outcome of a group of patients with Neer grade III/IV proximal humeral physeal fractures who were treated with reduction of the fracture and maintenance of reduction until fracture consolidation. A total of 28 patients treated between 1984 and 1999 at a large children's hospital were included in this study. Nineteen of the 28 patients were 15 years or older (range 5-16 y). All patients were treated in the operating room with closed reduction followed by immobilization (n = 3), closed reduction and pin fixation (n = 20), open reduction and screw fixation (n = 3), or open reduction and pin fixation (n = 2). Postoperatively, all had Neer grade I or II displacement, which was maintained until fracture union. No operative or postoperative complications occurred. At an average follow-up of 4 years, all patients had near-normal glenohumeral motion and excellent strength and uniformly reported regaining full preinjury functional use of the involved extremity. Achieving and maintaining reduction in Neer grade III/IV proximal humeral epiphyseal fractures can be safely performed and results in excellent long-term shoulder function. This is of particular significance in the older adolescent who has minimal remodeling potential.     

Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases

We analyzed 507 consecutive minimally displaced proximal humeral fractures and showed that, if the AO classification is used, there is variation in the incidence of minimally displaced fractures in the different AO sub-groups. Patients with Type A minimally displaced fractures are significantly younger than those with Type B or C fractures. 376 patients were followed for 1 year and 88% achieved excellent or good results with nonoperative management. Age was the main determinant of outcome, according to the Neer score and the time taken to return to activities of daily living. Subjectively, older patients felt that the results of treatment were better than the objective measurement of gleno-humeral function would indicate. Many patients with fair or poor results had co-morbidities that prevented a good result. The length of the physiotherapy course affected the outcome at 1 year.     

手术治疗移位肱骨近端骨折

2000年3月～2005年1月,我科采用手术治疗移位肱骨近端骨折51例,临床疗效满意。     

Four-part displaced proximal humeral fractures: treatment with hemiarthroplasty

Between 1996 and 2000 a total of 25 hemiarthroplasties of the shoulder in just as many patients were carried out. A total of 15 were followed-up (minimum 1 year, maximum 5 years, mean 2.5 years; mean age 75.5 years). The Constant score showed a mean of 73.26 points (with a maximum score of 90 and a minimum of 40). One patient obtained a reduced Constant score (40 points) because of severe lesions of the rotator cuff and continuous pain, even during the night. Patients reported that they were satisfied in 75% of cases. We believe that the integrity of the cuff is an essential condition for final success, alongside important indications such as type of fracture, bone quality, age and motivations of the patient, with respect for rules governing method of implantation and protocols for rehabilitation used.     

Internal fixation of displaced proximal humeral fractures with two one-third tubular plates

BACKGROUND: Operative treatment of displaced proximal humeral fractures often results in poor functional outcome. We report a technique that provides improved rotational stability of the fracture and thus allows early functional treatment. METHODS: Seventy-one consecutive patients (67 +/- 18 years) with displaced fractures of the proximal humerus (two-part, n = 10; three-part, n = 41; four-part, n = 20) were treated by open reduction and internal fixation using two one-third tubular plates on the anterior and lateral aspects of the proximal humerus. Passive motion was started on the third postoperative day, followed by actively assisted exercises on day 6. RESULTS: Seven patients (12%) had complications (fracture redisplacement, avascular necrosis of the humeral head, frozen shoulder, subacromial impingement, and implant loosening) that required further surgical intervention. Sixty patients (85%) were available for follow-up evaluation 17 +/- 10 months after the injury. Using the Constant score, 34% of the patients had very good results, 29% had good results, 25% had fair results, and 12% had poor results. Age (< 60 years or > or = 60 years) and fracture type had no influence on functional outcome. CONCLUSION: These results demonstrate the high stability of internal fixation with two one-third tubular plates that allowed early mobilization of the shoulder in all patients and emphasize this technique as a preferred treatment option for displaced fractures of the proximal humerus.     

Axillary artery entrapment following proximal humeral fracture: a case report and review of literature

Injury to the axillary artery following proximal humerus fracture is a very rare occurrence. The most common mechanism of axillary artery injury is fracture dislocation, resulting with intimal tears, arterial lacerations or avulsions. The most common lesion is the subtotal transaction of the vessel. In this report, we aim to define entrapment of axillary artery by tethering of anterior circumflex humeral artery, which is an unreported mechanism of injury that occurred after a proximal humerus fracture. Diminution of pulse with abduction of arm was the only finding at initial examination, and diagnosis was confirmed with angiography. Treatment was accomplished through ligation and release of anterior circumflex artery with reduction and fixation of fracture fragments, resulting with full recovery. We also have reviewed current literature about axillary artery injuries following proximal humeral fracture.     

Functional outcome following proximal humeral interlocking system plating for displaced proximal humeral fractures

Aim:

To assess the functional outcome following internal fixation with the PHILOS (proximal humeral interlocking system) for displaced proximal humeral fractures.

Patients and Methods:

We reviewed 30 consecutive patients treated surgically with the proximal humeral locking plate for a displaced proximal humeral fracture. Functional outcome was determined using the American Shoulder and Elbow Society (ASES) score and Constant Murley score.

Results:

Average age of the patients was 58 years (range, 19-92 years). The average overall ASES score was 66.5. The average overall Constant score was 57.5.

Conclusion:

Our results show that good fracture stability was achieved, and the functional outcome was very good in younger patients and it declined with increasing age. Early mobilization of the shoulder can be achieved without compromising fracture union.     

Surgical management for displaced pediatric proximal humeral fractures: a cost analysis

Purpose

The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods

A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results

A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions

Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.     

Clinical and radiological evaluation of minimally displaced proximal humeral fractures

Introduction  

The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization.     

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

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

Functional results of angular-stable plate fixation in displaced proximal humeral fractures

INTRODUCTION: The availability of angular-stable plate/screw systems led to a euphoric use of these implants for the treatment of displaced proximal humerus fractures. The high implant costs seem to be justified by a potentially improved outcome. PATIENTS AND METHODS: Thirty one patients (20 female, 11 male, mean age: 62+/-16 years) with two-, three- and four-part proximal humerus fractures (Neer classification) were operated using the proximal humeral internal locking system (PHILOS). The mean follow-up time was 19+/-3 postoperative months (range: 340-720 days). Functional results (Constant score, UCLA-score) were analysed and compared to an equivalent historic control group of 60 patients operated for the same fracture types using two one-third tubular plates. Additionally, total implant costs for each technique were compared. RESULTS: Complications in the PHILOS group included one implant failure with refracture, one secondary dislocation, two cases of subacromial impingement, and two cases of partial avascular necrosis of the humeral head. The mean Constant score (age- and sex-matched) was 80+/-11% for the affected side and 104+/-13% for the healthy side. The UCLA scores were excellent in 10%, good in 67%, and fair in 23% of the patients. Complication rate and functional results did not differ significantly from the control group treated with one-third tubular plates. Implant costs were significantly higher for the PHILOS group (684+/-40 Euro vs. 158+/-20 Euro, p<0.05). CONCLUSION: Our study showed similar functional results using either plate. Although the PHILOS plate may provide important advantages in specific situations, such as osteoporotic bone, its use as a standard must be carefully judged under the economic aspect of the significant higher implant costs.