Treatment of fractures adjacent to humeral prostheses

Fifteen patients with fractures adjacent to a humeral prosthesis were treated between 1986 and 2002. There were 10 females and 5 males. The average age was 58 years. The fractures were classified as to location relative to the prosthesis. Type I fractures (N = 3) occurred proximal to the tip of the prosthesis. Type II fractures (N = 7) occurred in which the fracture line extended from the proximal portion of the humeral shaft to beyond the distal tip of the prosthesis. Type III (N = 5) fractures occurred entirely distal to the tip of the prosthesis. Two type I and 3 type II fractures were managed with a fracture orthosis. The remainder of the fractures were treated surgically with a combination of cerclage wires and long stem prosthesis. All fractures progressed to union at an average of 11 weeks. Average forward elevation for the group was 124 degrees . No patient required a shoulder spica or bone grafting to obtain union. Treatment resulted in fracture union, prosthesis stability, and a paucity of complications.     

Fractures of the proximal humeral epiphysis. Their influence on humeral growth

We have reviewed the notes and radiographs of 57 patients with fractures of the proximal humeral epiphysis and examined 30 of them at 2 to 8 years after injury. Regardless of treatment the maximum shortening of the humerus was 2 cm and residual varus angulation was insignificant. Manipulation of a displaced, fresh fracture did not improve the final outcome with respect to humeral growth or function; and open reduction is very rarely indicated.     

Fractures of the humeral head

Fractures of the humeral head are very common in elderly people, with 70% of all such fractures being seen at an age of more than 60 years. For the radiological examination of the fracture, x-rays from two levels are mandatory. The number and position of the fragments, assessment of intact or ruptured periosteum between the fragments and muscle forces acting on the fragments have to be determined from the x-rays. A 3-D CT scan can be very useful for better understanding of the character of the fracture. The remaining displacement between fragments after reduction have to be evaluated according to their location. Even small incongruities between fragments in the subacromial space will impair the gliding mechanism, whereas remaining displacements between the head and shaft can be accepted to a much larger extent. According to the fracture mechanism, we can basically differentiate between avulsion fractures and depression fractures. The avulsion fractures are characterised by a varus tendency of the humeral head,whereas the depression fractures are characterised by a valgus position of the head fragment. This has to be taken into consideration when choosing the implant for fixation. The indication for reconstructive surgery or prosthetic replacement depends on the type of fracture, on the quality of bone and on the familiarity of the surgeon with the treatment of humeral head fractures. The implants currently used for fixation can basically be differentiated between rigid and semi-rigid. The indication for the one or the other depends on the fracture type and the bone quality. In general, for simple fractures and in case of poor bone quality semi-rigid implants are indicated. Despite the fact that an understanding of the character of the fractures and implants has improved over the last few years, there are still types of fractures which need primary prosthetic replacement.     

Fractures of the proximal humeral epiphysis

Summary Twenty-two patients with marked displacement of a fracture of the proximal humeral epiphysis have been treated with closed or open reduction and fixation by Kirschner wires. At an average follow-up of 6.8 years there have been good functional results in almost all patients (91.1), with better results in patients under 13 years of age particularly with less residual displacement or angulation. Since there is a greater occurence of residual deformity and symetria and limitation of motion in older patients, a more aggressive approach to correct the initial displacement and angulation is warranted in those over the age of 13 years.

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Résumé Les auteurs présentent une étude rétrospective de 22 cas de fracture de l'extrémité supérieure de l'humérus, avec déplacement important, qui ont été traitées par réduction et synthèse par broches de Kirschner, à foyer fermé dans la plupart des cas. Malgré un taux élevé de complications lors du contrôle final (limitation de mobilité, dysmétrie et angulation résiduelle), et ceci après une durée d'observation moyenne de 6, 8 ans, les résultats fonctionnels ont presque toujours été bons (91.1%). Les résultats les meilleurs ont été obtenus dans les cas qui n'ont présenté, après la réduction et la synthèse, ni déplacement latéro-latéral, ni angulation résiduelle. De même on constate des résultats uniformément bons chez les enfants de moins de treize ans. Les auteurs recommandent une attitude thérapeutique plus agressive chez les enfants de plus de treize ans, présentant une fracture de l'extrémité supérieure de l'humérus avec déplacement.

     

Fractures of the femur in relation to cemented hip prostheses

We have reviewed the results of treating 75 fractures of the proximal femoral shaft in the presence of a cemented femoral prosthesis. A simple radiographic classification into four types is proposed, and suggestions are made on the appropriate management of each. Comminuted fractures around the implant need early revision, whilst spiral fractures in this region may be treated conservatively or by operation. Transverse fractures at the level of the tip of the prosthesis are difficult to manage, and may require open reduction and internal fixation.     

Fixation of proximal humeral prostheses and rotational micromotion

Twenty pairs of cadaveric humeri were used to compare the rotational stability of proximal humeral prostheses fixed by proximal cementation with the stability offered by press fit or full cementation. For each proximally cemented specimen, only the upper portion of the prosthesis was coated with cement. For the fully cemented specimens, a cement restrictor was used just distal to the prosthesis, and a finger-packing technique was used to fill the proximal humeral medullary canal. Torque was applied to the Morse taper of the prostheses, and rotational micromotion was measured at the level of the osteotomy. In each of 11 pairs of cadaveric humeri, one side was press fit and the contralateral side was proximally cemented; in each of 9 pairs, proximal cementation was compared with full cementation. Proximally cemented prostheses' micromotion was significantly less than that of press-fit prostheses (P = .0016). There was no difference in micromotion between proximal cementation and full cementation (P = .82). Proximal cementation increased initial fixation over press fit. Full cementation did not increase rotational stability.     

Fractures of the distal humeral articular surface

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100,000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.     

Fractures involving splitting of the humeral head

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.     

Fractures of the lateral humeral condyle in children

I conducted a clinical review of thirty-nine fractures of the lateral condyle of the humerus in children and drew the following conclusions: (1) epiphyseal arrest is rare (it occurred in only one patient, despite malreduction in ten), and (2) fishtail deformity of the distal part of the humerus occurs commonly when malreduction is present. Only two poor results were encountered, both in patients in whom the reduction was grossly inadequate.     

Fractures of the distal humeral metaphyseal-diaphyseal junction in children

BACKGROUND: To our knowledge, there is no report in the English-language literature of metaphyseal-diaphyseal junction fractures of the distal humerus in children. The purpose of this study was to review our experience with this uncommon fracture. METHODS: Between 1998 and 2004, 422 displaced supracondylar humerus fractures underwent operative reduction and fixation at our institution. A retrospective review of medical records and radiographs revealed that 14 (3.3%) of these fractures occurred at the metaphyseal-diaphyseal junction just proximal to the olecranon fossa. In 8 patients, the fracture line was oblique (group A), and in 6 patients, the fracture line was transverse (group B). RESULTS: Average age at the time of fracture was 4.9 years (range, 1.5-10 years). All patients were treated by closed reduction and Kirschner wire fixation and had at least 1-year follow-up. In group A, operative time for reduction and fixation was significantly increased in comparison to the 408 remaining supracondylar humerus fractures. However, the clinical course in group A was uncomplicated, and no loss of fixation at follow-up was noted. The operative time in group B was even longer. These fractures were more problematic as loss of fixation occurred in 5 of the 6 patients, 4 occurring in the sagittal plane. In addition, multiple complications arose in group B including reoperation, cubitus varus, pin migration, and prolonged loss of motion. CONCLUSION: Metaphyseal-diaphyseal junction fractures of the distal humerus in children are rare but can be problematic. The transverse fracture pattern requires additional attention in the operating room with optimal pin fixation. Close postoperative follow-up is necessary. The oblique fracture pattern, while requiring increased time in the operating room for reduction and fixation, is typically stable with the usual fixation used for supracondylar humerus fractures. In summary, metaphyseal-diaphyseal junction fractures of the distal humerus are uncommon elbow fractures in children that should be differentiated from the more common supracondylar humerus fracture for optimal outcomes. LEVEL OF EVIDENCE: Therapeutic level 4 (case series).     

Fractures of the humeral shaft associated with multiple injuries

A study has been made of 488 patients with fracture of the humeral shaft treated during the period 1951–70. Of this number 456 were treated as out-patients, but 32 patients had multiple injuries in addition and required admission to hospital. In this latter group there was a significantly higher incidence of involvement of the radial nerve, delayed union and non-union.

Conventional methods of immobilization were found to be unsatisfactory if the patient had to remain recumbent and in many of these cases there was loss of the initially good reduction. Early internal fixation was not often practicable because of the patient's general condition and the nature of the other injuries. Furthermore, those patients who had delayed elective internal fixation also showed a high incidence of delayed union and non-union. A simple method of controlled skin traction is described, which was found to be satisfactory, and it is suggested that it is a simple and safe alternative to internal fixation.     

Treatment of proximal humeral fractures with reverse prostheses in elderly patients

Fractures of the humeral head account for about 5% of all skeletal fractures and they occur mainly in elderly persons. About 25% of these fractures are dislocated and require open surgical treatment. Fractures in three or four parts (Neer’s classification) often have a poor prognosis when synthesized with internal fixation. Furthermore, treatment with hemiarthroplasty does not ensure good results, especially in elderly patients, due to the bad quality of the rotator cuff. We report preliminary results following our choice to use the non-cemented reverse shoulder prosthesis (SMR Modular Shoulder System, Lima-LTO, Italy) in the treatment of three- and four-part fractures of the proximal humerus. We implanted 18 SMR prostheses for such fractures, in patients with mean age 75.2 years. In all cases the rotator cuff was very weak or absent and a biceps tenodesis was performed. This treatment aims at achieving pain relief and a sufficient functional restoration in very elderly patients. The use of a reverse shoulder prosthesis makes it possible to minimize the arm immobilisation and to start functional rehabilitation immediately. We followed up the patients after 3 and 6 months and the results were clinically and radiographically evaluated, using the Constant score and the simple shoulder test. Even considering the limited number of cases and the short follow-up, results appear good with regard to pain and good/sufficient with regard to functional.