闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折

目的：通过分析28例闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折的临床疗效，探讨治疗体会及教训。方法：2005年11月至2006年11月采用闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折28例，男12例，女16例；年龄31-73岁，平均54．7岁。均为新鲜骨折。骨折根据Neer分型：两部分外科颈骨折18例，外展嵌插两部分大结节骨折10例。结果：本组平均手术时间42min,口均Ⅰ期愈合，X线片显示骨折对位满意，向前成角基本矫正。外展嵌插两部分大结节骨折的颈干角从术前的平均175°（160°-200°）恢复至平均136°（128°～142°），大结节移位小于3mm。随访6-13个月，平均10．3个月，骨折均愈合，未出现肱骨头缺血坏死现象，术后8—10周取出内固定。根据ASES及Constant-Murley肩关节评分系统，本组ASES评分平均91．2分（63～100分），Constant—Mudey评分平均90．4分（67-100分）。本组优12例，良14例，一般2例。结论：闭合或有限切开经皮穿针固定治疗肱骨近端两部分骨折的操作有相当难度，且须在透视下进行，但具有损伤小、康复快的优点，是治疗特定类型肱骨近端骨折的有效方法。骨质情况是决定固定稳定程度的必要条件。     

Percutaneous fixation of proximal humeral fractures

The purpose of the current study is to evaluate the technique of closed reduction and percutaneous pinning of proximal humeral fractures and to determine whether this technique provides enough stability to permit early active range of motion and subsequent fracture healing. Fractures were classified according to Neer et al and were included if the surgical or anatomic neck were angulated greater than 45 degrees, separation between fragments was greater than 1 cm, or the greater tuberosity was displaced more than 0.5 cm. There were 21 Type II, 16 Type III, and four Type IV fractures. Fractures were pinned using distally threaded Dynamic Hip Screw guide pins, 2-mm Kirschner wires, or 2.5-mm distally threaded Schantz pins. Patients were evaluated for union rates and motion. Assessment was made using the Modified American Shoulder and Elbow Surgeons Form. Thirty-six patients with 37 fractures were available for review with followup averaging 40 months (range, 12-68 months). All patients with Neer Type IV fractures did not respond to fixation and three had avascular necrosis develop, irrespective of the type of pin used. In the remaining 33 patients with Neer Type II and Type III fractures, a union rate of 94% was observed at an average of 2.6 months. All patients had good functional results. In the current series, there were no failures using Schantz pins. There was a 20% failure rate with Dynamic Hip Screw pins (2% if the patients with Type IV fractures were excluded) and a 100% failure rate with Kirschner wires. Stable fixation with early motion and subsequently good results can be obtained using percutaneous fixation in patients with Type II and Type III fractures; however, terminally threaded pins must be used and smooth Kirschner wires must be avoided. Percutaneous fixation cannot be recommended in patients with Type IV fractures.     

Open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus

Twenty-two patients aged 20 to 82 years (average 56 years) were followed for 1.1 to 8.9 years (average 3.3 years) after open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus. There were 14 two-part displaced surgical neck fractures, seven three-part displaced greater tuberosity and surgical neck fractures, and one three-part displaced lesser tuberosity and surgical neck fracture. Fixation was achieved with heavy nonabsorbable sutures or wire that incorporated the rotator cuff tendons, tuberosities, and shaft. In cases with significant surgical neck comminution, humeral Enders nails were incorporated in a tension-band construct to provide longitudinal stability. Eighteen (82%) of the 22 patients had good or excellent results. Three (14%) of the 22 had satisfactory results, and one (5%) had an unsatisfactory result. The use of a technique of limited internal fixation for these displaced fractures without the use of plates and screws achieved fracture stability and a high percentage of acceptable results.     

Behandlung der kindlichen proximalen Humerusfrakturen

Due to the outstanding remodeling capacity of the proximal humerus region in children, the majority of proximal humeral fractures and epiphyseal separations are managed without reduction by application of a Gilchrist bandage for 3 weeks. This overview aims to describe the indications for reduction and operative fracture stabilization and to describe the techniques applied to treat these injuries in children and adolescents. A visible valgus deformity in children and displaced epiphyseal fractures in adolescents with reduced remodeling capacity of the proximal end of the humerus represent the main indications for operative treatment. When closed reduction and percutaneous Kirschner (K) wire fixation is performed with the ends left through the skin, K-wires can be removed without general anesthesia in outpatient clinics and image intensifier radiation time is usually lower when compared with elastic stable intramedullary nailing (ESIN). However, K-wire fixation results in limited biomechanical stability thus precluding postoperative functional treatment without immobilization. The ESIN procedure allows postoperative functional treatment but requires a second surgical procedure under general anesthesia for implant removal. The interposition of soft tissues such as the periosteum or in rare cases the tendon of the long head of the biceps muscle causes a considerable rate (50 %) of open reductions when performing operative fracture stabilization.     

Four-part valgus impacted fractures of the proximal humerus

There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury.     

Percutaneous pinning for proximal humerus fractures

Proximal humerus fractures are relatively frequent. The are several possibilities for fixation of proximal humerus fractures: close reduction and fixation with percutaneous pinning or intramedullary rod, open reduction and fixation with tension band or a plate. Close reduction and percutaneous pinning have the advantage to be an easy technique, with good results and it is considered to be ideal in young patients with two-part fractures. The number and the directions of the pins depend upon the number of fragments displaced, reducibility, bone quality, patient age, other pathology associated. Some authors consider being enough the placement of 2 or 3 ascending pins, while others recommend at least 4 pins, ascending and descending. Usually we prefer the techniques in witch are used 3 ascending pins. The operative technique is presented. The most common intra-operative complication in percutaneous pinning is the possibility of damaging the adjacent neuro-vascular structures or tendons. Post-operative complications which may occur are: loosing reduction, pins migrations, aseptic necrosis of humeral head, pins infection. In conclusion percutaneous pinning for proximal humerus fractures it is an easy technique with good results. In this manner are avoided large incisions to the shoulder with can lead to aseptic necrosis of the humeral head. This technique can be used in young patients, with good bone quality, but also in elderly patients, with osteoporosis and other pathology associated. In some three or four-part fractures some reduction problems can occur, but this are rare in two-part fractures.     

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.     

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.     

Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning

Surgical management of two-part and three-part proximal humerus fractures is difficult and requires familiarity with more than one method of fixation. Poor bone quality, comminution, and the deforming forces of the rotator cuff on the tuberosities influence the choice of operative approach and fixation techniques. Closed reductions and percutaneous pinning offer the potential advantage of minimal soft-tissue dissection; however, good bone quality and minimal comminution are prerequisites. Selected two-part surgical neck fractures and valgus-impacted fractures lend themselves well to this technique. Open reduction and internal fixation is indicated in two-part surgical neck fractures with poor bone quality or extensive comminution, two-part greater tuberosity or lesser tuberosity fractures, and most three-part fractures. The choice of surgical approach is dictated by the fracture pattern and includes an extended deltopectoral approach and a superior deltoid-splitting approach. Fixation techniques are myriad and are dependent on the fracture pattern. Potential fixation methods include intramedullary rods, interfragmentary sutures or wires, and extramedullary plates and screws or blade plates. Successful results are predicated on obtaining adequate enough fixation to allow early passive motion. Results also are influenced by the quality of the reduction and patient compliance.     

Reduction and pinning of pediatric supracondylar humerus fractures in the prone position

Supracondylar humerus fractures are common pediatric injuries; the preferred treatment for displaced fractures is closed reduction and percutaneous pin fixation. We present a technique for closed reduction and pinning using prone-patient positioning. Prone positioning facilitates fracture reduction and safe pin placement while avoiding elbow hyperflexion. We prefer this technique to the commonly described method of fracture reduction and pinning with the patient supine.     

两种方法治疗大龄儿童肱骨外科颈骨折的疗效比较

目的观察大龄儿童移位型肱骨外科颈骨折经闭合复位逆向弹性髓内针内固定以及克氏针内固定两种不同手术方法的临床疗效对比。 方法回顾性分析十堰市人民医院创伤骨科从2016年5月至2018年12月2.5年间符合纳入标准的手术内固定治疗的儿童及青少年移位型肱骨外科颈骨折45例患者，按照内固定方法分为两组：逆向弹性髓内针内固定23例(弹性髓内针组)；闭合复位克氏针内固定22例(克氏针组)。采用t检验或卡方检验分析骨折愈合时间，肩关节功能评分、并发症个数及优良率。 结果所有病例骨折均达到良好愈合，骨折愈合时间为(8.0±2.1)周。术后6周两组功能评分弹性髓内针组优于克氏针组(t＝5.295，P<0.05)；术后3个月功能评分无明显差异(P>0.05)。88.9%患者肩关节功能均达到了优良效果，两组优良率无明显差异(X²＝0，P>0.05)。弹性髓内针组有1例出现桡神经挫伤，2例出现弹性髓内针穿出；4例出现复位再丢失。但克氏针内固定组出现了克氏针松动、脱落4例；骨折复位丢失3例；无血管神经损伤并发症。 结论采用逆向弹性髓内针及克氏针内固定治疗儿童移位型肱骨外科颈骨折，都是微创、有效的治疗方法，值得临床推广运用。术者应选择熟悉的手术方法避免并发症。     

Ascending cluster pinning of the humerus inserted through the deltoid tuberosity

Summary Goal of Surgery Stable internal fixation of extraarticular proximal humeral fractures. Indications Extraarticular fractures angulated more than 30° which can be reduced closely or through a small incision. Epiphysiolysis. Fracture-dislocation of the humeral head. Contraindications Pathological fractures. Four part fractures. Segmental fractures of the humerus. Positioning and Anaesthesia Supine; the affected shoulder overhanging the edge of the table and supported by a radiolucent board. General or regional anaesthesia. Surgical Technique Closed pinning of two part and certain three part fractures of the proximal humerus being displaced, unstable, and mainly at the metaphyseal level. Introduction of Kirschner wires through a diaphyseal window and advancement into the proximal fragments after reduction which is controlled by image intensification. Postoperative Management Temporary immobilization in a sling. Passive and active assisted movements after a few days. Active movements after 2 weeks. Removal of wires after 3 months. Possible Complications Fracture of the humerus at the site of the cortical window. Injury to the radial nerve. Results 32 patients, mean age 49 years, 30 two part fractures and 2 three part fractures. Number of Kirschner wires used: 3 to 6, mean 4. Two out of 3 patients complained of pain at the site of wire insertion. All fractures consolidated. No avascular necrosis nor infection. Complications: Partial loss of internal fixation in 3 patients. One fracture of the humeral shaft. Sympathetic reflex dystrophy in 3 patients. Half of the patients had a normal range of motion. Time of follow-up: 6 to 24 (mean 10) months. Division of Orthopaedics and Traumatology, Purpan Hospital, Toulouse, France.     

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).     

Closed percutaneous K-wire stabilization for displaced fractures of the surgical neck of the humerus

We report a series of 22 displaced fractures of the proximal humerus treated by percutaneous Kirschner wire stabilization. Poor results (69 per cent) in the older age group of patients is a reflection of the severity of the fracture and the difficulties of closed reduction. Reduction in a poor position in this series has led to a poor range of movement. Good functional results can only be expected with a good reduction. Experience of migration with smooth K-wires has resulted in a strong recommendation for the use of threaded pins.     

Percutaneous fixation with Schanz screws for displaced two- and three- part fractures of the proximal humerus in patients above fifty years of age

Purpose:

The aim of this study is to evaluate whether two 3.0 mm Schanz screws in two-part proximal humeral fractures (plus one additional Schanz screw or K wire in three-part fractures) can provide enough stability to allow early mobilization until healing occurs in elderly patients.

Settings and Design:

This prospective study was performed in the Orthopaedic Department of our University Hospital.

Patients and Methods:

We performed closed reduction and percutaneous pinning for thirty-three patients with proximal humerus fractures. Twenty-seven patients were available for the final follow-up. Of those 27 patients, 17 had two-part surgical neck fractures; while 10 had three-part fractures. For fixation, we used two 3.0 mm Schanz screws in patients with two-part fractures plus one additional Schanz screw or K wire in the 10 patients with three-part fractures.

Results:

The mean Constant score modified according to the age and sex was 89.8% (range: 77.3-97.2%). Fifteen patients had excellent results, 11 patients had good results, and one patient had a fair result.

Conclusion:

Closed reduction and percutaneous pinning with two Schanz screws for two-part surgical neck humeral fractures, plus an additional Schanz screw or K wire for three-part proximal humeral fractures is a useful and effective technique that provides enough stability to allow an early rehabilitation program till union occurs in elderly patients.

Level of Evidence:

IV; therapeutic study, case series.     

Metaizeau's technique for displaced metatarsal neck fractures

Metaizeau's technique can be applied to reduce the displaced metatarsal head distally from the fracture in an easier way and to keep the fracture site closed, as compared with retrograde Kirschner wires. We present seven fractures treated anterograde with progressive weight-bearing after 2 weeks. Open reduction was unnecessary in all cases. This technique permitted correct control of the distal fracture fragment, obtained good reduction of the metatarsal heads without opening the fracture site, and with no lesion of the capsulo-ligamentosus metatarsophalangeal joint structures. We obtained the radiographic healing of all and showed correct alignment. Metaizeau's technique is a valid alternative to retrograde Kirschner wires fixation in the treatment of displaced metatarsal neck fractures.     

Innovations in the management of displaced proximal humerus fractures

The management of displaced proximal humerus fractures has evolved toward humeral head preservation, with treatment decisions based on careful assessment of vascular status, bone quality, fracture pattern, degree of displacement, and patient age and activity level. The AO/ASIF fracture classification is helpful in guiding treatment and in stratifying the risk for associated disruption of the humeral head blood supply. Nonsurgical treatment consists of sling immobilization. For patients requiring surgery, options include closed reduction and percutaneous fixation; transosseous suture fixation; open reduction and internal fixation, with either conventional or locking plate fixation; bone graft; and hemiarthroplasty. Proximal humerus fractures must be evaluated on an individual basis, with treatment tailored according to patient and fracture characteristics.     

Transitory percutaneous pinning in fractures of the proximal humerus

We report 31 patients with displaced fractures of the proximal humerus treated by transitory percutaneous pinning. The Neer fracture classification was used; there were 7 two-part, 20 three-part, and 4 four-part fractures. The Constant score was used for evaluation of the results; the mean score was 80 points. The high mean age of our patients (68 years) diminished the score because of the 25 points attributed to the strength. Avascular necrosis was observed in 5 cases: 2 three-part and 3 four-part fractures. Transitory percutaneous pinning is a good technique for the management of displaced 3-part fractures of the proximal humerus even in the older population, keeping in mind that the shoulder will tolerate a moderate residual deformity without changing the functional outcome significantly. Transitory percutaneous pinning, on the other hand, is not a satisfactory method for the management of 4-part fractures.     

Transosseous suture fixation of proximal humeral fractures

BACKGROUND: The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. METHODS: Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. RESULTS: All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. CONCLUSIONS: The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.     

Die minimal-invasive Behandlung massiv dislozierter kindlicher Radiushalsfrakturen durch perkutane Joystick-Reposition und Prevot-Nagelung

Undisplaced fractures of the proximal radius can generally be treated conservatively with good results. In children, spontaneous correction of some angular deformities can be expected during growth. Nevertheless, more severely displaced fracture types may require reduction in children, too. Open reduction and internal fracture fixation have shown to lead to a loss in range of motion frequently. A technique of percutaneous fracture reduction is demonstrated that can provide good results in cases when closed techniques have failed. A Kirschner wire is used to manipulate the fracture fragments percutaneously, which can often prevent open techniques. An additionally performed elastic-stable intramedullary nailing can add to an effective stabilisation and encourage to early physiotherapy.