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.     

Treatment of severely displaced proximal humeral fractures in children with retrograde elastic stable intramedullary nailing

We report our experience of elastic stable intramedullary nailing (ESIN) of severely displaced proximal humeral fracture Type III and IV according to Neer in children. Thirty-five children (mean age 12.7 years) with 19 Salter–Harris Type II epiphyseal fractures and 16 children with metaphyseal fractures of the proximal humerus were treated with ESIN by one-nail or two-nail-technique. There were the following complications: two perforations of the nail at the head of the humerus with loss of position, one loss of position without nail perforation, one misplacement of a nail, one revision due to haematoma and two difficult removals of metal. For follow-up examinations after 26 months the children were classified by use of the Constant–Murley score. On average they gained 99 points. All children were able to resume their sporting activities as before. For the treatment of displaced proximal humeral fractures in children more than 10 years old the retrograde ESIN represents a safe minimal invasive surgical procedure.     

交锁髓内钉治疗肱骨外科颈骨折的临床疗效

目的观察交锁髓内钉治疗肱骨外科颈骨折的临床疗效。方法应用肱骨交锁髓内钉治疗肱骨外科颈骨折21例．其中男6例,女15例;年龄35～78岁．平均58．3岁。结果所有患者随访6～18个月,以Neer评分评估其功能,优7例,良13例,可1例,优良率为95．24％。结论髓内钉治疗肱骨外科颈骨折．具有创伤小、操作简易、术后能早期功能锻炼、骨折愈合快、肩关节功能恢复快等优点．是一种值得推广的治疗方法。     

A preliminary clinical experience with Polarus nail for proximal humeral fractures. A pilot study on ten patients

The Polarus nail has recently been popularised to fix proximal humeral fractures. In the current pilot study we reviewed the early results obtained using this nail. Ten patients with proximal humeral fracture (four pathological, 5 traumatic and one non-union) were fixed using a Polarus nail. The fractures were classified according to Neer (7 two-parts and 3 three-part fractures). The mean followup was 22 months (6–39) months. The following criteria were assessed: pain, range of shoulder movement and function. Seven patients were satisfied with their operation, their fractures healed in a mean period of 3 months (2–4 months). No postoperative neurovascular complications were encountered; the re-operation rate, was however 30%. Conclusion: in the authors' brief pilot study in 10 patients, and despite the heterogenous fracture types, we came in to conclusion that the indications for using Polarus nail is limited due to the high complications rate associated with the procedure when used for displaced three or four part surgical neck fracture of humerus.     

应用肱骨近端锁定型髓内针治疗肱骨近端骨折的临床疗效分析

目的探讨应用肱骨近端髓内针治疗肱骨近端两部分外科颈骨折的疗效。方法回顾性分析22例应用锁定型肱骨近端髓内针治疗两部分外科颈新鲜骨折患者的临床资料,患者平均年龄57岁。最终随访时拍摄肩关节X线片以评价愈合情况,并应用可视模拟评分法（VAS）评分,美国肩肘外科医师评分（ASES）,Constant-Murley评分,UCLA评分以及简易肩关节测验（SST）问卷评估。结果所有患者均获随访,平均随访时间为13个月,22例患者骨折均在术后8周内初步愈合。随访过程中未出现感染、肱骨头坏死以及任何与内固定物有关的并发症。术后患肢主动前屈上举平均为147．8°,主动体侧外旋平均为45．5°,主动内旋平均达T10水平。术后患者疼痛VAS评分平均为1．5。平均ASES评分为81．2,Constant-Murley评分为85．4,UCLA评分为29．9,SST评分为9．5。18例患者的肩关节功能评估为优或良,4例患者肩关节功能评估为差。结论闭合复位、锁定型肱骨近端髓内针固定术是治疗肱骨近端两部分外科颈骨折的一种有效的手术方式。     

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.     

交锁髓内钉与锁定钢板治疗肱骨近端骨折的疗效研究

目的 探讨交锁髓内钉与锁定钢板治疗肱骨近端骨折的近期疗效.方法 对2003年1月至2008年6月应用交锁髓内钉与锁定钢板治疗的36例肱骨近端骨折患者进行回顾性研究,男11例,女25例;年龄26～78岁,平均60.3岁.根据治疗方法不同分为交锁髓内钉组(21例)与锁定钢板组(15例).按Neer分型:交锁髓内钉组:Ⅱ型6...     

肱骨近端锁定钢板治疗老年肱骨外科颈粉碎骨折

目的评价肱骨近端锁定钢板治疗老年肱骨外科颈粉碎骨折的疗效。方法采用肱骨近端锁定钢板治疗31例老年肱骨外科颈粉碎骨折。平均随访6个月（4-14个月）。结果术后无伤口感染、骨折不愈合和内固定松动发生。骨折愈合时间为术后2．5～6．1个月。肩关节功能按照Constant评分标准，功能优9例，良18例，中4例，优良率87．1％。结论肱骨近端锁定钢板对老年胧骨外科颈骨折固定可靠、并发症少，可早期功能锻炼，具有防止复位丢失、保护板下血运和骨折愈合快等优点。     

Antegrade interlocking nailing of humeral shaft fractures

The results of 39 humeral shaft fractures (37 patients) treated with antegrade locked nailing using a Russell–Taylor nail were reviewed. There were 30 acute fractures, 6 fractures malaligned in a hanging cast or brace, and 3 pathological fractures. Patient age ranged from 26 to 80 years (average, 59.7 years) and average follow-up was 25.7 months (range, 6–48 months). Fracture union was achieved in 92.3% of our cases, while shoulder function was excellent or good in 87.2% of cases. Antegrade locked nailing offers a dependable solution for the treatment of humeral shaft fractures, especially in polytrauma patients and cases of segmental or pathological fractures. Far less satisfactory results were obtained in comminuted fractures of the proximal third in the humerus, especially in osteoporotic patients, and we therefore advocate caution with the use of intramedullary nailing in this type of fracture. Certain technical aspects such as avoiding nailing the fracture in distraction, properly countersinking the tip of the nail, and achieving adequate fixation stability have been found to be of paramount importance to reduce the incidence of delayed union/non-union rate and to obtain better functional results from the shoulder joint.     

Internal fixation of proximal humerus fractures using the T2-proximal humeral nail

Introduction

Surgical management of proximal humerus fractures remains controversial and there is an increasing interest in intramedullary nailing. Created to improve previous designs, the T2-proximal humeral nail (PHN) (Stryker^®) has been recently released, and the English literature lacks a series evaluating its results. We present a clinical prospective study evaluating this implant for proximal humeral fractures.

Method

We evaluated the functional and radiological results and possible complications. Twenty-nine patients with displaced fractures of the proximal humerus were treated with this nail. One patient was lost right after surgery and excluded from the assessment. Eighteen patients were older than 70 years.

Results

There were 21 fractures of the proximal part of the humerus and 7 fractures that also involved the shaft; 15 of the fractures were two-part fractures (surgical neck), 5 were three-part fractures, and 1 was a four-part fracture. All fractures healed in a mean period of 2.7 months. There was one delayed union that healed in 4 months. One case of avascular necrosis of the humeral head was observed (a four-part fracture), but remained asymptomatic and did not require further treatment. In one case a back-out of one proximal screw was observed. A final evaluation with a minimum 1 year follow-up was performed by an independent observer; in 18 patients, the mean Constant score was 65.7 or 76.1% with the adjustment of age and gender; in 19 patients, the mean Oxford Shoulder Score was 21.7. The results obtained with the T2-PHN nail indicate that it represents a safe and reliable method in the treatment of two- and three-part fractures of the proximal humerus. The proximal fixation mechanism diminishes the rate of back-out of the screws, a frequent complication described in the literature. Better functional results were obtained from the patients younger than 70 years, but these were not statistically significant.

     

Fixation of proximal humeral fractures with the Polarus nail

Thirty patients with fractures of the proximal humerus were treated by internal fixation with an intramedullary locked nail. Fourteen of these patients were more than 60 years of age; 23 patients had 2-part fractures (surgical neck fractures) and were operated on within an average of 3 days after injury. At follow-up, 20 (80%) of 25 patients showed satisfactory to excellent functional outcomes, as measured by Constant score. All but 1 fracture progressed to clinical and radiologic union. The good functional results indicate that the Polarus nail is a satisfactory mechanical device that can be used in the treatment of displaced proximal humeral fractures in both the young and the elderly with osteopenic bone.     

Humeral medullary nailing--a new implant

A new technique of medullary nailing of the humerus using a screw-headed nail is described. Eighteen patients with two-part fractures of the surgical neck of the humerus were reviewed. Fifteen had satisfactory results while three were unsatisfactory. Nine patients with fractures of the shaft of the humerus were also treated with satisfactory results in eight. Three patients with non-union of the humerus had unsatisfactory results.     

Technique of Kirschner wire reduction and fixation of displaced two-part valgus angulated proximal humerus fractures at the surgical neck

This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.     

经皮穿针固定治疗肱骨近端骨折

目的　对应用经皮穿针固定治疗肱骨近端骨折的疗效、适应证和手术方法进行总结分析。方法　随访 4 9例应用经皮穿针固定治疗的肱骨近端新鲜闭合骨折患者 ,平均随访时间 16 9个月。患者平均年龄 4 0 4岁。 2部分外科颈骨折 39例 ,2部分大结节骨折 6例 ,外展嵌插 4部分骨折 4例。最终随访时进行ASES评分、Constant Murley评分、UCLA评分以及SST(SimpleShoulderTest)问卷评估。结果　 4 9例患者ASES评分平均为 91 4 ,VAS疼痛评分平均为 1 7,肩关节活动度平均为前屈上举 14 6 7°,外旋 39 6°,内旋T8～T9水平 ;Constant Murley评分平均为 88 2 ;UCLA评分平均为 31 2 ;SST问卷中回答“是”的问题平均为 10 1个。 4 9例患者骨折均愈合 ,平均愈合时间为 8 8周。患者对于疼痛的满意度为 95 9% (4 7/ 4 9) ,对于功能恢复的满意度为 91 8% (4 5 / 4 9)。最终随访时均未出现肱骨头坏死的征象。结论　应用经皮穿针固定治疗大多数 2部分外科颈骨折、外展嵌插型的 2部分大结节骨折以及外展嵌插 4部分骨折可得到良好的治疗效果 ;结合及时、充分的术后康复 ,经皮穿针固定是治疗特定类型肱骨近端骨折的一种有效的方法     

Absorbable polyglycolide pins in fixation of displaced fractures of the radial head

Summary In a prospective study 24 patients with a displaced fracture of the radial head were treated by open reduction and internal fixation using absorbable polygly-colide pins, 2 mm in diameter. All patients admitted with fractures involving a quarter or more of the radial head, whether comminuted or not, were included in the study whenever there was a displacement of 2 mm or more between the fragments. The mean follow-up time was 28 months (range 15–43 months). A postoperative redisplacement of 1–3 mm between the fragments was seen in four patients with severely comminuted fractures. A transient inflammatory reaction around the implants occurred in two cases 8–12 weeks postoperatively. The functional end-result was classified as excellent or good in 22 patients (91%). This study indicated that successful fixation of displaced fractures of the radial head can be accomplished by using absorbable pins.     

Complex fractures of the femur: treatment with a long gamma nail: short- and medium-term experience

The introduction of the gamma nail and of the long gamma nail, associating the principle of intramedullary nailing and of the sliding screw-plate, has led to good results in the treatment of complex fractures such as per-sub-trochanteric fractures and associated fractures of the femoral neck-diaphysis. In this study, our experience with the long gamma nail (Long Gamma Nail Howmedica) is presented. Of the 43 patients treated between 1993 and 1998, 21 (49%) with a mean follow-up of 2.5 years (1-5 years) were reviewed. Clinical and a radiographic evaluations were obtained for each of the patients. This study showed that there was a high incidence of poor consolidation (dysmetria in 10 patients, torsion deficit in 7, consolidation in varus of the femoral neck in 1 patient) particularly in associated fractures of the femoral neck and diaphysis, accompanied, however, by good functional recovery (only 3 patients with modification in the angle of progression of the foot) and by the satisfaction of the patients questioned. Thus, indications for the use of this device in proximal fractures of the femur, particularly in elderly patients and in high-energy traumas, are demonstrated.     

Pinning technique for shoulder fractures in adolescents: computer modelling of percutaneous pinning of proximal humeral fractures

Background

In the technique of percuatenous pinning of proximal humerus fractures, the appropriate entry site and trajectory of pins is unknown, especially in the adolescent population. We sought to determine the ideal entry site and trajectory of pins.

Methods

We used magnetic resonance images of nonfractured shoulders in conjunction with radiographs of shoulder fractures that were treated with closed reduction and pinning to construct 3-dimensional computer-generated models. We used engineering software to determine the ideal location of pins. We also conducted a literature review.

Results

The nonfractured adolescent shoulder has an articular surface diameter of 41.3 mm, articular surface thickness of 17.4 mm and neck shaft angle of 36°. Although adolescents and adults have relatively similar shoulder skeletal anatomy, they suffer different types of fractures. In our study, 14 of 16 adolescents suffered Salter–Harris type II fractures. The ideal location for the lateral 2 pins in an anatomically reduced shoulder fracture is 4.4 cm and 8.0 cm from the proximal part of the humeral head directed at 21.2° in the coronal plane relative to the humeral shaft.

Conclusion

Operative management of proximal humerus fractures in adolescents requires knowledge distinct from that required for adult patients. This is the first study to examine the anatomy of the nonfractured proximal humerus in adolescents. This is also the first study to attempt to model the positioning of percutaneous proximal humerus pins.     

Ununited ipsilateral femoral neck and shaft fractures: treatment of 16 patients

Introduction Ununited ipsilateral femoral neck and shaft fractures are very rare, and their treatment is very complicated. Until now, no single treatment method has been recommended in the literature.Materials and methods Eighteen patients sustained femoral shaft fractures, which were treated with reamed intramedullary nails but remained ununited. Concomitant, ipsilateral femoral neck fractures were neglected for 2–16 months (median 4 months). The neck fractures were treated by subtrochanteric valgus osteotomy with sliding compression screw stabilization, and the shaft fractures by dynamic compression plating with supplementary cancellous bone grafting. Postoperatively, ambulation with protected weight-bearing was encouraged as early as possible.Results Sixteen patients were followed up for at least 2 years (range 2–7 years), and all fractures healed. The neck fracture healed at 3.7±0.6 months (p<0.001), the osteotomy site at 5.3±0.9 months, and the shaft fracture at 5.6±1.0 months (p=0.07). All patients could walk without aids. Complications included one osteonecrosis of the femoral head (6.3%), which was followed up regularly without further treatment.Conclusion The described technique provided a high union rate with a low complication rate. In addition, the surgical procedure was relatively simple. Therefore, it might be considered for all indicated cases.     

Classic nail versus DHS. A prospective randomised study on operative fixation of trochanteric femur fractures Eine prospektiv-randomisierte Studie zur Behandlung pertrochant?rer Femurfrakturen

The intramedullary hip screw system Classic-Nail and the Dynamic Hip Screw (DHS) were evaluated in a prospective-randomized clinical trial for operative treatment of trochanteric femur fractures. Hundred and ten geriatric patients (mean age 82 years) were runningly included in the study (56 Classic Nail, 54 DHS). No significant differences between the two study groups were observed with regard to treatment and follow-up data. With the Classic-Nail one complete femur shaft fracture and one incomplete fracture occured at the tip of the nail intraoperatively and could successfully be fixed with cerclage wires. In the DHS group two patients underwent reoperation for significant loss of reduction early postoperatively. At an avarage follow-up of 3.7 months all fractures were healed with no difference in functional outcome between the two groups. – Classic Nail and DHS both lead to equally good results in the operative treatment of trochanteric femur fractures.     

Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective,randomised study

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.