Diagnosing displaced four-part fractures of the proximal humerus: a review of observer studies

Displaced four-part fractures comprise 2-10 % of all proximal humeral fractures. The optimal treatment is unclear and randomised trials are needed. The conduct and interpretation of such trials is facilitated by a reproducible fracture classification. We aimed at quantifying observer agreement on the classification of displaced four-part fractures according to the Neer system. Published and unpublished data from five observer studies were reviewed. Observers agreed less on displaced four-part fractures than on the overall Neer classification. Mean kappa values for interobserver agreement ranged from 0.16 to 0.48. Specialists agreed slightly more than fellows and residents. Advanced imaging modalities (CT and 3D CT) seemed to contribute more to classification of displaced four-part patterns than in less complex fracture patterns. Low observer agreement may challenge the clinical approach to displaced four-part fractures and poses a problem for the interpretation and generalisation of results from future randomised trials.     

Displaced proximal humeral fractures. Selecting treatment, avoiding pitfalls

This article, based on years of modified classification of displaced proximal humeral fractures, presents the treatment alternative for each type of injury and the problems to be avoided with each method. The authors recommend reduction and fixation in active patients with displaced proximal humeral fractures. Percutaneous pin fixation for two-part fractures, tension band fixation for three-part fractures, and hemiarthroplasty for four-part fractures are advocated.     

移位性肱骨近端四部分骨折人工肱骨头置换及术后早期个体化康复治疗

目的探讨人工肱骨头置换结合术后个体化康复手段治疗移位性肱骨近端四部分骨折的临床疗效,为基层医院开展肱骨近端复杂骨折治疗提供临床经验。方法对9例移位性肱骨近端四部分骨折患者施行人工肱骨头置换,并于术后给予个体化康复治疗,采用Constant评分进行临床效果评估。结果术后随访5～24个月,平均15.4个月。手术前和末次随访时的Constant评分分别为（14.5±6.5）分和（80.5±5.6）分。结论人工肱骨头置换是治疗移位性肱骨近端四部分骨折的有效方法,正确选择适应证、术中精细操作、术后进行个体化康复锻炼是减少并发症和取得满意疗效的关键。     

Fractures of the proximal humerus

The Neer four-part classification for displaced proximal humeral fractures is the most useful classification so far devised for consistent diagnosis and treatment. Nevertheless, there are several points in the Neer classification that need changing. Group II fractures, i.e., displaced fractures of the anatomical neck have a severe prognosis, excluding a mild graduation as in group II. Displaced four-segment fractures can be classified in group IV as well as in group V, which means the classification less than sharp. Without disregarding Neer's criteria, we use our own simplified classification: group A: extra-articular non-displaced two- to four-segment fractures; group B: extra-articular displaced two- to four-segment fractures; group C: intra-articular impacted or dislocated two- to four-segment fractures. The prognosis following fracture treatment is heavily influenced by the outcome of avascular necrosis of the head. Additionally, surgical treatment offers the change of further devascularization. Rigid plate fixation leads to a high incidence of avascular necrosis. In the case of displaced fractures, we prefer open reduction and internal fixation by means of tension-band wiring. Screws have a limited use in the presence of decreased pullout strength in osteoporotic bone. A Neer II prosthesis is indicated as a primary procedure for impacted fractures of the humeral head, displaced or dislocated four-part fractures and dislocated three-part fractures in elderly patients. In other patients primary open reduction with internal fixation is preferred. Relief of impaction of the humeral head should be avoided. In case of a late osteonecrosis in younger patients hemiarthroplasty is indicated as a secondary procedure.     

Proximal humerus fractures in the elderly are we operating on too many?

Proximal humerus fractures in the elderly are a relatively rare injury, the treatment of which remains controversial, especially regarding Neer displaced two-part, and three-part and four-part fractures. Operative indications for most displaced proximal humerus fractures in the elderly remain poorly defined, but recent literature is actually supporting less aggressive approaches except for the most severe fractures. Recent epidemiological and larger scale retrospective studies fail to show a significant functional difference between operative and non-operative treatment of displaced two-part and three-part fractures in the elderly. Most four-part fractures appear to be best treated with hemiarthroplasty. Recent meta-analyses show a need for well-executed, randomized, prospective studies that can be used to provide evidence-based templates for appropriate management of displaced proximal humerus fractures in the elderly.     

Operative treatment of displaced proximal humeral fractures: follow-up and analysis of 31 patients'

OBJECTIVE: To study the methods and the results of operative treatment of displaced proximal humeral fractures. METHODS: We reviewed thirty-one patients who had been diagnosed as having displaced proximal humeral fractures and had been operated on from July 1989 to December. 1998 in our hospital. The mean follow-up time was 40.5 months (8 - 124 months). Their age ranged from 15 to 62 years (average, 36.8 years); 18 patients were male and 13 female. Neer fracture classification system and rating system were used. In all patients, delto-pectoral approach was adopted. Twelve fractures were fixed with plates, fifteen fractures with screws, and four fractures with Kirschner wire and plaster. RESULTS: Of two-part surgical neck fractures, nine of thirteen patients (69%) were excellent or good with no necrosis and un-union. In three-part or four-part fractures, the rate of satisfaction with open reduction and internal fixation (ORIF) was rather lower. In three-part fractures, the rate of humeral head necrosis was 44%, and in four-part fractures, over 75%. CONCLUSIONS: In two-part and three-part fractures, ORIF is a better treatment, but care should be taken to avoid using plates. As for classic four-part fractures, the rate of satisfaction with ORIF is poor and the rate of necrosis is higher.     

Displaced three- and four-part proximal humerus fractures: evaluation and management

Three- and four-part fractures are the most severe injuries in the spectrum of fractures of the proximal humerus. Despite the shortcomings of the currently available imaging techniques, fracture displacement remains an important principle in guiding management. As a result, increasing emphasis has been placed on the use of Neer's criteria in intraoperative decision making. Patients with four-part fractures with valgus impaction of the head fragment should be treated with limited open reduction and minimal internal fixation, as the blood supply to the humeral head is better preserved than with other fracture patterns and the potential for osteonecrosis is less. In the case of displaced three- and four-part fractures, the physiologic age and bone quality also help guide treatment selection. In young patients with good bone quality, attempts to preserve the humeral head by meticulous handling of soft tissues and the use of low-profile implants to secure fracture fragments is recommended. Vertical fixation alone with Rush rods in patients with poor bone quality and in those with four-part fractures is no longer considered adequate and should not be used. For selected patients with three-part fractures and satisfactory bone quality, fixation with Ender rods and tension-band wiring may be appropriate. Elderly patients and those with poor bone quality have a greater risk of loss of reduction after open reduction and internal fixation, and the current consensus is that early hemiarthroplasty is the appropriate treatment. Late reconstruction necessitated by malunion and soft-tissue contracture is technically difficult, and the outcome is less favorable. The outcome of treatment of three- and four-part fractures is dependent on the surgeon's ability to analyze the fracture pattern and execute appropriate techniques to restore anatomy and function. The use of cement for prosthetic fixation and rigorous attention to tuberosity stabilization and anatomic reduction are two factors that will optimize outcome. Adequate pain relief after hemiarthroplasty has been consistently demonstrated, but return of motion and function is less predictable.     

Triplane fractures of the distal tibial epiphysis

Triplane distal tibial fractures can occur as two-, three-, or four-part fractures with or without a fibular fracture. Diagnosis of the particular anatomy of each fracture is ascertained by plain radiographs; if the fracture is displaced 2 mm or more on any view, anteroposterior and lateral tomograms and, if possible, a limited computerized tomography (CT) scan should be done. A plaster cast in situ for non-displaced fractures or closed reduction for displaced fractures should be attempted first by internal rotation and anterior movement of the fibular metaphyseal piece. Failure to obtain and/or maintain an adequate closed reduction (less than 2 mm displacement), determined by plain radiographs, is an indication for operative treatment. Operative treatment consists of screw fixation for the metaphyseal fragment alone in two-part fractures and both metaphyseal and epiphyseal screw fixation in three-part fractures. Associated fibular fractures may also require internal fixation. The prognosis is generally good if adequate reduction has been achieved by closed or open means.     

三叶草钢板治疗肱骨近端移位骨折

目的探讨肱骨近端移位骨折采用三叶草钢板治疗的临床价值。方法用三叶草钢板治疗肱骨近端骨折38例,按N eer分类,二部分骨折20例,三部分骨折13例,四部分骨折5例,其中骨折伴脱位3例。结果36例获得平均13个月(3~28个月)随访,2例失访。36例均骨性愈合,无畸形愈合,无肱骨头坏死。按N eer评分标准评分,优27例,良6例,可2例,差1例,总优良率91.6%。结论采用三叶草钢板内固定治疗肱骨近端移位骨折,固定牢靠,可早期功能训练,术后功能恢复满意,值得提倡。     

Primäre Schulterendoprothetik nach Trauma

Indications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.     

Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment

Introduction A variety of different treatment options are available for displaced three- or four-part fractures. In a retrospective cohort study we evaluated the results of intramedullary nailing with the ACE nail and conservative treatment of displaced proximal humeral fractures. Materials and methods Twenty-four patients suffered a neer 4, 5 or 6 proximal humeral fracture who were treated with intramedullary nailing. Sixteen patients received conservative treatment for their Neer 4, 5 or 6 fracture. Results Taking critical remarks in consideration, the results of intramedullary nailing are not very satisfactory compared to the conservative-treated group. However functional results of our operative group are comparable to those from other studies in literature. Conclusion Displaced three- or four-part proximal humeral fractures can be treated by intramedullary nailing. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful operative treatment outcome. Most complications in the operative treatment group can be avoided; inadequate reduction can lead to wrong insertion place with secondary problems (dislocation and subacromial impingement). Also future improvements in osteosynthesis like angle stable screw fixation (osteoporosis) and minimally invasive device will probably decrease the complication rate.     

The results of internal fixation of three- and four-part proximal humeral fractures with the Polarus nail

Twenty-three patients with acute displaced three- and four-part fractures of the proximal humerus, including seven patients with associated shaft involvement, were treated with the Polarus intramedullary interlocking nail using a closed technique.At the 1-year follow up, the median Neer scores were 89 and 60 for the three- and four-part fractures, respectively.Three patients (13%), all of whom were in the four-part group, continued to have significant pain at final review.We found the implant to be extremely satisfactory and particularly useful in the treatment of combined neck and shaft fractures of the humerus.     

Percutaneous fixation of proximal humerus fractures

Closed reduction and percutaneous fixation is a viable treatment option for displaced two-part, three-part, and valgus-impacted four-part proximal humerus fractures. Despite biomechanical studies demonstrating inferior stability compared with plate and intramedullary nail constructs, percutaneous fixation offers a minimally invasive approach with potential clinical advantages. Decreased scarring, improved cosmesis, and lower rates of avascular necrosis have been reported. Potential complications include pin migration, infection, avascular necrosis, neurovascular injury, and malunion. Clinical outcomes have been comparable with conventional techniques, with studies reporting approximately 70% good to excellent results.     

Rigid internal fixation of fractures of the proximal humerus in older patients

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus.     

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.     

肱骨近端骨折的手术治疗

目的探讨肱骨近端骨折手术治疗效果。方法手术治疗移位的肱骨近端骨折52例,行开放复位、肱骨近端解剖型钢板或三叶草型钢板内固定45例,肱骨头假体置换术7例。结果所有病例获随访6-24个月,优34例,良11例,可6例,差1例。结论肱骨近端移位骨折采用手术治疗可取得满意的效果。对NeerⅣ型骨折以假体置换术为佳。     

Four-part proximal humeral fractures: diagnosis with the ��sunset�� sign on anteroposterior radiograph

INTRODUCTION

Four-part proximal humeral fractures require surgical intervention. However, they can be difficult to diagnose in radiological images. We aim to define a new, easily recognisable, radiological sign as a predictor of four-part fracture of the proximal humerus in a plain anteroposterior radiograph of the shoulder.

PATIENTS AND METHODS

We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proven otherwise. Between 2002 and 2006, 80 consecutive patients had surgical treatment of their proximal humeral fractures in our unit. Pre-operative radiographs and operative notes of 79 patients were evaluated independently by three blinded observers. The presence of ‘sunset’ sign was recorded. Findings were then correlated with the operative diagnoses to confirm whether they were four-part fractures or not. With 95% confidence interval, we calculated the sensitivity, specificity, positive and negative predictive values for our diagnostic sign.

RESULTS

Of 79 patients, 30 displayed ‘sunset’ sign in their pre-operative radiograph. Of these, 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign was 93%. The specificity and sensitivity were 95% and 78%, respectively. The sensitivity was affected by eight patients with four-part fractures with displaced articular head fragment which had dropped either medially or posteriorly.

CONCLUSIONS

These results suggest that, in patients with proximal humeral fractures, the presence of ‘sunset’ sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.     

Long-term results after non-plate head-preserving fixation of proximal humeral fractures

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70–75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.     

Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus

BACKGROUND: Controversy persists concerning the preferred treatment of displaced fractures of the proximal part of the humerus. The present study was undertaken to evaluate the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus and the functional limitations of patients in whom avascular necrosis of the humeral head develops as a complication of this fracture. METHODS: We assessed the intermediate and long-term results for sixty patients with a three or four-part fracture of the proximal part of the humerus who had undergone open reduction and internal fixation with cerclage wires or a T-plate. The Constant score and a visual analog score for pain were calculated, and radiographs of the proximal part of the humerus were evaluated. RESULTS: After an average of ten years of follow-up, fifty-two patients (87%) had a good or excellent result on the basis of the Constant score whereas eight patients (13%) had a poor result. Fifty-one patients (85%) were satisfied with the result at the time of the most recent examination. Twenty-two patients (37%) had development of avascular necrosis of the humeral head, and seventeen (77%) of these twenty-two patients had a good or excellent Constant score. CONCLUSIONS: Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. This option should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head, as this complication did not preclude a good result.     

Intramedullary nailing of displaced four-part fractures of the proximal humerus

BackgroundIntramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail.Designprospective monocentric cohort study.Settingsingle level 1 traumacenter.Materials and MethodsFrom February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study.ResultsAfter mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity.ConclusionsIntramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result.Level of evidenceLevel 2b – monocentric prospective cohort study.