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A case of axillary artery injury resulting from a minimally displaced fracture of the neck of the humerus is reported. Very few such injuries have been reported previously. The mechanism of injury can be from sharp bony fragments, overstretching of the artery especially when atheromatous, or torn intima. Angiography should be performed, followed by exploration where indicated.
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This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed.
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OBJECTIVE: To investigate the influence on fracture stability by different pin construct during percutaneous pinning for the treatment of proximal humerus fractures. METHODS: Eighteen pairs (36) adult fresh-frozen humeri were match-paired and divided into 4 groups. Dual-energy bone density scan had been used in order to rule out the influence by different degrees of osteoporosis of the cadaver. Two-part surgical neck fracture model was carried out unanimously in all 36 humeri. Four terminal threaded pins (2.5 mm in diameter) were used in fixation for all specimen. Parallel type pinning (box type) were carried out in 2 groups and convergent type pinning (fan shape) in the other 2 groups. Instron5566 biomechanical tester was applied in determining both anti-shear and anti-torsion ultimate load of each specimen. RESULTS: There was no statistical difference between parallel pin construct and convergent construct in regard of anti-shear resistance (P = 0.73). But by mean of anti-torsion resistance, the parallel construct had significant advantage over the convergent construct (P = 0.04). CONCLUSION: According to our biomechanical data, parallel pin construct seems to have better torsional stability. We suggest that parallel pin fixation should be applied whenever possible. Convergent pin construct should be considered when parallel construct is not possible or the distance between pins are too small (< 1 cm).
Acromioclavicular joint dislocation with intact coracoclavicular ligaments accompanied by fracture of the coracoid process is a rare injury. The patients are treated with conservative and/or surgical methods. A 30-year-old male patient developed type 3 acromioclavicular dislocation and coracoid process fracture due to a fall in the right shoulder. Both injuries were treated surgically. Following open reduction, the acromioclavicular joint was fixed with a Knowles pin, and the coracoid process was fixed with a 4.0-mm malleolar screw. Active-assisted rehabilitation of the shoulder was initiated a week after surgery. The patient returned to office work with a long arm splint at three weeks. Pain-free, active, and complete shoulder movements were seen in the fifth week. The Knowles pin in the acromioclavicular joint was removed under local anesthesia seven months postoperatively. A year after surgery, he resumed full shoulder functions without pain and there were no signs of complications such as heterotopic ossification.
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.