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Non-union is an uncommon but troublesome complication of proximal humeral fractures. A number of surgical techniques have been reported. We describe the use of a contoured limited-contact dynamic compression plate in the surgical management of proximal humeral non-union.
The purpose of this study was to assess the clinical outcome of an unreported technique of the least possible fixation for valgus-impacted fractures. Using an open technique without any sharp deep soft tissue dissection, the split between the tuberosities is opened to allow elevation of the impacted humeral head fragment. The tuberosities are reduced and repaired with absorbable sutures between the rotator cuff insertions. No bone grafting, Kirschner wire or other fixation device was used. For 11 patients, with an average age of 55 years, who were operated between 1989 and 1998, the mean follow-up period was 69 months. The patients were assessed radiologically and clinically using the Constant-Murley score. As a percentage of the normal side, the Constant-Murley scores ranged from 55 to 100% (mean 86%); there were eight patients with scores >80%, two patients with scores between 70 and 79% and one patient with score <70%. One patient (9%) showed avascular necrosis (AVN). This fixation allows preservation of the soft tissues in an open approach and avoids the dangers of other fixation methods. There is a low risk of AVN and it allows a good functional result.
The 4-part fracture dislocation of the proximal humerus remains an unsolved problem in young patients. The majority of 4-part fracture dislocations are best managed by humeral head replacement, although open reduction and internal fixation in young patients with good bone quality may be considered. Better results are obtained associated with limited exposure, careful soft tissue dissection, and stable fixation. We present an unpublished technique of reduction with arthroscopic assistance and percutaneous stabilization, which preserves the soft tissue around the fragments, avoiding the deltopectoral approach.
PROBLEM: The primary goal in treating fractures in elderly persons is safe and rapid restoration of their functional capabilities to secure independence in everyday activities. The intention of this paper is to present an overview of treatment principles useful in this age group. METHODS: We analysed a series of 404 patients above the age of 70 years who underwent surgery for fractures of the arm between 1981 and 1997. RESULTS: Diaphyseal fractures are less frequent in this age group and their treatment does not differ significantly from principles established for younger patients. The majority of fractures of the proximal humerus and the distal radius can be treated by conservative means. Unstable fractures are frequent in the distal humerus and the olecranon requiring operative reduction and osteosynthesis. CONCLUSIONS: Preferred operative techniques in aged persons inflict minimal surgical trauma and have a low rate of complications and secondary interventions. In contrast, anatomical reconstruction has the highest priority in younger individuals.
We measured healing in 7 cases of surgical neck fracture of the humerus by applying a strain gauge measuring bar between the external fixation pins. Repeated measurements provided a healing curve for the individual cases. The gradual decrease in deflection of the fracture zone reached a plateau of about 50 percent after 2 to 4 weeks in 6 cases. Removal of the frame at this time proved safe, as solid healing occurred. In one fracture no such decrease was seen and nonunion developed.
Rigid internal fixation is frequently difficult to obtain in the proximal humerus, as osteoporotic bone and small fracture fragments may preclude firm purchase of plates and/or screws. We describe our clinical results using a semitubular plate, fashioned into a blade plate device, for fixation of four displaced fractures and three osteotomies of the proximal humerus. All patients were clinically and radiographically united by 4 months postoperatively and had a functional range of motion. The strength of this fixation was compared to that of an AO "T" plate in an oblique subcapital osteotomy model using 10 matched pairs of human humeri. No statistically significant difference could be demonstrated between the two fixation methods with regard to load to failure, yield load, energy absorbed to failure, or stiffness. As a consequence of these studies, we believe the semitubular blade plate expands the options available for challenging fixations in the proximal humerus.
UNLABELLED: A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation. LEVEL OF EVIDENCE: Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.
OBJECTIVE: To compare the mechanical stability of a fixed-angle blade plate with that of a locking plate in a cadaveric proximal humerus fracture-fixation model subjected to cyclic loading. A secondary objective was to evaluate whether the use of synthetic humerus specimens would replicate significant differences found during cadaveric tests. DESIGN: Mechanical evaluation of constructs in bending and torsion. SETTING: Biomechanical laboratory in an academic medical center. METHODS: Simulated humeral neck fractures (Orthopaedic Trauma Association (OTA) classification 11A3), in matched-pair cadaveric and synthetic specimens underwent fixation using either a 3.5-mm, 90-degree cannulated LC-Angled Blade Plate or a 3.5-mm LCP Proximal Humerus Locking Plate. Cadaveric specimen constructs were cyclically loaded in bending and torsion; synthetic specimens were tested in torsion. MAIN OUTCOME MEASURE: Humeral shaft-bending displacements and angular rotations for respective cyclic bending loads and axial torques were recorded and compared at repeated cyclic intervals to evaluate construct loosening. RESULTS: Locking-plate constructs exhibited significantly less loosening than blade-plate constructs for torsional loading in cadaveric specimens (P = 0.036). The two types of constructs performed similarly for torsional loading in synthetic specimens (P = 0.100). Under cyclic, closed-bending load conditions in which the plates served as tension members, both types of constructs performed similarly in cadaveric specimens (P = 0.079). CONCLUSIONS: For simulated humeral neck fractures subjected to cyclic loading, locking-plate constructs demonstrated significantly greater torsional stability and similar bending stability to blade plates in a cadaveric specimen model. In contrast, these same constructs performed similarly with torsional loading when using synthetic humerus specimens. These results indicate potential advantages for locking-plate fixation. They also indicate that the synthetic specimens tested may not be appropriate for evaluating fixation stability in the humeral head, where cancellous bone fixation predominates.
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Fourteen elderly patients with a two-part fracture, in osteopenic bone, of the surgical neck of the humerus were treated with a valgus impaction osteotomy and tension band fixation--that is, the parachute technique. Thirteen patients were followed, and all were able to perform activities of daily living without difficulty and were satisfied with the result of the surgery. The average age of these thirteen patients was sixty-eight years, and the average duration of follow-up was 18.5 months. Union was achieved in all patients, at an average of 45.5 days. No patient demonstrated osteonecrosis of the humeral head. This technique of valgus impaction osteotomy with Dacron-tape tension band fixation leads to rapid union. Patient satisfaction and function were excellent.
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The aim of the study was to compare of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children. We assessed retrospectively the type and result of treatment of 23 children. We obtained very good results in all cases treated by closed reposition secured by percutaneous K-wire fixation. In the group treated by skeletal traction, in 5 cases reposition was inadequate with subsequent limitation of range of motion in the elbow joint. According to our results closed reposition and percutaneous fixation should be the method of choice in displaced supracondylar humeral fractures in children.
Posttraumatic inferior subluxation of the humerus can be a possible cause of nerve injury and is therefore an alarming symptom. Etiology and frequency of subluxation after surgery of fractures of proximal humerus in group of 53 patients, including 4 cases of nerve injuries were studied. X-rays performed during treatment of this patients were analyzed. We confirmed high rate (41.5%) of this subluxation in our patients, 4 times more often in comminuted fractures, as result of deltoid atony, impaction of bony fragments and distention of the joint by hematoma. Surgical trauma and heavy cast immobilization were additional factors. We remarked after bone plating subluxation more frequent (62.5-75%) and duration longer than after nailing (13.6-34%). We concluded subluxation is secondary to many factors, needs meticulous evaluation for excluding injury of nerves, and for avoiding surgical trauma and cast immobilization should be minimized.
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From 1982 to 1986, a total of 106 children with supracondylar fractures of the humerus were treated at the trauma surgery clinic in Braunschweig. Undisplaced or slightly displaced fractures were treated with plaster casts. More severely displaced fractures were initially treated by closed reduction under general anesthesia and percutaneous Kirschner wiring. In 72 cases (= 85.7%) a follow-up examination revealed a very good or good result. In 9 cases (= 10.7%) satisfactory results were found and in 3 cases (= 3.6%) unsatisfactory results. The most common complication prejudicing the result was cubitus varus. It was found in 27 cases (= 32.1%), most often with a varus under 10 degrees (19 of the 27 cases). A retrospective study of the 12 cases in which the results were classified as satisfactory or unsatisfactory showed 8 insufficient reductions in fractures with severe instability.
OBJECTIVE: To analyze the surgical approaches for treating displaced proximal humeral two-and three-part fractures in elderly patients. METHODS: Nineteen elderly patients with displaced proximal humeral fractures were analyzed, including 13 patients with displaced two-part fractures and 6 with displaced three-part fractures. All the patients were treated by open reduction and fixation with humeral anatomical bone plates. RESULTS: The rate of excellent or good healing was 76.9% for two-part fractures without nonunion or humeral head necrosis, and was 66.7% for three-part fractures with a rate of humeral head necrosis of 16.7%. CONCLUSION: Displaced proximal humeral fractures in elderly patients should be managed with minimal open reduction and fixed with humeral anatomical bone plate.