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PubMed1996

[Proximal humerus fracture in advanced age].

Functional results after plate osteosynthesis of unstable and displaced proximal humeral fractures, occurring in elderly patients, are good to excellent in 70% of patients, when surgery is performed according to the no-touch-technique. The incidence of aseptic necrosis of the humeral head and non-union are, in comparison with other internal fixation techniques, low. In four-part fractures and fracture-dislocations, primary arthroplasty remains the treatment of choice.

Aged↗
PubMed1998

[Antegrade or retrograde intramedullary nailing in diaphyseal or sub-capital humeral fractures in the adult].

The aim of this retrospective study was the evaluation of three current medullary nailing techniques and their approach related problems in diaphyseal and proximal humeral fractures. 28 patients (15 female, mean age 65 y; 13 male, mean age 53 y) with either diaphyseal (n = 22) or proximal humeral (n = 6) fractures treated with different nailing systems were reviewed (mean follow up 18.3 months). Two main groups were formed according to the surgical approach: an anterograde nailing group (AN), stabilized with Seidel (Howmedica) nails (n = 12) versus a retrograde nailing group (RN) with either Prévot (Landos) nails (n = 7) or Hackethal (Ulrich) nails (n = 9). The two groups were comparable regarding to age, follow up and fracture type. The subjective scores (global function, all day activity, pain, ROM) of the two groups (AN and RN) showed no statistically significant differences. Subacromial impingement led to reoperation in 50% (6/12) of the AN patients (Seidel nail). In 3/16 patients a reoperation was necessary due to secondary proximal or distal nail migration (Hackethal or Prévot nails). Delayed union was found either in one. Seidel or one Prévot nailed humerus. No postoperative infections or neurological problems (3 preoperative radial palsies recovered) due to the operative pro cedure were seen. The AN related subacromial impingement seems to be more disabling than RN related reduction of elbow function (extension deficit).

Adult↗
PubMed2002

Adults with pediatric-onset spinal cord injury: part 2: musculoskeletal and neurological complications.

OBJECTIVE: To determine the prevalence of musculoskeletal and neurological complications of adults with pediatric-onset spinal cord injuries (SCI), and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained SCI at < or = age 18 years and were > or = age 24 years at interview. OUTCOME MEASURES: Prevalence of musculoskeletal and neurological complications: fractures during the past 3 years; scoliosis; heterotopic ossification; hip dislocation or contractures; ankle contractures or pain; shoulder pain; elbow contractures or pain; pain at other sites; neurological deterioration; syringomyelia; and spasticity since injury. RESULTS: The 216 individuals who were interviewed had mean age at injury of 14 years and mean age at follow-up of 29 years. Most common complications were pain at any site (69%), spasticity (57%), shoulder pain (48%), scoliosis (40%), hip contractures (23%), and back pain (22%). There were no statistically significant associations between gender and the complications. Whites were more likely than nonwhites to experience pain. Younger age at injury was significantly associated with scoliosis and hip subluxation, and older age at injury was associated with ankle pain and spasticity. Older age at follow-up and longer duration of injury were both associated with elbow and shoulder pain, fractures, and neurological deterioration. Longer injury duration was also associated with hip subluxation and scoliosis. Ankle pain, elbow contractures, and spasticity were more common in those with tetraplegia, and hip contractures were associated with paraplegia. American Spinal Injury Association motor scores were significantly lower in those with elbow contractures and spasticity, and significantly higher in those with hip contractures and neurological deterioration. CONCLUSION: Musculoskeletal and neurological complications are common sequelae among adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can identify at-risk individuals.

Adolescent↗
PubMed2004

[Results of the provision of unstable proximal humeral fractures in geriatric patients with a new angle stabilizing antegrade nail system].

Treating unstable proximal humeral fractures in elderly patients with osteoporosis and limited compliance is still demanding for trauma surgeons. The failure rate of operative treatment is high. We studied the use of a new antegrade intramedullary humeral nail with special locking bolts for head fixation. The first 41 procedures in 39 patients with a mean age of 81 years (61-102) were analyzed. Half of the patients were mentally deranged. There were 16 two-part, 22 three-part, and 3 four-part fractures of the humeral head treated. After closed or partial open reduction, antegrade nailing was performed via a delta split and limited incision of the rotator cuff. Greater and lesser tuberosities were fixed with screws through threaded holes of the proximal nail leading to high stability. Early functional active treatment was performed avoiding maximal rotation. Follow-up was 13 months (7-21 months). Clinical examination was performed in 32 cases. Four patients were questioned by phone. Three patients died (mean age: 92 years) before follow-up. The mean Constant score was 57+/-12. The mean age-related and side-related Constant scores were 86+/-17% and 90+/-7%. All fractures healed. Activities of daily life were possible in every case. There was only one loss of reduction after a fall out of bed. After hemiarthroplasty the patient was excluded from the study. One shaft fissure occurred during distal interlocking and healed uneventfully. Because of stable fixation, rehabilitation without immobilization was possible and led to good functional results. In comparison to common implants, the new antegrade intramedullary nail allowed a stable osteosynthesis in unstable proximal humeral fractures in old and very old patients with limited compliance without the usual implant-related complications.

Aged↗
PubMed2006

[Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures].

BACKGROUND: Proximal fracture of the humeral head is the third most frequent fracture in humans. Most (70%) of those affected are over 60 years old. It is hoped that advanced locking medullary screws or plates will reduce the risk of secondary dislocation of screws or fracture segments when the bone of the humeral head is osteoporotic. METHODS: From January 2002 to August 2005, 225 displaced humeral head fractures in 223 patients aged on average 66+/-15 years were treated with a new locking proximal humeral plate. RESULTS: In 176 patients in whom follow-up was possible, the average Constant Score after 9 months was 70+/-19 points (raw data), or 81+/-22% in the normalized score. No significant difference was detected between the younger group up to 65 years of age (73% points) and those over 65 years of age (80% points). Axial deviations by more than 30 degrees were noted in 11 (5%), and of 159 displaced tubercles, malreduction by more than 5 mm was noted in 14 (9%). Two infections and two haematomas had to be treated so far. Primary screw perforations were seen in 24 (11%) cases as well as further implant dislocations in 3 (1,7%). Plate dislocations out of the shaft existed in 4 (2,4%) and 14 collapses of the humeral head with secondary screw perforations were recorded. All other complications arose out of technical faults, such as 24 screw perforations (11%) into the glenohumeral joint and 3 (1.7%) cases of secondary implant dislocation from the humeral head and 5 (3%) from the shaft, and 14 (8%) sinterings with glenohumeral screw perforation. So far, in addition to 1 case of pseudarthrosis with a broken plate, 5 (3%) cases of total and 9 (5%) of partial avascular humeral head necrosis have been observed. CONCLUSION: The new implant provides superior stability in the fixation of humeral head fragments and has proved its worth in everyday clinical practice when additional indirect fixation of the tubercle is needed, as it frequently is in elderly patients.

Aged↗
PubMed2004

Health-related quality of life after osteoporotic fractures.

OBJECTIVE: To estimate the impact of osteoporosis fractures on health-related quality of life (HRQOL) in postmenopausal women. METHODS: To compare the impact on HRQOL of different osteoporotic fractures, 600 consecutive women 55-75 years old with a new fracture (inclusion fracture) were invited by mail. After exclusions by preset criteria (high-energy fractures, ongoing osteoporosis treatment, or unwillingness to participate), 303 women were included, 171 (56%) of whom had a forearm, 37 (12%) proximal humerus, 40 (13%) hip, and 55 (18%) vertebral fracture, respectively, and all were investigated and treated according to the current local consensus program for osteoporosis. In addition, HRQOL was evaluated by the SF-36 questionnaire and compared with local, age-matched reference material. Examinations were performed 82 days (median) after the fracture and 2 years later. RESULTS: HRQOL was significantly reduced at baseline regarding all SF-36 domains after vertebral fractures and most after hip fractures, but only regarding some domains after forearm and humerus fracture. After 2 years, improvements had occurred after all types of fractures, and after forearm or humerus fracture, HRQOL was completely normalized in all domains. However, 2 years after hip fracture, HRQOL was still below normal regarding physical function, role-physical and social function, while after vertebral fracture, scores were still significantly lower for all domains, physical as well as mental. Patients with one or more previous fractures before the inclusion fracture had lower HRQOL at baseline and after 2 years, compared with those with no previous fracture. Patients with osteoporosis (T-score <-2.5 in hip or spine) had lower HRQOL than those with normal BMD. CONCLUSION: Vertebral and hip fractures have a considerably greater and more prolonged impact on HRQOL than forearm and humerus fractures. The number of fractures was inversely correlated to HRQOL. These differences should be taken into account when making priorities in health care programs.

Age Factors↗
PubMed2006

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.

Adult↗
PubMed1990

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.

Adolescent↗
PubMed1996

Patterns of fracture among the United States elderly: geographic and fluoride effects.

The purpose of this study was to examine whether geographic area or water fluoride were related to the occurrence of fractures among the elderly in the United States. We used a 5% sample of the white U.S. Medicare population, aged 65 to 89 years during the period 1986-1990, to identify fractures of the hip, proximal humerus, distal forearm, and ankle. The association of geographic region and fluoridation status with fracture rates was assessed using Poisson regression. We found that rates of hip fracture were generally lower in the northern regions of the United States and higher in the southern regions. For fractures of the distal forearm and proximal humerus, lower rates were found in the Western states, and higher rates in the East. No discernible geographic pattern was found for ankle fractures. Adjustment for water fluoridation did not influence these results. Independent of geographic effects, men in fluoridated areas had modestly higher rates of fractures of the distal forearm and proximal humerus than did men in nonfluoridated areas; no such differences were observed among women, nor for fractures of the hip or ankle among either men or women. In conclusion, our data suggest that fractures of the distal forearm and proximal humerus have etiologic determinants distinct from those of fractures of the hip or ankle.

Aged↗
PubMed2006

Locked vs. unlocked plate osteosynthesis of the proximal humerus - a biomechanical study.

BACKGROUND: Locked plates (internal fixators) have been found to be an optimal method for the fixation in proximal humeral fractures. In a biomechanical cadaver study the difference between locked and non-locked osteosyntheses was investigated. METHODS: Paired humeri were harvested, bone density measured. Locked internal fixators were mounted on one specimen; identical plate-screw-systems without locking mechanism applied to the contralateral specimen for comparison. After that, a transverse subcapital osteotomy was performed. With 7 pairs of humeri static tests with increasing axial loads and with 5 pairs dynamic tests with 10 N preload and 80 N maximal axial load for up to 1 million cycles were performed. RESULTS: In the static experiments the elastic stiffness of the construct was 74% higher in the locked group (median 80 N/mm, quartile range 77-86 N/mm) compared with the non-locked group (46 N/mm, 35.5-56.5 N/mm). The difference was statistically significant (Wilcoxon test for paired samples, P<0.05). Similarly, the linear range until failure was definitely extended in the locked group by 64% (92 N, 89-98 N vs. 56 N, 36.5-73.5 N, P<0.05). Under dynamic loading the non-locked group showed fixation failures between 97,000 and 500,000 cycles. In the locked group no failure was observed until the end of the experiment at 1 million cycles (P<0.0.5). The final deformation was found to be 1 mm (median, quartil range 1.0-1.2 mm) in the non-locked group and 0.3 mm (0.2-0.3 mm) in the locked group (P<0.05). The differences were found equally in lower as well as in higher bone density specimen. INTERPRETATION: Because of the optimal load transfer between implant and cancellous bone, a locked screw plate interface will reduce fixation failure in proximal humeral fractures.

Biomechanical Phenomena↗
PubMedDate not supplied

Treatment of proximal humeral fractures with Polarus nail fixation.

A chart review of 20 patients who sustained acute proximal humeral fractures and who were treated by surgical stabilization with locked antegrade humeral intramedullary nails (Polarus nails) was undertaken. The clinical outcome measurements were fracture healing, infection, and neurologic injury. Radiologic outcome measurements included fracture alignment, loosening, fixation and hardware failure, and malunion and nonunion. Of 20 fractures, 11 healed without complications. The mean immediate postoperative and final radiographic valgus neck/shaft angulation measured 131 degrees. Of the 20 implants, 3 had proximal fixation screw loosening. Of the 20 implants, 2 underwent revision surgery for proximal fixation failure. With certain fracture types, the Polarus intramedullary humeral nail can be an effective implant. In fracture cases involving an unstable or comminuted lateral metaphyseal fracture, if the starting point extends into the greater tuberosity, fixation failure or fracture displacement may result.

Adolescent↗
PubMed1989

[Osteosynthesis using the "palm-tree" nail technic in fractures of the surgical neck of the humerus].

Presented in 1974, this technique consists of internal fixation of the humeral neck by means of three divergent K-wires. These are introduced through a proximal entry point located on the lateral aspect of the humeral diaphysis at the lower end of the "V" shaped insertion of the deltoid which is one of the three subcutaneous areas of this bone. The two principles of this technique are: anchorage of the epiphysis by three divergent pins driven into the cancellous bone of the head and introduction of the pins from a very proximal point that allows easy access across the fracture without the disadvantages of nerve and joint proximity, as in other techniques involving other pins through the olecranon fossa (April), or medial epicondyle or lateral (Vichard). Moreover, this technique is quite different from the Hackethal technique by nails introduced through the olecranon fossa. An oblique hole is drilled at the selected point, and three 2 mm K-wires, after bending their ends are introduced into the medullary canal. After reduction of the fracture, they are driven into the cancellous humeral head bone. By turning the handle, the pins are made to diverge. Exceptionally, operative reduction is necessary by a separate axillary approach. X-ray control or the use of an image intensifier permits one to see if a K-wire is too long and to pull it out somewhat. No cast, no operation splinting, is used. Active and passive mobilization is possible the next day so the functional results are excellent in most cases. Pin removal is possible after 3 weeks in children and 5 in adults. The indications are all the upper extremity humeral fractures, and especially in children (epiphyseal fractures); in adults and aged people, except comminuted fractures.

Adolescent↗
PubMedDate not supplied

Fixation of fractures of the proximal humerus with the PlantTan Humerus Fixator Plate: early experience with a new implant.

The majority of fractures of the proximal humerus can be managed nonoperatively. However, displaced fractures generally require operative repair, and in the young patient with good bone quality, the results are usually satisfactory. In contrast, the osteoporosis found in the elderly patient makes internal fixation problematic and frequently contributes to failure of fixation and poor results. We report our early experience with a new plate that locks two humeral head cancellous screws to the plate. In 3 of 7 patients, all under 65 years of age, the results were good. However, in the remaining 4 patients, all over the age of 75 years, there was a 100% failure rate, with screw penetration of the head in 3 patients and secondary displacement of the fracture at 7 days postoperatively in another. We conclude that this implant is unsatisfactory for patients with osteopenic bone in the humeral head.

Adult↗
PubMed1996

Surgical treatment of complex fracture of the proximal humerus.

Sixteen patients aged 19 to 63 years (average, 52 years) were observed from 1.8 to 5.6 years (average, 3.8 years) after open reduction and internal fixation with or without external fixation of 3- and 4-part displaced fractures of the proximal humerus. There were 12, 3-part displaced greater tuberosity and surgical neck fractures with 6 concomitant dislocations. Four cases were 4-part fractures with 3 concomitant dislocations. Fixation was achieved with heavy sutures or wire that incorporated the rotator cuff tendon, tuberosities, and shaft combined with threaded pins or Hoffmann external fixation to enhanced stability for early rehabilitation. According to Neer's criteria, 14 (87%) of the 16 patients had satisfactory or excellent results. Two (13%) of the 16 had unsatisfactory results. The use of a technique of limited soft tissue dissection and internal fixation with or without external fixation achieved good fracture stability and a high percentage of satisfactory results. The limitations of the procedure include (1) patients who could not tolerate anesthesia, (2) complex displaced fractures in older patients with osteoporotic bone that cannot hold pins or external fixation, (3) older patients with 4-part fracture dislocations in which avascular necrosis of the humeral head occurs frequently and in which a subsequent endoprosthesis insertion is inappropriate if osteosynthesis fails, and (4) head splitting fractures. The described approach provides an alternative method for the treatment of complex displaced fractures of the proximal humerus.

Adult↗