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PubMed1985

Fractures of the proximal humerus in adults.

Fractures of the proximal humerus are a common upper-extremity injury, particularly in the elderly. The literature suggests that the results of treatment of displaced fractures are generally unsatisfactory. Since Neer's articles in 1970 we found little reported in the literature on these fractures. We conclude from our review of 90 fractures that the results of treatment of displaced fractures continue to be unsatisfactory, and we believe that displaced proximal humeral fractures, along with femoral neck fractures, should be classified as unsolved fractures.

Adult↗
PubMed2002

[Reconstruction of shoulder-girdle symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage].

The aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1+/-0.9 years in group 1 and 2.9+/-0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly ( P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78+/-23 in group 1 and 97+/-4 in group 2 ( P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

Adolescent↗
PubMed2003

[Descending intramedullary nailing for the treatment of displaced supracondylar humeral fractures in children].

BACKGROUND: Supracondylar humeral fractures are the most common lesions in childhood. Severely displaced fractures are commonly treated by crossed K-wire osteosynthesis. Such stabilized fractures require a cast and often involve postoperative complications such as iatrogenic lesions of the n. ulnaris and secondary displacements,sometimes leading to a consecutive cubitus varus. This study analyzed possible advantages of elastic stabile intramedullary nailing (ESIN) with postoperative release of motion. PATIENTS AND METHOD: All children aged 1-14 years suffering from a supracondylar humeral fracture, with a displacement in at least two planes,were included in this study (period: 1 June 1999-30 April 2001). Movement was permitted for all patients postoperatively. A follow-up examination was scheduled at least 6 months after trauma. RESULTS: This study included 20 female and 30 male patients. Neither iatrogenic lesions of the n. ulnaris nor secondary displacements occurred. Five slight technical pitfalls (perforating wire, gapping with consecutive axis deviation) occurred. Postoperative X-rays most often revealed a remaining axis deviation in the sagittal plane. Comminuted fractures with corresponding zones resulted in cubiti vari and valgi. Of the 50 patients, 47 appeared for follow-up (94%). The ROM coincided with the acquired radiological data. Only one patient (2%) showed a functional deficit greater than 10 degrees. CONCLUSION: As soft tissue swelling does not hinder the surgeon, ESIN shows a high rate of closed stabilizations. No cast has to be applied and free ROM can be permitted for all patients. Avoidance of iatrogenic lesions of the n. ulnaris and secondary displacements are other advantages of this method.

Adolescent↗
PubMed1996

[Impalement injury of the colon, iliac vein and sacrum--a rare combination in penetrating abdominal trauma. A case report].

We report on the treatment of a patient who sustained a penetrating abdominal wound with injury of the left common iliac vein, the sigmoid colon and the sacrum in a motorbike accident. The left iliac vein injury was treated using a Gore-Tex vein patch and an A-V fistula. The colon was restored after an intraoperative washout. The punched fragment of the sacrum was removed. An additional fracture of the proximal left humerus was managed with an osteosynthesis in a second operation. The principles of management of combined colon and vascular injuries are discussed and a short review of the literature is given.

Abdominal Injuries↗
PubMed2006

[Operative treatment of proximal humeral fractures with helix wire].

BACKGROUND: Between 1 January 2000 and 31 December 2002, a total of 50 patients with a dislocated or unstable fracture of the proximal humerus were treated surgically with a titanium helix wire introduced retrogradely into the medullary cavity. MATERIAL AND METHODS: Fracture classification showed 8 cases of a two-fragment fracture, 32 cases of a three-fragment fracture, and 10 cases of a so-called four-fragment fracture. A retrospective radiographic and medical review of all 50 patients showed postoperative complications in 24% of the cases; in 8 cases (16%) secondary loss of retention occurred with consecutive projection of the helix wires into the subacromial joint space. There were two cases each (4%) of perforation of the helix wire into the joint space without loss of retention and fracture dehiscence because of a blocking mechanism by the helix wire in the subcapital fracture gap. The postoperative revision rate was 18% (9/50) as a result. Of 50 patients with a titanium helix wire, 38 (76%) were reviewed after an average of 23 months (12-31). Radiologically partial necrosis of the head of the humerus was seen in two patients and there was necrosis of the head of the humerus with pseudarthrosis in one patient, which had a negative effect on the Constant score. RESULTS: Because of a change of procedure (n=5) and intercurrent deaths (n=5) only 2 of 12 patients, in whom complications had occurred postoperatively, could be followed up clinically; the results of the follow-up are sure to be distorted by this selection effect. Of 38 patients, 32 (84%) showed very good to good results functionally; the average Constant score was 74 points and the average age- and sex-specific corrected score was 92%. DISCUSSION: Thus, the procedure does not achieve better functional results compared to other rigid and semirigid internal fixation methods while it has a high complication and revision rate compared to other rigid and semirigid internal fixation methods. Moreover, early functional treatment is not possible so that the titanium helix wire represents a retention aid rather than stable internal fixation. Overall we cannot recommend the procedure for the operative management of proximal humerus fractures further and have abandoned it ourselves.

Adult↗
PubMed2006

[Ulnar nerve lesions after osteosynthesis of a supercondylar humerus fracture during childhood. Indications for revision].

Since 1948, closed reduction and osteosynthesis for supracondylar humeral fractures using two K-wires from the medial and lateral side has been performed on a regular basis. Although this procedure is used routinely, many authors have described paralysis of the ulnar nerve after blindly inserting the medial K-wire. Only very few publications describe the treatment options after iatrogenic paralysis of this nerve. The patients described showed progressive paralysis of the ulnar nerve after K-wire osteosynthesis. Intraoperatively, all patients showed scarring but intact continuity. After surgical revision and neurolysis, all four patients showed complete restitution after 1 year. If patients show progressive paralysis of the ulnar nerve early operative revision after 3 months should be performed.

Bone Wires↗
PubMed1997

[Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis?].

PROBLEM: The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three-and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. PATIENTS AND METHODS: Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The "X" represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7-72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P < 0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P < 0.05). RESULTS: Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P < 0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer),but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6-12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. CONCLUSION: In displaced three-and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered.

Adult↗
PubMed2004

Open reconstruction of anterior glenoid rim fractures.

The present study evaluates the clinical and radiological results of patients with anterior glenoid rim fractures treated with two different open surgical techniques depending on the size of the bony fragment. In patients with displaced glenoid rim fractures involving less than 25% of the glenoid surface (Type I, II and IIIA fractures) suture anchor repair was performed. Patients with a bony defect involving more than 25% of the glenoid surface (Type IIIB fractures) underwent open reduction and internal fixation using cannulated screws. After a mean follow-up of 22 months, 15 patients (mean age 42.2 years) treated with suture anchor repair achieved an average Constant Score of 85.5 points (range 67.1-100) and an average Rowe Score of 94 points (range 70-100). In six patients the bony fragment was located in an unimproved medial position compared to the preoperative X-ray. In another six patients the fragment was consolidated medially to the level of the glenoid rim, and in three cases an anatomic situation was found. Patients treated with cannulated screws (ten cases, mean age 46.6 years) had a mean follow-up of 30 months and achieved a mean Constant Score of 81.9 points (range 61.7-96.1) and a mean Rowe Score of 90 points (range 70-100). Radiologically, the bony fragment was consolidated in an anatomic position in nine out of ten cases. Three patients suffered from screw impingement and one patient had screw loosening. No recurrent subluxations or dislocations were observed in either group. Three patients in group one and one patient in group two had glenohumeral osteoarthritic changes. In cases of small glenoid-rim fractures (Type I, II and IIIA fractures), suture anchor repair resulted in an excellent clinical outcome; however, the radiological results of chronic Type I fractures revealed in many cases a non-anatomical glenoidal reconstruction. For Type IIIB fractures with significant loss of glenoid concavity, open reduction and internal fixation with cannulated screws gave good clinical and radiological results; however the early complication rate was higher.

Adult↗
PubMed2005

Osteoporotic fractures of the proximal humerus, pelvis, and ankle: epidemiology and diagnosis.

Although fractures involving the wrist, spine, and proximal femur are known to be strongly associated with osteoporosis, the underlying bone insufficiency often receives insufficient diagnostic and therapeutic attention. Osteoporosis also increases the risk of fractures at other sites. Low-energy fractures in patients older than 50 years should lead to investigations for osteoporosis, the only exceptions being fractures of the skull, cervical spine, fingers, and toes. The incidence rates of fractures of the proximal humerus, pelvis, and ankle are climbing relentlessly. Whereas fractures of the proximal humerus and pelvis are undoubtedly related to osteoporosis, the link is less well established for fractures of the ankle. Mortality and morbidity rates associated with pelvic fractures are similar to those seen with fractures of the proximal femur, in keeping with the fact that both fractures occur in elderly individuals.

Aged↗
PubMed2001

Complex proximal humeral fractures in adults--a systematic review of management.

We performed a systematic review of the literature to compare the clinical outcomes of the management of three and four part fractures of the proximal humerus by conservative regimes, internal and external fixations and arthroplasty. We identified 147 reports of comparative trials and case series between 1969 and 1999. We selected only studies dealing exclusively with three and four part fractures of the proximal humerus, with at least 15 patients, treated within 48 h of injury by one of the three modalities studied, in which at least one of the outcomes of interest (pain, range of motion, infection and restoration of anatomy) was described. Also, to be included, studies had to have a follow-up period of at least 6 months, in which a minimum of 85% of patients were followed-up. Twenty four reports met our eligibility criteria. Conservatively managed patients had more pain and a poorer range of motion than those managed by either fixation or arthroplasty. Better restoration of anatomy was delivered in the fixation group. There was no significant difference in the functional range of motion between the arthroplasty and fixation groups, but there were very few studies available to compare infection rates in these two management modalities. The results from the present systematic review suggest that the data from the published literature are inadequate for evidence-based decision making with regards to the treatment of complex proximal humeral fractures.

Arthroplasty↗