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PubMed1995

[Surgical therapy of bone metastases].

The surgical treatment of bone metastases is generally palliative. All operative procedures have to consider the mostly short life expectancy and therefore have to guarantee stability, early mobilization and short hospitalization. Surgery is absolutely indicated in patients with pathologic fractures of the long bones and innominate bone involving the hip joint, in patients with spinal lesions causing instability and progressive neural deficit and in patients with compression of peripheral nerves. Relative indications for surgery are given in cases where the risk of sustaining a pathologic fracture is high, in cases where spinal neurological deficit or root irritation can be expected, in patients where the tumor grows despite adequate irradiation or chemotherapy and finally in cases where open biopsy is useful to exclude primary malignant tumor or is necessary to define the further therapeutic management. As morbidity, hospitalization and complications increase in patients with pathologic fractures prophylactic stabilization is emphasized using well defined criteria. The standard surgical principles and techniques are presented and the results of 506 cases are reported.

Bone Neoplasms↗
PubMed1993

[Results of reconstructive surgery in fractures of the proximal humerus].

In treatment of comminuted dislocation fractures of the proximal humerus the most serious therapeutic problem still remains the 6th group of Neer's classification, in particular fractures with four fragments and with a completely dislocated and devitalized head. The authors present in a retrospective study an overall comparison of results assembled in 30 patients (and 19 checked patients resp.) who were operated by the technique of anatomical reconstruction (13 and 8 patients resp.) or by the authors own technique of non-anatomical reconstruction (17 and 11 patients resp.), all operated on account of comminuted dislocation fractures of the proximal humerus at the orthopaedic clinics of the First and Third Medical Faculty, Charles University, Prague in 1976-1988. Analysis of the results of the checked patients made the authors draw the following conclusions: 1. Fractures of the proximal end of the humerus is a relative frequent injury, in particular in the elderly. About 20% of these injuries call for surgical treatment. 2. In all non-anatomical reconstructions the mobility is very restricted in particular exorotation, in anatomical reconstructions the restriction is much smaller. 3. In all patients operated by the technique of non-anatomical reconstruction within three years necrobiotic reconstruction of the fragment of the head occurred which is the greater, the larger the fragment of the head which was preserved. 4. The result of the reconstruction depends on the preservation of nurture of the fragment of the head and on selection of an adequate technique of osteosynthesis. 5. In anatomical reconstructions the most frequent complication was loosening of the osteosynthetic material, a varus position of the head and pseudoarthrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

[Differential diagnosis and therapy of multi-fragment humeral head fracture--an analysis of three clinical studies].

Out of the total number of patients of three Centers for Orthopaedic and Trauma Surgery, 93 comminuted humeral head fractures were clinically and radiologically controlled by means of a retrospective analysis. The classification of the fractures was made according to C.S. Neer, the clinical evaluation according to the Constant-Score. The analysis of the results in relation to the respective therapeutic methods revealed fundamental differences between the various types of fractures depending on the number of fragments. The prognosis of the three-part fractures appears essentially determined by the biomechanical conditions. This means that the therapeutic method has to be applied according to the restitution of the respective position of the fragments. Open reduction and internal fixation (mean Constant-Score 83 resp 91 points) or conservative treatment (78 points) seem to be primarily indicated in these cases. The prognosis of the four-part fractures, on the contrary, is largely determined by the problems of vascular supply of the head fragment, with a high risk of a humeral head necrosis. For this reason a primary prosthetic replacement (mean Constant-Score in case of primary implantation 75 points, compared with 54 points in case of conservative treatment and 52 points for open reduction and internal fixation), should be recommended for this type of fracture. For therapeutic and prognostic reasons, fractures at the proximal end of the humerus require an exact classification on the radiological basis of at least a so-called "trauma series". However, for a more accurate visualisation especially of the region of the lesser tuberosity (which is difficult to assess by means of conventional radiology), and consequently for the precise determination of the number of fracture-parts and their respective positions, we consider a CT Scan to be compulsory.

Adult↗
PubMed2006

[The cloverleaf plate for osteosythesis of humeral head fractures. Definition of the current position].

In this prospective study we evaluated the functional and radiological results obtained in 62 patients who had been treated for fracture of the humeral head by internal fixation with a cloverleaf plate. They were examined postoperatively, after 14 weeks and after an average follow-up of 75 weeks. Nine patients (14.5%) had dislocated 2-part fractures, 36 had 3-part fractures (58%; additional dislocations of the greater or lesser tubercle), 13 patients (21%) had 4-part fractures and 4 (5.6%) had luxation fractures of the humeral head. Early functional physiotherapy was started on the third day after surgery. The complications observed were: subcutaneous infection (2 cases; 3.2%), haematoma (2 cases; 3.2%), temporal paraesthesia of the axillary nerve (1 case; 1.6%). Only 4 (6.5%) patients suffered from necrosis of the humeral head (partial in 3, total in 1); in 2 cases (3.2%) we switched to a different procedure; in both these patients a humeral head prosthesis was implanted; in both these cases the clinical result was poor because of progressive varus dislocation. To improve mobility we performed arthrolysis in 8 cases (12.9%) and acromioplasty in 10 (16.1%), in addition to removing the plates after fracture consolidation confirmed by X-ray examination. In the present study those of our patients who had been treated with open reduction and internal fixation with a cloverleaf plate achieved average Neer scores of 77+/-13 and average Constant scores of 72.4+/-18, and the rates of complications or revisions were low. "Good" or "very good" results were obtained according to the Constant score in 59% of the treated patients. Even patients with complex 4-part fractures had average Constant scores of 72.7 points ("good"). The accuracy of the refixation of the greater tubercle, sufficiently low fixation of the cloverleaf plate and avoidance of varus position when the humeral head was repositioned were significant parameters influencing the functional outcome in our patients.

Adult↗
PubMed2005

The treatment of proximal humeral fractures with intramedullary titanium helix wire by 97 patients.

INTRODUCTION: The displaced proximal humeral fracture continues to be a problem and remains the "unsolved fracture". Many guidelines for surgical treatment of different types of these fractures have been described. A conservative functional therapy is recommended as well as a closed or open reposition and internal fixation. Other authors prefer the primary prosthetic replacement of the displaced humeral head. The purpose of this article is to describe a minimal invasive technique--the intramedullary titanium helix wire--and to analyse results and specific problems of this method compared to other techniques. MATERIALS AND METHODS: In a prospective study done over a period of 5 years from 1998 to 2002, 97 patients with two-, three- and four-part-fractures of the proximal humerus were treated with the intramedullary titanium helix wire and given follow-up clinical and radiological checks after 12 months. The functional outcome was evaluated with a 1-year follow-up in 95 of 97 patients. RESULTS: Our 1-year results include: 41 very good, 24 good, 16 satisfactory, 14 poor (average 76 points Constant functional score, 30.7 points UCLA score). CONCLUSION: The advantages of the method arising from the results lie in both the simple operation approach without nerve lesions or wound infections, and also in the indirect, intramedullary splinting of the fracture without damage to the surrounding soft parts, while iatrogenic necroses of the humeral head can be avoided.

Aged↗
PubMed2003

Late complications following clavicular fractures and their operative management.

We describe our experience of the operative treatment of sequelae from high-energy injuries of the clavicle. Surgery was performed on 17 patients who often had more than one indication. This included the following: painful non-union (nine patients), neurogenic thoracic outlet syndrome (TOS), hypertrophic non-union three patients, hypertrophic malunion five patients, bony spike two patients), vascular TOS (two patients) and brachial plexus neuroma (one patient). At clinical review, functional outcome was assessed by using a Constant score, a visual analogue pain score, return to work status and by patient subjective satisfaction rating. We performed 11 decompressions with callus excision, three simple neurolysis, eight fixations for non-union, one osteotomy and three excisions of bone spikes. Two patients required a further decompression procedure; one patient developed deep sepsis requiring sequestrectomy and two patients required removal of metalwork. At mean follow-up of 49 months the average Constant score was 64 (range 27-93). The mean pain score was 4. Ten patients returned to work at an average of 8 months. Five patients were completely asymptomatic, eight reported occasional paraesthesiae and three had significant cold intolerance. Patient satisfaction scores were 14% very satisfied, 50% satisfied, 14% unsatisfied and 22% very unsatisfied. High-energy clavicle injuries can cause significant morbidity due to non-union and TOS. Refractory symptoms can be improved by operative intervention with satisfactory functional outcome. However, the majority of patients experience some degree of residual symptoms.

Adult↗
PubMed1984

Fractures of the proximal end of the humerus caused by convulsive seizures.

Fractures due to convulsions are known to occur. The purpose of this study was to find the frequency of convulsive seizures as the cause of fractures of the proximal end of the humerus, which are the most common of these fractures. Of 278 cases admitted to the department, 2 per cent occurred after a seizure without other contributory causes. The manner of injury is discussed, and it is demonstrated that the diagnosis is often delayed. The importance of early reduction in cases with dislocation or displacement of the fracture is emphasized.

Adult↗
PubMed2000

Is there a place for external fixation in humeral shaft fractures?

There is a good indication for unilateral axial dynamic external fixation in fractures of the humeral shaft when the fracture appears in the distal third or in cases of bilateral fractures. A non-union or a posttraumatic paralysis of the radial nerve may be indications for external fixation as well as fractures associated with multiple injuries. Further indications include osteitis, infected non-union and comminuted fracture. There is maximum protection of the soft tissue with this method of treatment. External fixation combines the advantages of conservative and operative treatment by influencing callus formation by dynamizing, distraction or compression. Minimizing soft tissue damage facilitates the decision for early exploration of the radial nerve in cases of palsy. A safer positioning technique of the distal screws of the fixator is described.

Adult↗
PubMed1997

Long-term outcome of isolated lesser tuberosity fractures of the humerus.

Ten cases of an isolated fracture of the lesser tuberosity and their long-term outcome are described. The patient ages at the time of injury ranged from 11 to 68 years, averaging 30 years. In six cases, the injury was acute; in four cases, it had occurred more than 6 months previously. Of the six acute cases: three were treated conservatively, and the result was satisfactory for all of them; surgery was carried out in the other three cases, of which, two outcomes were judged to be excellent, and one outcome was satisfactory. Regarding the four chronic cases, muscle-strengthening exercises were given in two cases, whereas an operation was performed after exercise failed in the remaining two cases. The results of all four cases were graded as excellent. The combination of open reduction and internal fixation is the method most often recommended for acute cases. In chronic cases, conservative treatment is usually the most appropriate. However, when conservative treatment proves to be ineffective, then open reduction and internal fixation should be considered.

Accidental Falls↗
PubMed2003

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3).

BACKGROUND: A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus. METHODS: After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending). RESULTS: Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws. CONCLUSION: Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.

Biomechanical Phenomena↗