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PubMed2001

Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head.

Percutaneous reduction and fixation of severe humeral head fractures would be the treatment of choice since it will not increase the risk of necrosis already inherent in these fractures. Nevertheless, the question arises of whether anatomical reduction is possible with the percutaneous technique and whether the reduced fracture can be adequately stabilized. It is important to study the fracture closely before the operation in order to determine the fracture type and identify the relationship of the individual fragments to each other. Radiographs taken in at least two planes are essential and a CT scan with 3D reconstruction would be desirable. Besides extraarticular fractures, surgical neck fractures with avulsion of the greater tuberosity (B1 and B2 fractures) and valgus impacted fractures (C1 and C2 fractures) are good indications for this method due to the fact that in these cases intact connections to rotator cuff tendons or remnants of intact periosteum between fragments still exist. Less good indications are fractures with severe lateral displacement of the articular segment and severely displaced fracture dislocations (C2 and C3 fractures). From 1990 to 1999, a total of 88 patients with 37 B1 and B2 fractures and 41 C1 and C2 fractures were operated on percutaneously. The initial 27 patients with 9 B1 and B2 and 18 C1 and C2 fractures were followed up. All B1 and B2 fractures showed good to very good functional results (Constant Score 91%). The Constant Score of the C1 and C2 fractures was 87%. The necrosis rate of the C1 and C2 fractures was 11%. In conclusion, it can be said that the presence of soft tissue bridging of the various fragments is crucial for the reduction to gain benefit from the ligamentotaxis effect. Thus, fractures such as valgus impacted or three-part fractures are very good indications for this technique. It can also be stated that the necrosis rate is low or at least not increased compared to cases treated by open reduction. Since the fracture is not exposed, adhesion within the surrounding gliding surfaces is reduced and the rehabilitation period is shorter.

Bone Screws↗
PubMed1993

Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band.

Thirty-five patients with four-part displaced proximal humeral fractures and fracture-dislocations were retrospectively reviewed from the years 1977-1990. Thirty-three patients were available for study. All fractures were treated by open reduction and internal fixation allowing early motion. Surgical technique was as atraumatic as possible with the goal of restoring normal anatomy of the proximal humerus with a minimal fixation system. The fixation device consisted of two modified Kirschner wires introduced through the tuberosities and reinforced by a tension band wiring. Neer's criteria were used to evaluate results. With a mean follow-up of 7 years, results were excellent and satisfactory in 21 cases, nonsatisfactory in 10, and poor in two. The most common complication was avascular necrosis (nine patients). All cases of fracture-dislocations corresponded with the nonsatisfactory and poor results. Because of our results, we conclude that in four-part displaced fractures, open reduction and internal fixation with our system of osteosynthesis should be indicated initially. Prosthetic replacement should be considered as primary treatment in cases with marked comminution of the humeral head, in fracture-dislocations, and in patients > 75 years of age.

Adult↗
PubMed1999

Upper extremity stress fractures in athletes: clinical features of 44 cases.

PURPOSE: To review the clinical features of a large series of active patients with a stress fracture in a non-weight-bearing location of the upper extremity or ribs. DESIGN: Multicenter cross-sectional study. SETTING: Multiple academic medical centers. PARTICIPANTS: 44 patients with a diagnosis of upper extremity or rib stress fracture. MAIN OUTCOME MEASURES: Clinical features according to anatomic location, primary sport, and subdivided according to the nature of the sport-specific skills involved. RESULTS: A diagnosis of stress fracture was made in 44 patients based on history and physical examination, and confirmed by radiography, scintigraphy, magnetic resonance imaging (MRI), computed tomography (CT), or a combination of imaging techniques. Patients were subjectively divided into four categories based on the predominant type of upper extremity activity required for participation in their sport: 1) weight lifter (e.g., football, weight lifting, wrestling); 2) upper extremity weight bearer (e.g., gymnastics, diving, cheerleading); 3) thrower (e.g., pitcher, soccer goalie, javelin); or 4) swinger (e.g., golf, tennis). We noted that all fractures in the weight bearers occurred distal to the elbow, whereas in the throwers most fractures affected the shoulder girdle. Lower rib stress fractures predominated in the swingers group, whereas weight lifters had fractures located throughout the upper extremity. CONCLUSION: Stress fracture should be considered in the differential diagnosis of athletes presenting with upper extremity or rib pain of bony origin that is of insidious onset. Further study of the sport-specific patterns of injury described here may improve our ability to treat and prevent these injuries.

Adolescent↗
PubMedDate not supplied

Two-incision technique for treatment of complex proximal humerus fractures.

The treatment of complex proximal humerus fractures that involve displacement of the greater tuberosity remains challenging. Good functional outcomes and decreased pain are possible with open reduction and internal fixation. Keys to a successful outcome include preservation of blood supply through decreased soft-tissue stripping, restoration of normal anatomic relationships (particularly the greater tuberosity), and stable internal fixation that allows early range of motion. To attain these goals, we advocate fixation with a fixed-angle locking proximal humerus plate using a 2-incision approach. A deltopectoral incision is used to expose the humeral shaft and head while the greater tuberosity is visualized by using a lateral incision. The fracture fragments are reduced and the plate is secured by working through these 2 incisions.

Adult↗
PubMed2000

Rigid internal fixation of fractures of the proximal humerus in older patients.

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 +/- 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus.

Activities of Daily Living↗
PubMed1999

Occult fractures of the greater tuberosity of the humerus: radiographic and MR imaging findings.

OBJECTIVE: The purpose of this study is to discuss the clinical implications of diagnosing a one-part greater tuberosity fracture on radiography and to describe associated rotator cuff findings on MR imaging. CONCLUSION: One-part greater tuberosity fractures are traditionally treated conservatively. Because clinical findings simulate those of rotator cuff abnormalities, some patients with missed or nonvisible fractures may be referred for MR imaging for further examination. In our study, MR imaging revealed no associated cuff abnormalities that required early surgery. Diagnosis of such a fracture on radiography may obviate the need for unnecessary MR imaging and arthroscopic surgery.

Female↗
PubMed1992

Prevention of heterotopic bone formation with low dose radiation therapy.

Radiation therapy to control heterotopic bone formation does not appear to be commonly used in sites other than hips where effective control is evident following arthroplasty. Reported are the results in 12 sites in 10 patients including three with treatment to the elbow, humerus, and ulna. Ten sites received a radiation dose of 10.00 Gy, one 16.00 Gy, and one was treated to 20.00 Gy, all delivered in 2.00 Gy fractions. Preoperative and follow-up x-rays were reviewed and graded. There was no clinically significant regrowth of heterotopic bone. Five sites (42%) demonstrated mild regrowth or persistence following surgery with the other seven (58%) showing no evidence of heterotopic bone. No complications were seen. Radiation therapy is effective for the prevention of heterotopic bone after total hip arthroplasties as well as surgery for fractures to other areas.

Adult↗
PubMed1991

[Results of treatment of compartment syndrome of the upper arm].

Only a small number of cases of compartment syndrome in the upper arm has been reported in the literature. The authors have reviewed 14 patients with 14 cases of compartment syndrome treated at their institution from 1980 to 1988. In the majority of cases in this series, compartment syndrome was caused by blunt, high-energy trauma. There were 9 patients with multiple trauma, 7 of whom were motor cyclists, and fracture of the upper arm was present in most of these. In 5 patients scapulothoracic dissociation with disruption of the neurovascular bundle of the upper extremity concerned was present. In this series, 2 patients died of their injuries and three arms had to be amputated. At final follow-up after an average of 45 months (range 11-91 months) the functional result was dependent mainly on the severity of the associated injuries. Patients with isolated compartment syndrome had full recovery of upper limb function.

Adolescent↗
PubMed1988

Salter-Harris type III fracture of the proximal humeral physis.

Salter-Harris type III, IV and V injuries of the proximal humeral physis are rare. We report an undisplaced Salter-Harris type III injury of the humeral head physis in a 10-year-old girl. The fracture united with non-operative treatment.

Accidents, Traffic↗
PubMed2003

Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens.

BACKGROUND: The objective of this study was to determine the in vitro characteristics of the clinically used and newly developed implants for the stabilization of proximal humeral fractures under static and cyclic loading. The goal was to optimize implant stiffness for fracture stabilization even in weak bone stock. METHODS: In a laboratory study using 35 fresh human humeri, the specimens were randomized into 5 groups, which included the clinically used humerus T-plate (HTP), the cross-screw osteosynthesis (CSO), the unreamed proximal humerus nail with spiral blade (UHN), the recently developed Synclaw Proximal Humerus Nail (Synclaw PHN) and the angle-stable Locking Compression Plate Proximal Humerus (LCP-PH). The implant stiffness was determined for three clinically relevant load cases: axial compression, torsion and varus bending. In addition, a cyclic varus-bending test was performed to determine the implant properties under cyclic loading. RESULTS: In contrast to a rather elastic and minimally invasive implant(LCP-PH), the conventionally designed ones (Synclaw PHN, CSO, HTP, UHN) showed rather high stiffness values under static loading. In cyclic loading, a strong decrease in stiffness ( p<0.05) was found for the rigid implants HTP and UHN. In comparison with the other implants, only the elastic implant (LCP-PH) showed a significantly lower load reduction in a weak bone stock (17+/-6.2%). CONCLUSION: The high initial stiffness of rigid implants led to an early loosening and failure of the implant-bone interface under cyclic loading. Implants with low stiffness and elastic characteristics, however, appear to minimize the peak stresses at the bone-implant interface, making them particularly suitable for fracture fixation in osteoporotic bone.

Adult↗
PubMed2002

Treatment of complex proximal humeral fractures with minimally invasive fixation of the humeral head combined with flexible intramedullary wire fixation - introduction of a new treatment concept.

The treatment of three- or 4-part proximal humerus fractures is still a matter of scientific discussion. The following study presents the results of a combined procedure using limited invasive fixation techniques for reconstruction of the humerus head and retrograde intramedullary wiring with elastic nails for the treatment of displaced three- or 4-part fractures. A prospective study of 24 patients with 3-part and 4-part fractures was performed from September 1995 to December 1998. Combined biologic fixation for reconstruction of the humerus head, including intramedullary wiring, was utilized. Fracture reduction was performed in an open soft-tissue-preserving technique through a limited lateral approach. Fixation of the head fragments was performed using screw and/or cerclage wire fixation. The reconstructed humerus head was stabilized to the shaft with intramedullary wires, with retrograde insertion 2 cm above the olecranon fossa. Supportive fixation of the head fragments was achieved using fully threaded cancellous screws. At the 1-year postoperative follow-up, 40% of the 18 patients had excellent results using the Neer and Constant score. Forty-five percent had satisfactory and 15% unsatisfactory results. The initial results of this study reveal that a combination of limited internal fixation of the humerus head and retrograde elastic intramedullary wiring provide stable fixation with limited soft-tissue destruction. This approach has been shown to be especially useful for the combined treatment of three- or four-part fractures of the humeral head.

Adult↗
PubMedDate not supplied

Restraining patients and shoulder dislocations during seizures.

We describe 3 patients whose shoulders dislocated as the movements of the arm were restricted during a generalized tonic clonic seizure over an 18-month period. The first patient had both shoulders dislocated when observers sat on his arms during the convulsion. The second patient had a convulsion while in a forced lateral decubitus position and dislocated the shoulder on that side. The third patient dislocated the shoulder and fractured the acromion as she was held by her arms in a chair during a convulsion. Despite the large number of patients with refractory epilepsy under our care, no cases of spontaneous shoulder dislocation occurred during that period of time.

Adult↗