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PubMed2000

Percutaneous fixation of proximal humeral fractures.

The purpose of the current study is to evaluate the technique of closed reduction and percutaneous pinning of proximal humeral fractures and to determine whether this technique provides enough stability to permit early active range of motion and subsequent fracture healing. Fractures were classified according to Neer et al and were included if the surgical or anatomic neck were angulated greater than 45 degrees, separation between fragments was greater than 1 cm, or the greater tuberosity was displaced more than 0.5 cm. There were 21 Type II, 16 Type III, and four Type IV fractures. Fractures were pinned using distally threaded Dynamic Hip Screw guide pins, 2-mm Kirschner wires, or 2.5-mm distally threaded Schantz pins. Patients were evaluated for union rates and motion. Assessment was made using the Modified American Shoulder and Elbow Surgeons Form. Thirty-six patients with 37 fractures were available for review with followup averaging 40 months (range, 12-68 months). All patients with Neer Type IV fractures did not respond to fixation and three had avascular necrosis develop, irrespective of the type of pin used. In the remaining 33 patients with Neer Type II and Type III fractures, a union rate of 94% was observed at an average of 2.6 months. All patients had good functional results. In the current series, there were no failures using Schantz pins. There was a 20% failure rate with Dynamic Hip Screw pins (2% if the patients with Type IV fractures were excluded) and a 100% failure rate with Kirschner wires. Stable fixation with early motion and subsequently good results can be obtained using percutaneous fixation in patients with Type II and Type III fractures; however, terminally threaded pins must be used and smooth Kirschner wires must be avoided. Percutaneous fixation cannot be recommended in patients with Type IV fractures.

Adult↗
PubMed1981

Bone-metal bonding after Kirschner wire studding. A case observation.

A clinical case is reported on in which there were difficulties in removing Kirschner wires from the bone four years after arthrodeses of a shoulder. These could only be removed with great force. They displayed muff-like mantling with bone. The histological investigations revealed that the bone had deposited directly on the metal surface and that absolutely stable bonding between the bone and the metal had occurred. In connection with similar observations in the literature, the importance of this case is pointed out with regard to the cement-free implantation of endoprostheses.

Adult↗
PubMed2002

Reappraisal of neonatal clavicular fracture. Relationship between infant size and risk factors.

OBJECTIVE: To examine the role of fetal size in neonatal clavicular fracture. STUDY DESIGN: A retrospective, case-control study was performed on infants diagnosed with neonatal clavicular fractures and born vaginally between July 1997 and June 2000. For each index case, a control matched for gestational age (within one week) and birth weight (within 250 g) and delivered within the same 24-hour period was selected at random from the delivery suite registry. The maternal and intrapartum factors were compared and the results analyzed according to whether the infants were large for gestational age (LGA) or not. RESULTS: Among 9,540 neonates delivered vaginally during this period, 151 (1.6%) had a fractured clavicle. Multivariate analysis indicated that the independent risk factors were shoulder dystocia and vacuum extraction. When analyzed according to fetal size, shoulder dystocia was significant only for LGA infants, while vacuum extraction was significant only for non-LGA infants. CONCLUSION: Independent risk factors for neonatal clavicular fracture are related to fetal size.

Adult↗
PubMed1996

Arachnoid cyst and chronic subdural haematoma in a child with osteogenesis imperfecta type III resulting from the substitution of glycine 1006 by alanine in the pro alpha 2(I) chain of type I procollagen.

The features of a child with osteogenesis imperfecta type III (OI III) resulting from the heterozygous substitution of glycine 1006 by alanine in the pro alpha 2(I) chain of type I procollagen were studied. He was born at term with the clinical features of severe OI, including deep grey-blue sclerae. He had severe osteopenia and all long bones were smaller than normal with cortical thinning, metaphyseal expansion, poor metaphyseal modelling, and multiple fractures. However, the vertebrae, pelvis, and shoulder girdle were of normal shape and there were few rib fractures. Histological examination of the calvarium and tibial shaft showed woven bone without lamellar bone or Haversian systems. The shafts of the long bones were widened owing to repeated fractures. Progressive enlargement of the calvarium occurred between 3 and 4.5 months of age owing to bilateral chronic subdural haematomata and a large arachnoid cyst in the Sylvian fissure. The cyst was probably developmental in origin while the subdural collections were probably the result of perinatal skull trauma. The cyst and the subdural collections resolved following drainage but ventricular dilatation with normal cerebrospinal fluid pressure followed. The proband is the first reported case of OI with a glycine substitution by alanine in the pro alpha 2(I) chain of type I procollagen.

Adult↗
PubMedDate not supplied

The location of the biceps tendon in completely displaced proximal humerus fractures in children: a report of four cases with magnetic resonance imaging and cadaveric correlation.

The location of the biceps tendon is a matter of concern for clinicians treating completely displaced proximal humeral fractures in children. This article describes four patients (one 12-year-old boy, two 12-year-old girls, and one 14-year-old girl) who underwent magnetic resonance imaging evaluation of their fractures to discern the location of the biceps tendon. In no case did the tendon become entrapped in the fracture site. At latest follow-up (1.5, 2, 1, and 2 years, respectively), full pain-free shoulder function and only mild radiographic abnormality were documented. Further investigation of proximal humeral fracture displacement using an adult cadaver model revealed that even extreme fracture displacement did not result in biceps tendon entrapment. The only displacement pattern that resulted even in fracture fragment contact with the biceps tendon was one where the shaft fragment was displaced 100% anteriorly.

Adolescent↗
PubMed1999

[Subacromial pain syndromes as a possible results of errors in the initial diagnosis and therapy of the shoulder joint].

The author in this paper shows possible diagnostic mistakes in the development of subacromial painful arc syndrome (cases with inadequate diagnostics). A hundred cases with acute shoulder's injury (without fractures and luxationes) who were admitted at the Clinic for bone surgery and Emergency Department of Clinical Centre, CUC Sarajevo in period between 1 January 1998-30 June 1998. Only clinical and X-ray examination in part were performed. A very interesting case with subacromial impingement as a consequence of such kind of treatment is presented in this paper. It can be concluded that it is necessary to use as a routine a comparative advantages of Echosonography, CT, MRI, as non invasive diagnostic methods at clinically suspected intra or extra articular lesions.

Adult↗
PubMed1996

Arterial injury of the axilla: an unusual case after blunt trauma of the shoulder.

The lesion of an axillary artery after a shoulder dislocation without bone fractures is very rare. The most common lesion is the subtotal transection of the vessel. Vascular injuries may be associated with nervous lesions whose incidence ranges from 27 to 44%. The nervous lesions are highly invalidating. The symptoms which recur most frequently are motor and sensitive deficiencies and a distal ischemia which, in some cases, may not be noted owing to the extensive collateral network. Whenever these symptoms are covered or absent, as in this case report, an angiography of the upper limb becomes essential for correct diagnosis and treatment.

Accidental Falls↗
PubMed1997

Salter-Harris type III fracture-dislocation of the proximal humerus.

Salter-Harris type III fractures of the proximal humerus are rare injuries. We report a Salter-Harris type III anterior fracture-dislocation of the proximal humerus in a 10-year-old boy that was open reduced and internally stabilized. A bone scan performed during the initial hospitalization and at 2-year follow-up revealed devascularization and subsequent revascularization of the humeral head. At 2-year follow-up, the patient had full motion of the shoulder, no pain, and arm strength equal to that of the contralateral side. Four cases of Salter-Harris type III fractures of the proximal humerus have been previously reported; good early clinical outcomes were obtained in all. Despite devascularization of the epiphyseal fragment, excellent clinical outcomes may result.

Child↗
PubMed1985

[Late results following the surgical treatment of proximal humerus fractures in adults].

In this paper late results of 65 proximal humeral fractures, operated upon between 1970 and 1980 are reported. Fractures were classified according to Neer in two-part-(28), three-part-(15), four-part-fractures (21) and fractures of the articular surface (1). In 34 cases internal fixation was performed by a T-plate. In 15 cases either open reduction without internal fixation or open reduction and minimal internal fixation was done using screws and K-wires. Primary prosthetic replacement of the head was done in 8 patients with four-part-fractures. The follow-up period ranged from 2.5 years up to 13 years with an average of 7 years. The functional results were excellent in 25 patients, good in 14, fair in 10 and poor in 16 patients. Better results were obtained in young patients, isolated shoulder injuries and patients with two- or three-part-fractures. On the contrary the results in aged and polytraumatized patients or patients with four-part-fractures and fracture dislocations were less favourable. Avascular necrosis of the humeral head was encountered in 4 cases of four-part-fractures and fracture dislocations, 3 of them fixed by T-plate and 1 by minimal internal fixation. No case of avascular necrosis of the humeral head was encountered in two- or three-part-fractures, fixed by T-plate. We can conclude, that cases, having a high risk for developing avascular necrosis of the humeral head, i.e. four-part-fractures and fracture dislocations, are better treated with minimal internal fixation avoiding the use of T-plate, for it was found to increase the already present damage.

Adult↗
PubMed2001

Functional outcome of proximal humeral fractures.

The functional outcome of 27 patients (16 males, 11 females) with a proximal humeral fracture was evaluated using the Simple Shoulder Test. Fifteen patients were also assessed using the Constant system. The mean age of the patients was 46.3 years (range 16-90 years) and the mean follow-up was 14 months (range 6-29 months). There were ten 2-part fractures, eight minimally displaced fractures, two 3-part fractures, three 4-part fractures, three 1-part fracture-dislocations and one 3 parts fracture-dislocation. Twenty-four fractures were treated conservatively and 3 surgically. Thirteen patients (48%) regained full function on the simple shoulder test and almost all regained range of movement sufficient for activities of daily living. Six patients were not able to return to their previous job. All patients were pain free at rest and were able to sleep on the affected side comfortably, although 9 patients had pain with activity, even though most pain were mild in nature. The mean Constant scores for the fractured arm and the normal arm were 72.5 points and 91 points respectively. The strength of shoulder abduction was reduced by a mean of 34%. Although the outcome was generally satisfactory, there was nevertheless a statistically significant deterioration of function following the fracture.

Adolescent↗
PubMed1987

[Surgical therapy of dislocation fractures of the head of the humerus in adults. Personal procedure and results].

Surgical intervention is indicated in the vast majority of humerus head fracture dislocations. In the present paper, we report on the results of 24 such interventions performed between 1975 and 1984. Implantation of a T-plate is considered the standard procedure to obtain osteosynthetic stability during exercise. However, in elderly patients or in cases of multiple fragment fracture, this procedure is inadequate to achieve the required stability. In such cases, development of a humerus head necrosis would rather be promoted. If a sufficiently stable osteosynthesis without the risk of necrosis cannot be achieved, we prefer replacement of the humerus head by a shoulder prosthesis to humerus head resection, resection-interposition-arthroplasty or shoulder arthrodesis. However, not only optimal surgical management of humerus head fracture dislocations has a decisive influence on the later function of the most flexible human joint with the important rotator cuff, but also properly performed active and systematic postoperative physiotherapy.

Adult↗
PubMed2005

[Simultaneous bilateral ventral and dorsal shoulder dislocation following an epileptic convulsion--a rare combination of injuries].

We report about a 29 year old male patient who had a simultaneous bilateral ventral and dorsal shoulder dislocation. The dislocation happened during a first incident of an epileptic convulsion, previously not diagnosed. On the right shoulder following a closed reduction manoeuvre a dislocation fracture was seen. It needed operative open reduction and fixation with angular stable plate osteosynthesis. The locked dorsal shoulder dislocation on the left was operated dorsally secondary via a dorsal approach. In a first step the reduction was carried out and in the same intervention the humeral head defect was lifted and supported in a closed technique under radiographic control.6 months postoperatively the patient was free of pain in both shoulder joints. The range of motion was unimpeded on the left and only with slight deficits in abduction and anteversion on the right. The diagnostics and the treatment strategy for this rare injury combination are described critically in this paper.

Adult↗
PubMed2006

Clinical importance of comorbidity in patients with a proximal humerus fracture.

UNLABELLED: The aim of this prospective study of 100 consecutive patients with a proximal humerus fractures primarily was to investigate the prevalence and importance of poor health and comorbidity. Seventeen men and 83 women with a mean age of 73 years were involved together with 138 age and gender-matched controls. Twenty patients with a mean age of 81 years, were severely ill with a physical and/or mental disorder when they got their proximal humerus fracture. The 1-year mortality of this subgroup was 40% compared with 8% in the control group. Fifty-seven patients with a mean age of 74 years reported concomitant disorders compared with 54 of 78 (69%) controls. Twenty-three patients with a mean age of 67 years, reported no comorbidity compared with 25 of 34 (74%) in the control group. Sixty-seven patients were followed up on for 1 year and were evaluated clinically and radiographically. The Constant-Murley shoulder assessment was used. The 12 surviving severely ill patients were not able to attend the followup evaluation. In the remaining patients there was no significant difference after 1 year in pain, function, Constant-Murley score or radiographic healing of the injured shoulder between individuals with or without comorbidity. Patients with symptomatic shoulders at followup initially had significantly more frequently displaced fractures. LEVEL OF EVIDENCE: Prognostic study, Level II (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2003

Acute complications associated with shoulder dislocation at an academic Emergency Department.

Shoulder dislocation is the most frequent dislocation treated in the Emergency Department (ED). Orthopedic literature cites up to a 55% incidence of fracture, vascular or neurologic injury associated with this injury, but these studies suffer from referral bias. No large ED series has been reported. This retrospective chart review was conducted in an academic ED for patients with shoulder dislocation presenting July 1, 1995-June 30, 2000. There were 263 charts identified; 73 were miscoded and 5 were lost, leaving 190 for analysis. Mean age was 34.3 years. Fifty-five patients had at least one fracture (29%), 48 of which (76%) were of the Hill-Sachs type. Despite presence of a fracture, all shoulders underwent successful ED reduction. Sensory nerve deficits were found in 24 (12.6%), which persisted after reduction in 25% of these patients. No vascular injuries were identified. The finding of fracture in 33% of patients with shoulder dislocation is in the range of rates reported in the orthopedic literature (15-55%). The finding that, despite the presence of a fracture, all underwent successful closed reduction is important, as one-third of these patients will have this condition. Neurologic deficits in 12% is significantly lower than the 21-65% reported in the orthopedic literature. Although complications associated with shoulder dislocation were relatively common, they did not significantly affect ED management.

Academic Medical Centers↗
PubMedDate not supplied

Severely displaced proximal humeral epiphyseal fractures.

The purpose of this study was to document the late outcome of a group of patients with Neer grade III/IV proximal humeral physeal fractures who were treated with reduction of the fracture and maintenance of reduction until fracture consolidation. A total of 28 patients treated between 1984 and 1999 at a large children's hospital were included in this study. Nineteen of the 28 patients were 15 years or older (range 5-16 y). All patients were treated in the operating room with closed reduction followed by immobilization (n = 3), closed reduction and pin fixation (n = 20), open reduction and screw fixation (n = 3), or open reduction and pin fixation (n = 2). Postoperatively, all had Neer grade I or II displacement, which was maintained until fracture union. No operative or postoperative complications occurred. At an average follow-up of 4 years, all patients had near-normal glenohumeral motion and excellent strength and uniformly reported regaining full preinjury functional use of the involved extremity. Achieving and maintaining reduction in Neer grade III/IV proximal humeral epiphyseal fractures can be safely performed and results in excellent long-term shoulder function. This is of particular significance in the older adolescent who has minimal remodeling potential.

Adolescent↗
PubMed1984

Late effects of adjuvant radiotherapy for breast cancer.

Complications requiring in-hospital treatment were observed in 24 of 221 consecutively treated patients (11%) who were followed from 8 to 42 years after postmastectomy irradiation. There were four sarcomas of the treated chest wall, three squamous carcinomas (two in the esophagus), two angiosarcomas of the swollen homolateral arm, nine chronic ulcers, five respiratory insufficiencies, six pathologic fractures of the radiated shoulder or ribs, two fatal cardiomyopathies, one persisting leukopenia with fatal brain abscess, and one severe neurovascular impairment of the arm. In a comparable group of 394 consecutive postmastectomy patients who were not irradiated, one similar event, a myxosarcoma of an unswollen arm, was observed. Only long-term follow-up can determine the ultimate risks of radiotherapy.

Adult↗