Four-part fracture dislocations of the proximal humerus in young adults: Results of fixation
Orthopaedic Department, Faculty of Medicine, Cairo University, Egypt. Electronic address: . Injury
(Impact Factor: 2.14).
09/2012; 44(4). DOI: 10.1016/j.injury.2012.09.005
Four-part fracture dislocations of the proximal humerus occurring in young age are extremely difficult fractures with a high incidence of complications. The risk of avascular necrosis is high; hence, prosthetic replacement is the treatment of choice in older patients with these complex fractures; on the other hand, the longevity of the prosthesis is the main concern in young age. Thus, every effort should be made to fix these fractures in the young. The purpose of this study is to evaluate the results of fixation in a series of young patients with four-part fracture dislocations; to support the trend to fix these fractures; and reserve prosthetic replacement to older patients.
In a prospective study, 39 patients younger than 40 years of age with four-part fracture dislocations were treated with open reduction and fixation either with K-wires or with a proximal humerus plate. Ethibond sutures were used in all patients to supplement fixation of tuberosities. In 18 patients, the dislocation was anterior and in 21 patients it was posterior. Twelve patients had an anatomic neck fracture and 27 had a surgical neck fracture. Surgery was performed within 1 week after the injury. Physiotherapy was initiated according to the general condition of the patient and the stability of fixation; the average time was 5 days after surgery.
Patients were followed up for an average of 26 months. Union was achieved in 36 patients and three patients had nonunion, all in anatomic neck fractures. Avascular necrosis developed in eight patients, seven of which were fractures of the anatomic neck and one was in the surgical neck. The average Constant score was 77; 26 patients were pain free, nine had mild pain and four had moderate pain. The mean active anterior elevation was 145°. Patients were divided into two groups based on the anatomic configuration of the fracture; in 12 patients (group 1), the head was fractured at the anatomical neck and in 27 patients (group 2), the head was fractured at the surgical neck. In group 2, the active anterior elevation was significantly better and the Constant score was higher.
Anatomical reduction and rigid fixation with meticulous surgical technique can lead to satisfactory results. The results in surgical neck fractures are superior to anatomic neck fractures with significantly less complications.
Available from: Martin Kloub
- "Different techniques of stabilisation like mini-invasive K-wire fixation [20–23,40], MIPO   , ORIF plating                , nailing          , haemiartroplasty     to total replacement  have been used. Recent advances in anatomically designed angular stable plates and nails have significantly improved the stability of fixation [43,47–49,58–64]. "
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ABSTRACT: Long term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3-4 part fractures.
137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27-93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome - absolute Constant score (CS(abs)) and relative Constant score (compared to the contralateral side - CS(rel)) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed.
125 fractures healed uneventfully. Mean long term CS(rel) was 81% of the unaffected side. Mean CS(rel) was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CS(rel) higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CS(rel) less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CS(rel) was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CS(rel) to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CS(rel) was 52% and the rate of complete necrosis rose to 60%.
Long term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed.
Available from: Nicola Archetti Netto
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ABSTRACT: To propose a new system for classifying proximal humeral neck fractures, and to evaluate intra- and interobserver agreement using the Neer system that is the most commonly used in the area and the Arbeit Gemeinschaft für Osteosynthesefragen system created by an European group, and a new classification system proposed by the authors of this study.
A total of 56 patients with proximal humeral fractures were selected, and submitted to digitized simple radiography in antero-posterior shoulder and scapular profile. Radiographs were analyzed by three observers at time one, and then three and six weeks later. The kappa coefficient modified by Fleiss was used for the analysis.
The mean intra-observer Kappa agreement index (k=0.687) of the new classification, was higher than both the Neer classification (k=0.362) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.46). The mean interobserver Kappa agreement index (0.446) of the new classification, also had better results than both the Neer classification (k=0.063) and the Arbeit Gemeinschaft für Osteosynthesefragen (k=0.028).
the new classification considering bone compression had higher results for intra- and interobserver compared to the Neer system, and the Arbeit Gemeinschaft für Osteosynthesefragen system.
Available from: Chlodwig M Kirchhoff
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ABSTRACT: Trotz ihrer Häufigkeit wurden bislang keine eindeutigen Algorithmen zur Behandlung der Fraktur des proximalen Humerus veröffentlicht. Aufgrund der vorliegenden Daten empfehlen wir bei jungen Patienten mit hohem funktionellem Anspruch und gutem Rehabilitationspotenzial eher die osteosynthetische Versorgung der proximalen Humeruskopffraktur. Bei Auftreten einer symptomatischen Humeruskopfnekrose kann dann sekundär eine anatomische Endoprothese implantiert werden. Bei Patienten mit einem biologischen Alter > 70 Jahre und bestehendem Rotatorenmanschettendefekt bei proximaler Humerusfraktur stellen wir aufgrund guter klinischer Ergebnisse zunehmend die Indikation zur Implantation einer inversen Schulterendoprothese. Diese sollte aufgrund des technischen Anspruchs und der hohen Komplikationsrate dem Operateur mit schulterendoprothetischer Expertise vorbehalten sein. Zusammenfassend sollte der Unfallchirurg nach Analyse fraktur- und patientenspezifischer Risikofaktoren sowie der Leistungsansprüche zusammen mit dem Patienten die individuell beste Therapie wählen.
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