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Fractures of the proximal humerus are extremely common. While there is as yet no consensus regarding surgical management, this article discusses the rationale behind nailing and details the authors' technique.
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(iii) Intramedullary fixation
for fractures of the proximal
humerus
Merzesh Magra
Caroline Witney-Lagen
Balachandran Venkateswaran
Abstract
Fractures of the proximal humerus are extremely common. While there is
as yet no consensus regarding surgical management, this article dis-
cusses the rationale behind nailing and details the authors’ technique.
Keywords fracture; humeral nail; intramedullary; proximal humerus
Introduction
Proximal humerus fractures are very common, accounting for
5% of all fractures and they are the third most frequent fracture
in the elderly.
1
The incidence increases exponentially after the
fifth decade of life, and is almost twice as high in females in this
age group.
2
87% are caused by a fall from standing height.
3
Other
mechanisms include a direct blow to the proximal humerus,
electrical shock, and convulsions.
3
In the younger patient they
result from high-energy trauma. Proximal humeral fractures have
a significant impact on the patient’s quality of life, which is
particularly important in elderly patients who often become
partially or wholly dependant upon others for activities of daily
living. With ever increasing life expectancies in the developed
world, the incidence of proximal humeral fractures is likely to
continue to rise and consequently so will the medical and social
burden of managing them.
The vast majority of proximal humeral fractures are either
undisplaced or minimally displaced and can be managed non-
operatively with satisfactory long-term outcomes. However,
surgical intervention is usually necessary for displaced fractures
if a favourable outcome is to be achieved.
4e9
Surgical techniques
include intramedullary nailing, plate fixation, tension-band
wiring, Kirschner wires and hemi-arthroplasty. All are associated
with a high incidence of complications
10e14
and no single
method has been shown to be superior.
8,14
The controversy over
implant choice and the high complication rate are both related to
a number of important challenges encountered in the manage-
ment of these difficult fractures.
Management challenges
There are several problems associated with the management of
displaced proximal humerus fractures
5,14e16
including:
!Poor bone stock in elderly patients which makes fixation
difficult.
!Displacement of the tuberosities by the action of the rota-
tor cuff.
!Comminution and consequent technical difficulty.
!Secondary avascular necrosis.
!Post-traumatic and post-surgical stiffness.
General surgical principles
Surgical treatment aims to achieve stable anatomical reduction
thus permitting early mobilisation and pain-free function with
sound bony union. Such an outcome is dependant on many sur-
gical and patient factors. Surgical factors include choice of implant,
meticulous technique and the experience of the surgeon. Patient
factors include age, bone quality, fracture configuration, general
health, functional requirements, compliance and motivation.
To achieve a successful outcome requires meticulous surgical
technique, minimal soft-tissue disruption, anatomical reduction
and rigid fixation with the minimum of implants. In some cases
perfect anatomical fixation may have to be sacrificed for stability.
The operating surgeon should be aware of the various techniques
available, and choose the one appropriate for the individual pa-
tient and the pattern of the fracture. In this article the authors
have described their rationale and technique for intramedullary
nailing.
While reports of intramedullary nailing in the literature are
very varied
17e33
we believe that with good surgical technique, it
is possible to reduce the incidence of the commonly reported
complications which include:
!impingement syndrome
!backing out
!implant failure
!non- or mal-union
!avascular necrosis
!joint stiffness
The main advantage intramedullary fixation is a closed
reduction and consequent minimal disruption of the soft-tissue
envelope. The small incision makes for less damage to the blood
supply and a shorter operation time
22
than other techniques.
Other advantages include rigid angular-stable fixation, and,
compared with plate fixation, the biomechanical advantages of a
shorter lever arm as well as higher stiffness values in bending
and torsional load.
34e36
Authors recommended surgical technique
While there are many commercially available intramedullary
nails their concepts for use and surgical techniques are similar.
Merzesh Magra MBBS MRCS SpR Trauma and Orthopaedic Surgery,
Mid-Yorkshire NHS Trust, Pinderfields Hospital, Wakefield, UK. Conflict
of interest: none.
Caroline Witney-Lagen MBBS MRCS SpR Trauma and Orthopaedic
Surgery, Mid-Yorkshire NHS Trust, Pinderfields Hospital, UK. Conflict of
interest: none.
Balachandran Venkateswaran MS (Orth) FRCS (Tr&Orth) Consultant
Orthopaedic and Trauma Surgeon, Honorary Senior Lecturer, University
of Leeds, Mid-Yorkshire Hospitals NHS Trust, Pinderfields Hospital, UK.
Conflict of interest: none.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 144 !2013 Elsevier Ltd. All rights reserved.
Our personal preference is currently the Stryker"T2 proximal
humeral nail (T2-PHN).
The operation is carried out under general anaesthetic sup-
plemented with an interscalene brachial plexus block, which
makes for lighter anaesthesia and improves post-operative pain
control. Intravenous prophylactic antibiotics are administered.
The patient is positioned in the beach chair position on a
radiolucent operating table with their head turned to face away
from the operative side. This ensures optimal unrestricted access
to the shoulder. Before skin preparation and draping it is
important to correctly position the image intensifier on the
opposite side of the table to the operating surgeon. Then under
fluoroscopic control closed reduction of the fracture is attempted
by adducting the arm, and supinating the forearm while applying
longitudinal traction. This manoeuvre usually reduces the frac-
ture into an acceptable position, even in cases with severely
displaced fractures.
Using a marker pen the surface anatomy of the anterior and
posterior acromion are delineated. Our preference is for the
anterolateral Mackenzie approach to the proximal humerus
(Figure 1), which utilizes a relatively avascular plane, away from
the anterior and posterior circumflex humeral arteries. The
incision is deltoid-splitting and extends from the anterior border
of the acromion, parallel to the anatomic axis of the humerus.
The length of incision varies according to the complexity of the
fracture but should not usually be longer than 5 cm to avoid
damage to the anterior motor branch of the axillary nerve. If it is
necessary to extend the incision, the axillary nerve should be
identified, dissected free and protected. We do not wash the
fracture site with saline in order to preserve biology and any
fracture haematoma is preserved and if removed is retained and
reapplied at the end of the procedure.
It is important to restore the anatomical neck/shaft angle and
the medial buttress.
17,37,38
Restoring and maintaining the medial
buttress and soft-tissue attachments is essential to preserve the
vascularity in addition to conferring mechanical strength. In
three- and four part fractures it is of paramount importance to
accurately reduce the tuberosities.
17,27
Lack of soft-tissue
attachment to the head, especially in a four part fracture, may
preclude fixation and such cases may be better managed by
hemi-arthroplasty.
We recommend the use of grafted bank bone chips to support
the medial buttress and the head fragment before suturing the
tuberosities. The graft is compacted and tightly packed ensuring
anatomical head alignment and support to the medial buttress. In
two part fractures bone graft is usually not necessary unless there
is medial comminution.
The tuberosities with their rotator cuff tendon attachments
[Figures 2 and 3] are reduced by traction on number 5 Ethibond
(Ethicon", Johnson & Johnson Medical Ltd) To minimize the
risk of impingement, care must be taken bring the greater tu-
berosity fragment inferior to the articular surface of the humeral
head. When both tuberosities have been reduced the sutures are
tied to each other. This restores proximal humeral anatomy and
in essence converts three or four part fractures into a two part
fracture before nail insertion (Figure 4).
Figure 1 Anterolateral Mackenzie approach.
Figure 2 Displaced 4 part proximal humerus fracture.
Figure 3 Tuberosities sutured.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 145 !2013 Elsevier Ltd. All rights reserved.
The ideal entry point for guide pin insertion is usually on the
highest point of the articular surface just medial to the sulcus of
the greater tuberosity in line with the humeral anatomical axis
and between 1 and 1.5 cm behind the biceps tendon. The entry
point is exposed using a 1 cm longitudinal incision into supra-
spinatus in the same orientation as its muscle fibres. This mini-
mal approach through well vascularized tissue minimizes rotator
cuff damage. The proximal entry reamer is then introduced over
the guide pin followed by the selected nail which is inserted into
the medullary canal over the guide pin using gentle rotatory force
directed caudally. If initial passage of the nail is tight, hand-held
reamers are used to minimize the risk of iatrogenic fracture. The
nail is inserted to the desired level under fluoroscopic control.
Achieving an anatomic neck-shaft angle is extremely impor-
tant. Varus mal-reduction is associated with a particularly poor
outcome.
17
Thus it is particularly important to maintain the
anatomic neck-shaft angle of approximately 135 degrees.
39,40
During nail insertion the acromion can sometimes lateralize the
nail along with the head fragment relative to the shaft. To pre-
vent this, the arm is extended with traction to allow un-impeded
passage of the nail. It is extremely important to sink the proximal
end of the nail 3e4 mm below the greater tuberosity to prevent
the common complication of sub-acromial impingement.
Proximal locking is performed using the radiolucent proximal
locking jig (Figure 5). We regard three screws as the minimum
acceptable but prefer to use all four locking screws. It is impor-
tant to confirm the screw length under fluoroscopic control as
overly long screws can result in intra-articular joint penetration.
Burying the screws beyond the lateral outer cortex is not desir-
able, because they can be difficult to retrieve if nail removal is
clinically indicated at a later date. Thus screws should be
measured from the lateral cortex to a point 5 mm from the
articular surface of the humeral head (Figure 6).
The nail is locked distally in dynamic mode using the jig. This
prevents migration of the implant but allows a few millimetres of
collapse. Then the tuberosity fragments, which have already
been reduced and tied to each other, can be reinforced with
further stitches through drill holes or by using the screw heads of
the proximal locking screws. Reinforcement helps minimize the
incidence of tuberosity displacement secondary to the pull of the
rotator cuff muscles. Any previously saved fracture haematoma
is then placed around the fracture site as we believe that any
contained cells cytokines and growth factors etc. may help to
reduce time to union and reduce the risk of non-union. Finally
fluoroscopic screening is performed to assess dynamic fracture
reduction and stability. This also has the advantage of confirming
appropriate screw length and demonstrating that all humeral
head screws are 5 mm away from the articular surface. During
the wound closure the rotator cuff and deltoid are repaired.
Post-operative management
Initially the shoulder should be immobilized in internal rotation
using a shoulder immobilizer for one week. However, after the
first 24 h the patient is permitted to remove their arm from the
Figure 4 Fracture reduction.
Figure 5 Locking jig.
Figure 6 Final position of nail with reduced fracture.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 146 !2013 Elsevier Ltd. All rights reserved.
immobilizer to perform gentle pendular exercises as tolerated.
After one week passive assisted range-of-motion exercises are
commenced followed after three weeks by active assisted exer-
cises under physiotherapeutic supervision. In our post-operative
regime there is no restriction on the range of movement but
forced stretches are only permitted after six weeks. By six to eight
weeks there is often excellent radiographic and clinical evidence
of fracture healing.
Summary of operative principles
!Small superior deltoid-splitting approach permitting good
access but preserving blood supply
!Bone grafting to the medial buttress and head
!Anatomical reduction of the tuberosities and their rotator
cuff attachments prior to nail insertion
!Recessing the proximal end of the nail to preclude
impingement
!Restoration of the anatomical neck/shaft angle avoiding
valgus or varus mal-reduction
!Use of four proximal locking screws 5 m short of the
articular surface
!Early post-operative mobilisation
Discussion
Proximal humerus fractures are an orthopaedic conundrum.
They are difficult to evaluate and treat and currently there is no
consensus regarding their management
8,14
which has been
largely based on individual opinions and expertise. However,
there is general agreement that in younger patients with good
bone stock and high functional demand, all efforts should be
made to preserve the humeral head and fix the fracture.
There have been a number of papers reporting the results of
proximal humeral nailing in relatively small patient numbers.
These have shown very varied results.
17e33
We have previously
reported our results using the Stryker T2-PHN in a series of 61
patients.
17
We achieved a mean Constant Murley score of 64.9
and a mean Oxford Shoulder Score of 21.7. This is broadly in line
with other smaller series using the T2-PHN,
18e20
and comparable
with the results achieved using other nails
21e30
and with plate
fixation.
13,22,41
We found that statistically significantly better
results occurred in patients aged under seventy years, in 2- and
3-part fractures, in patients without medial metaphyseal
comminution and in patients with a neutral post-operative neck-
shaft alignment.
Avoiding complications
Our re-operation and complication rates were better than most
reported in the literature for both nails and plates. While the
surgeon cannot influence patient factors such as age and fracture
configuration, good surgical technique can help to avoid com-
mon complications.
In our early cohort of patients our most common complications
were impingement, followed by tuberosity non-union or mal-
union. Simple technique modification to ensure that the prox-
imal nail end was buried below the cortex reduced the rate of
impingement, and robust fixation of the tuberosities using number
5 Ethibond reduced tuberosity non-union and mal-union. Careful
attention to screw length and ensuring that they are 5 mm short of
the articular surface reduces the risk of intra-articular screw
penetration whilst ensuring adequate bone-purchase.
We have previously shown that a poorer prognosis is associ-
ated with medial metaphyseal comminution.
17
Medial column
support is also known to be important in maintenance of reduction
following plate fixation.
38
Therefore it is logical that reconstruc-
tion of the medial column using bone-grafting will help to reduce
the risks associated with loss of medial column support. Finally
achievement of a neutral post-operative nail alignment is partic-
ularly important. Varus mal-reduction decreases the lever arm of
the rotator cuff resulting in higher stresses and increased likeli-
hood of failure.
38
The importance of post-operative alignment was
also evidenced by our personal experience with no complications
in our 21 patients with neutral alignment compared to complica-
tions in 14 of our 18 varus malalignment patients ( p<0.001).
17
Studies of humeral nailing studies have reported violation of
the rotator cuff during nail entry to be associated with post-
operative shoulder pain.
31e33
Using a medial entry point
through the articular surface of the humerus has the potential to
cause less pain.
42
In our experience patients suffering from continuing post-
operative pain usually respond favourably to removal of the
fixation after union.
Conclusion
Intramedullary nails allow proximal humeral fractures to be
reduced and fixed through small incisions with minimal soft-
tissue disruption, preservation of humeral head periosteal
blood supply, reduced intra-operative blood loss and reduced
operative time.
22
Angular-stable locking nails offer a high degree
of stability, even in osteoporotic bone, permitting early mobili-
zation leading to favourable clinical outcomes.
15,43
Additionally
nails have biomechanical advantages over plates including a
shorter lever arm and improved stiffness values under bending
and torsional load.
34e36
Thus we believe that intramedullary nailing, in combination
with suturing of the tuberosities, provides stable fixation whilst
achieving minimal disruption of the soft-tissue envelope and
preservation of the periosteal blood supply. This permits early
motion, rehabilitation and return to function. They are not uni-
versally applicable and in elderly patients with head-splitting
injuries, severe comminution or limited functional goals, early
hemi-arthroplasty should be considered. A
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ORTHOPAEDICS AND TRAUMA 27:3 148 !2013 Elsevier Ltd. All rights reserved.
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Article
Full-text available
There is a lack of consensus regarding optimal surgical management of displaced and unstable three-part proximal humeral fractures. The objective of this prospective observational study was to compare the clinical and radiologic outcomes of plate versus nail fixation of three-part proximal humeral fractures. Two hundred eleven patients with unstable three-part proximal humeral fractures were treated with ORIF using plate (PHILOS [proximal humeral interlocking system]/LPHP [locking proximal humerus plate]) or nail (PHN [proximal humeral nail]) osteosynthesis. Outcome measurements included pain, Constant and Murley and Neer scores, and the occurrence of complications at 3, 6, and 12 months postsurgery. Regression analysis and the likelihood ratio test were used to evaluate differences between the cohorts. Throughout the 1-year followup period the Constant and Murley scores improved significantly for both cohorts; there was no significant difference between the nail group compared with the plate group. Also, 1-year Neer scores were similar between the two cohorts. Patients in the PHN group perceived significantly less pain compared with patients in the plate fixation group at 3, 6 and 12 months after surgery. We observed 79 local complications in 60 patients with no significant risk difference between the treatment groups; 35 intraoperative complications were directly related to the initial surgical procedure. The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures. Many complications were related to incorrect surgical technique and therefore can be avoided. Advanced surgical skills and experience are considered to be more critical for successful operative treatment of three-part proximal humeral fractures than the selection of the implant. Level II, therapeutic study (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.
Article
A study of 117 three-part and four-part displaced proximal humeral fractures, followed for from one to sixteen years, is presented. The ages of the patients averaged 55.3 years. Treatment began with closed reduction in seventy-seven patients, the result of which were accepted in thirty-one. Open reduction was done in forty-three patients, and prosthetic replacement in forty-three patients. Their results were rated by a numerical system. Closed reduction was found inadequate for active, healthy patients in either group. This was because of uncontrollable rotatory displacement in three-part fractures and avascular necrosis of the detached head in four-part fractures. Most of the poor results of open reduction in three-part displacements were due to errors in reduction or fixation while those in four-part displacements were due to avascular necrosis of the head. It. was concluded that the preferable method for three-part fractures was open reduction and that for four-part fractures was prosthetic replacement. Using these indications, the typical result was satisfactory but imperfect and many months were required for maximum recovery. Surgical errors and technique are discussed.
Article
Background Surgical treatment of displaced proximal humerus fractures remains controversial. There is little guidance on which patients are likely to do well with humeral nailing. Therefore we present our study evaluating the Stryker T2 proximal humeral nail (T2-PHN). Methods Sixty-one consecutive patients with acute unilateral displaced proximal humerus fractures were treated with the T2-PHN and followed up for a mean of 19 months. There were 46 females and 15 males with mean age 68 (range 36–97). By Neer's classification there were 25 two-part, 28 three-part and 8 four-part fractures. Results Union occurred at a mean of 3 months. Fifty-five patients had Constant-Murley scores with a mean score of 64.9. Mean Constant-Murley was 59.9 for over 70s, 69.7 in under 70s, 68.0 in 2-part fractures, 67.5 in 3-part fractures, 36.6 in 4-part fractures, 50.6 in post-operative varus, 73.5 in post-operative neutral, 72.7 in post-operative valgus, 55.5 in medial metaphyseal comminution and 69.5 without comminution. Fifty-four patients had Oxford Shoulder scores with a mean score of 21.7. Conclusions The T2-PHN has a learning curve. Important points include adequate recessing of the nail tip and suturing of tuberosities. The best results can be expected in under 70s, 2 and 3-part fractures, patients without medial metaphyseal comminution and patients with neutral post-operative neck-shaft alignment.
Article
no good reason why the results should not apply to the rest of the United Kingdom. It is expected that the total population of Scotland will remain constant over the next 20 years but that the number of children under 16 years of age will decline by 20% between 1996 and 2021. The working population will also decline but the pensionable population (men over 65 years and women over 60 years) will rise by almost 30% in the next 20 years. It is also expected that the number of people over 75 years of age will rise by about 30%. With increasing age and improved medical care patients are liable to be older and ¢tter in the future and unless there are dramatic improvements in the prevention and management of osteoporosis surgeons of the future will have to treat a rapidly increasing number of fractures in the elderly. Improved health and greater political involvement will mean that older patients will have higher demands and a greater expectation that fracture management will restore them to a reasonable functional level. It is also important that surgeons become aware of what constitutes a reasonable result of fracture management in the ¢t elderly population so that the patients can be given appropriate information. The paucity of information about the outcome of many of the common fractures in the elderly is remarkable.Few good studies of outcome have been undertaken and most of the fracture ¢xation techniques in use today were designed for younger bone.There are few techniques appropriate for the osteoporotic fractures that current and future surgeons will be required to treat and very few studies to determine the advantages of non-operative and operative treatment in the elderly population.
Article
Background: Internal fixation of proximal humeral fractures is associated with a considerable secondary malalignment rate. Fixed-angle implants have been suggested to increase the stability of fixation. Methods: The biomechanical properties of four different implants were tested. These included an internal fixator with semielastic properties (reference), the Synthes T-plate, a locked plate with rigid properties, and a spiral blade locked intramedullary nail (PHN). These implants were assessed in 24 osteotomized pairs of human cadaveric humeri. Specimens were subjected to 200 cycles of axial loading and torque, followed by loading until failure. Results: The PHN had greater axial stiffness than the reference and the T-plate. During torque, all implants were stiffer than the reference. During cyclic loading, there were no differences between the T-plate and the reference. Both the rigid internal fixator and the PHN had less irreversible deformation than the reference. Both implants resisted higher loads before failure. Conclusion: This study showed that the PHN and the rigid internal fixator are stronger than the semielastic locked plate and the Synthes T-plate for unstable subcapital proximal humeral fractures.
Article
Operationsziel Stabile Fixierung von Zwei- und Dreifragmentfrakturen des proximalen Humerus durch minimalinvasive Operationstechnik und rasche Ausheilung bei Wiederherstellung der ursprünglichen Anatomie. Erreichen einer frühzeitigen funktionellen Nachbehandlung mit dem Ziel der Wiederherstellung der ursprünglichen Beweglichkeit und der früheren Alltagsfunktion. Indikationen Instabile Zwei- und Dreifragmentfrakturen am proximalen Humerus (AO-Klassifikation: 11-A2, 11-A3, 11-B1, 11-B2, 11-B3). Subkapitale Humeruspseudarthrosen. Pathologische Frakturen. Kontraindikationen Kindliche Frakturen am proximalen Humerus. Frakturen am proximalen Humerus nach der AO-Klassifikation: 11-C2 und 11-C3. Floride lokale Infektion, z.B. nach Voroperationen. Operationstechnik Geschlossene Reposition. Anteriore Inzision im Akromionbereich, Spaltung des Musculus deltoideus und der Rotatorenmanschette. Eröffnung des Markraums mit dem Pfriem. Einbringen des Nagels. Einbringen der Spiralklinge in kanülierter Technik über Stichinzision. Distale Verriegelung über Zielbügel. Winkelstabile Verblockung von Nagel und Spiralklinge mit der Verschlussschraube. Weiterbehandlung Postoperative Ruhigstellung im Gilchrist-Verband bis zur Drainageentfernung; am 2. postoperativen Tag Beginn mit physiotherapeutischer Übungsbehandlung je nach Frakturtyp, Stabilität der Osteosynthese, Knochenqualität, Alter des Patienten, lokalen Begleitverletzungen, Schwellungssituation und Patientenmitarbeit. Abnahme des Gilchrist-Verbands zur Physiotherapie ab dem 2. Tag. Passive und assistive Bewegungsübungen im schmerzfreien Bereich je nach biomechanischen und biologischen Gegebenheiten. Ergebnisse 151 proximale Humerusfrakturen wurden mittels proximaler Humerusmarknagelung behandelt. 108 Patienten (71,5%) konnten 1 Jahr postoperativ nachverfolgt werden. Bedeutende Komplikationen waren Perforationen der Humerusgelenkfläche durch Bolzen oder Spiralklinge (n = 8), Schmerzen durch das Implantat (n = 10), Fragmentdislokationen (n = 2), Pseudarthrosen (n = 2), Humeruskopfnekrosen (n = 3) und ein oberflächlicher Wundinfekt. Der Constant- Murley-Score zeigte 1 Jahr nach Operation einen Mittelwert der verletzten Seite von 75,3 und der nichtverletzten Seite von 89,9. Der DASH-Score (Disability of the Arm, Shoulder and Hand) lag präoperativ bei 5,9 und 1 Jahr postoperativ bei 9,3. Die schlechtesten Ergebnisse fanden sich sowohl im Constant-Murley-Score als auch im DASH-Score bei den Typ-C-Frakturen. Objective Stable fixation of two- and three-part fractures of the proximal humerus through minimally invasive operative technique and rapid bone healing as well as restoration of original anatomy. Early functional training with the goal of restoration of former mobility and daily activities. Indications Unstabile two- and three-part fractures of the proximal humerus (AO classification: 11-A2, 11-A3, 11-B1, 11-B2, 11-B3). Subcapital nonunion of the humerus. Pathologic fractures. Contraindications Pediatric fractures of the proximal humerus. Fractures of the proximal humerus types 11-C2 und 11-C3 according to the AO classification. Active local infection, e.g., after former operation. Surgical Technique Closed reduction. Anterior acromial incision, splitting of the deltoid muscle and the rotator cuff. Opening of the medullary canal with the awl. Nail introduction. Spiral blade introduction in cannulated technique through stab incision. Distal interlocking through aiming device, angle-stable blocking of nail and blade through end cap. Postoperative Management Postoperative fixation in Gilchrist sling until 2nd postoperative day; then physiotherapy respecting fracture type and stability, local swelling, patient’s age and compliance, and concomitant injuries. Results 151 proximal humeral fractures were treated with a proximal humeral nail (PHN). 108 patients could be followed up 1 year postoperatively. Significant complications were perforation of the articular surface through bolts or blades (n = 8), implant-related pain (n = 10), fragment dislocation (n = 2), nonunion (n = 2), humeral head necrosis (n = 3), and superficial infection (n = 1). 1 year after the operation, the Constant-Murley Score showed a median value of 75.3 in the injured shoulder and of 89.9 in the uninjured shoulder. The DASH (Disability of the Arm, Shoulder and Hand) Score was 5.9 preoperatively and 9.3 at 1 year postoperatively. The worst results regarding the Constant-Murley Score as well as the DASH Score were found in C-type fractures.
Article
The ideal fixation technique for the treatment of proximal humeral fractures remains unclear. In the present study, we evaluated the experience of three surgeons with the treatment of two-part surgical neck fractures with angular-stable intramedullary fixation. Forty-eight patients with forty-eight Neer two-part surgical neck proximal humeral fractures were managed with locked angular-stable intramedullary nail fixation by three surgeons. Shoulder pain and outcomes were quantified with Constant scores and standard radiographs. Thirty-eight patients (including twenty-eight female patients and ten male patients) with a mean age of sixty-five years were followed for at least twelve months (mean, twenty months; range, twelve to thirty-six months). All fractures healed primarily. The mean follow-up Constant score (and standard deviation) was 71 ± 12 points (range, 37 to 88 points), with a mean age-adjusted Constant score of 97% (range, 58% to 119%). The mean Constant pain score was 13 ± 2.2 (possible range, 0 to 15 points, with 15 points representing no pain). The mean forward flexion was 132° ± 22°. All fractures but one healed with a neck-shaft angle of ≥125°. Patients who were managed with locked angular-stable intramedullary nailing of two-part surgical neck proximal humeral fractures via an articular entry point had reliable fracture-healing, favorable clinical outcomes, and little residual shoulder pain.
Article
To investigate the key parameters of three-dimensional anatomy of the proximal humerus and compare the differences between male and female, and between left and right sides in Chinese by volume rendering technique with multi-slice spiral CT (MSCT) so as to provide a reference for a new prosthesis of the proximal humerus which can adjust to the anatomical characteristics of Chinese. A total of 100 healthy volunteers were collected from Chongqing of China, including 59 males and 41 females with an average age of 40.4 years (range, 21-57 years). The humeral retroversion angle (RA), neck-shaft angle (NSA), medial offset (MO), and posterior offset (PO) were measured by volume rendering technique with MSCT. The average values were compared between male and female and between left and right sides, the correlation of these parameters was also analysed. In 100 volunteers (200 sides), the RA was (19.9 +/- 10.6)degrees, the NSA was (134.7 +/- 3.8)degrees, the MO was (4.0 +/- 1.1) mm, and the PO was (2.6 +/- 1.3) mm. There were significant differences in RA and MO between left and right sides (P < 0.05); there was no significant difference in NSA and PO between left and right sides (P > 0.05). The PO and RA of both sides in male were significantly larger than those in female (P < 0.05); the NSA and MO in male were similar to those in female (P > 0.05). PO was correlated positively with RA (r = 0.617, P = 0.000); MO was not correlated with NSA (r = - 0.124, P = 0.081). Because of significant side differences in RA and MO, and significant gender differences in RA and PO, the differences should be considered in the design of new proximal humeral prosthesis and proximal humerus reconstruction.